臺灣博碩士論文加值系統

指導教授推薦書
口試委員審定書
致謝 iii
中文摘要 iv
Abstract vi
目錄 viii
第一章 序論 1
1-1 研究背景 1
1-2 研究動機 3
1-3 研究目的 4
第二章 文獻回顧 5
2-1 股骨解剖構造簡介. 5
2-2 股骨轉子下骨折. 6
2-3 固定器介紹. 9
2-3-1 動態髖骨螺釘. 9
2-3-2 多軸式互鎖骨板. 10
2-3-3 髓內釘. 12
2-4 股骨轉子下骨折分型與治療之沿革. 14
第三章 材料與方法 19
3-1 研究流程概述. 19
3-2 第一部分：三維有限元素分析. 21
3-2-1 影像輪廓擷取 21
3-2-2 股骨轉子下不穩定骨折模型之建立 24
3-2-3 股骨三維有限元素模型建構與分析 28
3-2-4 材料性質 31
3-2-5 邊界條件 32
3-3 第二部分：體外力學實驗. 33
3-3-1 研究材料與設備 34
3-3-2 研究試件準備 40
3-3-3 體外力學實驗方法 48
3-3-3-1 靜態抗壓測試 48
3-3-3-2 數據紀錄與分析 49
第四章 結果 50
4-1 有限元素模型之收斂測試. 50
4-2 轉子下不穩定骨折之應力分析. 52
4-2-1 固定器之應力分析. 53
4-2-2 股骨表面之應力分析. 55
4-2-3 股骨球頭之垂直位移量. 57
4-3 轉子下不穩定骨折之體外力學實驗. 58
4-3-1 髓內釘固定之股骨. 58
4-3-2 多軸式互鎖骨板固定之股骨. 59
4-3-3動態髖骨螺釘固定之股骨. 60
4-3-4 動態髖股螺釘結合轉子穩定鋼板固定之股骨. 61
4-3-5各固定器之勁度值與骨折間距位移量. 62
第五章 討論 63
5-1 髓內外固定器比較. 63
5-2 固定器材質比較. 66
5-3 固定器應力值比較. 66
5-4 股骨表面應力值比較. 67
5-5 固定器應力分布區域. 67
5-6抗壓測試整體位移量與骨折間距位移量比較. 68
5-7動態髖骨螺釘增加轉子穩定鋼板差異比較. 69
5-8 研究限制. 71
5-8-1 轉子下骨折與固定器模型之假設. 71
5-8-2 簡化股骨受力情況. 72
5-8-3 接觸面假設. 72
第六章 結論 73
參考文獻 74
附錄 81


圖目錄
圖1- 1 股骨骨折的Seinsheimer分類圖 2
圖2-1 股骨骨折區域分類圖 7
圖2-2 股骨轉子下骨折之病患X光圖 7
圖2-3 髓內釘治療股骨轉子下骨折X光照 8
圖2-4 動態髖骨螺釘治療股骨轉子下骨折X光照 8
圖2-5 動態髖骨釘結合轉子穩定鋼板 9
圖2-6 傳統骨板示意圖 10
圖2-7 多軸式互鎖骨板調整角度示意圖 11
圖2-8 多軸式互鎖骨板螺帽設計示意圖 11
圖2-9 帶鎖髓內釘治療股骨轉子下骨折 13
圖3-1 研究流程架構圖 20
圖3-2 使用Armira開啟CT影像 22
圖3-3 使用Amira圈選之股骨輪廓外型 23
圖3-4 使用Amira連續堆疊完所得到的股骨輪廓模型 23
圖3-5 匯入SolidWork準備做疊層拉伸之股骨輪廓外型 24
圖3-6 股骨遠端幾何外型變化大切片間距為0.1mm 25
圖3-7 轉子下不穩定骨折模型示意圖 25
圖3-8 動態髖骨螺釘模型示意圖 26
圖3-9 多軸式互鎖骨板模型示意圖 26
圖3-10 髓內釘模型示意圖 27
圖3-11 動態髖骨螺釘結合轉子穩定鋼板模型示意圖 27
圖3-12 股骨轉子下不穩定骨折之有限元素實體模型 28
圖3-13 植入動態髖骨螺釘之有限元素實體模型 29
圖3-14 植入多軸式互鎖骨板之有限元素實體模型 29
圖3-15 植入髓內釘之有限元素實體模型 30
圖3-16 植入動態髖骨螺釘結合轉子穩定鋼板之有限元素實體模型 .30
圖3-17 邊界條件設定示意圖 33
圖3-18 人造股骨 34
圖3-19 動態髖骨螺釘 35
圖3-20 多軸式互鎖骨板 36
圖3-21 髓內釘 37
圖3-22 轉子穩定鋼板 38
圖3-23 MTS雙軸材料試驗機 39
圖3-24 REXON帶鋸機 40
圖3-25 模擬股骨轉子下不穩定骨折之示意圖 40
圖3-26 動態髖骨螺釘植入圖 41
圖3-27 動態髖骨螺釘植入之X光照片 41
圖3-28 多軸式互鎖骨板植入圖 42
圖3-29 動態髖骨螺釘植入之X光照片 42
圖3-30 髓內釘植入圖 43
圖3-31 髓內釘植入之X光照片 43
圖3-32 動態髖骨螺釘結合轉子穩定鋼板植入圖 44
圖3-33 動態髖骨螺釘結合轉子穩定鋼板植入之X光照片 44
圖3-34 低熔點錫金屬合金 45
圖3-35 低熔點錫金屬合金包埋股骨模具 45
圖3-36 股骨裝置定位系統調整 46
圖3-37 下夾具-可調整角度之虎頭鉗夾具 47
圖3-38 MTS Extensometer 47
圖3-39 靜態抗壓測試示意圖 49
圖4-1 收斂測試之 von Mises 應力曲線圖 51
圖4-2 固定器外側 von Mises 應力分佈圖：(a) IM Nail (b) PLP (c) DHS (d) DHS+TSP 53
圖4-3 固定器內側 von Mises 應力分佈圖：(a) IM Nail (b) PLP (c) DHS (d) DHS+TSP 54
圖4-4 外側股骨表面 von Mises 應力分佈圖：(a) IM Nail (b) PLP (c) DHS (d) DHS+TSP 55
圖4-5 內側股骨表面 von Mises 應力分佈圖：(a) IM Nail (b) PLP (c) DHS (d) DHS+TSP 56
圖4-6 股骨球頭垂直位移及骨折間距位移圖:(a) IM Nail (b) PLP (c) DHS (d) DHS+TSP 57
圖4-7 髓內釘之力量位移曲線圖(N/mm) 58
圖4-8 多軸式互鎖骨板之力量位移曲線圖(N/mm) 59
圖4-9 動態髖骨螺釘之力量位移曲線圖(N/mm) 60
圖4-10 動態髖股螺釘結合轉子穩定鋼板之力量位移曲線圖(N/mm) 61
圖4-11 抗壓測試之勁度值 62
圖4-12 股骨轉子下不穩定骨折之骨折間距位移量 62
圖5-1 髓內與髓外力臂長度比較 62
圖5-2 骨板斷裂 63
圖5-3 固定器之應力分佈區域 66
圖5-4 整體位移量與骨折間距位移量比較圖 67
圖5-5 DHS 增加 TSP 之應力值比較圖 68
圖5-6 DHS 增加 TSP 之勁度值比較圖 69
圖5-7 DHS 增加 TSP 之股骨球頭位移量與骨折間距位移量比較圖 69

表目錄
表3-1 材料性質之各項參數 31
表4-1 收斂測試之有限元素模型、節點數目 51
表4-2 股骨球頭垂直位移量及骨折間距位移量 57

[1] B. Gullberg, et al., "World-wide projections for hip fracture". Osteoporosis international, 7(5): p. 407-413.1997.
[2] Fielding JW, Magliato HJ., "Subtrochanteric fractures." Surg Gynec Obstet, 122:555.1966.
[3] K. Ünay, et al., "Risk factors for osteoporosis in women having hip fractures after 60 years of age". Acta orthopaedica et traumatologica turcica, 39(4): p. 295-299.2004.
[4] Seinsheimer, F. "Subtrochanteric fractures of the femur." The Journal of Bone &; Joint Surgery , 60(3): 300-306.1978.
[5] M.J. Gardner, et al., "Osteoporotic femoral neck fractures: management and current controversies". Instructional course lectures, 53: p. 427-439.2003.
[6] M. Tsuboi, et al., "Mortality and mobility after hip fracture in Japan A TEN-YEAR FOLLOW-UP". Journal of Bone &; Joint Surgery, British Volume, 89(4): p. 461-466.2007.
[7] H. Boyd and S.W. Lipinski, "Nonunion of trochanteric and subtrochanteric fractures". Surgery, gynecology &; obstetrics, 104(4): p. 463-470.1957.
[8] M.E. RUFF and L.M. LUBBERS, "Treatment of subtrochanteric fractures with a sliding screw-plate device". Journal of Trauma-Injury, Infection, and Critical Care, 26(1): p. 75-80.1986.
[9] R. Sanders and P. Regazzoni, "Treatment of subtrochanteric femur fractures using the dynamic condylar screw". Journal of orthopaedic trauma, 3(3): p. 206-213.1989.
[10] J.R. WHATLEY, et al., "Subtrochanteric fractures of the femur: treatment with ASIF blade plate fixation". Southern medical journal, 71(11): p. 1372-1375.1978
[11] Kjell Matre, "Treatment of trochanteric and subtrochanteric hip fractures", Dissertation for the degree of philosophiae doctor (PhD) at the University of Bergen, 2013
[12] J.B. GRIFFIN, "The calcar femorale redefined". Clinical orthopaedics and related research, 164: p. 211-214.1982.
[13] JUHA PARTANEN,Etiopathology and treatment-related aspects of hip fracture, Division of Orthopaedic and Trauma Surgery, Department of Surgery,University of Oulu 2003.
[14] Y.-C. Yoon, et al., "The pointed clamp reduction technique for spiral subtrochanteric fractures: A technical note". Injury, 45(6): p. 1000-1005.2014.
[15] D. Kumar, et al., "Metachronous bilateral subtrochanteric fracture of femur in an osteopetrotic bone: A case report with technical note". Journal of Clinical Orthopaedics and Trauma, 3(2): p. 103-106.2012.
[16] G.J. Haidukewych, et al., "Reverse obliquity fractures of the intertrochanteric region of the femur". The Journal of Bone &; Joint Surgery, 83(5): p. 643-650.2001.
[17] E. Gautier and C. Sommer, "Guidelines for the clinical application of the LCP". Injury, 34: p. 63-76.2003.
[18] G. Haidukewych, et al., "Results of polyaxial locked-plate fixation of periarticular fractures of the knee". The Journal of Bone &; Joint Surgery, 89(3): p. 614-620.2007.
[19] K.J. Wilkens, et al., "Polyaxial locking plate fixation in distal femur fractures: a biomechanical comparison". Journal of orthopaedic trauma, 22(9): p. 624-628.2008.
[20] P.M. ARONOFF, et al., "Intramedullary nail fixation as treatment of subtrochanteric fractures of the femur". Journal of Trauma-Injury, Infection, and Critical Care, 11(8): p. 637-650.1971.
[21] Brumback RJ, et al "Closed interlocking intramedullary nailing of subtrochanteric fractures. " OrthopT rans 11:478,1987
[22] Brumback RJ, et al: "Intramedullary nailing of femoral shaft fractures: I. Decision-making errors with interlocking fixation." J Bone Joint Surg Am 70:1441–1452, 1988
[23] A. Barquet, et al., "Intertrochanteric-subtrochanteric fractures: treatment with the long Gamma nail". Journal of orthopaedic trauma, 14(5): p. 324-328.2000.
[24] C. Bellabarba, et al., "Percutaneous treatment of peritrochanteric fractures using the Gamma nail". Journal of orthopaedic trauma, 17(8): p. S38-S50.2003.
[25] R. Bess and S. Jolly, "Comparison of compression hip screw and gamma nail for treatment of peritrochanteric fractures". Journal of the Southern Orthopaedic Association, 6(3): p. 173-179.1996.
[26] Kinast C, et al. "Subtrochanteric fractures of the femur." Clin Orthop, 238:122.1989.
[27] Wiss DA, et al. "Subtrochanteric fractures of the femur." Orthopedics, 8:797.1985.
[28] Zain Elabdien BS, et al. "Subtrochanteric fractures classification and results of ender nailing. " Arch Orthop Trauma Surg, 103:241.1984.
[29] P. Trafton, "Subtrochanteric-intertrochanteric femoral fractures". The Orthopedic clinics of North America, 18(1): p. 59-71.1987.
[30] Fielding JW. "Subtrochanteric fractures." Clin Orthop,192:86.1973.
[31] P.B. WILE, et al., "Treatment of subtrochanteric fractures with a high-angle compression hip screw". Clinical orthopaedics and related research, 175: p. 72-78.1983.
[32] A. Bedi and T. Toan Le, "Subtrochanteric femur fractures". Orthopedic Clinics of North America, 35(4): p. 473-483.2004.
[33] H.K. WATSON, et al., "Classification, treatment and complications of the adult subtrochanteric fracture". Journal of Trauma-Injury, Infection, and Critical Care, 4(4): p. 457-480.1964.
[34] R. Zickel, "An intramedullary fixation device for the proximal part of the femur. Nine years' experience". The Journal of Bone &; Joint Surgery, 58(6): p. 866-872.1976.
[35] K. Sehat, et al., "The use of the long gamma nail in proximal femoral fractures". Injury, 36(11): p. 1350-1354.2005.
[36] W.-P. Chen, et al., "Selection of fixation devices in proximal femur rotational osteotomy: clinical complications and finite element analysis". Clinical Biomechanics, 19(3): p. 255-262.2004.
[37] E. Brandt, et al., "Biomechanical analysis of the percutaneous compression plate and sliding hip screw in intracapsular hip fractures: experimental assessment using synthetic and cadaver bones". Injury, 37(10): p. 979-983.2006.
[38] R.J. Brumback, "The rationales of interlocking nailing of the femur, tibia, and humerus: an overview". Clinical orthopaedics and related research, 324: p. 292-320.1996.
[39] R.A. Winquist, et al., "Closed Intramedullary Nailing of Femoral Fractures A Report of Five Hundred and Twenty Cases". The Journal of Bone &; Joint Surgery, 83(12): p. 1912-1912.2001.
[40] R. Eveleigh, "A review of biomechanical studies of intramedullary nails". Medical engineering &; physics, 17(5): p. 323-331.1995.
[41] Rha JD, et al., "Factors affecting sliding of the lag screw in itertrochanteric fractures." International Orthopaedics (SICOT), 17(5):320-324. 1993
[42] A. Thomas, "Dynamic hip screws that fail". Injury, 22(1): p. 45-46.1991.
[43] K. Leung, et al., "Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients". Journal of Bone &; Joint Surgery, British Volume, 74(3): p. 345-351.1992.
[44] M. Chinoy and M. Parker, "Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies". Injury, 30(3): p. 157-163.1999.
[45] H. Banan, et al., "The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN)—our first 60 cases". Injury, 33(5): p. 401-405.2002.
[46] I. Schipper, et al., "Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation: review of literature". Injury, 35(2): p. 142-151.2004.
[47] J.C. Floyd, et al., "Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures". Journal of orthopaedic trauma, 23(9): p. 628-633.2009.
[48] J.-W. Kim, et al., "A biomechanical analysis of locking plate fixation with minimally invasive plate osteosynthesis in a subtrochanteric fracture model". Journal of Trauma and Acute Care Surgery, 70(1): p. E19-E23.2011.
[49] K. Matre, et al., "Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register". Injury, 44(6): p. 735-742.2013.
[50] J. Smith, et al., "Treatment of comminuted femoral subtrochanteric fractures using the Russell-Taylor reconstruction intramedullary nail". Orthopedics, 14(2): p. 125-129.1991.
[51] D. Warwick, et al., "The dynamic condylar screw in the management of subtrochanteric fractures of the femur". Injury, 26(4): p. 241-244.1995.
[52] R. Sanders and P. Regazzoni, "Treatment of subtrochanteric femur fractures using the dynamic condylar screw". Journal of orthopaedic trauma, 3(3): p. 206-213.1989.
[53] P.-C. Lee, et al., "Biologic plating versus intramedullary nailing for comminuted subtrochanteric fractures in young adults: a prospective, randomized study of 66 cases". Journal of Trauma-Injury, Infection, and Critical Care, 63(6): p. 1283-1291.2007.
[54] Y. Gotfried, "The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures". Clinical orthopaedics and related research, 425: p. 82-86.2004.
[55] P. Radford, et al., "A prospective randomised comparison of the dynamic hip screw and the gamma locking nail". Journal of Bone &; Joint Surgery, British Volume, 75(5): p. 789-793.1993.
[56] O. Borens, et al., "Long gamma nail in the treatment of subtrochanteric fractures". Archives of orthopaedic and trauma surgery, 124(7): p. 443-447.2004.
[57] D. Verettas, et al., "Fractures of the proximal part of the femur in patients under 50 years of age". Injury, 33(1): p. 41-45.2002.