从生物力学角度认识股骨解剖结构对膝关节置换的影响

doi:10.3969/j.issn.2095-4344.2914

中国组织工程研究 ›› 2020, Vol. 24 ›› Issue (36): 5850-5857.doi: 10.3969/j.issn.2095-4344.2914

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

从生物力学角度认识股骨解剖结构对膝关节置换的影响

李超，程静波，冯明利

首都医科大学宣武医院骨科，北京市 100053

收稿日期:2020-03-01 修回日期:2020-03-10 接受日期:2020-04-23 出版日期:2020-12-28 发布日期:2020-10-27
通讯作者: 冯明利，博士，主任医师。首都医科大学宣武医院骨科，北京市 100053
作者简介:李超，男，1990年生，山西省太原市人，汉族，2014年大连医科大学毕业，首都医科大学在读硕士，医师，主要从事骨关节疾病、创伤骨科研究。

Biomechanical study of the effect of femoral anatomy on knee arthroplasty

Li Chao, Cheng Jingbo, Feng Mingli

Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing 100053, China

Received:2020-03-01 Revised:2020-03-10 Accepted:2020-04-23 Online:2020-12-28 Published:2020-10-27
Contact: Feng Mingli, MD, Chief physician, Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
About author:Li Chao, Master candidate, Physician, Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing 100053, China

摘要/Abstract

摘要：

文题释义：

膝关节骨关节炎：是一种以退行性病理改变为基础的疾患，多患于中老年人群，其症状多表现为膝盖红肿痛、上下楼梯痛、坐起立行时膝部酸痛不适等。

股骨：是人体中最大的长管状骨，可分为一体两端，用于支撑人体的躯干及骨盆等。

背景：关节置换已成为重度膝关节骨关节治疗的主要方法之一，而股骨形态在关节置换中的作用日益受到重视，通过有限元分析股骨形态对关节置换后生物力学的影响。

目的：简述股骨解剖学特性及膝关节置换研究进展，通过有限元分析法对不同股骨形态对膝关节置换后生物力学影响的进展。

方法：通过输入“股骨形态，股骨解剖形态，股骨侧弓角，膝关节骨关节炎，膝关节置换术，全膝关节置换术，单髁关节置换术，生物力学，有限元分析，total knee arthroplasty，unicompartmental knee arthroplasty，finite element analysis”等关键词，利用计算机检索万方、维普、CNKI、PubMed、Elsevier和Web of Science数据库，通过阅读标题和摘要进行初步筛选，排除与主题相关度低的文献，最终共纳入102篇文献进行结果分析。

结果与结论：①股骨形态在不同人种、不同性别中存在较大差异；②不同股骨形态行膝关节置换时对股骨髓内定位杆插入点、股骨外翻截骨角度、胫骨截骨角度等均产生影响；③有限元分析相比于早期生物力学分析方法及体外实验的操作性更强，并且以已成为骨科生物力学研究的首选方法，通过有限元分析方法对股骨形态对膝关节置换的影响具有独特优势，被越来越多的人重视。

ORCID: 0000-0002-4625-7640(李超)

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

关键词: 骨, 股骨, 膝, 膝关节, 骨关节炎, 关节置换, 生物力学, 有限元分析

Abstract:

BACKGROUND: Joint arthroplasty has become one of the main methods in the treatment of severe knee disease. The effect of femur shape on joint arthroplasty has been paid more and more attention. The influence of femur shape on biomechanics after joint arthroplasty was analyzed by finite element method.

OBJECTIVE: To summarize the anatomical characteristics of femur and the research progress of knee arthroplasty, and to analyze the influence of different femur shapes on the biomechanics of knee arthroplasty by finite element method.

METHODS: The key words were “femur shape, femur anatomical shape, femur side arch angle, knee

osteoarthritis, knee arthroplasty, total knee arthroplasty, unicompartmental knee arthroplasty, biomechanics, finite element analysis”. A computer was used to retrieve Wanfang, VIP, CNKI, PubMed, Elsevier and Web of Science. Through the preliminary screening of reading titles and abstracts, the literatures with low relevance to the theme were excluded, and 102 literatures were finally included for the result analysis.

RESULTS AND CONCLUSION: (1) The femur shape has great difference in different race and sex. (2) The different shape of femur has influence on the insertion point of femoral intramedullary positioning rod, osteotomy angle of femoral valgus, and osteotomy angle of tibia. (3) Compared with the early biomechanical analysis, the finite element analysis method is practical and flexible in vitro experiment, with strong operability and has become the first choice of orthopedic biomechanics research. The finite element analysis method has a unique advantage in the influence of femur shape on knee arthroplasty, which has been paid more and more attention.

Key words: bone, femur, knee, knee joint, osteoarthritis, joint arthroplasty, biomechanics, finite element analysis

中图分类号:

李超, 程静波, 冯明利. 从生物力学角度认识股骨解剖结构对膝关节置换的影响[J]. 中国组织工程研究, 2020, 24(36): 5850-5857.

Li Chao, Cheng Jingbo, Feng Mingli. Biomechanical study of the effect of femoral anatomy on knee arthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(36): 5850-5857.

图/表（结果） 7

1.3 文献质量评估共检索到3 272篇文献，其中中文文献980篇，英文文献2 292篇，排除与研究目的的相关性差及内容陈旧、重复的文献，最终纳入102篇符合标准的文献进行综述。见图1。

2.1 股骨形态的概述人类股骨形态呈圆弧状弯曲状^[2]，可分为股骨上段、中段和远端。股骨上段髓腔存在着2个弯曲，股骨髓腔上部弯曲是朝后，下部弯曲朝前的，这说明股骨上段具有一定的弧度。在股骨中段，股骨弓向前，股骨髓腔呈开口向后的弧形，所以整个髓腔形态从侧位片上呈“S”形^[3]，股骨中段弯曲主要通过侧弓角度体现^[4-6]。股骨侧弓角的测量方法见图2。有研究发现人类股骨侧弓角的平均值为(4.88±1.24)°^[7]，但不同人种之间股骨侧弓角度并不相同。有研究发现非裔美国人股骨侧弓角较亚洲人和白种人小，并且认为人种间股骨侧弓角的差异是由于股骨长度所造成的^[4]。有研究发现黑色人种的股骨曲率半径大于白色人种，说明黑色人种的股骨侧弓角度要大于白色人种^[8]；有研究对100例股骨进行了分析，得出股骨前弓半径的平均值为108 cm，且该值与性别、年龄无关^[9]。有学者通过对426例股骨CT进行研究，得出股骨的前弓半径为(971.44±211.68)mm，且男性大于女性^[5]。有研究出日本人股骨曲率半径在矢状面为175 mm，冠状面为2 640 mm^[¹⁰^]。有研究对中国人的股骨形态经行研究后得出中国人股骨的外侧轮廓就像一根曲棍球棒的形状并且股骨曲率半径大于日本人^[1¹^]，见图3。中国北方地区人群中股骨侧弓的平均值为(1.4±2.4)°，股骨外翻角为(6.5±1.3)°^[1²^]。

膝关节单髁置换中股骨髓内定位杆插入点的选择依据牛津微创置换操作手册：股骨髓内定位杆插入点必须在股骨髁间窝前内缘的前方1 cm处，且紧贴股骨髁间窝内壁内侧，指向髂前上棘^[46-47]，见图4。这样可以保证术后下肢力线<0°，因为术后下肢力线内翻>5°则会加速聚乙烯衬垫的磨损; 而过度外翻将导致外侧软骨磨损^[48-49]；下肢力线内翻>8°就有可能导致假体脱位或松动，甚至需进行早期翻修。牛津微创置换操作手册并未对股骨形态的不同而选择不同股骨髓内定位杆插入点经行说明，这就导致术中需要手术医师依据经验进行选择^[50]。有研究对股骨髓内定位杆的位置经行研究后发现冠状位上股骨髓内导杆与股骨髓腔解剖轴线呈外侧交角，平均角度为0.96°；在矢状位上呈后方交角，平均角度为0.13°^[51]。MA等^[52]对20具尸体经行研究后得出在冠状面时股骨解剖轴距股骨髁间窝中心3.7 mm。蔡骏丰等^[47]基于单髁关节置换的尸体骨研究得出，中国人股骨平均外翻角约5.1°，最大7.78°，最小3.78°，并且该研究认为股骨髓内定位杆插入点的理想位置应在髁间窝最高点与髁间窝内侧缘中间距髁间窝水平线前方约1.46 cm的位置。

有限元分析方法的基本步骤大致为：①选定研究对象；②CT或MRI薄层扫描；③通过Mimcs软件经行三维重建及网格划分，见图5；④通过Solidworks进行布尔操作模拟关节置换手术过程，见图6；⑤通过Abaqus软件对不同组织进行特定的材料属性赋值，设置特定的边界条件；⑥负荷加载；⑦有限元分析，见图7。

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引言

材料方法

讨论

最近20年中，对于重度膝关节骨关节炎的治疗，膝关节置换已取得了较满意的结果。当进行膝关节置换时，需要明确每种置换类型的适应证，因为膝关节置换后假体的位置十分重要，假体位置不理想可能会导致下肢力线过度矫正或则矫正不足，前者易造成外侧间室压力负荷过度集中，进而引起对侧间室骨关节炎；后者则易造成聚乙烯衬垫磨损和松动^[101-102]。影响假体位置的一个重要原因就是股骨形态，但目前多数关节外科医生并不重视股骨形态对假体位置的影响，股骨形态对股骨髓腔定位杆插入点的位置选择以及全膝关节置换中股骨外翻截骨角度的选择都有较大影响。采用固定的髓腔定位杆插入点和外翻截骨角度可导致假体与骨皮质接触不充分，产生应力遮挡，降低假体稳定性或者导致假体撞击、聚乙烯衬垫磨损等情况。

传统生物力学方研究股骨形态对关节置换影响的分析准确性较低。近年来，有限元分析法在骨科生物力学的研究中取得了广泛的应用，通过对文献回顾发现有限元分析法与传统生物力学分析方法相比，具有更高的精度、可重复性及安全性。但目前针对股骨形态对关节置换的影响有不足之处：第一，目前国内外关于不同形态股骨的有限元分析较少，而股骨形态对膝关节置换的生物力学研究更加少见；第二，目前大多数研究主要依靠欧美人的股骨形态进行建模分析，未依据中国人的股骨形态进行研究，并且仅对股骨、胫骨假体内、外旋或内、外翻的位置经行分析，并未对假体同时存在上述2种情况进行分析；第三，大多数膝关节模型采用健康人群进行建模，而膝关节骨关节炎患者股骨形态变化范围大与健康人群的形态并不相同。

综上所述，关节置换后假体准确安放及准确重建下肢力线是膝关节置换的基本要求，也是影响膝关节假体远期临床效果的重要因素。虽然每种膝关节假体安放角度都有其允许范围，但如何针对不同股骨形态保证最佳安放角度仍需进行深入研究。不同股骨形态不仅对于膝关节置换后假体生存率有影响，而且也对肿瘤假体、创伤假体的设计及术后假体生存率都有影响。因此文章对膝关节假体的设计创新以及术中选择假体合理安放的角度从而进一步提高假体生存率都具有重要的参考意义。

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

从生物力学角度认识股骨解剖结构对膝关节置换的影响

Biomechanical study of the effect of femoral anatomy on knee arthroplasty

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