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股骨轉子間骨折合併骨質疏鬆及粉碎性骨折，向來是骨科界的棘手難題。現階段治療股骨轉子間骨折的標準方法為動態髖骨鏍釘固定。但使用動態髖骨鏍釘於不穩定轉子間骨折卻常發生鏍釘穿出股骨球頭及鏍釘過度滑動等併發症。另一種常用於治療不穩定轉子間骨折的固定器是髓內鋼釘。雖然骨水泥已被廣泛應用於增進骨鏍釘的固定效果，但是過去卻甚少有文獻針對骨質疏鬆情況，以力學觀點，探討利用動態髖骨鏍釘及髓內鋼釘兩種不同固定裝置及骨水泥施用與否來治療不穩定轉子間骨折的術後力學穩定性。
方法：本研究利用有限元素分析及體外力學實驗進行模擬與測試。有限元素分析：利用人造股骨的CT影像建立不穩定轉子間股骨骨折三維有限元素模型，並量測固定器尺寸建立動態髖骨鏍釘及髓內鋼釘的實體模型，將股骨模型給予正常骨質、骨質疏鬆及骨水泥三種材料性質，邊界條件設定為單腳站立分；體外力學實驗：使用模擬不穩定轉子間股骨骨折之人造股骨分別以動態髖骨鏍釘及髓內鋼釘固定，進行靜態抗壓實驗，探討術後穩定度。
結果：有限元素分析：使用動態髖骨鏍釘之球頭於正常骨、骨質疏鬆及骨水泥三種條件下的向下垂直位移分別為7.143 mm、8.714 mm、6.889 mm；而使用髓內鋼釘的球頭向下垂直位移則分別為1.869 mm、2.207 mm、1.859 mm，兩者球頭最大的向下垂直位移量皆發生在骨質疏鬆的條件下。此外，動態髖骨鏍釘於正常骨、骨質疏鬆及骨水泥三種骨質條件下應力分別為2112 MPa、2006 MPa、2084 MPa；髓內鋼釘則分別為1444 MPa、1452 MPa、1616 MPa，使用骨水泥時，固定器應力值都有增高的現象。體外力學實驗：當負載達到 2000 N時，動態髖骨鏍釘的垂直向下位移量為 11.3 mm，則髓內鋼釘為4.6 mm。
結論：利用髓內鋼釘治療不穩定轉子間骨折併發骨質疏鬆症，股骨球頭位移量低、股骨應力值小有較高的穩定度；此外，利用動態髖骨鏍釘，除術後穩定性較差之外，鏍釘穿出股骨球頭的機率亦較高，利用骨水泥可降低鏍釘穿出的機率，但同時會提高固定器破壞的風險。

Interochanteric fractures associated with severe osteoporosis and comminution remain a considerable challenge to orthopedic surgeon. The standard treatment of these fractures is by osteosynthesis with a dynamic hip screw (DHS). However, in unstable intertrochanteric fractures, complications of cut-out and excessive sliding of the lag screw occurred frequently. Another device frequently used to treat these unstable intertrochanteric fractures is the use of a intramedullary nail. Although PMMA bone cement has been widely applied as a secondary fixation to facilitate fracture stability, there has been few biomechanical studies regarding the significance of bone cement in unstable fracture patterns with osteoporotic bone, therefore this study was conducted to compare the biomechanical behavior between a PMMA cemented DHS and an intramedullary device in treatment of interochanteric fractures associated with severe osteoporosis.
Methods: Both finite element analysis (FEA) and In vitro experiment were conducted in current study. For FEA study, CT images obtained from standardized composite femur was used to create 3-D finite element model simulating unstable interochanteric fracture. The solid model and finite element model of DHS and intramedullary device were created by actual measurement. Loading condition simulating single leg stance was performed. Femora with three different degree of density (normal, osteoporotic and augmented with cemented) were compared. For experiment study, postoperative stability for femora with unstable interochanteric fracture treated with DHS and intramedullary device were compared.
Results: The results of finite element analysis indicated that, for femur treated with DHS, the maximal femoral head displacement for normal, osteoporotic and cemented femur were 7.143 mm, 8.714 mm and 6.889 mm, respectively; whereas for femur implanted with intramedullary device, the maximal femoral head displacement for normal, osteoporotic and cemented femur were 1.869 mm, 2.207 mm and 1.859 mm, respectively. Regardless of DHS or intramedullary device, unstable interochanteric fractures associated with severe osteoporosis exhibited the highest femoral head displacement. In addition, the maximal von Mises stress of DHS device for normal, osteoporotic and cemented femur were 2,112 MPa, 2,006 MPa and 2,084 MPa, respectively; whereas for femur implanted with intramedullary device, the maximal von Mises stress of intramedullary device for normal, osteoporotic and cemented femur were 1,444, 1,452, and 1,616 MPa, respectively. Regardless of DHS or intramedullary device, the application of bone cement increases the von Mises stress of fixation device. Furthermore, the results of in vito experiment indicated, under 2000 N compressive loading, the vertical displacement of femoral head for femora implanted with DHS and intramedullary device are 11.3 mm and 4.6 mm, respectively
Conclusion: The intramedullary device may be suitable to treat unstable interochanteric fractures associated with severe osteoporosis due to the lower displacement and stresses. DHS treated femur exhibits a higher risk of screw cut-out. The application of bone cement reduces the risk of screw cut-out, however, it increases the risk of implant damage.

指導教授推薦書
口試委員審定書
國家圖書館授權書 iii
長庚大學授權書 iv
誌謝 v
中文摘要 vi
Abstract viii
目 錄 x
圖目錄 xiii
表目錄 xx
第一章 緒論 1
1-1 引言 1
1-2 研究背景 3
1-3研究動機 6
1-4研究目的 6
第二章 基本理論 7
2-1股骨解剖構造簡介 7
2-2股骨轉子間骨折 9
2-3股骨轉子間骨折治療之沿革 14
2-4 文獻回顧 20
2-5 股骨轉子間骨折有限元素模型 25
第三章 研究方法 28
3-1研究流程 28
3-2 第一部分：三維有限元素分析 30
3-2-1影像輪廓擷取 30
3-2-2 模型的建立 32
3-2-3三維有限元素模型建立 35
3-2-4有限元素模型之收斂測試 36
3-2-5材料性質 38
3-2-6邊界條件 39
3-2-7接觸條件設定 40
3-3第二部分：生物力學實驗 41
3-3-1 研究材料與設備 41
3-3-2 研究樣試準備 45
3-3-3 研究方法 50
3-3-4 數據紀錄與分析 50
第四章 結果 51
4-1 不穩定轉子間骨折之應力分析 51
4-1-1 不同骨質使用動態髖骨鏍釘之應力分析 51
4-1-2 不同骨質使用髓內鋼釘之應力分析 54
4-1-3 股骨表面應力 57
4-1-4 固定器之應力分析 61
4-1-5 骨鏍釘之應力分析 66
4-2 不穩定轉子間骨折之垂直位移分析 69
4-2-1 股骨球頭之垂直位移量 69
4-2-2 固定器之垂直位移量 71
4-3 不穩定轉子間骨折之生物力學實驗 73
第五章 討論 77
5-1 三種不同骨質之比較 77
5-2 兩固定器之比較 79
5-3 靜態抗壓實驗 82
5-4 綜合討論 83
第六章 結論 84
參考文獻 87
附錄 A 2012 中華民國醫學工程年會摘要 96

圖1-1股骨骨折的AO分類圖，A1是簡單穩定骨折；A2是不穩定和粉 碎性骨折；A3是逆行性骨折 2
圖1-2不穩定性骨折，在AO股骨骨折分類圖裡，為A3-3型態 4
圖1-3動態髖骨螺釘因支撐住固定不良導致骨板斷裂 5
圖1-4新型髓內鋼釘因骨質疏鬆而固定不完全，導致螺釘嚴重滑脫 5
圖2-1股骨解剖構造 8
圖2-2AO股骨轉子間骨折分類 12
圖2-3股骨轉子間標準骨折 12
圖2-4股骨轉子間標準骨折之病患X光照 13
圖2-5動態髖骨螺釘與髓內鋼釘之治療穩定股骨轉子間骨折X光 13
圖2-6不穩定轉子間骨折，經骨釘固定，骨釘很容易穿股骨球頭 17
圖2-7將滑動股骨鏍釘固定於股骨之外側 18
圖2-8植入骨髓內釘後，因遠端螺釘固定，導致股骨幹骨折 18
圖2-9螺釘穿出球頭，導致手術失敗 19
圖2-10因骨質疏鬆，導致斷裂面骨片過度滑動 19
圖2-11 Sitthiseripratip學者等人所建立出得股骨三維有限元素模型 26
圖2-12 Seral學者等人利用有限元素所建立出的實體模型 27
圖2-12a股骨轉子間標準的骨折型式A1.1 27
圖2-12b股骨轉子間不穩定骨折A2.1 27
圖3-1研究流程架構圖 29
圖3-2使用Amira所圈選出來股骨之輪廓外型 31
圖3-3連續堆疊完所得到的股骨輪廓模型 31
圖3-4匯入SolidWork準備作疊層拉伸之股骨輪廓外型 33
圖3-5股骨遠端因幾何外型變化大，切片間距為0.1mm 33
圖3-6髓內鋼釘之繪出模型 34
圖3-7動態髖骨螺釘之繪出模型 34
圖3-8十節點四面體股骨實體模型 (a)動態髖骨鏍釘之股骨(b)髓內鋼釘之股骨 35
圖3-9設定邊界條件，將股骨遠端節點固定 39
圖3-10接觸條件：a.固定 b.摩擦係數= 0.3 c.摩擦係數= 0 40
圖3-11動態髖骨螺釘 41
圖3-12髓內鋼釘 42
圖3-13人造股骨 43
圖3-14 MTS雙軸材料試驗機 44
圖3-15模擬不穩定骨折之示意圖 45
圖3-16髓內鋼釘器械 – 將髓內鋼釘打入骨髓腔以固定角度方便植入近端骨釘 46
圖3-17髓內鋼釘植入圖 – 以髓內釘固定股骨球頭及X光照片 46
圖3-18動態髖骨鏍釘器械 – 將動態髖骨鏍釘鎖入骨髓腔以固定角度方便鎖定骨板 47
圖3-19 動態髖骨鏍釘植入圖 – 以動態髖骨鏍釘固定股骨球頭及X光片 47
圖3-20 人造股骨以液態的低熔點錫合金包埋 48
圖3-21抗壓測試夾具安裝 –將底部錫合金固定之試樣以虎頭鉗固定在MTS材料試驗機上 49
圖4-1使用動態髖骨鏍釘之術後前側股骨整體von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 52
圖4-2使用動態髖骨鏍釘之術後後側股骨整體von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 52
圖4-3使用動態髖骨鏍釘之術後內側股骨整體von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 53
圖4-4使用動態髖骨鏍釘之術後外側股骨整體von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 53
圖4-5使用動態髖骨鏍釘之術後近端股骨整體von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 54
圖4-6使用髓內鋼釘之術後前側股骨整體von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 55
圖4-7使用髓內鋼釘之術後後側股骨整體von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 55
圖4-8使用髓內鋼釘之術後內側股骨整體von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 56
圖4-9使用髓內鋼釘之術後外側股骨整體von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 56
圖4-10使用髓內鋼釘之術後近端股骨整體von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 57
圖4-11使用動態髖骨鏍釘之後側股骨頸von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 58
圖4-12使用髓內鋼釘之後側股骨頸von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 58
圖4-13使用動態髖骨鏍釘之內側股骨骨折處von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 59
圖4-14使用髓內鋼釘之內側股骨骨折處von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 60
圖4-15動態髖骨鏍釘之前側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 61
圖4-16動態髖骨鏍釘之後側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 61
圖4-17動態髖骨鏍釘之內側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 62
圖4-18動態髖骨鏍釘之外側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 62
圖4-19髓內鋼釘之前側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 63
圖4-20髓內鋼釘之後側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 64
圖4-21髓內鋼釘之內側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 64
圖4-22髓內鋼釘折之外側von Mises應力分佈圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 65
圖4-23動態髖骨鏍釘之滑動骨釘的近端von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 66
圖4-24動態髖骨鏍釘之滑動骨釘的遠端von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 67
圖4-25髓內鋼釘之近端骨釘的前側von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 67
圖4-26髓內鋼釘之近端骨釘的後側von Mises應力分佈圖。 (a)正常骨(b)骨質疏鬆(c)骨水泥 67
圖4-27動態髖骨鏍釘之股骨球頭的垂直位移量後側圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 69
圖4-28髓內鋼釘之股骨球頭的垂直位移量後側圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 70
圖4-29動態髖骨鏍釘之垂直位移量後側圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 71
圖4-30髓內鋼釘之垂直位移量後側圖。(a)正常骨(b)骨質疏鬆(c)骨水泥 72
圖4-31靜態抗壓測試 – 動態髖骨鏍釘在抗壓測試中N/mm圖形變化 73
圖4-32靜態抗壓測試 – 動態髖骨鏍釘之股骨球頭 74
圖4-33靜態抗壓測試 – 髓內鋼釘在抗壓測試中N/mm圖形變化 75
圖4-34靜態抗壓測試 – 髓內鋼釘之股骨球頭 76
圖5-1有限元素模型分析 – 兩固定器之股骨頸的表面最大應力 78
圖5-2有限元素模型分析 – 兩固定器之股骨球頭的垂直向下位移 78
圖5-3有限元素模型分析 – 兩固定器與骨幹之接合處的最大應力值 78
圖5-4有限元素模型分析 – 兩固定器在接合處應力集中所產生之最大應力值 80
圖5-5有限元素模型分析 – 兩固定器之骨鏍釘表面最大應力 80
圖5-6有限元素模型分析 – 髓內鋼釘之近端骨釘應力集中處在不同骨質下的應力值 81
圖5-7有限元素模型分析 – 兩固定器於不同骨質下的垂直向下位移 81
圖5-8體外力學實驗 – 兩固定器之靜態抗壓之力量位移曲線 82
圖5-9有限元素模型分析–兩固定器和股骨球頭的向下垂直位移 85
圖5-10股骨球頭對固定器之相對位移量 85

表3-1進行收斂測試之數據 37
表3-2材料性質之各項係數 38
表4-1股骨頸表面最大應力值 59
表4-2股骨骨折處之表面最大應力值 60
表4-3固定器之最大應力值 66
表4-4骨鏍釘之螺桿應力集中處的最大應力值 68
表4-5髓內鋼釘之近端骨釘應力集中處的最大應力值 68
表4-6兩固定器之股骨球頭的垂直向下位移量 70
表4-7兩固定器之垂直向下位移量 72

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