寰枢关节的生物力学研究与临床应用

寰枢关节作为枕颈部的移行部位和构成头颅旋转运动的重要结构，其形态结构复杂，作用关键，因其邻近颈髓、椎动脉和颈神经等重要结构，故该关节损伤后不仅可导致寰枢椎不稳，而且可造成高位颈脊髓急性或慢性的压迫并出现相应的临床症状。寰枢关节由寰椎、枢椎及维持其关节稳定的横韧带、翼状韧带等结构组成。了解寰枢关节的生物力学特征，可进一步揭示寰枢关节的运动和损伤机理，并为寰枢椎失稳的临床诊断和治疗提供可靠的理论依据。本文就寰枢椎的生物力学研究及常见临床应用作一综述。     

枕颈部三维运动范围的测量

目的：研究枕颈部正常的三维运动范围，为枕颈部不稳分析和治疗提供生物力学基础。方法：运用脊柱三维运动测量分析系统，对１１具成人新鲜枕颈部标本的三维运动范围进行测试。结果：寰枕关节的前屈、后伸、左／右侧屈、左／右轴向旋转运动范围分别是：１１．７°、９．６°、２．８°／２．７°、６．９°／５．４°；寰枢关节分别为：８．９°、５．９°、３．４°／４．２°、３７．５°／３８．７°；寰枢关节中性区为２７．４°，占主运动范围的７１．７％；枕颈部与脊柱其它部位相比，主运动时伴有更明显的藕合运动，屈伸、侧屈时伴有比主运动范围更大的藕合旋转运动，分别为１０．５°、１４．３°。结论：脊柱三维测试分析系统不仅能对枕颈部的三维运动范围进行精确的测量，且能反映枕颈部三维运动的特点。     

寰枕关节后路经关节螺钉固定的解剖学

目的:为国人提供枕寰枢复合体的相关解剖学参数,寻求枕寰枢后路经关节螺钉固定的解剖学依据和可行性。方法:测量枕骨髁和寰椎干燥标本;观察新鲜尸体标本的枕寰枢后部结构。结果:枕髁关节面舌下神经管间距约9.66mm,两侧枕髁前端间距约14.93mm,枕髁关节面内倾角,左侧约12.5°,右侧约11.6°。枕髁关节面的前后径和横径、寰椎侧块上关节面前后径、侧块上关节面横径、侧块与后弓移行处侧块厚度均在5mm以上。椎动脉第3段恒定行走于椎动脉沟。第1、2颈神经背侧支与寰椎侧块下关节突后方几无交叉,并有一定的活动度。结论:寰枕关节后路经关节螺钉内固定在解剖可行,其理想入钉点在寰椎后弓与侧块下关节突移行处的中点,螺钉指向枕骨髁前上方。     

前路经寰枕寰枢关节锁定钛板螺钉内固定系统的匹配性研究

目的　观察新型前路经枕寰枢关节锁定钛板螺钉内固定系统与枕颈复合体的匹配性,探讨此内固定系统临床应用的可行性。 方法　对枕颈部CT扫描数据进行三维重建,并通过数字化模拟手术进行解剖学匹配实验。通过观察钛板枢椎椎体前表面的切合性及螺钉的走行,测量经关节螺钉的理想钉道参数,评估此内固定系统与枕颈复合体的匹配性。 结果　钛板与枢椎椎体前表面相匹配;经关节螺钉均穿过寰枕关节及寰枢关节进入枕骨髁,无穿出骨质者,螺钉均未损伤舌下神经管。椎体固定螺钉均位于枢椎椎体骨质内,未进入椎管及椎间隙。经关节螺钉钉道理想钉道参数与内固定系统实际钉道参数差异无统计学意义。 结论　前路经寰枕寰枢关节锁定钛板螺钉内固定系统与枕颈复合体解剖学匹配性较好,具有临床应用可行性。     

寰枢椎不稳后路椎弓根螺钉固定的三维有限元分析

目的:建立寰枢椎后路椎弓根螺钉固定系统三维有限元模型,分析寰枢椎后路椎弓根螺钉固定的稳定性。方法:1例寰枢椎不稳标本行后路椎弓根螺钉系统固定,采用螺旋CT扫描,通过工作站将扫描获得的图像导入计算机中,利用ANSYS8.0软件建立寰枢椎不稳三维有限元模型。给予模型加载不同边界条件,模拟寰枢椎的不同运动,分析寰枢椎不稳采用后路椎弓根螺钉固定的稳定性。结果:寰枢椎不稳采用后路椎弓根螺钉系统固定在不同运动状态下应力主要集中在枢椎椎弓根螺钉的根部。前屈运动时,椎弓根螺钉根部的应力为0.350×109Pa,前屈角度为0.7°;后伸运动时,椎弓根螺钉根部的应力为0.427×109Pa,后伸角度为1.2°;侧弯运动时,椎弓根螺钉根部的应力为0.295×109Pa,侧弯角度为0.3°;旋转运动时,椎弓根螺钉根部的应力0.635×109Pa,旋转角度为0.8°。结论:寰枢椎不稳采用后路椎弓根螺钉系统固定具有良好的术后即时稳定性。     

齿突Ⅱ型骨折后枕颈部三维运动的变化规律

目的：研究齿突Ⅱ型骨折后枕颈部三维运动的变化规律，为临床选择治疗方法提供生物力学依据。方法：采用１１具新鲜尸体的枕颈部骨韧带标本（Ｃ０～Ｃ３），应用脊柱三维运动测量及分析系统，对标本施加１．５３Ｎｍ的纯力偶矩，就齿突Ⅱ型骨折后的枕颈部三维运动范围进行测量。结果：①寰枕关节的三维运动在齿突骨折后虽有增加，但无显著性意义；②寰枢关节三维运动范围有显著性增加的表现在旋转运动、前屈运动及屈伸、侧屈主运动时的藕合旋转运动。结论：齿突骨折后引起枕颈部不稳的主要原因系寰枢关节的轴向旋转不稳和前移不稳；手术治疗应以恢复齿突的完整和寰枢关节的稳定性为重点     

后路内固定系统修复寰枢椎不稳的生物力学特征

背景：随着对寰枢椎结构形态学、应用解剖学和生物力学的研究日趋深入,寰枢椎不稳的发生机制以及诊治越来越受到关注。但对寰枢椎不稳定性疾病的有效内固定治疗开展相对较晚,为此国内、外的学者进行了大量的研究。 目的：比较寰枢椎后路内固定修复中几种不同内固定方式的生物力学性能,评价其各自的稳定性。 方法：通过检索近年来关于不同后路内固定方式修复寰枢椎不稳定的对比性生物力学评价及其初步临床应用研究的相关文献,通过对正常人体的寰枢椎复合体、寰枢椎不稳模型的三维运动范围的测量等相关研究成果作回顾性分析,评价不同内固定方案在正常枕寰枢三维运动下的稳定性,为临床合理选择内固定提供生物力学基础。 结果与结论：寰枢椎后路固定包括Gallie钢丝固定、Brooks固定、Apofix和Halifax固定椎板钩内固定、经关节螺钉内固定以及寰枢椎椎弓根钉棒系统内固定等。Gallie技术有利于前方半脱位的复位,但力学稳定性较差。Brooks技术有很强的旋转和牵张力。Apofix和Halifix椎板钩装置提供更强的抗旋转与抗前移强度,力学上较Gallie技术稳定,经关节螺钉固定生物力学优于钢丝技术和Halifax,避免了枕颈融合固定,对于安装技术有较高要求。在选择内固定时, 既要注意应能提供即刻的颈椎稳定,以保护脊髓功能,又要尽可能保留上颈段的功能,达到枕骨、寰椎、枢椎间的解剖复位和维持,应根据每例患者的具体情况,选择合适的内固定方法。  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     

寰枕、寰枢关节滑膜皱襞解剖观测及临床意义

目的：观察寰枕、寰枢关节中各关节有无滑膜皱襞存在，皱襞的形态、位置和组织学，探讨其临床意义。方法：对16例12岁以下小儿和8例成人防腐尸体的寰枕、寰枢关节中的各关节进行解剖观测。结果：无论成人或小儿，除了寰枢后正中关节外，其它关节均有滑膜皱襞存在，滑膜皱襞总出现率66．7％。寰枢前正中关节中皱襞位于上关节间隙，寰枕关节、寰枢外侧关节的皱襞主要分布于前外侧，多数皱襞呈月牙形。与成人相比，小儿组皱襞数量多，总出现率达72．34％(成人组仅58．3％)，小儿以大中型皱襞为主(58．35％)，成人以小型皱襞为主(62．5％)且无大皱襞。镜下观察儿童有三种不同的组织学类型，其中以脂肪型和纤维脂肪型为主(88．9％)。结论：推测在儿童寰枕、寰枢关节中有更多更大的滑膜皱襞，在受到外伤或炎症作用下，皱襞肿胀变大，位置改变，发生嵌顿，这很可能是小儿好发某些上颈椎疾病，如寰枢椎旋转畸形的解剖学基础。     

寰枢关节后路动态固定的生物力学研究

目的探讨动态固定(转动钉、滑动钉)对寰枢关节稳定性的影响。方法用6具新鲜成人枕骨(Oc)～颈椎(C4)节段进行测试,分别模拟完整状态、损伤状态、坚强固定、转动钉固定、滑动钉固定。采用重复测量的实验设计,在完整、损伤和不同固定状态下,通过脊柱试验机对标本分别施加1.5 N·m前屈/后伸、左/右侧弯和左/右轴向旋转纯力偶矩。三维运动系统测量寰枢椎运动,分析比较固定节段角度的运动范围(range of motion,ROM)和中性区(neutral zone,NZ)。结果损伤状态下,寰枢关节ROM在前屈、后伸、侧弯和旋转方向上均显著增加,产生了寰枢关节不稳。在前屈、后伸、侧弯和旋转方向上,坚强固定和动态固定后ROM均显著减小。与坚强固定比较,动态固定仅在侧弯方向上ROM较大。动态固定显著减小了在屈伸、侧弯和旋转方向上的NZ,且与坚强固定之间的差异无显著性。结论寰枢关节动态固定后,在前屈、后伸和旋转方向上的稳定性与坚强固定相当,但在侧弯方向上较弱。动态固定能够维持寰枢关节的相对稳定。     

寰枢椎后路柔性固定的生物力学研究

目的分析细棒、PEEK棒固定对寰枢关节稳定性的影响。方法采用6具新鲜成人枕骨(occipital bone,Oc)~颈椎C4节段进行测试,模拟以下手术及固定状态:①完整状态;②损伤状态:枢椎齿状突II型骨折;③坚强固定:寰枢椎均采用普通椎弓根螺钉固定,直径3.5 mm钛棒连接;④PEEK棒:直径3.5 mm的PEEK棒连接;⑤细棒:直径2.0 mm钛棒连接。采用重复测量实验设计,在完整、损伤和不同的固定状态下,通过脊柱试验机对标本分别施加1.5 N·m的前屈/后伸、左/右侧弯和左/右轴向旋转的纯力偶矩。采用Optotrak三维运动测量系统连续采集标本运动,分析寰枢椎之间角度运动范围和中性区。结果采用直径3.5 mm的钛棒,2.0 mm的细棒以及3.5 mm的PEEK棒固定后,在前屈、后伸、侧弯和旋转方向上均显著减小了固定节段的运动范围(P<0.05)。直径3.5 mm和2.0 mm的棒固定后的运动范围,在各个方向上无显著性差异。PEEK棒固定的运动范围仅在侧弯方向上大于坚强固定(P=0.005),其他方向无显著性差异。3种固定方式在屈伸、侧弯和旋转方向上均显著减小了固定节段的中性区(P<0.05)。各种固定方式之间相比较,无显著性差异(P>0.05)。结论在寰枢关节采用直径2.0 mm的细棒固定,与坚强固定的稳定性相当。采用直径3.5 mm的PEEK棒固定,在前屈、后伸、旋转方向上与坚强固定的稳定性相当,在侧弯方向上弱于坚强固定。     

Success Rate in Puncture of the Temporomandibular Joint

Puncture of the temporomandibular joint (TMJ) is a minimally invasive treatment for various jaw disorders. This study used a cadaveric model to evaluate the procedure from two entrance points with respect to hit ratio and possible complications, such as extraarticular extrusion of injection fluid. Ten heads, embalmed with Thiel's method, were investigated. A straight line drawn with a colored pen connected the center of the tragus and the lateral canthus. The first portal “A” was located at a distance of 1 cm anterior and 2 mm caudal from the center of the tragus. Portal “B” was located 2 cm anterior and 1 cm caudal starting from the same reference point. Punctures “A” and “B” were performed alternately on the right and left sides. Specimens were dissected and the local distribution of the injected latex was recorded. With Approach A, four punctures (40%; 4/10) reached the TMJ, whereas with Approach B, six injections (60%; 6/10) entered the TMJ. There were no statistically significant differences between the tested puncture methods (P = 0.0317) and body sides (P = 1). With each method, for example, 35% (7/20) each, the injected latex was either periarticular or retromandibular. In a further 20% (4/20), it was located subperiosteally alongside the ramus of mandible. The latex was injected into the infratemporal fossa and the external acoustic meatus in one case each (each 5%). There was no statistically significant difference between the techniques. The adjacent anatomy has to be kept in mind during TMJ puncture as the complication rate was remarkably high, suggesting that ultrasound guided intraarticular injection could improve the hit rate. Clin. Anat., 33:683–688, 2020. © 2019 Wiley Periodicals, Inc.     

Movements of the elbow and shoulder during pronation of the forearm

It is known that medial and lateral movements of the lower end of the ulna occur during pronation and supination of the forearm, but there is little clear evidence as to where these movements originate. Twenty normal subjects pronated their forearm about either an undefined, lateral, or medial axis. Measurements were made from paired photographs taken at increments of 45° during the movement. Abduction of the ulna always occurred but its magnitude did not vary significantly with differing axes of pronation. During pronation about an undefined axis the abduction at the elbow produced a lateral movement of the ulna which was usually appropriate for the axis of pronation in use. Medial or lateral rotation of the humerus was used to increase or decrease the amount of lateral movement of the lower end of the ulna to suit the requirements of pronation about a medial or lateral axis.     

第1跖趾关节及趾趾间关节的血供特点及其临床意义

目的：弄清第１跖趾关节和趾趾间关节的血供。方法：正常动脉灌注红色乳胶成人足２４只,观测第１跖趾关节和趾趾间关节的结构,各关节血管及神经的分布情况。结果：第１跖趾关节的动脉关节支来源于第１跖背动脉、第１跖底动脉以及它们的分支趾趾背动脉、趾底动脉和横动脉。它有背胫侧、背腓侧、跖胫侧、跖腓侧、关节前和关节后６部分关节支。趾趾间关节的动脉关节支来源于趾趾背动脉、趾底动脉和横动脉。它有背胫侧、背腓侧、跖胫侧、跖腓侧和关节后５部分关节支。结论：第１跖趾关节和趾趾间关节的血供丰富,但跖侧多于背侧,腓侧多于胫侧,故这些部位手术时,切口尽可能在背胫侧,以减少对关节血供的影响。     

自体关节移植修复外伤性掌指关节缺损伤的临床效果分析

目的探讨自体关节移植修复外伤性掌指关节缺损伤的临床应用效果。 方法选择2007年6月至2020年1月深圳市中西医结合医院骨伤科收治的外伤性掌指关节缺损伤患者15例。术前患者完善各项常规检查,行患侧手及关节移植供足直接数字化X射线摄影系统检查,改善患者全身营养状况,纠正低蛋白血症和贫血;围手术期严禁吸烟,术前进行床上大、小便训练;亚急诊期患者行创面分泌物培养排除创面感染;二期手术患者术前用延长支架将待移植的关节延长到合适的关节移植间隙。术中对受区清创,止血,探查骨关节、伸屈肌腱、指血管和指神经损伤情况及关节皮肤缺损情况,测量骨关节缺损长度。根据患者受伤情况选择应用自体第2跖趾关节游离移植、自体废弃指的掌指关节移植修复、自体腕掌关节半关节移植修复3种方法进行修复。术后绝对卧床1周,绝对禁烟,保温灯保温;予抗感染、抗血管痉挛、抗凝血、全身支持等治疗;术后2周拆线,逐步进行康复训练,定期拍X线片检查骨愈合情况,骨愈合后拆除克氏针。术后1周对移植关节及携带的皮瓣和患指的血运情况进行观察,并观察是否出现血管危象;术后2周观察创面愈合情况;术后12周观察移植关节的骨愈合情况;术后门诊随访6~24个月,观察患者手功能恢复情况。 结果本组15例外伤性掌指关节缺损伤全部修复良好,术后移植的关节及携带的皮瓣均成活良好,修复的患指血运良好,皮瓣及患指均未发生血管危象,全部创面均甲级愈合。术后随访平均(14.5±4.6)个月,移植关节的骨接合端均有连续性骨痂通过,骨性愈合,局部无压痛、无纵行叩击痛、无异常活动。移植的掌指关节活动度：背伸0~10°,屈曲60°~90°(平均75°)。手功能恢复评价优10例,良5例,优良率为100%。 结论自体关节移植修复外伤性掌指关节缺损伤,可良好恢复患指的掌指关节功能,保留患指的完整性,疗效满意。     

Morphological parameters of the superior articular facets of the atlas and potential clinical significance

Background  Although remarkable investigations exist in regard to the morphology of the superior articular facets of the atlas in the literature, only a few data exist concerning the correlation of these facets with the age of the specimens. Methods  The superior articular facets of the atlas were studied in 86 dried vertebrae. Several non-metric parameters were recorded, like presence of notches, grooves, complete or partial dissociation, rough surfaces as well as their morphology. Results  No notch was found in 37.2% of the superior articular facets. The incidence of notch is decreased as the age progresses. No transverse groove was found in 24.4% and the presence is increased with the age. The incidence of complete and partial dissociations was also found to be age-related. The incidence of rough surfaces, which corresponds to the site of maximum weight bear, was found to be increased in the old age. We classified the shape of the facets into the following types: oval-shaped, kidney-shaped, S-like, triangle, circular and two portioned. Conclusions  We assume that the increase of incidence of the dissociation, the rough surfaces, the grooves and the decrease of notches could be possibly the result of a restriction of the atlanto-occipital motion in the old age.     

Functional anatomy of the temporomandibular joint

Summary A study of 72 temporomandibular joints of adults without any gross signs of degenerative changes was made, in order to analyse the stress on individual regions of the joint, and to determine the path of the split line pattern in the articular cartilage. The cancellous architecture and the material distribution in the juxta-articular bone were also investigated. Zones of high-density compact substance in the lateral region of the joint, and the presence of attractive singular points in the split line orientation in this localization, suggest great stress on the lateral part of the temporomandibular joint. This increased stress in the lateral region is confirmed by the fact that arthrotic changes in the temporomandibular joint first almost always appear laterally. Degenerative changes usually originate at the articular disc, affect the articular tubercle after a delay, and finally spread to the condyle. Besides the greater physiological, mechanical stress on the lateral region of the joint, the force acting on every individual temporomandibular joint is influenced by the dental condition. The molars and bicuspids serving as a support zone play a decisive role in this context.Dedicated to Professor Dr. H. Haug on the occasion of his 70th birthday     

吻合血管神经第1跖趾关节移植重建肘关节的解剖学基础

目的：为吻合血管神经第1跖趾关节移植重建肘关节提供解剖学基础。法：20侧灌注红色乳胶的成人下肢标本解剖观察第1跖趾关节的血管神经分布及关节的构造，24只足部动脉铸型标本对关节支作对照观察。结果：第1跖趾关节的血供有背胫侧、背腓侧，跖胫侧、踊腓侧和关节后5部分关节支，腓侧关节支多和粗于胫侧，关节支外径0．3～0．5mm。关节支发自第1跖背动脉、腓侧趾背动脉、第1跖底动脉、趾底动脉和横动脉近侧支。关节的神经支与动脉相似，主要发自腓深神经、腓浅神经内侧支、第1趾足底总神经和趾底固有神经。结论：吻合血管神经的第1跖趾关节移植适用于修复重建单纯性肘关节缺损或强直，供区移植骨融合对足的外形功能影响不大。     

Stress in the human elbow joint

Summary The proximal radio-ulnar joint has two different types of articular surfaces. The contact area between the articulating surfaces is at its greatest when the joint is in a middle position. The highest density of osseous material is found on the ulnar side of the head of the radius. The subchondral bone beneath the radial notch of the ulna has a higher density at the edges than in the middle. In photoelastic experiments the intensity and configuration of isochromatics correspond to the material density of the osseous tissue of ulna and radius. The analysis of spongiosa near the joint shows bands of compressive cancellous trabeculae radiating axially into the subchondral cortex, crossed at right angles by bands of tensile cancellous trabeculae. These findings are in agreement with the course of the trajectories found in photoelastic experiments. The composition of the annular ligament is variable. The palmar and dorsal parts are made up of firm connective tissue; opposite the radial notch of the ulna, however, cartilage cells are embedded in the ligament.The histological composition of the annular ligament and the cancellous architecture in the radius and the ulna are in agreement with Pauwels' (1963) hypothesis that part of the compressive force in the elbow joint is transferred to the proximal radio-ulnar joint via the annular ligament. The distribution of the material in the subchondral bony tissue indicates that there is only partial contact between he radial head circumference and the radial notch of the alnal in all positions of the joint.Supported by the Deutsche Forschungsgemeinschaft (Ti 121/2; Zi 192/1 and Zi 192/3)Dedicated to Professor Dr. Benno Kummer in honor of his 60. birthday     

拇指腕掌关节囊和韧带的形态特点及其临床意义

目的：为拇指腕掌关节损伤修复与功能重建提供形态学基础。方法：福尔马林固定的成人尸体上肢标本20例（40侧），解剖观察关节囊及其韧带的起止和附着部位，新鲜成人尸体手标本3例（6侧）制成生物塑化连续断面薄片，观察韧带纤维形态、方向。结果：关节囊背侧厚而紧张，掌侧薄而松驰，周围有后斜韧带、前斜韧带、背桡侧韧带、掌侧韧带和掌骨间韧带，背桡侧韧带粗壮。结论：修复和重建关节周围韧带对拇指腕掌关节的稳定有重要作用。