臺灣博碩士論文加值系統

研究目的：以非直接於骨折碎片上施行之經皮鋼板內固定術來治療股骨遠端骨折可有良好之臨床預後。傳統經皮鋼板內固定術通常使用動力髁螺釘（dynamic condylar screw,簡稱DCS）及微創骨折內固定系統(Less Invasive Stabilization System,簡稱LISS)來執行。生物力學研究顯示LISS，系統具備較高負荷載重能力。但目前並無研究針對以DCS與LISS系統治療股骨遠端骨折之差異做比較。本研究之研究目的即在概述以DCS及LISS治療股骨遠端骨折之所有臨床及影像結果差異。
研究方法及資料：本研究以無使用骨植入體之DCS或LISS方法執行45例微創經皮鋼板內固定術來治療股骨髁上或髁間骨折。有26位病人26例骨折以動力髁螺釘治療，為DCS組;19位病人19例骨折以微創骨折內固定系統治療，為LISS組。我們針對此兩種不同固定裝置之臨床及影像結果資料進行比較。
研究結果：45例中有41例達到完全癒合（91.1％），DCS組之成功率為96.2％，LISS組為94.7％（P = 0.672）;DCS組之平均融合時間為19.18週，LISS組為19.38週（P = 0.835）;DCS組之膝關節平均活動範圍(range of motion,簡稱ROM)為111.65度，LISS組為116.26度（p=0.334）。早期植體失敗只發生在DCS組（11.5％，p=0.252，勝算比=1.826 [95％ CI：1.387～2.404]）。DCS組之併發症總發生率為15.4％，LISS組為15.8％（P=0.641）;DCS組之平均骨折冠狀面活動損失角度為-0.77度，LISS組為-0.19度（P=0.125）。
結論與建議：以DCS或LISS施行微創經皮鋼板內固定術治療股骨遠端骨折皆能達到良好且併發症少之預後。兩者皆能使軟組織受到最低創傷。但微創骨折內固定系統(LISS)比動力髁螺釘（DCS）有較低之早期置入鬆脫風險。

Background: Treatment of distal femoral fractures by percutaneous plating without direct manipulation of the fracture fragments leads to good clinical outcome. Percutaneous plating has traditionally involved using a dynamic condylar screw (DCS) and the less invasive stabilization system (LISS) was reported. The biomechanical study showed that the LISS had the enhanced ability to withstand higher loads. However, there were no clinical comparison study of distal femoral fractures treated with DCS and LISS. The aim of this study was to outline any differences in clinical and radiological results between the DCS and the LISS for treating distal femoral fractures.
Methods: Forty-five supracondylar or intercondylar femoral fractures were treated by minimally invasive percutaneous plating with the DCS or the LISSwithout bone graft. There were 26 patients with 26 fractures in the DCS group and 19 patients with 19 fractures in the LISS group. The data of the clinical and radiographic outcomes were compared between the two different fixation devices.
Results: Complete union was achieved in 41 of the 45 patients (91.1%). The success rate was 96.2% in the DCS group and 94.7% in the LISS group (p = 0.672). The mean fusion time was 19.18 weeks in the DCS group and 19.38 weeks in the LISS group (p = 0.835). The average range of motion of the knee joint was 111.65 degrees in the DCS group and 116.26 degrees in the LISS group (p = 0.334). Early implant failure only occurred in the DCS group (11.5%, p = 0.252, odds ratio =1.826 [95% CI: 1.387–2.404]). The total complication rate was 15.4% in the DCS group and 15.8% in the LISS group (p = 0.641). The mean loss of coronal fracture fragment angle was -0.77 degrees in the DCS group and -0.19 degrees in the LISS group (p =0.125).
Conclusion: Minimally invasive percutaneous plating with the DCS or the LISS provides good outcome with few complications in the treatment of distal femoral fractures. Both systems minimize soft tissue trauma. LISS has lower risk of early implant loosening than the DCS.

第一章 緒論
第一節 研究背景與動機---------------------------------------1
第二節 研究目的--------------------------------------------2
第二章 文獻回顧
第一節 股骨
第一.一 股骨解剖--------------------------------------------3
第一.二 股骨解剖部位-----------------------------------------3
第二節 骨板內固定術之演變
第二.一 骨板固定術之歷史與演變---------------------------------6第二.二 穩定骨折與血管斷裂------------------------------------9
第二.三 鎖定骨板-------------------------------------------10第二.四 鎖定骨板與接骨系統-----------------------------------15
第二.五 以LISS治療股骨骨折----------------------------------17
第三章 病人與方法
第一節 病患收集及骨折分類-----------------------------------21
第二節 研究所使用手術方法-----------------------------------23
第三節 術後照護-------------------------------------------28
第四章 研究結果-------------------------------------------- 33
第五章 討論與建議 -------------------------------------------38
第六章 參考文獻-------------------------------------------- 42
附錄：Protocol ( Flow chart ) of decision process----------56



圖表說明
圖1：鎖定骨板 ( A ) 。一般骨板 （B）--------------------------10
圖2 : 微創內固定系統（LISS）骨板----------------------------- 12
圖3：動力髁螺釘（DCS）骨板------------------------------------13
圖4：微創內固定系統（LISS）骨板與導引系統-----------------------15
圖5 : 微創內固定系統（LISS）骨板及鋼釘-------------------------16
圖6：一名68歲男性之AO/OTA C2型股骨髁上骨折（A和B）。此骨折以DCS微創經皮鋼板治療（C和D）。治療後骨折癒合（E和F）且膝關節活動度令人滿意（G和H）。--------------------------24
圖7：一名37歲女性之AO/OTA C2型股骨髁上骨折。此骨折以DCS微創經皮鋼板治療（A）。術後約三個月於病患部分承重後，因近端螺釘鬆動而造成植入體破裂（B）。--------------------------------- 30
圖8：一名50歲女性之AO/OTA A3型股骨髁上骨折（A和B）。此骨折以LISS微創經皮鋼板治療（C和D）。骨折復原狀況良好，骨位排列整齊（E和F）。------28
圖9：一名68歲女姓之AO/OTA C2型股骨髁上骨折。此骨折以LISS微創經皮鋼板治療（A）。於術後約一年發生近端螺絲鬆動（B）。---------------------31
圖10：冠狀骨折碎片角度。--------------------------------------29

表 1病患基本資料及特點------------------------------------22
表 2使用 Neer criteria 評估臨床結果-----------------------34
表 3術後併發症--------------------------------------------35
表 4手術X光的結果----------------------------------------36
附表一: 遠端股骨骨折AO分類--------------------------------57
附表二: 修定過之Neer標準-------------------------------------58
對照表-----------------------------------------------------60

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