背景：对于良性骨病变患者，经过外科手术治疗后通常可获得良好的生存周期，通过不断对手术方式进行改进，利用有限元分析技术研究良性骨病变术后股骨近端受力情况，预测并降低术后病理骨折、二次骨折风险，探讨最佳术式与预后，对延长并改善患者生活质量存在重要意义。

目的：利用三维有限元技术对股骨近端良性病变的不同术式模型进行受力分析，比较不同术式模型差异性并验证钢板置入内固定的合理性与有效性，并针对术后患者随访验证有限元模型的可靠性。

方法：对符合纳入标准的10 例股骨近端良性病变患者行术前CT 检查，采用MIMICS 分别建立患肢刮除术后(A)、空腔内置钉再灌注骨水泥(B)与空腔内灌注骨水泥联合钢板螺钉内固定(C)3 种模型，在模拟条件下测量出3 种骨皮质模型开窗部位前侧、后侧的最大应力数值并进行对比。所有患者对试验方案均知情同意，且得到医院伦理委员会批准。

结果与结论：①3 组模型中骨皮质开窗部前侧、后侧最大应力数值比较结果为A＞B＞C，两两比较，差异有显著性意义(P＜ 0.05)，说明A 组骨折风险高，B 组部分模型骨折风险较高，C 组应力均可控制在合理范围内，骨折风险低；②因此10 名受试者均采用C 种术式进行治疗，术后随访复查预后良好，未出现二次骨折；术后1年国际骨与软组织肿瘤协会评分为27-30 分；③提示股骨模型皮质开窗后易出现局部应力数值增高现象，在添加骨水泥与钢板后，模型开窗处应力数值显著降低。股骨近端良性病变刮除后，通过置入骨水泥与钢板，可有效降低开窗部位的应力，手术部位发生骨折概率明显降低，说明钢板置入具有合理性。

BACKGROUND:For the patients with benign osteopathy, the patients usually get a good life cycle after surgical treatment. Through continuous improvement of the operation mode, the stress of the proximal femur after the operation of benign osteopathy is studied by using the finite element analysis. The risk of pathological fracture and secondary fracture is predicted and reduced. To explore the best operation and prognosis is of great significance for prolonging and improving the quality of life of patients.

OBJECTIVE:Three-dimensional finite element technique was used to analyze the different surgical models of benign proximal femoral lesions. The differences of different surgical models were compared and the rationality and effectiveness of internal fixation were verified. The reliability of the finite element model was verified in the follow-up of patients after operation.

METHODS:Preoperative CT examination was conducted in 10 patients with benign proximal femoral lesions who met the inclusion criteria. Three models of limbs scraping (group A), cavity internal nail re-infusion bone cement (group B) and intracavitary bone cement joint plate screw (group C) were established by MIMICS. The maximum stress values of the left and right side windows of the cortical model of group A, B and C were measured under simulated conditions, and the stress values of the three groups were compared. All patients signed the informed consent. This study was approved by the Hospital Ethics Committee.

RESULTS AND CONCLUSION:(1) The comparison of the maximum stress values of the anterior and posterior sides of the cortical fenestration in the three groups of models was group A ＞ group B ＞ group C (P＜ 0.05). The risk of fracture was high in group A, and the risk of fracture in group B was large. The stress in group C was controlled within a reasonable range, and the risk of fracture was low. (2) Therefore, 10 subjects underwent the treatment in group C. The prognosis was good and there were no secondary fractures. The Musculoskeletal Tumor Society score was 27-30 points 1 year after surgery. (3) The model stress is prone to increase the local stress after opening the window. After adding bone cement and steel plate, the stress value of the model window is significantly reduced. After the benign lesions of the proximal femur are scraped, the stress of the fenestration can be effectively reduced by placing the bone cement and the steel plate, and the fracture probability at the surgical site is significantly reduced. Steel plate placement is reasonable.

0 引言 Introduction

股骨近端解剖复杂，松质骨与皮质骨共同维持近端力学支撑，在受到暴力时易发生股骨头与转子间骨折。在股骨近端肿瘤患者中由于良性病变，特别是肿瘤的侵袭性质，良性骨肿瘤细胞易侵袭松质骨，部分交界性肿瘤易侵犯皮质骨，造成局部受力不均匀，在行走或暴力作用下易发生病理性骨折。手术需将骨皮质开窗刮除病灶，开窗范围常需要与瘤体长度一致，开窗同样会破坏股骨近端力学结构，受实际因素影响无法获得较多的尸体股骨标本、无法进行真人试验，不能准确获得可靠股骨近端数据，目前尚无实际数据支持股骨近端肿瘤术后局部受力改变及何种内固定具有优势。TAKEUCHI等[1]应用骨水泥填充骨巨细胞瘤病灶刮除后空腔获得良好稳定性。临床目前常用治疗方式为刮除后植骨、刮除后骨水泥填塞、联合动力髋螺钉(dynamic hip screw)或钢板螺钉，依据临床经验，在病损范围较大时添加内固定物可增加局部稳定性及降低病理性骨折发生概率[2]。但是理论数据是否支持临床经验，骨病灶刮除后是否需要添加钢板等内固定物增加局部稳定性？此次研究通过对股骨近端病变患者的研究，运用有限元技术探讨不同手术方式对术后稳定性影响的差异，通过虚拟模型与实际案例对比探究手术是否会降低开窗部位应力并降低骨折风险，验证内固定置入的合理有效性，为临床工作提供数据支持。

文章来源：《肿瘤药学》 网址: http://www.zlyxzz.cn/qikandaodu/2020/0813/439.html