Effect of the simultaneous correction of pectus excavatum and scoliosis on the thoracic deformity

doi:10.3969/j.issn.2095-4344.2017.19.011

Abstract

Abstract:

BACKGROUND: Studies on the biomechanical properties in NUSS procedure have obtained some achievements, but the effect of scoliosis surgical correction of scoliosis on thoracic deformity remains unclear.

OBJECTIVE: To explore the effect of simultaneous correction of pectus excavatum and scoliosis on thoracic deformity so as to provide reference for designing a rational orthopedic scheme.

METHODS: The three-dimensional reconstruction model of the chest was established based on the CT data of the patients with pectus excavatum and scoliosis. The surgical correction of pectus excavatum and scoliosis was simulated by numerical simulation method.

RESULTS AND CONCLUSION: (1) Results after correction showed that the bilateral spinous processes at T_3-5segments displaced to the left (X direction) about 1 mm, suggesting that the simultaneous correction is favorable for the correction of scoliosis. (2) Compared with the single NUSS procedure, the displacement at Y direction was increased by 13.358 mm in the simultaneous correction; meanwhile, there was significant difference in the shortest displacement between two methods. (3) In views of Von Mises stress distribution, the stress in the simultaneous correction was decreased by 24.6 MPa compared with the single Nuss procedure, indicating that the simultaneous correction can significantly reduce the Von Mises stress on the chest, which contributes to alleviate the postoperative pain. (4) Our results show that the simultaneous correction cannot only improve scoliosis, but also improve the symptoms of pectus excavatum.

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: Funnel Chest, Scoliosis, Orthopedic Procedures, Tissue Engineering

CLC Number:

R318

Lu Guang-pu, Ye Jin-duo, Feng Jing-jing, Geng Li-yang, Liu Ji-fu, Zhong Wei-hong, Dong Li-min. Effect of the simultaneous correction of pectus excavatum and scoliosis on the thoracic deformity [J]. Chinese Journal of Tissue Engineering Research, 2017, 21(19): 3017-3022.

Figures/Tables 3

2.1 微创矫形与脊柱拉伸矫形的数值模拟结果微创矫形与脊柱拉伸矫形后可以得到胸廓的位移场和应力场。图3，4绘制了矫形结束后，胸廓在矢状面的位移。从中可看出胸骨柄(矢状面)被抬高41.953 mm，肋骨随之向上移动，漏斗胸塌陷病症得到改善。脊柱在矢状面的位移UX位移场最大值为2.19 mm，位于T7-T8节胸椎，向右移动；最小值为-2.995 mm，位于T3-T4节胸椎，向左移动。脊柱向上最大位移8.176 mm，Cobb角明显减小，数值模拟达到了漏斗胸与脊柱侧弯同时矫形的效果。从应力分布来看，整体应力较为均匀，最大应力集中在第2块胸骨中端和胸椎T1-T4处，最大值分别为76.6 MPa和23.4 MPa，说明在矫形过程中胸骨的抬高是疼痛的主要原因。数值计算的矫形力与矫形位移如图5所示，矫形力与矫形位移基本成线性关系，随着矫形位移的增大矫形力逐渐增大。当矫形完成时，最大矫形力达到319.52 N。在开始矫正时，所需要的矫形力较小，随着矫正位移的增大，脊柱侧弯症状得到减轻，在脊柱拉伸矫形中，侧弯角度减小，矫形力矩的力臂也逐渐减小，矫形力矩取决于矫形力和矫形力臂，矫形力会出现呈增大趋势。 2.2 拉伸矫形释放后的数值模拟结果将同时矫形脊柱轴向拉伸的位移卸载，仅保留漏斗胸微创矫形。胸廓在矢状面的位移场如图6A所示，计算结果显示，整体胸廓最大矫形位移为-41.48 mm，发生在第2块胸骨右下方，与胸骨相连的左3、左4、左5、左6和右3、右4、右5、右6肋骨均有明显的抬高，左一和右一两根肋骨位移则变化不大，漏斗胸整体症状得到明显改善。图6B为前胸廓矫正后的等效应力分布，数值模拟结果显示，应力最大位置发生在第2块胸骨上，与矫形板所施加位移的位置一致，最大应力为45.9 MPa。图6C为胸廓变形矢量图，从图中可以看出胸骨柄位移较大。在拉伸脊柱矫形过程中，除了矫正了脊柱冠状面的侧弯，也矫正了胸椎矢状面的正常生理后凸。数值模拟计算的脊柱矫形位移场的应力场如图7所示，从数值结果来看，T3-T5节胸椎两侧的横突有向左(X方向)移动1 mm左右，这说明漏斗胸和脊柱侧弯同时矫形对脊柱侧弯有一定的帮助。脊柱所受到的最大应力为22.6 MPa，出现在胸椎T1段两侧的横突上，这可能与施加的位移的位置有关。"

References

[1] 梁林,叶金铎,王志芹,等. Nuss手术矫正漏斗胸过程的数值模拟[J]. 生物医学工程与临床, 2011,15(4):316-318.

[2] Felts E, Jouve JL, Blondel B, et al. Child pectus excavatum: Correction by minimally invasive surgery. Orthop Traumato Surg Res. 2009;95 (3) :190-195.

[3] Dean C, Etienne D, Hindson D, et al.Pectus excavatum (funnel chest): a historical and current prospective, Surg Radiol Anat. 2012;34(7):573.

[4] Iida H. Surgical repair of pectus excavatum. Gen Thorac Cardiovasc Surg. 2010;58(2):55-61.

[5] 曹强,王启,许瑞彬. 漏斗胸的诊断与外科治疗[J]. 辽宁医学院学报,2014,35(1):98-101.

[6] 韩冰,寇瑛琍. 漏斗胸患者Nuss手术前后肺功能的对比分析[J]. 四川大学学报(医学版),2014,45(1):177-178.

[7] 赵媚娇. 漏斗胸合并脊柱侧弯微创矫形过程的数值模拟[D]. 天津理工大学, 2015.

[8] 孙相华,洪志鹏.漏斗胸发病机制研究进展[J].医学综述, 2006 , 12 (20) :1261-1263.

[9] 冯杰雄.漏斗胸病因学研究进展[J].中华小儿外科杂志, 2002 , 23 (2) :172-173.

[10] Frick SL. Scoliosis in children with anterior chest wall deformities. Chest Surg Clin North Am. 2000;10(2): 427-436.

[11] 戈烽,廖泉,肖蜀梅,等. Wada手术治疗成人漏斗胸[J]. 综合临床医学,1996,12(3):27-28.

[12] 苏群,张宝,韩志峰. Nuss手术与胸骨翻转术治疗漏斗胸效果比较[J]. 实用心脑肺血管病杂志,2013,12:124-125.

[13] 况军. 改良胸骨抬举术治疗儿童先天性漏斗胸临床分析[J]. 现代诊断与治疗,2013,24(10):2251-2252.

[14] 曾骐,张娜,范茂槐,等. Nuss手术与改良Ravitch手术的对比研究[J]. 中华小儿外科杂志, 2005, 26(8): 397-398.

[15] 余升华,尹得龙,杨展翔.青少年脊柱侧弯的研究进展[J].岭南现代临床外科, 2014, 14 (6) :708-711.

[16] Cobb J.Outline for the study of scoliosis. Instruct Course Lect. 1947;5 :261-275.

[17] 唐云德.青少年特发性脊柱侧凸的脊柱后路矫形及其影响因素[J]. 中国组织工程研究,2015,20(48):7770-7775.

[18] 杨卫周,李涛,李锋,等.运用CT三维重建测量重度先天性脊柱侧凸Cobb角的临床应用[J]. 现代生物医学进展, 2015,15(34): 6664-6667+6707.

[19] 黄忍,王星,李志军,等.青少年特发性脊柱侧弯的诊治进展[J].中国临床解剖学杂志,2016,34(4):472-475.

[20] Emans JB, Kaelin A, Bance P, et al.The Boston bracing system for idiopathic scoliosis. Follow-up results in 295 patients. Spine. 1986;11(8) :792-801.

[21] 赵自平,兰海峰,冯建忠.Providence夜用型支具治疗青少年特发性脊柱侧凸的效果分析[J].中国当代医药, 2014, 21(17) :26-28.

[22] 柳思羽,陈庆贺,王仑.非手术方法治疗青少年特发性脊柱侧凸[J].中国矫形外科杂志, 2013 , 21(7) :722-725.

[23] 赵吕国,蒋仁伟,陆炳全,等. 鲁克(luque)手术在脊柱矫形外科的应用[J].川北医学院学报, 1988,14(3): 62-65.

[24] Cotrel Y, Dubousset J. Nouvelle technique dosteosynthese rechidienne segmentaire Par voie posterieure.Revue de Chirurgie Orthopedique. 1984;70 :489.

[25] 陈丽萍,刘安琴.C-D手术矫治脊柱侧凸的护理[J].中华护理杂志, 2001, 36 (1) :29-31.

[26] 叶启彬,主编.脊柱侧弯的预防与治疗[M].北京:北京医科大学/中国协和医科大学联合出版社,1994.

[27] 叶启彬,主编.脊柱侧弯外科学[M].北京:中国协和医科大学联合出版社,2003.

[28] 杨智君. 32例漏斗胸患者行微创矫形术(NUSS)的麻醉处理[D]. 中国医科大学, 2012.

[29] 梁海龙,刘吉福,赵京,等.Nuss手术矫正成年人漏斗胸22例临床分析[J]. 临床军医杂志, 2011, 39(1): 76-78.

[30] 刘士杰.6例胸腔镜下漏斗胸矫形术患儿的护理[J].中华护理杂志, 2008, 43(7): 603-604.

[31] Chang PY, Hsu ZY, Chen DP, et al. Preliminary analysis of the forces on the thoracic cage of patients with pectus excavatum after the Nuss procedure. Clin Biomech. 2008;23(7):881-885.

[32] 胡辉莹,何忠杰,吕丽萍,等.应用Mimics软件辅助重建人体胸廓三维有限元模型的研究[J].解放军医学杂志,2008,33(3):273-275.

[33] 胡辉莹,钟世镇,聂晨阳. 人体骨骼生物力学中有限元分析的研究进展[J]. 广东医学,2007,28(9):1532-1534.

[34] 胡辉莹,钟世镇,张美超,等.人体胸廓三维有限元模型的建立及应力分析研究[J]. 中国急救医学,2007,27(12):1098-1100+1164.

[35] 胡辉莹,何忠杰,张美超,等. 人体胸廓胸外按压的生物力学测试[J]. 中国临床解剖学杂志,2009,27(5):592-594.

[36] Nagasao T, Noquchi M, Miyamoto J, et al. Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum. J Thoracic Cardiovasc Surg.2010;140(6): 1294-1299.

[37] Ye JD, Liu BL, Liu JF, et al. Research on electrical measurement experiment of deformation of artificial thorax model. J Mech Med Biol. 2016. doi: 10.1142/ S0219519417500 579.

[38] 彭春政,张胜年,陆爱云.人体躯干骨骼-肌肉-韧带结构三维有限元模型的建立和验证[J].中国运动医学杂志, 2010,29(6):702-705.

[39] 田慧中.脊柱侧弯合并漏斗胸的诊断与治疗[J]. 中国矫形外科杂志,2005,13(5):393-394.

[40] Bafus BT, Chiravuri D, van der Velde ME, et al.Severe hypotension associated with the prone position in a child with scoliosis and pectus excavatum undergoing posterior spinal fusion. J Spinal Disord Tech. 2008;21(6):451-454.

[41] 张春月. 漏斗胸合并脊柱侧弯微创矫形数值模拟计算模型的研究[D].天津理工大学, 2016.