基于三维重建技术对国人胫骨近端截面的形态学测量

[目的]通过建立正常膝关节数字模型,测量胫骨近端不同截面线性参数,探讨性别及截骨厚度差异对胫骨假体基底部形态设计的影响.[方法]选取36例正常成人左侧膝关节,男女各半,年龄18～55岁,平均43岁;利用原始CT扫描图像资料重建膝关节,对胫骨近端进行模拟截骨,测量各截面内外侧前后径和横径.比较各测量值在性别间及截骨面间的差异.[结果]获取正常胫骨近端截面内外侧前后径、横径、前后径与横径的比值,内外侧前后径、横经、前后径与横径的比值在不同性别的差异具有统计学意义,内外侧前后径、前后径与横径的比值在不同截骨面高度的差异具有统计学意义.[结论]胫骨平台截面的几何形态不同于西方人,应用进口胫骨假体要考虑国人的特点;性别及胫骨截骨厚度会影响胫骨假体的设计和置换术中假体的选择.     

TKA术后胫骨近端截骨块参数测量及其临床意义

[目的]测量全膝关节置换术(TKA)术后患者的胫骨平台截骨骨块参数,为制作符合国人解剖特点的TKA胫骨假体提供数值依据,并为建立国人全膝关节置换术胫骨近端数据库提供数值参考.[方法]回顾分析2011年7月～2012年8月在本院进行全膝关节置换术患者共60例,其中男性30例,女性30例,测量术后胫骨平台截骨骨块的各项参数指标,通过多元回归分析,分析国人的性别、年龄及身高等因素对截骨骨块的影响.[结果]全膝关节置换术胫骨平台截骨骨块前后径为(51.31±5.70)mm,胫骨平台内外径为(71.53-5.05) mm,胫骨平台面率(前后径/内外径)为(0.73 ±0.07) mm.性别、年龄对胫骨平台截取骨块的前后径、内外径、胫骨平台面率(前后径/左右径)的影响无统计学意义,但身高对胫骨平台截骨块的前后径、内外径及胫骨平台面率的影响均有统计学差异.[结论]国人胫骨平台截面的几何形态近似方圆,随着身高的增加,胫骨平台截骨骨块的前后径、内外径及胫骨平台面率都随之增加,可为符合国人解剖特点的胫骨平台假体的设计提供有效的数据参考.     

国人正常胫骨近端几何形态学的初步研究

目的探讨国人正常胫骨近端截面线性参数测量新方法,为国产人工膝关节假体设计以及全膝关节置换术（TKA）临床操作提供参考依据。方法选取82例／135膝（男85膝,女50膝）国人正常膝关节,年龄19～82岁,平均47．2岁;分别按照性别、年龄和侧别进行分组;利用原始CT扫描图像资料重建膝关节,并在工作平台上对胫骨进行旋转、切割,测量计算不同截骨高度各截面的相关线性参数。结果测得所有受试者胫骨各截面的横径平均值为（75．03±4．88）mm;距离内外侧平台边缘向中心10％、20％、30％、40％及50％点的前后径分别为36．14、46．41、51．04、49．80、48．41、48．63、47．41、44．14、36．96mm;截面纵横比平均值为0．678;并分析得出胫骨截面横径及各百分点的前后径在不同性别间差异有显著统计学意义,而在年龄组和侧别组则无统计学意义。结论国人正常胫骨近端的几何形态同西方人有明显的区别;应用西方人设计的胫骨平台假体要考虑到国人的特点和性别差异;设计国人膝关节假体以及进行TKA手术时应该注意到性别的差异。     

国人胫骨平台截骨面与西方进口胫骨假体解剖学参数的偏差

 目的 测量中国北方汉族人胫骨平台截骨面与进口胫骨假体解剖学参数的偏差。方法 中国北方汉族健康志愿者82名（135膝）,男52名（85膝）,女30名（50膝）;年龄19～82岁,平均47.2岁。行膝关节横断面CT扫描,获得“.dicom”格式图像。将图像存储至与CT机联网的计算机三维重建工作站（Adw 4.3）,利用三维容积重建软件建立膝关节三维图像。对三维图像的胫骨进行旋转、切割,测量不同截骨高度及后倾角度各截骨面的胫骨近端横径、前后径及纵横比;采用5 mm容差范围法对三种西方进口假体（A、B、C）与国人胫骨平台截骨面的匹配程度进行初步评估。结果 男性胫骨近端截骨面横径平均值为（78.03±2.92） mm,女性为（69.85±2.70） mm;男性胫骨近端截骨面前后径平均值为（50.62±2.46） mm,女性为（46.14±2.61） mm;男性胫骨近端截骨面纵横比平均值为0.649±0.032,女性为0.661±0.031。不同性别胫骨近端截骨面横径与前后径的差异均有统计学意义,男性大于女性;纵横比平均值女性大于男性,差异有统计学意义。假体A对所有受试者各截骨面的平均涵盖率为42.55%,假体B平均为44.61%,假体C平均为27.41%。A与B两种假体涵盖率的差异无统计学意义,而两者与假体C涵盖率的差异均有统计学意义。结论 国人正常胫骨平台截骨面的几何形态与西方进口假体的匹配度普遍较低。     

维吾尔族人正常胫骨平台线性参数测量及特性分析

目的 初步获得维吾尔族人胫骨平台线性参数正常参考值,为国产人工膝关节假体设计以及针对性的进行全膝关节置换术提供参考依据.方法 选取45例87膝,男21例40膝,女24例47膝,维吾尔族人正常膝关节;年龄l8～65岁,平均33.9岁;按照性别进行分组;利用原始CT扫描图像资料重建膝关节,并在工作平台上对胫骨进行旋转、切割,测量胫骨平台相关线性参数.结果 测得所有受试者胫骨平台宽平均为(70.98±2.21)mm,胫骨内侧平台宽(28.66±1.20)mm,胫骨外侧平台宽(31.04±1.22)mm,胫骨内侧平台前后径(44.96±1.66)mm,胫骨外侧平台前后径(38.95±1.51)mm;并分析得出胫骨平台各线性参数在不同性别间差异均有显著统计学意义(P<0.01).结论 维吾尔族人正常胫骨平台形态同汉族国人存在一定的区别;应用西方人设计的胫骨平台假体要考虑到维吾尔族人的特点和性别差异;设计国人膝关节假体以及进行全膝关节置换手术时应该注意到民族及性别的差异.     

胫骨近端截骨面与胫骨假体的数字化形态学研究

目的 利用数字化技术获取健康成人正常胫骨近端截而及假体的参数参考值,探讨适合不同人种且具有性别差异的胫骨假体设计.方法 对55名志愿者中的92侧正常膝关节(男42侧,女50侧)进行螺旋CT扫描,将断层扣描数据导入Mimics10.1软件建立膝关节三维数字模型,然后将模型导入Geomagic Studio 8软件系统对胫骨近端模型进行模拟截骨、形态学测量,分析不同性别胫骨近端截面的形态学差异.再将获得的模型与通过激光扫描获得的假体(PFC和Nexgen)三维模型进行模拟装配、参数测量.结果 胫骨近端截骨面的前后径(AP)为(49.87 ±3.90)mm、内外侧横径(ML)为(73.50±5.60)mm,AP与ML呈正相关.男性胫骨平台AP为(53.24±4.10)mm、ML为(75.85±3.50)mm,均比女性[AP为(47.61±3,70)mm,ML为(67.68±2.60)mm]大.内侧前后径(MAP)比外侧前后径(LAP)大,男性平均大(3.90±2.90)mm,女性平均大(3.70±2.70)mm.PFC假体(0.75±0.05)和Nexgen假体(0.69±0.03)的AP/MP比值与本研究正常成人(0.68±0.03)相比,差异均有统计学意义(P<0.05).结论 不同性别及人种的胫骨截面形态存在显著差异,为提高人工膝关节胫骨假体的覆盖率,胫骨假体设计及临床操作均要考虑不同人种和性别的形态学特点.     

中国汉族与维吾尔族胫骨平台几何特点的对比及临床意义研究

[目的]通过对新疆维吾尔族胫骨平台几何参数的测定为提高少数民族全膝关节置换术的成功率及假体匹配性提供数据支持;同时对中国汉族与新疆维吾尔族胫骨平台几何特征的对比,掌握我国民族间的差异和共性,为假体多样性设计及选择提供理论依据.[方法]选取50例/100膝(男50膝,女50膝)汉族人正常膝关节,年龄18～74岁,平均43.2岁.选取100例/200膝(男100膝,女100膝)维吾尔族人正常膝关节,年龄18～65岁,平均31.4岁.按照性别进行分组,利用原始CT扫描图像资料重建膝关节,并在工作平台上对胫骨进行旋转、切割,测量胫骨平台相关线性参数.[结果]同一民族组内比较,男性胫骨平台各项线性指标均明显大于女性(P<0.01);外侧平台比内侧平台宽,但前后径小于内侧平台(P<0.05);维吾尔族受试组胫骨平台的内外侧宽及内外侧前后径分别要比同性别的汉族受试组更接近(P<0.05);在汉族和维吾尔族受试组中,胫骨平台宽与内外侧胫骨平台前后径存在着正相关关系(P<0.05);维吾尔族受试组男性、女性胫骨平台线性参数分别大于同性别的汉族受试组(P<0.05),但小于西方人群.[结论]维吾尔族人正常胫骨平台形态同汉族国人存在一定的区别;应用西方人设计的胫骨平台假体要考虑到维吾尔族人的特点和性别差异;设计国人膝关节假体以及进行全膝关节置换手术时应该注意到民族及性别的差异.     

国人类风湿关节炎术中髌骨厚度的测量及置换技术的探讨

[目的] 调查国人类风湿关节炎中髌骨的厚度及解剖学特点,探讨髌骨置换术的方法和安全性.[方法] 自2005年1月～2006年1月,对59例患者95个类风湿膝关节行全膝置换术,术中测量髌骨最厚处、最薄处和髌骨截骨后骨床的厚度以及安装髌骨假体后髌骨复合物厚度,术后对患者随访,观察膝前痛和髌骨骨折的发生率.[结果] (1)截骨前髌骨的厚度测量为最高处(22.01±1.64) mm(18～26 mm),最低处为(11.69±2.33) mm(6～16 mm).(2)截骨后髌骨的骨床厚度测量结果为(13.23±0.96) mm(11～16 mm),其中11 mm 4膝(4.2%),12 mm 15膝(12.7%),13 mm 38膝(40%),14 mm 32膝(33.7%),15 mm 5膝(5.3%),16 mm 1膝(1.1%).髌骨复合物的厚度平均为21.42 mm(20～25 mm),90.5%(86/95)的髌骨厚度在术后等于或稍低于原髌骨厚度.(3)术后随访轻度膝前痛3例,无髌骨骨折或髌骨松动病例.[结论] (1)类风湿膝关节中髌骨的厚度小于国人正常髌骨厚度的均值.(2)类风湿膝关节髌骨置换时保留12～14 mm厚度的骨床是一种安全的选择.(3)类风湿膝关节置换髌骨短期随访临床疗效肯定.     

胫骨高位截骨对胫骨近端解剖形态的影响

[目的]测量胫骨高位截骨术后胫骨近端解剖形态,并与术前比较,探讨其变化的临床意义.[方法]2001～2005年,35例(59膝)因膝关节内侧室骨性关节炎接受胫骨高位截骨术患者的完整影像学资料,在术前、术后标准正侧位X线片中测量胫骨角;胫骨后倾角度;胫骨近端关节面外移;关节线高度.所得资料采用配对t检验进行统计学分析,以P＜0.01为差异有显著性意义.[结果]胫骨角术前平均为99.1°±4.3°,术后平均为91.1°±3.8°;胫骨后倾角度术前平均为8.9°±2.6°,术后平均为5.0°±2.3°;胫骨近端关节面外移术前平均为(46.2±3.6)%,术后平均为(53.1±3.9)%;关节线高度术前平均(41.2±3.6)mm,术后平均(38.0±3.2)mm.手术前后差异均有显著性意义(P＜0.01).[结论]胫骨近端解剖形态在胫骨高位截骨术后会发生明显变化,如胫骨角变小,后倾角度变小,胫骨近端关节面外移,关节线高度相对下降等,将对转行全膝关节置换术产生不良影响.     

应用组合式金属垫块修复胫骨近端AORIⅡ型骨缺损的全膝关节置换

[目的]探讨应用组合式金属垫块修复胫骨近端AORI Ⅱ型骨缺损后全膝关节置换术的治疗方法和临床效果.[方法]2004年8月～2008年5月,作者对9例(12膝)应用组合式金属垫块修复胫骨AORI Ⅱ型骨缺损的全膝关节置换病例进行了随访,男3例(3膝),女6例(9膝),年龄48～76岁,平均69岁.[结果]术后随访6～42个月,平均26个月.患者内、外翻畸形均得到有效矫正,疼痛消失,活动度良好,膝关节HSS评分由术前14.5(10～25)分提高到术后85.5分(74～95)分,膝关节屈曲活动度由术前74.6°(15～100°)提高到术后110.3°(80～155°).[结论]在全膝关节置换术中应用组合式金属垫块修复胫骨近端AORI Ⅱ型骨缺损,手术操作方便,提高了假体的稳定性和手术的成功率.     

胫骨骨干端延长对胫骨生长板纵向生长的影响

[目的]研究胫骨骨干端截骨延长对胫骨生长板和纵向生长的影响。[方法]建立兔胫骨骨干端截骨和延长的动物模型;拍摄标准胫骨放射照片以测量其长度,胫骨远近端骨骺生长板做成组织切片以测量其厚度。[结果]胫骨中部骨干行单纯截骨后,增加胫骨纵向生长和胫骨远近端骨骺生长板的厚度,胫骨中部骨干行截骨延长后,胫骨纵向生长和胫骨远近端骨骺生长板的厚度没有改变。[结论]胫骨骨干截骨延长术不会妨碍胫骨的纵向生长。     

Different responsiveness of alveolar and tibial bone to bone loss stimuli.

Mandibular and systemic bone loss are poorly associated. We compared the effect of isocaloric protein undernutrition and/or ovariectomy on BMD and microstructure of mandibular alveolar and proximal tibia sites in adult rats. Mandibular bone was significantly less affected. INTRODUCTION: Whether mandibular bone and axial or peripheral skeleton respond similarly to systemic bone loss remains a subject of controversy. We have previously shown that mechanical loading during mastication influences bone mass and architecture of the mandibular alveolar bone. Isocaloric protein undernutrition and ovariectomy are known to cause bone loss and deterioration of bone microarchitecture at various axial and peripheral skeletal sites. We studied how the mandible, which is subjected to heavy, abrupt, and intermittent forces during mastication, responds to low-protein intake and/or ovariectomy and compared this response to that of the proximal tibia in adult rats. MATERIALS AND METHODS: Forty-four 6-month-old female Sprague-Dawley rats underwent transabdominal ovariectomy (OVX; n=22) or sham operation (n=22) and were pair-fed isocaloric diets containing either 15% or 2.5% casein (sham 15%, n=11; sham 2.5%, n=11; OVX 15%, n=11; and OVX 2.5%, n=11) for 16 weeks. BMD and bone microarchitecture parameters (e.g., bone volume fraction [BV/TV] and trabecular thickness and number) of the mandible and the proximal tibia were measured at the end of the experiment using DXA and microCT. RESULTS: Mandibular alveolar bone was negatively influenced by both protein undernutrition and OVX, but to a significantly lesser extent than the proximal tibia. In sham-operated animals, low-protein intake led to a 17.3% reduction of BV/TV in the mandible and 84.6% in the tibia (p<0.001). In normal protein diet-fed animals, OVX led to a reduction of BV/TV of 4.9% in the mandible but 82% in the tibia (p<0.001). In the mandible, protein undernutrition resulted in thinner trabeculae (p<0.05), whereas OVX led to a reduction of trabecular number (p<0.05). CONCLUSIONS: Mandibular alveolar bone was found to be less sensitive to either protein undernutrition or OVX than the proximal tibia spongiosa. We hypothesize that the mechanical loading of the alveolar process during mastication may protect the alveolar bone from the detrimental effects observed in other skeletal sites, such as the proximal tibia. Morphological and embryological differences between the two skeletal sites might also play a role.     

胫骨上端恶性骨肿瘤广泛切除与重建

[目的]探讨胫骨近端恶性骨肿瘤广泛切除手术技巧、重建方法与临床疗效.[方法]胫骨近端恶性骨肿瘤病人45例,男27例,女18例,平均年龄28岁(12～62)岁.肿瘤类型:骨肉瘤25例,恶性骨巨细胞瘤7例,软骨肉瘤6例,恶性纤维组织细胞瘤、纤维肉瘤各3例,淋巴瘤1例.手术取膝关节前内侧切口30例,膝关节前外侧切口15例,肿瘤累及上胫腓关节时一并切除腓骨上段13例,肿瘤侵入膝关节内行关节外广泛切除2例,部分瘤段骨灭活复合型假体5例,切断结扎胫前血管28例.本组病例均采用国产定制肿瘤型假体重建,软组织重建采用腓肠肌内侧头肌瓣移位42例,腓肠肌外侧头肌瓣移位3例,部分胫骨假体较长的病例联合应用胫骨前肌肌瓣覆盖假体下段前方.骨肉瘤、恶性纤维组织细胞瘤病人行新辅助化疗.[结果]45例患者随访时间平均为4.6年(8个月～9年),4例局部复发,6例肺部转移,1例恶性纤维组织细胞瘤患者术后6年发生L3椎体转移,行全脊椎整块切除术.假体相关并发症包括假体周围感染3例,1例行清创、置管冲洗后治愈,2例截肢;假体脱位3例,假体松动2例,假体断裂1例,假体周围骨折1例,均行切开复位、假体翻修或骨折内固定术.膝关节平均活动度92°(50°～120°),伸膝延迟平均4.4°(0°～20°);按照MSTS肢体功能评分标准,所保留肢体平均功能恢复率为76.7％.[结论]胫骨上端恶性骨肿瘤的广泛切除与重建要求较高,安全的手术边界,规范的切除技术,常规应用腓肠肌内侧头或外侧头肌瓣移位覆盖假体前方并重建伸膝装置,必要时联合应用胫骨前肌肌瓣覆盖假体下段,方可保障保肢术达到较好的疗效.     

Triplane fracture of the proximal tibial epiphysis.

Our purpose is to report a very rare case of proximal tibia triplane fracture, focusing the particular pattern of fracture and the long-term follow-up result. The triplane fracture is an exceptional fracture that occurs in the 3 planes (coronal, sagittal and transverse) close to the end of the growth period. A 15-year-old boy was admitted to our Center for a left femoral diaphyseal fracture and an ipsilateral lateral proximal tibia triplane fracture following a road accident. The femur was fixed with an intramedullary nail, the triplane fracture was anatomically reduced and percutaneously fixed. After 4 years follow-up, the knee was stable and with no complaints. Its range of motion was complete. Radiographs and MRI did not show any abnormality on the left leg and knee. In order to stabilize a proximal tibia triplane fracture a surgical internal fixation is usually required, with the possibility of a good long-term outcome also due to the growth potential remaining, if physeal arrest does not occur.     

Injury to the anterior tibial system during percutaneous plating of a proximal tibial fracture

Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe.     

外侧闭合楔形胫骨近端截骨术的远期疗效分析

[目的]探讨胫骨近端截骨术治疗原发性胫骨近端骨性关节炎的远期疗效以及最佳的截骨矫正角度.[方法]自1985～1997年,79例(111膝)原发性骨性关节炎患者接受了胫骨近端截骨术.其中男5例(5膝),女74例(106膝);年龄37～70岁(平均55岁).根据术后胫股角(FTA)分为3组.Ⅰ组61膝FTA<7°;Ⅱ组23膝FTA7°～9°;Ⅲ组27膝FTA≥10°.所有病例术前、术后按特种外科医院评分系统(HSS)评分.[结果]术后随访2年4个月～14年1个月(平均9年6个月).术前HSS平均60分,术后1年平均94分,末次随访平均87分.采用2种方法判定手术失败:方法1为需行人工全膝火节置换术者,随访4年和14年手术成功率分别为99%和85%;方法2为需行人工全膝关节置换术者或术后HSS评分<60分,随访4年和14年手术成功率分别为96.4%和75.1%.[结论]胫骨近端截骨术是治疗单间室骨性关节炎的有效方法,但术后胫股角应矫正到外翻7°以上(范围10°～15°).     

Volume analysis of the proximal tibial metaphysis.

PURPOSE: The Vitrea 2 imaging software (Vital Images Inc, Minnetonka, MN) was used for the volume analysis of the proximal tibial metaphysis. MATERIALS AND METHODS: Eighteen computed tomography scans of the proximal tibia were processed through the software, and 3-dimensional imaging of the proximal tibia was reconstructed. RESULTS: The volume and area of the proximal tibia that were generated resulted in a mean area of 127 cm(2) and a mean volume of 77.2 cm(2). CONCLUSION: This study supports the use of the proximal tibial metaphysis as a source of low to moderate volume of autologous bone. When compared with the accepted average volume of 25 cm(2), the computed results showed that there could be up to 3 times the amount of bone available in the proximal tibial metaphysis. The reported volume of bone harvested from previous studies was based on need and not the total amount available; subsequently, the results showed the possibility of a larger resource of bone, which provides the surgeon with the volumetrical limits of the proximal tibia metaphysis.     

Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee

From 1960 through 1979, a closing-wedge varus osteotomy of the proximal part of the tibia was performed in thirty-one knees (twenty-eight patients) for painful osteoarthritis of the lateral compartment of the knee that was associated with a valgus deformity. The patients were followed for two to seventeen years (average, 9.4 years). Twenty-four knees (77 per cent) had either no pain or only occasional mild pain at the last evaluation. Six knees had moderate pain and one, severe pain. Six knees required a subsequent total knee arthroplasty at an average of 9.8 years after the osteotomy. No patient had an infection or non-union. Osteotomy of the proximal part of the tibia is a reasonable method of treating unicompartmental degenerative arthritis in a knee with a valgus deformity. Although some patients with as much as 20 degrees of anatomical valgus deformity obtained a good result in this series, osteotomy in the supracondylar region of the femur is probably preferable if the valgus angulation exceeds 12 degrees or if the tilt of the tibial articular surface that will result from the surgery will exceed 10 degrees. Correction beyond the normal 5 to 7 degrees of valgus angulation to zero degree of anatomical tibiofemoral alignment is recommended to prevent recurrence of the valgus deformity and to decrease the load on the lateral tibiofemoral compartment.