有限元分析运用于股骨头坏死诊断与治疗应用的最新进展

doi:10.3969/j.issn.2095-4344.2017.03.023

中国组织工程研究 ›› 2017, Vol. 21 ›› Issue (3): 450-455.doi: 10.3969/j.issn.2095-4344.2017.03.023

• 骨与关节综述 bone and joint review • 上一篇下一篇

有限元分析运用于股骨头坏死诊断与治疗应用的最新进展

洪郭驹^1，2，3，韩晓蕊⁴，方斌^1，2，周广全¹，何伟^1，2，陈雷雷^1，2

¹广州中医药大学，国家重点学科中医骨伤科学实验室，广东省广州市 510405；²广州中医药大学第一附属医院关节骨科，广东省广州市 510405；³西澳大学病理与实验医学院，西澳大利亚珀斯 6009；⁴广州中医药大学第一附属医院影像科，广东省广州市 510405

出版日期:2017-01-28 发布日期:2017-03-14
通讯作者: 陈雷雷，博士，主治医师，广州中医药大学，国家重点学科中医骨伤科学实验室，广州中医药大学第一附属医院关节骨科，广东省广州市 510405
作者简介:洪郭驹，男，1990年生，广东省汕头市人，汉族，广州中医药大学在读医学硕士。
基金资助:
国家自然科学基金资助项目(81673999，81302990)；广东省杰出青年科学基金(2015A030306037)；广东省高等学校学科与专业建设专项资金项目(2013LYM 0010)

Finite element analysis applied to the diagnosis andtreatment of osteonecrosis of femoral head: latest progress

Hong Guo-ju^{1, 2, 3}, Han Xiao-rui⁴, Fang Bin^{1, 2}, Zhou Guang-quan¹, He Wei^{1, 2}, Chen Lei-lei^{1, 2}

¹The National Key Discipline and the Orthopedic Laboratory, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; ²Orthopedic Department, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; ³School of Pathology and Laboratory Medicine, The University of Western Australia, Nedlands WA 6009, Australia; ⁴Radiographic Department, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China

Online:2017-01-28 Published:2017-03-14
Contact: Chen Lei-lei, M.D., Attending physician, The National Key Discipline and the Orthopedic Laboratory, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; Orthopedic Department, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
About author:Hong Guo-ju, Studying for master’s degree, The National Key Discipline and the Orthopedic Laboratory, Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; Orthopedic Department, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China; School of Pathology and Laboratory Medicine, The University of Western Australia, Nedlands WA 6009, Australia
Supported by:
the National Natural Science Foundation of China, No. 81673999, 81302990; the Outstanding Youth Science Foundation of Guangdong Province, No. 2015A030306037; the Discipline and Specialty Construction Foundation of Higher Education Schools in Guangdong Province, No. 2013LYM0010

摘要/Abstract

摘要：

文章快速阅读：

文题释义：

有限元分析：利用数学近似的方法对真实物理系统(几何和载荷工况)进行模拟，还利用简单而又相互作用的元素，即单元，就可以用有限数量的未知量去逼近无限未知量的真实系统。

股骨头坏死：是一个病理演变过程，初始发生在股骨头的负重区，应力作用下坏死骨骨小梁结构发生损伤即显微骨折以及随后针对损伤骨组织的修复过程。造成骨坏死的原因不消除，修复不完善，损伤-修复的过程继续，导致股骨头结构改变、股骨头塌陷、变形，关节炎症及功能障碍。

摘要

背景：目前有限元分析技术已可以完成建模，预测诊断，治疗的设计，以及手术方案等功能，并应用于股骨头坏死领域。

目的：总结和汇总有限元分析对在股骨头坏死生物力学领域的最新临床与实验研究进展。

方法：由第一作者通过计算机检索PubMed，Google，SpringerLink，CNKI 等数据库在2010年1月至2015年12月的已发表文献。检索式为(finite element analysis OR finite elment) AND (osteonecrosis OR osteonecrosis of femoral head)或(有限元分析OR有限元)AND(骨坏死OR股骨头坏死)。纳入原始文献内容与文章主旨紧密相关，原始文献有可靠依据与主题，原始文献观点及数据分析充分，活体与离体研究。

结果与结论：共纳入27篇。文章综述近5年来有关股骨头坏死中有限元分析应用文献，总结发现目前最新的有关运用有限元进行股骨头坏死建模可行性分析、特征病理的预测和诊断、手术治疗的创新技术辅助等发展水平，从而明确有限元分析在股骨头坏死的诊断和治疗未来发展方向。

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程
orcid: 0000-0002-5716-5565(Hong Guo-ju)

关键词: 骨科植入物, 数字化骨科, 有限元分析, 股骨头坏死, 保髋手术, 应力分析, 塌陷预测, 髋关节表面置换, 国家自然科学基金

Abstract:

BACKGROUND: At present, finite element analysis technology can set up the model, predict diagnosis, treatment design, as well as surgical plan, and can be used in the treatment of necrosis of femoral head.

OBJECTIVE: To sum and discuss recent progress in clinical and experimental research regarding biomechanical study in osteonecrosis of femoral head by using finite element analysis.

METHODS: A computer-based retrieval was performed by the authors (Hong Guo-ju and Zhou Guang-quan) in PubMed, Google, SpringerLink, ChinaNational Knowledge Infrastructure databases for literatures published from January 2010 to December 2015. The key words were “(finite element analysis OR finite element) AND (osteonecrosis OR osteonecrosis of femoral head)”. Inclusive criteria: studies with contents closely related to this paper; original papers with reliable topics and evidence; or papers with clear points and all-round analysis and both studies in vitro and in vivo.

RESULTS AND CONCLUSION: A total of 27 studies were included. The articles in the latest five years related to femoral head osteonecrosis and finite element analysis application were concentrated on. We summarized the latest research progress and problems, including the applied research carried out in the femoral head osteonecrosis clinical cases, innovational skills, so as to point out the direction of future research in the finite element analysis.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tissue Engineering, Hip Joint, Femur Head Necrosis

中图分类号:

R318

洪郭驹，韩晓蕊，方斌，周广全，何伟，陈雷雷. 有限元分析运用于股骨头坏死诊断与治疗应用的最新进展[J]. 中国组织工程研究, 2017, 21(3): 450-455.

Hong Guo-ju, Han Xiao-rui, Fang Bin, Zhou Guang-quan, He Wei, Chen Lei-lei. Finite element analysis applied to the diagnosis andtreatment of osteonecrosis of femoral head: latest progress[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(3): 450-455.

图/表（结果） 3

ONFH and finite element model

There were many ONFH finite element models exiting, such as cone model, spherical model and pathological models. However, with further development of the technology and the needs from clinical practices, model design and building experiments were required to be invented on the basis of previous modeling application by using the original CT data from ONFH patients^[12]. Li et al.^[13] used the 142-layer of 0.625-mm-thick consecutive CT Dicom format images to scan the ONFH, and then define the threshold of bone tissue, extract each outline, partition each edges, edit and repair by hole processing. Finally, they created the three-dimensional geometry model and meshed body line, assigned, and generate a model. The author believes that this method can quickly establish realistic femoral head in computer and calculate the precise three-dimensional finite element model of ONFH. Undeniably, some limitations exist in modeling by CT, due to its poor ability to detect cartilage and other tissues, which reduces credibility of the biomechanical analysis.

Innovative application was used by Pang et al. to register several radiologic images and fuse them into a three-dimensional reconstruction of femoral head^[14]. By combining X-ray images, CT and MRI image model of individual ONFH patients after images conversion, the radiologic images are registered by Mimic software and then successfully integrated into a model. This multi-images registration technique allows the model to cover cortical bone, cancellous bone, cartilage, necrosis areas and trabecular bone (Figure 2).

Stress analysis in femoral head necrotic area

Biomechanical effect of sclerosis rim: Sclerosis band is a common pathologic feature in ONFH around the necrosis area, although its biomechanical effect is seldom to be paid attention^[15]. Sclerosis band is a specific mechanical product after ONFH progress with the formation of necrosis, but also the marker of necrosis healing^[16]. Natural history of sclerosis formation is less studied. Nevertheless, it can be regarded as a biomechanical support to postpone or prevent ONFH from malformation^[17]. Protection of sclerosis band keeps further damage away, including collapse. Yu et al.^[18] use finite element analysis to evaluate the stress of sclerosis band at the proximal femur. The study simulated different proportions of sclerosis band in the proximal edge and added loads on it. Series of indicators are ultimately evaluated, like total deformation value, maximum stress, minor stress and the contacted pressure. The results showed sclerosis rim increased gradually with the total value of the femoral head deformation and maximum stress decreasing in turn. Therefore, the authors believe that the proximal edge of the sclerosis band can provide effective mechanical support for the femoral head. Chen et al.^[19] hold the same views for sclerosis band. They simulated the stress distribution after bone remodeling and calculated the maximum Von-Mises stress of bone. The results suggest that sclerosis band is an adaptive mechanical product to compensate the elastic modulus of the femoral head. Sclerosis band is an alternative mechanical reinforcing structure, which can significantly reduce the pressure loading in the subchondral bone, but only when the necrosis is small. However, Karasuyama et al.^[20] made use of the finite element model to assess stress distribution in fracture zones of ONFH. They found that both necrosis healing and fracture appearing are resulted from the change of sclerosis band.

Stress distribution and collapse

Range of necrosis area and stress distribution have a significant impact on the collapse occurring^[21]. Stress levels in necrosis area decrease and stress distribution concentrate around the necrotic bone, both result in trabecular fracture and interruption of blood vessel, which will inevitably lead to biomechanical instability in the femoral head^[22-23]. Currently, focus of the researches has breakthrough the original base in gross stress analysis, and inclined to study each supporting column in the femoral head. Such kinds of methods in simulating every portion are the innovational tendency to investigate the collapse stress.

Fang et al.^[24] established different volumes of necrotic tissue in ONFH by a finite element model, and put on and increase the load on the model (Figure 3). It was found that the range of necrosis area would confirmedly influence stress distribution in femoral head. The stress in the surface is higher than the one in bottom of the necrotic area. The pathologic mechanism can be described that cancellous bone fracture occurs under the subchondral region when the peak stress exceeds a critical value, which is the direct cause of the collapse of the femoral head.

Karasuyama et al.^[20] assessed the stress distribution and evaluate the subchondral fracture zone by measuring Von Mises value. In the meantime, the results are combined with the detection of osteoclasts count in necrosis tissue by pathologic methods. The authors finally concluded that the shear stress and shear tension force tend to be concentrated on trabecular site near the thicken border and osteoclast activity is reason to enhance the rate of collapse.

Finite element analysis for therapy

Finite element analysis and kinds of hip preservation surgeries

Core decompression with multiple drilling, a kind of mature hip preservation surgery, aims to reduce intramedullary pressure, prevent the development of ONFH progress and recover the microcirculation through the hole and tunnel^[25-26]. This surgery is relatively simple and easy to operate, even if there are still some technical difficulties^[27-28]. For example, a lack of mechanical support, selection of the optimal entry for grafting, suitable number of the drilling holes and so on. Bae et al.^[28] studied drilling technique by finite element analysis and investigated the clinical effect of the quantity and entry location of drilling holes. They calculated femoral stress and strain state when the surgeons took the drilling technique. They also analyzed cadavers to assess the best number of the drilling, related trabecular bone density near the entrance according to Von-Mises stress. The results supported that the treatment with multiple drilling is a stable operation. Tran et al.^[29] had a similar study in simulating and analyzing core decompression. The results showed that the use of standard drilling core decompression combined with graft implanted will prevent patients from a risk of hip fracture in daily activities. Only when the entry point is at the distal femur, the risk of hip fracture increases. The optimal entry point should be placed at a proximal end of the rotor. Thilo et al.^[27]studied core decompression with tantalum rod implant. Moreover, they concluded that core decompression using small drill holes seems to be better compared to the tantalum implant and to conventional core decompression for its low risk of fracture. The results also suggest that a superior performance for core decompression presumably due to the lack of complete bone ingrowth of the tantalum implant. Shi et al.^[31] compared the collapse level and collapse ranges under different weights after the patients accepted tantalum rod implant, fibula implant or core decompression. The results showed that smaller necrosis range (60°) is, less different the three operations effect on collapse level. When the necrotic area is in a wide range (120°), all the operations can reduce this level. Lutz et al.^[32]compared three kinds of operations by simulating models in finite element analysis, including core decompression, minimal invasive drilling and tantalum rod implant, and then predict their long-term efficacy. Zhou et al.^[10] found that the finite element can reconstruct the biomechanical transfer path of the femoral head and reduce the risk of a collapse in the cortical bone (Figure 4).

Hip resurfacing arthroplasty

Hip resurfacing arthroplasty is a mature surgical treatment for ONFH^[33]. Biomechanical changes surrounding the hip resurfacing arthroplasty, however, have not been completely studied^[34]. The studies are focused on individual necrosis range and different insertion angles of the implant. Tai et al.^[35] investigated that ONFH patients who accepted hip resurfacing arthroplasty were usually to have fracture near femoral neck in long-term follow-up. This phenomenon is caused by stress shielding. The authors simulated four different degrees of necrotic area (0°, 60°, 100°, 115°) and three different insertion angles of implant (10° vara, neutral hip, 10° valgus) in the finite element model. It was noted that the stress distribution after prosthesis of hip resurfacing arthroplasty occurs in the femoral neck. Sakagoshi et al.^[36] evaluated the biomechanical changes of HRA in various degrees of necrosis area and implantation angles. Similarly, the authors established three modes of necrosis range of femoral head surface and designed five hip resurfacing arthroplasty handle angles. The results show that the maximum stress distribution on the implant was decreased with stem angles ranging from 130° to 140°. In addition, the peak stress of cement increased with the stem angle turns to vara. Thus, it is required to be mentioned that a large area of necrosis, valgus or varus prosthesis are likely to worsen the biomechanical environment, even resulting in revision arthroplasty.

Other operations and surgical planning

Besides the treatment as described above, there are many other kinds of innovative affiliated technologies used in reducing head stress or supporting collapse in ONFH^[37]. Surgeons can also utilize finite element analysis to demonstrate their feasibility. Xiao et al.^[11] analyzed a support device for collapse femoral head. According to finite element analysis of the femoral head surface load stress and strain, author reported that stress concentration of normal femoral head model is in the distance of the femur. The model of the implant stress concentration should focus on the lower part of the lesser trochanter of the femur and the displacement of the stress point is smaller than normal. The authors believed that the device can effectively maintain the biomechanical properties of the femoral neck. Zhou et al.^[38] use finite element analysis to modulate the process of percutaneous balloon filling with bone cement femoral head necrosis. The steps include simulating the walking by a single leg and hip peak stress; simulating the avascular necrosis model and balloon filling with bone cement model respectively; calculating Von-Mises values at the top of the femoral head, femoral neck and surrounding area. Fresh human avascular necrosis of femoral head specimens for biomechanical analysis showed that percutaneous balloon filling with bone cement can indeed prevent collapse. Pang et al.^[39] used finite element analysis to have a quantitative research in hip preservation surgery based on surgical indications and optimized surgical plan the finite element analysis provided. Finite element analysis can calculate the necrotic area, location, size, volume, weight loading area, percentage of necrosis area in three-dimensional visualization and simulate the procedures of core decompression surgery, bone graft supporting surgery, fibula supporting surgery so as to determine and optimize various indexes in the hip preservation program.

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[6] Ueo T, Tsutsumi S, Yamamuro T, et al. Biomechanical aspects of the development of aseptic necrosis of the femoral head. Arch Orthop Trauma Surg. 1985;104(3):145-149.

[7] Yang JW, Koo KH, Lee MC, et al. Mechanics of femoral head osteonecrosis using three-dimensional finite element method. Arch Orthop Trauma Surg. 2002;122(2):88-92.

[8] Yu T. Research Progress on role of sclerosis band in the collapse of osteonecrosis of the femoral head. Medical Recapitulate. 2015;21(1):84-86.

[9] Shi J, Chen J, Wu J, et al. Evaluation of the 3D finite element method using a tantalum rod for osteonecrosis of the femoral head. Med Sci Monit. 2013;20(4):2556-2564.

[10] Penix AR, Cook SD, Skinner HB, et al. Femoral head stresses following cortical bone grafting for aseptic necrosis. A finite element study. Clin Orthop Relat Res. 1983;(173): 159-165.

[11] Xiao D, Ye M, Li X et al. Development of femoral head interior supporting device and 3d finite element analysis of its application in the treatment of femoral head avascular necrosis. Med Sci Monit. 2015;21(7):1520-1526.

[12] Volokh KY, Yoshida H, Leali A, et al. Prediction of femoral head collapse in osteonecrosis. J Biomech Eng. 2006; 128(3): 467-470.

[13] Li XL, Lv ZP and Liu YJ. Constructing a finite element model of osteonecrosis of the femoral head. Zhongguo Zuzhi Gongcheng Yanjiu yu Linchuang Kangfu. 2011;30: 5522-5525.

[14] Pang ZH, Wei QS, Zhou GQ, et al. Establishment and application of subject-specific three-dimensional finite element mesh model for osteonecrosis of femoral head. Shengwu Yixue Gongchengxue Zazhi. 2012;2:251-255.

[15] Liu ZH, Li ZR, Sun W, et al. Risk factors for collapse inpatients with osteonecrosis of bilateral femoral heads: Retrospectiveanalysis based on MRI and CT. J Clin Rehabil Tissue Eng Res. 2008;22:4249-4252.

[16] Hofstaetter JG, Wang J, Yan J, et al. Changes in bonemicroarchitecture and bone mineral density following experimental osteonecrosis of the hip in rabbits. Cells Tissues Organs. 2006;184(3-4):138-147.

[17] Yu T, Xie L, Zhang Z, et al. Prediction of osteonecrosis collapse of the femoral head based on the proportion of the proximal sclerotic rim. Int Orthop. 2015;39(3):1045-1050.

[18] Yu T, Xie L, Chu F. A sclerotic rim provides mechanical support for the femoral head in osteonecrosis. Orthopedics. 2015;38(5):e374-e379.

[19] Chen ZP, Xu Y, Qi XQ. The formation and function of the sclerosis rim in the femoral head: a biomechanical point of view. Med Eng Phys. 2015;(15):1-8.

[20] Karasuyama K, Yamamoto T, Motomura G, et al. The role of sclerotic changes in the starting mechanisms of collapse: a histomorphometric and FEM study on the femoral head of osteonecrosis. Bone. 2015:644-648.

[21] Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am. 2010;92(12):2165-2170.

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[23] Aruwajoye OO, Kim HKW, Aswath PB. Bone Apatite Composition of Necrotic Trabecular Bone in the Femoral Head of Immature Piglets. Calcif Tissue Int. 2015;96(4): 324-334.

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有限元分析运用于股骨头坏死诊断与治疗应用的最新进展

Finite element analysis applied to the diagnosis andtreatment of osteonecrosis of femoral head: latest progress

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