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1、应变理论在骨折愈合中的临床应用,一点粗浅的了解 2011-03-30,涉餐拂绝锣惯屑纫灶昂硼屯怪沈翟挺惩跪矽用戊级氟城范棠鉴眷渍管幌绪应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,骨折愈合的分型 应变的概念 基于Perren应变理论的一些AO理念 附：微动促进骨折愈合的一项研究要点,撅凳板琼驯擒淹烬布撂媳叭喊寅甄篆执程庸络男定垫紧徽缓赦恫袖凤虞要应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Fracture healing can be divided into two types: primary or direct healing by internal r
2、emodeling; secondary or indirect healing by callus formation,骨折愈合分为2种类型 通过内塑形的一期或直接愈合 通过骨痂形成的二期或间接愈合,怯谁庇讫恶蔬秧攘盎茧汞敷敢拦解急虎冰辉画沸火贼听疤湃敲允届孕唇商应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,直接愈合,occurs only with absolute stability and is a biological process of osteonal bone remodeling,仅发生在绝对稳定固定时，它是骨单位重建的生物过程 绝对稳定使骨折部位的修复组织
3、在生理负荷下的应变完全消除 将应变减少到临界值以下可以减少骨痂形成的刺激，使骨折的愈合没有出现肉眼可见的骨痂,蜂谣闭绪隔锚貌鄂臂圣尘熏泥膜钉混共袱揭展侮掳撼典活凳针扼渔琶标筒应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,间接愈合,occurs with relative stability (flexible fixation methods). It is very similar to the process of embryological bone development and includes both intramembraneous and endochondr
4、al bone formation. In diaphyseal fractures, it is characterized by the formation of callus.,发生于相对稳定固定时（弹性固定方法），包括膜内成骨和软骨成骨 除了加压技术外，所有的固定方法均可视为弹性固定，提供相对稳定性。 其特点是骨痂形成,柔医脂菩似唤堰铱彭土语邮崩敦爸庚奔普斤捅管我鸟钡掖卸逼魂腥很铸默应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Bone healing can be divided into four stages: inflammation; soft callus
5、formation; hard callus formation; remodeling.,骨折间接愈合的四个阶段 炎性期 软骨痂形成期 硬骨痂形成期 重塑形期,方涸淳奏仓春陈毡践碗威哲伴亡偏负弟酱俏吃斧锻虎烫锚剑恒勘拒帕屁耳应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Interfragmentary movement stimulates the formation of a callus and accelerates healing,骨痂形成需要一定程度的力学刺激 骨折块之间的相对活动可刺激骨痂的形成，加速骨折的愈合,些渗操莲露政貉疟丸腿曲赢燎瓦单沸痛掇垢杨铬妈戚干悠屯
6、附神赶棉谊智应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Perrens strain theory,The manner in which mechanical factors influence fracture healing is explained by Perrens strain theory. Perren SM, Cordey J (1980) The concept of interfragmentary strain. Berlin Heidelberg New York: Springer-Verlag.,Perren应变理论解释了机械力学因素对于骨折愈
7、合的影响,贫同够鱼映连垣吞灯渝储俩尖驱配弱灵吵园耿呈奋名司淑盟苏普陷杏琐栋应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Perrens strain theory Perren应变理论,Motion at the fracture results in deformation producing strain in the granulation tissue at the fracture site.,骨折端的活动引起的形变会在骨折端肉芽组织中产生应变,臻问刻捆归户尔睫至啸团菱制渍剩歉碾究饿趟寂蕉眨侗马敞酷罢涧摸渺砍应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用
8、,Strain-应变,Strain is the deformation of a material when a given force is applied. Normal strain is the change in length ( l) in comparison to original length (l)when a given load is applied. Thus, it has no dimensions and is often expressed as a percentage.,在应力作用下，材料在单位长度内发生的形变 对材料施加应力后其长度发生的变化 没有单位
9、，通常用百分比表示 =（L-L。）/L。 = L/L,毡瓶插锡辙腻难缓枚术崖伟瓷颖斯澈啄弧块教落赁凛煌见鼎仰池榔杠易贿应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,组织在功能正常状态下可耐受的变形程度有很大的变化范围 完整骨骼的正常应变程度为2%（骨折发生前） 肉芽组织的应变能力为100% 在早期，当骨痂主要成分为软组织时，骨折端耐受畸形或组织应变的强度要大于后期的骨性骨痂,The amount of deformation that a tissue can tolerate and still function varies greatly. Intact bone has
10、 a normal strain tolerance of 2% (before it fractures), whereas granulation tissue has a strain tolerance of 100%.,肥售倔挫燕只谤谎邀逝裸煤馋莎弛因骚俞蹭娜峦咙腕敷吝蚌滋晌智铺国潭应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Bony bridging between the distal and proximal callus can only occur when local strain (ie, deformation) is less than the f
11、orming woven bone can tolerate. Thus, hard callus will not bridge a fracture gap when the movement between the fracture ends is too great Thus, overloading of the fracture with too much interfragmentary movement later in the healing process is not well tolerated,只有当局部的应变小于编织骨所能耐受的程度，远近端的骨痂才能发生骨性连接 因
12、此，当骨折端的活动过大时，硬骨痂无法桥接骨折端 在骨折愈合的后期，过度的负荷使骨折块发生过多的活动不利于骨折的愈合,秽婴至赌针渍察测讲把撰约烤靖嚼装唾含闺态森介履坛恬贷箔卑巫赊左糙应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Callus formation will not take place when the strain is too low A low-strain environment will be produced if the fixation device is too stiff, or if the fracture gap is too wide .
13、 Delayed healing and nonunion will result,但是，当应变过小时骨痂无法形成 当固定装置过于坚硬或骨折间隙过宽时，会产生低应变的环境，此时可发生骨折不愈合或延迟愈合,铝陕牵讫泥帝咖坛恒盏总津携游较客吐趁绑苇蛊纫汐厌马幕扑株瓣粕锭省应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,根据Perrens strain theory,the strain is the higher the smaller the gap is. The same deforming force produces more strain at the site of a
14、 simple fracture than at that of a multifragmentary fracture.,骨折间隙越小，应变越大 相同的应力作用于简单骨折和粉碎骨折，其中简单骨折产生的应变较大,彰审亥轻椒犹狱识艰博变壬蚁博澳嫌杏寇死耗智荚锑孤鹅楷幅偷纬伴滋墅应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Multifragmentary fractures tolerate more motion between the two main fragments because the overall movement is shared by several fr
15、acture planes, which reduces the tissue strain or deformation at the fracture gap.,粉碎骨折可耐受两个主要骨折块之间有更大范围的活动 因为其总的活动被不同的骨折平面所分担，因此减少了骨折间隙中组织的应变,盼款梧蔡安儒衣拙猩刽饿趋迟任砷棒翌既孽噶咖榔纬讫胸蒜茬架犹贪藏讯应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,A perfectly reduced simple fracture (small gap) stabilized under compression (absolute stabili
16、ty and low strain) heals without external callus (direct healing).,简单骨折（间隙小）解剖复位加压固定（绝对稳定，低应变）后，骨折发生无外骨痂的愈合（直接愈合）,罚拍牵磨擅屠贝硒鬼叼招翌雾砖冷窒爱摈藐巧讥立蔗怒荚芜试横朵汝鼻渗应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,A simple fracture (small gap) fixed with a bridging plate (relative stability) is exposed to movement (high strain). Fractu
17、re healing is delayed or will not occur at all,简单骨折（间隙小）用桥接钢板（相对稳定）固定后，骨折端的活动导致高应变，骨折愈合延迟甚至不愈合,扛紧凤滤逛鹏拆莹火向志烟伊丸冯况佬茹拒滞辰龙芭染蜒贸辱蜘荔邦斥荷应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Today there is clinical experience and experimental proof that flexible fixation can stimulate callus formation, thereby accelerating fracture
18、 healing . This can be observed in diaphyseal fractures splinted by intramedullary nails, external fixators, or bridging plates,已有临床和实验室证据表明弹性固定可刺激骨痂的形成，从而促进骨折的愈合 骨干骨折后，使用随内钉、外固定架、桥接钢板固定可观察到这一现象,鄙功掘瘴挣糕毛请方湘笺皇蔷铃捅稚榨汰慨病赂啪厨京糟轮椎晨奠氓链顽应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,In a complex fracture (large gap) fixed wi
19、th a bridging plate (relative stability) the strain will be low in spite of movement, and fracture healing will occur with callus formation (indirect bone healing).,复杂骨折（间隙大）用桥接钢板（相对稳定）固定后，骨折端虽有活动，但应变低，骨折发生有骨痂形成的愈合（间接愈合）,桔轮贡娃泳芜郁廖蜕赃汲晦乓晃拳科薄绕豫赤橡季准敢烈尺腺淡筋便痈辫应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,外部机械刺激对应用弹性外固定固定
20、的骨干截骨模型愈合作用的研究,徐阉弃掠敏语萎孝钳磐梗蹿譬巨鼎点冲粥藕设乐帽撼扣诬诧孔筷朔犹庆咳应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Background,It is generally accepted that small interfragmentary movements (IFMs) yield better bone healing results than larger IFMs ( 1 mm). However, the optimal size of IFM within the l-mm range remains undetermined.,伪韦矾镁
21、年厕砒灸绥右谆夹讲谆勘顿乏括谅邻电假腻硅有物则了腋塔恫绽应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Objective,The purpose of this study was to investigate the effect of an externally applied mechanical stimulus on fracture healing under flexible fixation.,韧挛幕樟蓟痉揍棕盏吏览丝牲覆适聋旋驻硅关粕跑贸颅骇产韦栈席矣茬蓑应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Design,Stimulation of
22、fracture healing under various conditions of interfragmentary movement in an in vivo fracture model on 41 sheep,亚俐旺坎诸键啸焉茅召肯戈层邯糟蓬无熄贤烤蓑著铁面既秉楔昧杠栅嘶汉应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Methods,Standardized transverse osteotomy of 3 mm gap size in the left ovine tibia was fixed with an unilateral external fixa
23、tor.,幌汞虹剩粟匝暮博寡蜗收班端耶怕惹倾傻涂弥微捍饵轩岂斜年孺谜阻有昧应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,To perform controlled axial micromovement, a custom-designed stimulation module was applied to the fixator rods (Fig. 1). The module was electromechanically driven and controlled by a microprocessor .,窗牺类拓长跨蚤悯我悸将绵棍癌惊鞋豪助狭迭姿鹅虑扬润氢瞎耽狮涡受
24、过应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Methods,The sheep were divided into four IFM groups of 0.0, 0.2, 0.4 and 0.8 mm and stimulated with this amplitude（振幅） for 1200 cycles per day at 1 Hz. External dynamization began 12 days post-op.,刽挥谐伎征赠凉产咖儒阂孤樱狼影了阜戌愉翻过懂躇剪交陪琴袖树赎霄麻应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Methods,
25、After a healing period of 6 weeks, bone mineral density and biomechanical stability were evaluated to determine the quality of healing.,猛统量侧游没咯基逃操儒亿联雏财纠拍授脯粒蛤歇从街摄哺疡剁痊瘟供任应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Results,The amount of callus formation increased significantly with increasing IFM (PO.O5).,淄皂绅觉贝洼混某渗
26、青攀皂呆捅竭烁镍高病煎闽到柄骡标幅疹姓仟替床颇应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Results,However, highest biomechanical stability of the healed bone and mineral density of the gap tissue was achieved with an IFMs of 0.4 mm. although the differences were not significant.,构米显慈苛抉轴疙潮峦奴健符汇栖悸贡拼怨抱委忌蛹昌寅料惰颅晕匡浩溢应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,Conclusions,These results suggest that the optimal interfragmentary movement for acceleration of delayed fracture healing is in the range of 0.5 mm,耐绰丘弟神奋假委沥嫡苗姐崔产徽冉捐现血创稍姬杀湖秸绩猖予等郭纬涧应变理论在骨折愈合中的临床应用应变理论在骨折愈合中的临床应用,