解剖状骨水泥占位器在治疗内侧柱缺失型肱骨近端骨折中的实用性的有限元分析

doi:10.3877/cma.j.issn.2095-5790.2023.03.008

目的

应用有限元分析方法，探讨比较腓骨、柱状骨水泥、解剖状骨水泥占位器联合锁定钢板治疗内侧柱缺失型肱骨近端骨折的生物力学特性。

方法

建立肱骨近端骨折伴内侧柱缺失的三维有限元模型后，将单纯外侧锁定钢板（lateral locking plate, LLP）、外侧锁定钢板联合腓骨髓内支撑（lateral locking plate-fibular shaft allograft,LLP-FS）、外侧锁定钢板联合柱状骨水泥髓内支撑占位器（lateral locking plate-column cement spacer, LLP-CC）、外侧锁定钢板联合解剖状骨水泥髓内支撑占位器（lateral locking plate-anatomic cement spacer,LLP-AC）、以及外侧锁定钢板联合前内侧重建钢板（lateral locking plate-medial reconstruction plate, LLP-MRP）五种不同内固定系统植入进行装配组合。在正常和骨质疏松的情况下，对模型施加外展、内收、屈伸、轴向压缩和旋转载荷。通过比较各组模型内固定物的结构刚度、最大应力及应力分布、骨折断端位移来评估比较生物力学特性。

结果

LLP-FS、LLP-CC、LLP-AC三组髓内支撑的生物力学特性均较LLP组有不同程度的提升。与其他两种髓内支撑方法相比，在各项载荷下LLP-AC组整体结构刚度明显更高，内植物最大应力更小，应力分布更均匀，骨折断端位移最小。其生物力学特性更接近甚至优于LLP-MRP组。

结论

从有限元的角度看，解剖状骨水泥髓内支撑占位器可以提供强而有效的内侧柱支撑，从而更好地分散LLP上的应力，增强LLP固定系统的生物力学性能。解剖状骨水泥髓内支撑占位器联合锁定钢板可以有效地治疗内侧柱缺失型肱骨近端骨折。

关键词: 肱骨近端骨折, 髓内支撑, 骨水泥占位器, 有限元分析, 生物力学

Background

The application of bone cement to partial head screws or metaphyseal defects to enhance the fixation system's stability is effective in treating proximal humeral fractures. In addition, relevant studies have shown that bone cement material will not cause damage to bone or cartilage. This paper presents an anatomic intramedullary supporting bone cement placeholder designed according to the intramedullary geometry of the proximal humerus to support the humerus head and compensate for the absence of the medial column. It can be simulated and fabricated before surgery, inserted into the marrow cavity through the fracture window, attached to the medial cortex, and supported by the medial column. Based on previous clinical trials, we speculated that cement intramedullary support spacers could provide more substantial medial column support than intramedullary fibula support, and their mechanical properties were more similar to those of anteromedial plates. At the same time, they would not increase the risk of intraoperative nerve and vascular injury due to excessive stripping of medial soft tissue.

Objective

To compare the biomechanical characteristics of fibula, columnar cement, and anatomic cement spacer combined with locking plate in treating proximal humerus fractures with disrupted medial column instability by finite element analysis.

Methods

After establishing a three-dimensional finite element model of proximal humerus fracture with disrupted medial column instability, lateral locking plate (LLP) , lateral locking plate combined with fibular shaft allograft (LLP-FS) , and lateral locking plate combined with column cement spacer (LLP-CC) , lateral locking plate combined with anatomic cement spacer (LLP-AC) , and lateral locking plate combined with medial reconstruction plate (LLP-MRP) different internal fixation systems were implanted for assembly. Under normal and osteoporotic conditions, abductive, adductive, flexion, axial compression, and rotational loads were applied to the models. The biomechanical properties were evaluated and compared by comparing the structural strength, the maximum stress and stress distribution of the internal fixators, and the vertical displacement in the fracture region.

Results

Compared with the LLP group, the biomechanical properties of the LLP-FS, LLP-CC, and LLP-AC were improved to different degrees. Compared with the other two methods of intramedullary support, the overall structural stiffness of the LLP-AC group was significantly higher under various loads, the maximum stress in the plant was smaller, the stress distribution was more uniform, and the vertical displacement in the fracture region was minimal. Its biomechanical properties are closer to or even better than the LLP-MRP group.

Conclusion

From the perspective of finite element, an anatomic cement intramedullary support spacer can provide a solid and practical medial column support, which can better disperse the stress on the lateral locking plate and enhance the biomechanical properties of the lateral locking plate fixation system. Anatomic cement intramedullary support spacer combined with a lateral locking plate can effectively treat proximal humerus fractures with disrupted medial column instability.

Key words: Proximal humeral fracture, Intramedullary support, Cement spacer, Finite element analysis, Biomechanics

图1 内侧柱缺失的肱骨近端骨折模型　图A：肱骨整体正面观；图B：肱骨近端内侧面观；图C：肱骨近端外侧面观

图2 装配后各组模型注：LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

表1 有限元模型中各材料弹性模量及泊松比

材料	弹性模量（MPa）	泊松比
正常皮质骨	13 400	0.3
骨质疏松皮质骨	8 844	0.2
正常松质骨	2 000	0.3
骨质疏松松质骨	660	0.2
腓骨	13 400	0.3
骨水泥	3 000	0.3
钛金属钢板	114 000	0.3

表1 有限元模型中各材料弹性模量及泊松比

材料	弹性模量（MPa）	泊松比
正常皮质骨	13 400	0.3
骨质疏松皮质骨	8 844	0.2
正常松质骨	2 000	0.3
骨质疏松松质骨	660	0.2
腓骨	13 400	0.3
骨水泥	3 000	0.3
钛金属钢板	114 000	0.3

表2 截骨模型及各组装配后节点数与单元数

组别	节点数	单元数
截骨模型	107 286	63 694
LLP	113 837	67 253
LLP-FS	118 594	69 766
LLP-CC	118 594	69 766
LLP-AC	127 510	75 389
LLP-MRP	126 410	73 449

表2 截骨模型及各组装配后节点数与单元数

组别	节点数	单元数
截骨模型	107 286	63 694
LLP	113 837	67 253
LLP-FS	118 594	69 766
LLP-CC	118 594	69 766
LLP-AC	127 510	75 389
LLP-MRP	126 410	73 449

图3 不同内固定模型结构刚度情况　图A：外展载荷；图B：内收载荷；图C：屈伸载荷；图D：轴向压缩载荷；图E：旋转载荷注：Nor为正常骨质组；Ost为骨质疏松骨质组；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

图4 外展载荷下各组应力分布云图　图A：正常骨质组；图B：骨质疏松骨质组注：图A和图B中从左至右依次为LLP、LLP-FS、LLP-CC、LLP-AC、LLP-MRP；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

图5 内收载荷下各组应力分布云图　图A：正常骨质组；图B：骨质疏松骨质组注：图A和图B中从左至右依次为LLP、LLP-FS、LLP-CC、LLP-AC、LLP-MRP；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

图6 屈伸载荷下各组应力分布云图　图A：正常骨质组；图B：骨质疏松骨质组注：图A和图B中从左至右依次为LLP、LLP-FS、LLP-CC、LLP-AC、LLP-MRP；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

图7 轴向压缩载荷下各组应力分布云图　图A：正常骨质组；图B：骨质疏松骨质组注：图A和图B中从左至右依次为LLP、LLP-FS、LLP-CC、LLP-AC、LLP-MRP；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

图8 旋转载荷下各组应力分布云图　图A：正常骨质组；图B：骨质疏松骨质组注：图A和图B中从左至右依次为LLP、LLP-FS、LLP-CC、LLP-AC、LLP-MRP；LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

表3 不同内固定模型最大应力情况

载荷	正常骨质（MPa）					骨质疏松骨质（MPa）
载荷	LLP	LLP-FS	LLP-CC	LLP-AC	LLP-MRP	LLP	LLP-FS	LLP-CC	LLP-AC	LLP-MRP
外展	458.08	255.52	260.76	84.29	108.15	601.40	250.28	255.26	118.59	168.90
内收	370.47	346.77	345.24	169.85	93.33	457.20	345.29	370.28	161.67	119.98
屈伸	239.60	387.96	380.00	196.90	210.19	268.06	433.73	424.73	211.00	227.34
轴向压缩	211.73	99.92	98.59	18.12	37.12	211.99	105.72	104.80	23.44	55.41
旋转	376.66	190.46	164.45	66.34	90.15	398.60	233.47	233.98	91.59	93.32

表3 不同内固定模型最大应力情况

载荷	正常骨质（MPa）					骨质疏松骨质（MPa）
载荷	LLP	LLP-FS	LLP-CC	LLP-AC	LLP-MRP	LLP	LLP-FS	LLP-CC	LLP-AC	LLP-MRP
外展	458.08	255.52	260.76	84.29	108.15	601.40	250.28	255.26	118.59	168.90
内收	370.47	346.77	345.24	169.85	93.33	457.20	345.29	370.28	161.67	119.98
屈伸	239.60	387.96	380.00	196.90	210.19	268.06	433.73	424.73	211.00	227.34
轴向压缩	211.73	99.92	98.59	18.12	37.12	211.99	105.72	104.80	23.44	55.41
旋转	376.66	190.46	164.45	66.34	90.15	398.60	233.47	233.98	91.59	93.32

图9 不同内固定模型断端位移情况　图A：正常骨质组；图B：骨质疏松骨质组注：LLP为外侧锁定钢板；LLP-FS为外侧锁定钢板联合腓骨髓内支撑；LLP-CC为外侧锁定钢板联合柱状骨水泥占位器髓内支撑；LLP-AC为外侧锁定钢板联合解剖状骨水泥占位器髓内支撑；LLP-MRP为外侧锁定钢板联合前内侧重建钢板

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Utility of anatomic cement intramedullary support spacer to stabilize proximal humeral fractures with disrupted medial column instability: a finite element analysis

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Utility of anatomic cement intramedullary support spacer to stabilize proximal humeral fractures with disrupted medial column instability: a finite element analysis