动力加压髋螺钉对股骨上段生物力学特征性的影响

目的：探讨股骨上端骨折,以动力加压髋螺钉进行骨固定治疗,骨折愈合后,取出动力加压髋螺钉以后的股骨上段与完整的股骨上段的生物力学特性相比较,为临床内固定取出术后功能锻炼的强度提供量化依据。方法：收集8具新鲜尸体股骨标本进行实验应力分析,分别测定完整股骨上段和动力加压髋螺钉取出后股骨上段的力学特性改变。结果：动力加压髋螺钉取出术后股骨上段的力学特性与完整股骨上段的力学特性相比有显著的差异（P＜0．01）。结论：股骨上端骨折如果以动力加压髋螺钉为治疗手段,在骨折愈合取出内固定后,功能锻炼只能控制在慢速步行水平,不能进行奔跑、跳跃等活动,以防止再骨折等并发症的发生。     

Model of loadings acting on the femoral bone during gait

An evaluation of the model of loadings acting on the femoral bone during the whole gait cycle was the main aim of the paper. A computer simulation of the musculoskeletal system based on the gait data collected during gait was used to determine the muscle forces as well as the hip joint reaction. Kinematic parameters as well as the ground reaction force for ninety-nine healthy persons of both sexes (18–36 years old) who had no history of musculoskeletal disease were registered during normal gait with preferred speed and used as inputs for musculoskeletal modelling and numerical simulation with the use of the AnyBody software. Time waveforms of the values of force generated by 21 muscles having attachments on the femoral bone as well as the hip joint reaction force were obtained. Directions of particular forces were presented using a femoral coordinate system. Attachment points for all muscle forces were obtained on the basis of the unscaled standard model with the length of the femur equal to 0.41 m. The presented model of loadings acting on the femoral bone element can be useful for the biomechanical analysis of bone development and remodelling as well as for the optimisation of implant or bone stabilizer design and pre-clinical testing.     

Loads acting in an intramedullary nail during fracture healing in the human femur.

The form and function of the musculo-skeletal system is closely related to the forces acting in its components. Significant forces are present in the long bones, but their magnitudes have so far only been estimated from mathematical models. Fracture fixation by means of metal implants provides an opportunity to measure the implant-born forces and to estimate the long bone forces before healing occurs. The load changes during fracture healing may provide additional information. Therefore, a telemetrized, interlocking femoral nail for wireless transmission of forces and moments acting across the fracture site was developed. The design was based on the geometry and material of a 16 mm AO nail with a circular, closed cross-section allowing full protection of the electronic circuits from the body fluids. After careful testing, it was implanted in a 33-year-old patient who had sustained a multifragmentary fracture of the left femur. Measurements at a rate of approx. 0.4 Hz were performed in different patient postures between the 2nd and 26th postoperative week. Significant axial forces and bending moments were measured during several activities such as sitting, unsupported leg elevation and partial weight bearing in a standing position. Forces orthogonal to the nail axis remained small. The reductions of the implant loads due to fracture consolidation were in the order of 50%. Dynamization of the nail did not change the forces. Even though the telemetry system did not allow for dynamic measurements and the results presented here provide data from one subject only, the new information will be useful with respect to implant design, biomechanics of fracture fixation and evaluation of healing progression.     

Numerical Simulation of Callus Healing for Optimization of Fracture Fixation Stiffness

The stiffness of fracture fixation devices together with musculoskeletal loading defines the mechanical environment within a long bone fracture, and can be quantified by the interfragmentary movement. In vivo results suggested that this can have acceleratory or inhibitory influences, depending on direction and magnitude of motion, indicating that some complications in fracture treatment could be avoided by optimizing the fixation stiffness. However, general statements are difficult to make due to the limited number of experimental findings. The aim of this study was therefore to numerically investigate healing outcomes under various combinations of shear and axial fixation stiffness, and to detect the optimal configuration. A calibrated and established numerical model was used to predict fracture healing for numerous combinations of axial and shear fixation stiffness under physiological, superimposed, axial compressive and translational shear loading in sheep. Characteristic maps of healing outcome versus fixation stiffness (axial and shear) were created. The results suggest that delayed healing of 3 mm transversal fracture gaps will occur for highly flexible or very rigid axial fixation, which was corroborated by in vivo findings. The optimal fixation stiffness for ovine long bone fractures was predicted to be 1000–2500 N/mm in the axial and >300 N/mm in the shear direction. In summary, an optimized, moderate axial stiffness together with certain shear stiffness enhances fracture healing processes. The negative influence of one improper stiffness can be compensated by adjustment of the stiffness in the other direction.     

股骨骨折术后1年随访骨愈合模型的有限元分析

目的：对股骨骨折髓内钉术后1年骨愈合模型快速建模,通过有限元分析研究对比术前术后模型,通过术前判定内固定取出后骨折断端是否断裂。方法：运用Mimics、Geomagic Studio、Abaqus等软件采用快速个体化建模方法对股骨骨折髓内钉术后1年内固定取出术前后的多层螺旋CT数据进行快速建立模型,术前模型模拟剥除钢板后进行有限元分析,施加人体单腿站立时的静力载荷和约束,并将分析结果与术后模型进行对比,观察米塞斯应力分布情况、最大值及其所处部位。结果：按照材料属性进行区别显示米赛斯应力的最大值及最小值,在不同应力载荷下,手术前后各类型材料的米赛斯应力最大值及最小值部位相同,各类型材料中,最大值均没有位于骨折断端,不同方法的最大应力值部位相近,均在股骨中远端1/4交界处,手术前后应力分布基本相同。结论：采用个体化建模方法可以对骨折内固定取出前的骨愈合模型进行运算分析,快速预判术后是否导致骨折断端断裂。     

In vivo gait analysis in a mouse femur fracture model

Although the mouse has become a preferred species for molecular studies on fracture healing, gait analysis after fracture fixation and during bone healing has not yet been performed in mice. Herein, we introduce a novel technique for gait analysis in mice and report the change of motion pattern after fracture and fixation. A standardized femur fracture was stabilized by a common pin. The non-fractured tibia was additionally marked with a pin, allowing continuous analysis of the tibio-femoral angle by digital video-radiography. Dynamic gait analysis was performed at day fourteen after surgery in a radio-opaque running wheel. Fracture fixation resulted in a significantly reduced range and maximum of the tibio-femoral angle compared to non-fractured controls. This was associated with a significantly reduced stride length. Because stride frequency was slightly increased and, thus, stride time diminished, stride velocity was not significantly reduced compared to controls. Thus, our study demonstrates distinct alterations of the gait of mice at 2 weeks after femur fracture and stabilization. Our results support the need of gait analysis in fracture healing studies to assess the animals’ well-being.     

微创经皮LCP 接骨术治疗老年股骨近端粉碎骨折

目的:本研究通过观察微创锁定钢板接骨术治疗老年股骨近端粉碎骨折临床效果,旨在找出最佳治疗方式。方法:自2007年12月～2010年03月,应用股骨近端锁定加压钢板治疗老年股骨近端粉碎骨折23例。记录术中出血量、手术时间,术后并发症、骨折愈合时间及最后一次随访时功能恢复情况。结果:骨折临床愈合时间为12～28周,平均16周。除1例患者髋内翻畸形,1例锁定加压钢板断裂外,其他患者均达到骨性愈合。结论:股骨近端锁定钢板具有创伤小、固定可靠、骨折愈合快、功能恢复满意的特点,尤其适用于老年股骨近端粉碎骨折。     

Physiologically based boundary conditions in finite element modelling

Finite element analysis has been used extensively in the study of bone loading and implant performance, such as in the femur. The boundary conditions applied vary widely, generally producing excessive femoral deformation, and although it has been shown that the muscle forces influence femoral deflections and loading, little consideration has been given to the displacement constraints. It is hypothesised that careful application of physiologically based constraints can produce physiological deformation, and therefore straining, of the femur. Joint contact forces and a complete set of muscle forces were calculated based on the geometry of the Standardised Femur using previously validated musculoskeletal models. Five boundary condition cases were applied to a finite element model of the Standardised Femur: (A) diaphyseally constrained with hip contact and abductor forces; (B) case A plus vasti forces; (C) case A with complete set of muscle forces; (D) distally constrained with all muscle forces; (E) physiological constraints with all muscle forces. It was seen that only the physiological boundary conditions, case E, produced physiological deflections (< 2.0mm) of the femoral head in both the coronal and sagittal planes, which resulted in minimal reaction forces at the constrained nodes. Strains in the mid-diaphysis varied by up to 600 micro-strain under walking loads and 1000 micro-strain under stair climbing loads. The mode of loading, as indicated by the strain profiles on the cortex also varied substantially under these boundary conditions, which has important consequences for studies that examine localised bone loading such as fracture or bone remodelling simulations.     

To what extent is joint and muscle mechanics predicted by musculoskeletal models sensitive to soft tissue artefacts?

Musculoskeletal models are widely used to estimate joint kinematics, intersegmental loads, and muscle and joint contact forces during movement. These estimates can be heavily affected by the soft tissue artefact (STA) when input positional data are obtained using stereophotogrammetry, but this aspect has not yet been fully characterised for muscle and joint forces. This study aims to assess the sensitivity to the STA of three open-source musculoskeletal models, implemented in OpenSim.A baseline dataset of marker trajectories was created for each model from experimental data of one healthy volunteer. Five hundred STA realizations were then statistically generated using a marker-dependent model of the pelvis and lower limb artefact and added to the baseline data. The STA׳s impact on the musculoskeletal model estimates was finally quantified using a Monte Carlo analysis.The modelled STA distributions were in line with the literature. Observed output variations were comparable across the three models, and sensitivity to the STA was evident for most investigated quantities. Shape, magnitude and timing of the joint angle and moment time histories were not significantly affected throughout the entire gait cycle, whereas magnitude variations were observed for muscle and joint forces. Ranges of contact force variations differed between joints, with hip variations up to 1.8 times body weight observed. Variations of more than 30% were observed for some of the muscle forces.In conclusion, musculoskeletal simulations using stereophotogrammetry may be safely run when only interested in overall output patterns. Caution should be paid when more accurate estimated values are needed.     

An efficient and accurate prediction of the stability of percutaneous fixation of acetabular fractures with finite element simulation

Posterior wall fracture is one of the most common fracture types of the acetabulum and a conventional approach is to perform open reduction and internal fixation with a plate and screws. Percutaneous screw fixations, on the other hand, have recently gained attention due to their benefits such as less exposure and minimization of blood loss. However their biomechanical stability, especially in terms interfragmentary movement, has not been investigated thoroughly. The aims of this study are twofold: (1) to measure the interfragmentary movements in the conventional open approach with plate fixations and the percutaneous screw fixations in the acetabular fractures and compare them; and (2) to develop and validate a fast and efficient way of predicting the interfragmentary movement in percutaneous fixation of posterior wall fractures of the acetabulum using a 3D finite element (FE) model of the pelvis. Our results indicate that in single fragment fractures of the posterior wall of the acetabulum, plate fixations give superior stability to screw fixations. However screw fixations also give reasonable stability as the average gap between fragment and the bone remained less than 1 mm when the maximum load was applied. Our finite element model predicted the stability of screw fixation with good accuracy. Moreover, when the screw positions were optimized, the stability predicted by our FE model was comparable to the stability obtained by plate fixations. Our study has shown that FE modeling can be useful in examining biomechanical stability of osteosynthesis and can potentially be used in surgical planning of osteosynthesis.     

Estimation of muscle forces in gait using a simulation of the electromyographic activity and numerical optimization

Clinical gait analysis provides great contributions to the understanding of gait patterns. However, a complete distribution of muscle forces throughout the gait cycle is a current challenge for many researchers. Two techniques are often used to estimate muscle forces: inverse dynamics with static optimization and computer muscle control that uses forward dynamics to minimize tracking. The first method often involves limitations due to changing muscle dynamics and possible signal artefacts that depend on day-to-day variation in the position of electromyographic (EMG) electrodes. Nevertheless, in clinical gait analysis, the method of inverse dynamics is a fundamental and commonly used computational procedure to calculate the force and torque reactions at various body joints. Our aim was to develop a generic musculoskeletal model that could be able to be applied in the clinical setting. The musculoskeletal model of the lower limb presents a simulation for the EMG data to address the common limitations of these techniques. This model presents a new point of view from the inverse dynamics used on clinical gait analysis, including the EMG information, and shows a similar performance to another model available in the OpenSim software. The main problem of these methods to achieve a correct muscle coordination is the lack of complete EMG data for all muscles modelled. We present a technique that simulates the EMG activity and presents a good correlation with the muscle forces throughout the gait cycle. Also, this method showed great similarities whit the real EMG data recorded from the subjects doing the same movement.     

中西医结合内固定治疗股骨远端骨折30例临床研究

目的探讨DCS内固定配合中医药对30例股骨远端骨折的治疗效果。方法按AO分类：A型14例,B型6例,C型10例,经股骨下段前外侧切口入路整复骨折,并用DCS固定骨折配合中药内服外敷,术后早期进行康复训练。结果经1年随访,骨折愈合,平均愈合时间6个月,关节功能优良率85.71%,其中C型骨折1例术后出现膝内翻。结论DCS内固定配合中医药是治疗股骨远端骨折是较理想的方法。可早期进行康复训练。     

Development and validation of a multi-body model of the canine stifle joint

Multi-body musculoskeletal models that can be used concurrently to predict joint contact pressures and muscle forces would be extremely valuable in studying the mechanics of joint injury. The purpose of this study was to develop an anatomically correct canine stifle joint model and validate it against experimental data. A cadaver pelvic limb from one adult dog was used in this study. The femoral head was subjected to axial motion in a mechanical tester. Kinematic and force data were used to validate the computational model. The maximum RMS error between the predicted and measured kinematics during the complete testing cycle was 11.9 mm translational motion between the tibia and the femur and 4.3° rotation between patella and femur. This model is the first step in the development of a musculoskeletal model of the hind limb with anatomically correct joints to study cartilage loading under dynamic conditions.     

Musculoskeletal model choice influences hip joint load estimations during gait

The prevalence of musculoskeletal modeling studies investigating hip contact forces and the number of models used to conduct such investigations has increased in recent years. However, the consistency between models remain unknown and differences in model predicted hip contact forces between studies are difficult to distinguish from natural inter-individual differences. The purpose of this study was therefore to evaluate differences in hip joint contact forces during gait between four OpenSim models. These models included the generic models gait2392 and the Arnold Lower Limb Model, as well as the hip specific models hip2372 and London Lower Limb Model. Data from four individuals who have had a total hip replacement with instrumented hip implants performing slow, normal, and fast walking trials were taken from the HIP98 database to evaluate the various models effectiveness at estimating hip loads. Muscle forces were estimated using static optimization and hip contact forces were calculated using the JointReaction analysis in OpenSim. Results indicated that, for gait, the hip specific London Lower Limb Model consistently predicted peak push-off hip joint contact forces with lower magnitude and timing errors compared to the other models. Likewise, root mean square error values were lowest and correlation coefficients were highest for the London Lower Limb Model. These results suggest that the London Lower Limb Model is the most appropriate model for investigations focused on hip joint loading.     

Rotational moment arms of the medial hamstrings and adductors vary with femoral geometry and limb position: implications for the treatment of internally rotated gait

Persons with cerebral palsy frequently walk with a crouched, internally rotated gait. Spastic medial hamstrings or adductors are presumed to contribute to excessive hip internal rotation in some patients; however, the capacity of these muscles to produce internal rotation has not been adequately investigated. The purpose of this study was to determine the hip rotation moment arms of the medial hamstrings and adductors in persons with femoral anteversion deformities who walk with a crouched, internally rotated gait. A musculoskeletal model with a "deformable" femur was developed. This model was used, in conjunction with kinematic data obtained from gait analysis, to calculate the muscle moment arms for combinations of joint angles and anteversion deformities exhibited by 21 subjects with cerebral palsy and excessive hip internal rotation. We found that the semimembranosus, semitendinosus, and gracilis muscles in our model had negligible or external rotation moment arms when the hip was internally rotated or the knee was flexed -- the body positions assumed by the subjects during walking. When the femur was excessively anteverted, the rotational moment arms of the adductor brevis, adductor longus, pectineus, and proximal compartments of the adductor magnus in our model shifted toward external rotation. These results suggest that neither the medial hamstrings nor the adductors are likely to contribute substantially to excessive internal rotation of the hip and that other causes of internal rotation should be considered when planning treatments for these patients.     

逆行可膨胀髓内钉与锁定钢板治疗股骨远端骨折的疗效比较

目的:探讨比较运用逆行可膨胀髓内钉与股骨远端锁定钢板治疗股骨远端33A、33C1型骨折的疗效。方法:对2013年3月至2015年6月收治并符合纳入标准的43例股骨远端33A、33C1型骨折患者进行回顾性研究。按照不同的手术固定方式分为逆行可膨胀髓内钉组(n=18)和锁定钢板组(n=25),记录并比较两组手术时间、失血量、愈合时间及功能结果、术中及术后并发症。结果:所有骨折最终都获得愈合;逆行可膨胀髓内钉组在手术时间及失血量上都显著低于锁定钢板组,两组在愈合时间及功能评定方面无明显差异;5例开放性骨折的患者中1例出现浅表伤口感染,1例患者延迟愈合。结论:股骨远端逆行可膨胀髓内钉在获得与锁定钢板相当的骨折愈合时间及患肢功能的情况下,具有操作简单、手术时间短、失血量少等特点,对于股骨远端33A、33C1型骨折来说是一个较好的选择。     

Influence of gait loads on implant integration in rat tibiae: Experimental and numerical analysis

Implanted rat bones play a key role in studies involving fracture healing, bone diseases or drugs delivery among other themes. In most of these studies the implants integration also depends on the animal daily activity and musculoskeletal loads, which affect the implants mechanical environment. However, the tissue adaption to the physiological loads is often filtered through control groups or not inspected. This work aims to investigate experimentally and numerically the effects of the daily activity on the integration of implants inserted in the rat tibia, and to establish a physiological loading condition to analyse the peri-implant bone stresses during gait. Two titanium implants, single and double cortex crossing, are inserted in the rat tibia. The animals are caged under standard conditions and divided in three groups undergoing progressive integration periods. The results highlight a time-dependent increase of bone samples with significant cortical bone loss. The phenomenon is analysed through specimen-specific Finite Element models involving purpose-built musculoskeletal loads. Different boundary conditions replicating the post-surgery bone–implant interaction are adopted. The effects of the gait loads on the implants integration are quantified and agree with the results of the experiments. The observed cortical bone loss can be considered as a transient state of integration due to bone disuse atrophy, initially triggered by a loss of bone–implant adhesion and subsequently by a cyclic opening of the interface.     

Simultaneous prediction of muscle and contact forces in the knee during gait

Musculoskeletal models are currently the primary means for estimating in vivo muscle and contact forces in the knee during gait. These models typically couple a dynamic skeletal model with individual muscle models but rarely include articular contact models due to their high computational cost. This study evaluates a novel method for predicting muscle and contact forces simultaneously in the knee during gait. The method utilizes a 12 degree-of-freedom knee model (femur, tibia, and patella) combining muscle, articular contact, and dynamic skeletal models. Eight static optimization problems were formulated using two cost functions (one based on muscle activations and one based on contact forces) and four constraints sets (each composed of different combinations of inverse dynamic loads). The estimated muscle and contact forces were evaluated using in vivo tibial contact force data collected from a patient with a force-measuring knee implant. When the eight optimization problems were solved with added constraints to match the in vivo contact force measurements, root-mean-square errors in predicted contact forces were less than 10 N. Furthermore, muscle and patellar contact forces predicted by the two cost functions became more similar as more inverse dynamic loads were used as constraints. When the contact force constraints were removed, estimated medial contact forces were similar and lateral contact forces lower in magnitude compared to measured contact forces, with estimated muscle forces being sensitive and estimated patellar contact forces relatively insensitive to the choice of cost function and constraint set. These results suggest that optimization problem formulation coupled with knee model complexity can significantly affect predicted muscle and contact forces in the knee during gait. Further research using a complete lower limb model is needed to assess the importance of this finding to the muscle and contact force estimation process.     

Three-dimensional strain fields in a uniform osteotomy gap

Stable internal fixation usually results in a unique histological healing pattern which involves direct cortical reconstruction and an absence of periosteal bridging callus. While it has been suggested that longitudinal interfragmentary strain levels control this healing pattern, the complex, multiaxial strain fields in the interfragmentary region are not well understood. Based on an in-vivo study of gap healing in the sheep tibia by Mansmann et al., we used several finite element models of simplified geometry to: explore modeling assumptions on material linearity and deformation kinematics, and examine the strain distribution in a healing fracture gap subjected to known levels of interfragmentary strain. We found that a general nonlinear material, nonlinear geometric analysis is necessary to model an osteotomy gap subjected to a maximum longitudinal strain of 100 percent. The large displacement, large strain conditions which were used in the in-vivo study result in complex, multiaxial strain fields in the gap. Restricting the maximum longitudinal strain to 10 percent allows use of a linear geometric formulation without compromising the numerical results. At this reduced strain level a linear material model can be used to examine the extent of material yielding within a homogeneous osteotomy gap. Severe local strain variations occurred both through the thickness of the gap and radially from the endosteal to periosteal gap surfaces. The bone/gap interface represented a critical plane of high distortional and volumetric change and principal strain magnitudes exceeded the maximum longitudinal strains.     

微创内固定对股骨远端骨折患者炎症反应和关节功能的影响

目的:探讨微创内固定系统治疗对股骨远端骨折患者炎症应激反应和关节功能的影响。方法:收集2011年5月-2014年5月期间于我院接受治疗的股骨远端骨折患者100例,根据手术方式不同,将患者分为观察组和对照组,每组各50例。观察组患者给予微创内固定系统治疗,而对照组患者给予股骨髁钢板内固定治疗。比较两组患者术后炎症应激反应和关节功能状况。结果:观察组患者手术时间、手术中出血量、影像学检查患者愈合时间、完全负重下地活动时间均优于对照组,两组比较差异具有统计学意义(P0.05);术后6个月及12个月,观察组患者HSS评分与Harris评分均明显高于对照组,两组比较差异具有统计学意义(P0.05);手术后观察组患者的IL-1、ACTH、E、NE水平均明显优于对照组,比较差异具有统计学意义(P0.05)。结论:微创内固定系统治疗可有效减小手术创伤以及软组织的损伤,有效缓解患者炎症应激反应,进一步促进手术后骨折的愈合,改善患者关节功能,值得临床推广。