臺灣博碩士論文加值系統

背景：脛骨遠端骨折由於骨折部位接近踝關節並且經常伴有嚴重的軟組織損傷和骨粉碎，此類骨折的治療，甚仍然具有挑戰性。利用內側板固定脛骨遠端骨折可以減少軟組織的損傷並得到良好的臨床結果，因此這種手術方法常被用於治療遠端脛骨骨折。然而，使用內側板固定技術卻也常常發生諸如軟組織壓迫變形，皮膚壞死和固定板外露的併發症。最近，骨科界已開始引入外側板固定脛骨遠端骨折，以期減少上述併發症，證實效果良好。雖然以內側和外側鋼板治療遠端脛骨骨折皆有良好的臨床效果，但是過去卻鮮少有文獻以力學觀點，比較前述兩種不同固定方法對於術後脛骨的力學行為差異性。
方法：利用標準人造脛骨斷層影像，先行建立正常脛骨之三維有限元素模型。以獲得之正常脛骨有限元素模型為基礎，修改並分別建立八種不同有限元素模型。此八種模型包含：四種不同骨折型態(缺口朝內及缺口朝外之楔型骨折、內高外低及外高內低之斜型骨折)，每種骨折型態再施以兩種不同鋼板固定位置（內側固定、外側固定）之手術方法。為評估術後脛骨結構的力學行為，邊界條件設定脛骨遠端固定，另脛骨平台則於施以一合力為400N之垂直向下壓力。分析比較前述八種不同有限元素模型之鋼板及脛骨之應力與位移分佈。
結果： 1).無論何種骨折型態和鋼板固定方法，八種有限元素模型均顯示鋼板最高應力區皆發生在骨折位置；2).就楔型骨折而言，相較於將鋼板固定於楔型骨折開口對側，以開口同側固定鋼板獲致較低之鋼板應力分佈及位移分佈；3). 就斜型骨折而言，無論何種骨折方向（內高外低或外高內低），相較於外側鋼板，以內側鋼板治療脛骨遠端斜型骨折均可獲致較低之鋼板應力分佈及位移分佈。
結論：內側鋼板適用於治療各種斜斷方向之脛骨遠端斜型骨折；但是對於脛骨遠端楔型骨折而言，則鋼板應以封閉楔型開口為原則，固定於楔型開口同側。

Background: Treatment of distal tibia fractures remains challenge because the fracture sites are near to the ankle joint and often accompanied with severe soft tissue injury and bone comminution. Medial plate fixation has been favored to treat distal tibia fractures because this procedure reduces injury to soft tissues and produces good clinical results. However, the complications such as skin irritation, skin necrosis, and plate exposure are frequently occurred with use of the medial plate fixation technique. Recently, lateral plate fixation was introduced to reduce the aforementioned complications, and favorable outcome have been reported. However, to the best of our knowledge, previous literatures comparing the biomechanical behavior of medial- and lateral plate fixation in treatment of distal tibia fractures is lacking.
Methods: Computed tomography images of a standard composite tibia were used to create the 3-D finite element (FE) intact tibia model. Based on the intact model, eight models simulating four different fracture types (medial- or lateral-open wedge fractures, superolateral-to-inferomedial or superomedial-to-inferolateral oblique fractures) treated with two different plate fixation techniques (medial- or lateral-fixation) were created. A total load of 400 N was assumed to apply on the tibial plateau to evaluate the biomechanical performance of the tibia construct. The von Mises stress and displacement distributions of each model were analyzed and compared.
Results: 1). Regardless of fracture types and fixation techniques, the highest stresses of fixation plate located on the fracture sites for all eight FE models. 2). For wedge fractures (medial- or lateral-open), a lower stress distribution on fixation plate together with a lower stress and displacement distribution of tibia structure were found for model with plate fixed in the ipsilateral site of the wedge open direction. 3). For oblique fractures, regardless of oblique direction (superolateral-to-inferomedial or superomedial-to-inferolateral), tibia structures with medial plate fixation presented a lower stress distribution on fixation plate together with a lower stress and displacement distribution of tibia structure.
Conclusion: Regardless of the oblique direction, medial plate fixation was recommended for treatment of tibia with a distal oblique fracture; whereas ipsilateral plate fixation to seal the wedge open site was suggested for tibia with a distal wedge fracture.

指導教授推薦書
口試委員審定書
致謝 iii
中文摘要 iv
英文摘要 vi
目錄 viii
圖目錄 xii
表目錄 xvi
第一章 緒論 1
1.1 研究背景 1
1.2 研究動機 4
1.3 研究目的 6
第二章 文獻回顧 7
2.1脛骨解剖構造簡介 7
2.1.1踝關節 8
2.2脛骨骨折 9
2.2.1簡介 9
2.2.2脛骨遠端骨折 11
2.2.3脛骨遠端骨折類型 12
2.3脛骨遠端骨折治療 13
2.3.1微創手術 15
2.3.2脛骨遠端骨折之治療 18
第三章 材料與方法 21
3.1研究設備 21
3.2 研究流程 24
3.2.1研究流程圖 25
3.3 實體模型之建立 26
3.3.1人造脛骨影像處理 26
3.3.2脛骨遠端骨折模型建立 30
3.4三維有限元素模型建立與分析 38
3.4.1網格生成 39
3.4.2材料性質 42
3.4.3邊界條件 43
第四章、結果 45
4.1有限元素模型之收斂測試 45
4.2應力分析比較 48
4.2.1楔型骨折開口朝內應力 48
4.2.2楔型骨折開口朝外應力 49
4.2.3斜型骨折內低外高應力 50
4.2.4斜型骨折內高外低應力 51
4.2.5楔型骨折螺釘應力 52
4.2.6斜型骨折螺釘應力 53
4.2.7楔型骨折以內側或外側鋼板固定之最大應力 54
4.2.8斜型骨折以內側或外側鋼板固定之最大應力 55
4.3位移分佈比較 56
4.3.1楔型骨折開口朝內位移分佈 56
4.3.2楔型骨折開口朝外位移分佈 57
4.3.3斜型骨折內低外高位移分佈 58
4.3.4斜型骨折內高外低位移分佈 59
4.3.5遠端骨折總位移分佈比較 60
4.3.6遠端骨折總位移比較 61
4.3.7楔型骨折開口移動百分比 62
第五章、討論 63
5.1楔型骨折以內側鋼板固定 63
5.2楔型骨折以外側鋼板固定 65
5.3斜型骨折以內側或外側鋼板固定之應力比較 67
5.4螺釘斷裂風險 68
5.4.1楔型骨折之螺釘斷裂分析 68
5.4.2斜型骨折之螺釘斷裂分析 68
5.5研究限制 69
5.5.1脛骨遠端骨折模型之假設 69
5.5.2簡化正常脛骨受力行為 70
第六章、結論 71
參考文獻 72
附錄 A 79
附錄 B 85


圖目錄
圖1- 1、髓內釘固定脛骨中斷骨折 3
圖1- 2、脛骨遠端骨折 3
圖1- 3、利用微創手術治療脛骨遠端骨折 5
圖2- 1、右腳脛骨、腓骨 7
圖2- 2、踝關節 8
圖2- 3、脛骨骨折分類 10
圖2- 4、簡單型脛骨遠端骨折 11
圖2- 5、遠端骨折類型 12
圖2- 6、脛骨遠端骨折之髓內釘固定 13
圖2- 7、脛骨遠端骨折之內側鋼板固定 14
圖2- 8、脛骨遠端骨折之外固定 14
圖2- 9、微創手術治療脛骨遠端骨折之X光圖 17
圖2- 10、微創手術治療脛骨遠端骨折 17
圖3- 1、左為脛骨模型尺寸，右為人造脛骨實體模型 21
圖3- 2、內側鋼板之實體模型 22
圖3- 3、外側鋼板之實體模型 23
圖3- 4、研究流程架構圖 25
圖3- 5、人造脛骨CT影像 28
圖3- 6、人造脛骨CT影像圈取 28
圖3- 7、完成圈選之脛骨模型 29
圖3- 8、脛骨網格化並存成STL檔之脛骨模型 29
圖3- 9、SOLIDWORKS建立脛骨模型流程圖 30
圖3- 10、脛骨皮質骨之實體模型 31
圖3- 11、脛骨海綿骨之實體模型 32
圖3- 12、人造脛骨之完整實體模型 32
圖3- 13、骨折示意圖 33
圖3- 14、脛骨遠端楔型朝內骨折固定內側鋼板之實體模型 33
圖3- 15、脛骨遠端楔型朝外骨折固定內側鋼板之實體模型 34
圖3- 16、脛骨遠端斜型內低外高骨折固定內側鋼板之實體模型 34
圖3- 17、脛骨遠端斜型內高外低骨折固定內側鋼板之實體模型 35
圖3- 18、脛骨遠端楔型朝內骨折固定外側鋼板之實體模型 35
圖3- 19、脛骨遠端楔型朝外骨折固定外側鋼板之實體模型 36
圖3- 20、脛骨遠端斜型內低外高骨折固定外側鋼板之實體模型 36
圖3- 21、脛骨遠端斜型內高外低骨折固定外側鋼板之實體模型 37
圖3- 22、內側鋼板之網格模型 39
圖3- 23、外側鋼板之網格模型 39
圖3- 24、楔型骨折固定內側鋼板之網格模型 40
圖3- 25、斜型骨折固定內側鋼板之網格模型 40
圖3- 26、楔型骨折固定外側鋼板之網格模型 41
圖3- 27、斜型骨折固定外側鋼板之網格模型 41
圖3- 28、脛骨遠端設定為固定之網格模型 44
圖3- 29、脛骨平台邊界條件設定 44
圖4- 1、從左到右5 MM至3 MM之脛骨網格模型 46
圖4- 2、從左為2 MM右為1 MM之脛骨網格模型 46
圖4- 3、收斂測試結果圖 47
圖4- 4、楔型骨折開口朝內之應力分佈 48
圖4- 5、楔型骨折開口朝外之應力分佈 49
圖4- 6、斜型骨折內低外高，固定之應力分佈 50
圖4- 7、斜型骨折內高外低，固定之應力分佈 51
圖4- 8、楔型骨折螺釘 52
圖4- 9、斜型骨折螺釘 53
圖4- 10、楔型骨折固定內側及外側鋼板最大應力 54
圖4- 11、斜型骨折固定內側及外側鋼板最大應力 55
圖4- 12、楔型開口朝內，固定之總位移分佈 56
圖4- 13、楔型開口朝外，固定之總位移分佈 57
圖4- 14、斜型骨折內低外高，固定之總位移分佈 58
圖4- 15、斜型骨折內高外低，固定之總位移分佈 59
圖4- 16、脛骨遠端骨折之之總位移分佈。 60
圖4- 17、脛骨遠端骨折之總位移 61
圖5- 1、楔型骨折固定內側鋼板之應力分佈 63
圖5- 2、楔型骨折固定內側鋼板之最大應力 64
圖5- 3、楔型骨折固定外側鋼板之應力分佈 65
圖5- 4、楔型骨折固定外側鋼板之最大應力 66


表目錄
表3- 1、材料性質之各項參數 42
表4- 1、收斂測試結果表 47
表4- 4、開口位移量及百分比 62
表5- 1、楔型骨折固定內側鋼板之主應力 64
表5- 2、楔型骨折固定外側鋼板之主應力 66
表5- 3、斜型骨折固定內側鋼板或外側鋼板之主應力 67

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