臺灣博碩士論文加值系統

因為膝關節生長板不正常之生長而導致膝外翻為小兒骨科常見之疾病，其變形將導致發育期間膝關節或者下肢在活動時有不穩定或者疼痛之症狀。其影響膝關節變形因子可能包括遺傳、骨生長不全、佝僂症或者骨外傷。外科矯正手術可幫助其變形之膝關節達成下肢對稱、恢復正常關節軸線以及下肢關節受力之目的。引導性成長矯正手術可藉由調控生長板成長速度之不同而達成矯正變形膝關節之目的。目前對於進行引導性成長矯正手術病人的步態分析為數有限。因此本研究目的在於利用步態分析，進行功能性動作下肢運動學與動力學分析，對因雙膝膝外翻之患者於接受引導性成長矯正手術前後步態的影響，本研究假設接受引導性成長矯正手術的患者，術後會有較小的步寬，較小的膝關節、踝關節外展角度，較小的髖關節內收角度以及術後膝關節會有較大的外展力矩。希望可以詳細得知膝外翻之患者於執行引導性成長矯正手術後之效果，以提供臨床醫師手術規劃、臨床評估及復健計畫之重要依據。
研究結果顯示，對於接受引導性成長矯正手術矯正雙膝膝外翻之患者，術後步寬顯著下降，且在額狀面術後髖關節內收的角度、膝關節外展的角度皆下降；術後髖關節外展力矩、術後膝關節外展力矩皆上升，然而，踝關節在額狀面的關節角度以及下肢三個關節在矢狀面術後不論是關節角度、關節力矩都沒有明顯改善。綜合以上結論，手術對於髖關節和膝關節額狀面的關節角度和關節力矩有明顯改善，但對於踝關節在額狀面的關節角度和矢狀面的關節角度以及關節力矩卻無明顯改善，因此推測手術植入植入物時是否考量骨頭生長方向以及是否需要考量矯正踝關節以改善踝關節角度亦或小朋友尚未改變原先走路方式，需由術後復健以達到矯正目的。

Deformities of the knee joint in the children sometimes extend beyond the physiological limit to produce symptoms. Factors including family history, bone dysplasia, Blount’s disease, Rickets, fracture, and trauma would interfere with the normal angular alignment of the lower limbs. Corrective procedures for the angular deformities of the knees were needed to achieve equal limb lengths, neutral mechanical axes, and horizontal knees by skeletal maturity. The guided growth surgery which enable the hemiepiphyseal arrest to achieve the angular correction. The aims of the current study were to evaluate the performance and lower limb joint kinematics and kinetics in the patients receiving guided growth surgery for correction bilateral valgus knee. It was hoped that a complete knowledge of the general outcome and factors influencing the performance of the guided growth surgery could be established, which would be helpful for future clinical decision-making. It was hypothesis that these patients who receiving guided growth surgery would show decreased step width, lower abduction angle of knee and ankle. These patients would also show decreased adduction angle of hip and greater abductor moment of knee. The postoperative group was found displayed decreased the step width. The angle and moment of hip and knee on gait were improved in frontal plane. However, the angle and moment were not improved in sagittal plane. The angle of the ankle was not improved in frontal plane. It is suggested that the position of implant should be meticulous, the deformity of the ankle should be considerate and the patients could do exercise training to strengthen the muscle of lower limbs.

目錄
致謝 I
摘要 II
Abstract III
目錄 IV
圖目錄 VI
表目錄 VII
第一章 緒論 1
第一節 研究背景 1
一、 膝外翻簡介 1
二、 術式簡介 4
三、 步態研究 7
第二節 研究目的 10
第二章 材料與方法 11
第一節 受試者 11
第二節 實驗設備 14
第三節 實驗流程 16
第四節 生物力學與動作分析模型 18
一、 局部座標系統定義 18
二、 廣義/局部座標系統轉換 24
三、 測力板壓力中心 25
四、 關節運動學 25
五、 關節力動學 - 逆向動力學 25
第五節 步態分期定義 27
第六節 統計分析 27
第三章 結果 28
第一節 膝關節角度 28
第二節 時空參數 32
第三節 各關節角度及力矩 33
第四節 身體質量中心移動軌跡 41
第五節 地面反作用力 44
第六節 最大值 46
第四章 討論 50
第一節 膝外翻對步態之影響 50
第二節 膝外翻患者術後步態之影響 52
第三節 引導性成長矯正手術之改善 53
第四節 限制與未來展望 55
第五章 結論 57
參考文獻 58
附錄 62

參考文獻
1.Goldman, V. and D.W. Green, Advances in growth plate modulation for lower extremity malalignment (knock knees and bow legs). Current Opinion in Pediatrics, 2010. 22(1): p. 47-53.
2.Arazi, M., T.C. Ogun, and R. Memik, Normal development of the tibiofemoral angle in children: A clinical study of 590 normal subjects from 3 to 17 years of age. Journal of Pediatric Orthopaedics, 2001. 21(2): p. 264-267.
3.Sass, P. and G. Hassan, Lower extremity abnormalities in children. American Family Physician, 2003. 68(3): p. 461-468.
4.Salenius, P. and E. Vankka, DEVELOPMENT OF TIBIOFEMORAL ANGLE IN CHILDREN. Journal of Bone and Joint Surgery-American Volume, 1975. A 57(2): p. 259-261.
5.Jackson, D.W. and L. Cozen, GENU VALGUM AS A COMPLICATION OF PROXIMAL TIBIAL METAPHYSEAL FRACTURES IN CHILDREN. Journal of Bone and Joint Surgery-American Volume, 1971. A 53(8): p. 1571-&.
6.Balthazar, D.A. and A.M. Pappas, ACQUIRED VALGUS DEFORMITY OF THE TIBIA IN CHILDREN. Journal of Pediatric Orthopaedics, 1984. 4(5): p. 538-541.
7.Mielke, C.H. and P.M. Stevens, Hemiepiphyseal stapling for knee deformities in children younger than 10 years: A preliminary report. Journal of Pediatric Orthopaedics, 1996. 16(4): p. 423-429.
8.Lin, C.J., et al., Physiological knock-knee in preschool children: Prevalence, correlating factors, gait analysis, and clinical significance. Journal of Pediatric Orthopaedics, 1999. 19(5): p. 650-654.
9.Kumar, A., et al., Comparative study between staples and eight plate in the management of coronal plane deformities of the knee in skeletally immature children. Journal of Childrens Orthopaedics, 2016. 10(5): p. 429-437.
10.Felson, D.T., et al., Valgus Malalignment Is a Risk Factor for Lateral Knee Osteoarthritis Incidence and Progression Findings From the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative. Arthritis and Rheumatism, 2013. 65(2): p. 355-362.
11.Andrish, J.T., Biomechanics of the Patellofemoral Joint. Operative Techniques in Sports Medicine, 2015. 23(2): p. 62-67.
12.Pretkiewicz-Abacjew, E., Knock knee and the gait of six-year-old children. Journal of Sports Medicine and Physical Fitness, 2003. 43(2): p. 156-164.
13.Ganesan, B., et al., Kinetic and kinematic analysis of gait pattern of 13 year old children with unilateral genu valgum. European Review for Medical and Pharmacological Sciences, 2016. 20(15): p. 3168-3171.
14.Dutoit, M., Percutaneous partial epiphysiodesis for persistent adolescent genu valgum. Revue De Chirurgie Orthopedique Et Reparatrice De L Appareil Moteur, 1998. 84(7): p. 623-627.
15.Stevens, P.M., et al., Physeal stapling for idiopathic genu valgum. Journal of Pediatric Orthopaedics, 1999. 19(5): p. 645-649.
16.Rubinovitch, M., et al., PRINCIPLES AND RESULTS OF CORRECTIVE LOWER-LIMB OSTEOTOMIES FOR PATIENTS WITH VITAMIN-D-RESISTANT HYPOPHOSPHATEMIC RICKETS. Clinical Orthopaedics and Related Research, 1988(237): p. 264-270.
17.Sharma, L., et al., The role of knee alignment in disease progression and functional decline in knee osteoarthritis. Jama-Journal of the American Medical Association, 2001. 286(2): p. 188-195.
18.Tanamas, S., et al., Does Knee Malalignment Increase the Risk of Development and Progression of Knee Osteoarthritis? A Systematic Review. Arthritis & Rheumatism-Arthritis Care & Research, 2009. 61(4): p. 459-467.
19.Felson, D.T., et al., The effect of body weight on progression of knee osteoarthritis is dependent on alignment. Arthritis and Rheumatism, 2004. 50(12): p. 3904-3909.
20.Stevens, P.M., Guided growth for angular correction - A preliminary series using a tension bond plate. Journal of Pediatric Orthopaedics, 2007. 27(3): p. 253-259.
21.Petersen, W. and P. Forkel, Medial closing wedge osteotomy for correction of genu valgum and torsional malalignment. Operative Orthopadie Und Traumatologie, 2013. 25(6): p. 593-607.
22.Pinkowski, J.L. and D.S. Weiner, COMPLICATIONS IN PROXIMAL TIBIAL OSTEOTOMIES IN CHILDREN WITH PRESENTATION OF TECHNIQUE. Journal of Pediatric Orthopaedics, 1995. 15(3): p. 307-312.
23.Steel, H.H., R.E. Sandrow, and P.D. Sullivan, COMPLICATIONS OF TIBIAL OSTEOTOMY IN CHILDREN FOR GENU VARUM OR VALGUM - EVIDENCE THAT NEUROLOGICAL CHANGES ARE DUE TO ISCHEMIA. Journal of Bone and Joint Surgery-American Volume, 1971. A 53(8): p. 1629-&.
24.Popkov, D., et al., The normal radiological anteroposterior alignment of the lower limb in children. Skeletal Radiology, 2015. 44(2): p. 197-206.
25.Simonsen, O.H., et al., Mechanical Axis of the Lower Extremity Determined by a New Digital Photographic Method. Orthopedics, 2013. 36(8): p. E1077-E1081.
26.Sabharwal, S., C. Zhao, and M. Edgar, Lower Limb Alignment in Children Reference Values Based on a Full-Length Standing Radiograph. Journal of Pediatric Orthopaedics, 2008. 28(7): p. 740-746.
27.Lysholm, J., et al., THE EFFECT OF A PATELLA BRACE ON PERFORMANCE IN A KNEE EXTENSION STRENGTH TEST IN PATIENTS WITH PATELLAR PAIN. American Journal of Sports Medicine, 1984. 12(2): p. 110-112.
28.Mycoskie, P.J., COMPLICATIONS OF OSTEOTOMIES ABOUT THE KNEE IN CHILDREN. Orthopedics, 1981. 4(9): p. 1005-1015.
29.Sung, K.H., et al., Rate of Correction After Asymmetrical Physeal Suppression in Valgus Deformity: Analysis Using a Linear Mixed Model Application. Journal of Pediatric Orthopaedics, 2012. 32(8): p. 805-814.
30.Eastwood, D.M. and A.P. Sanghrajka, Guided growth RECENT ADVANCES IN A DEEP-ROOTED CONCEPT. Journal of Bone and Joint Surgery-British Volume, 2011. 93B(1): p. 12-18.
31.Bohm, H., et al., Correction of static axial alignment in children with knee varus or valgus deformities through guided growth: Does it also correct dynamic frontal plane moments during walking? Gait & Posture, 2015. 42(3): p. 394-397.
32.Kulkarni, R.M., et al., Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years. Indian Journal of Orthopaedics, 2015. 49(2): p. 208-218.
33.Stevens, P.M. and J.B. Klatt, Guided Growth for Pathological Physes Radiographic Improvement During Realignment. Journal of Pediatric Orthopaedics, 2008. 28(6): p. 632-639.
34.Ballal, M.S., C.E. Bruce, and S. Nayagam, Correcting genu varum and genu valgum in children by guided growth TEMPORARY HEMIEPIPHYSIODESIS USING TENSION BAND PLATES. Journal of Bone and Joint Surgery-British Volume, 2010. 92B(2): p. 273-276.
35.Canale, S.T., T.A. Russell, and R.L. Holcomb, PERCUTANEOUS EPIPHYSIODESIS - EXPERIMENTAL-STUDY AND PRELIMINARY CLINICAL-RESULTS. Journal of Pediatric Orthopaedics, 1986. 6(2): p. 150-156.
36.Schwartz, M.H., A. Rozumalski, and J.P. Trost, The effect of walking speed on the gait of typically developing children. Journal of Biomechanics, 2008. 41(8): p. 1639-1650.
37.Jelinek, E.M., et al., The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: a retrospective analysis of thirty five patients. International Orthopaedics, 2012. 36(3): p. 599-605.
38.Wu, G., et al., ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion - part 1: ankle, hip, and spine. Journal of Biomechanics, 2002. 35(4): p. 543-548.
39.Lu, T.-W., Geometric and mechanical modelling of the human locomotor system. 1997, University of Oxford.
40.Meng, X.L., et al., Biomechanical model-based displacement estimation in micro-sensor motion capture. Measurement Science and Technology, 2012. 23(5): p. 11.
41.Chang, C.F., et al., Residual gait deviations in adolescents treated during infancy for unilateral developmental dysplasia of the hip using Pemberton''s osteotomy. Gait & Posture, 2012. 35(4): p. 561-566.
42.Huang, S.C., et al., Effects of severity of degeneration on gait patterns in patients with medial knee osteoarthritis. Medical Engineering & Physics, 2008. 30(8): p. 997-1003.
43.Sharma, L., et al., The mechanism of the effect of obesity in knee osteoarthritis - The mediating role of malalignment. Arthritis and Rheumatism, 2000. 43(3): p. 568-575.
44.Cerejo, R., et al., The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis and Rheumatism, 2002. 46(10): p. 2632-2636.
45.Andriacchi, T.P., et al., A framework for the in vivo pathomechanics of osteoarthritis at the knee. Annals of Biomedical Engineering, 2004. 32(3): p. 447-457.
46.Brouwer, G.M., et al., Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis and Rheumatism, 2007. 56(4): p. 1204-1211.
47.Hayashi, D., et al., Knee malalignment is associated with an increased risk for incident and enlarging bone marrow lesions in the more loaded compartments: the MOST study. Osteoarthritis and Cartilage, 2012. 20(11): p. 1227-1233.
48.Inan, M., G. Chan, and J.R. Bowen, Correction of angular deformities of the knee by percutaneous hemiepiphysiodesis. Clinical Orthopaedics and Related Research, 2007(456): p. 164-169.
49.Ferrick, M.R., J.G. Birch, and M. Albright, Correction of non-Blount''s angular knee deformity by permanent hemiepiphyseodesis. Journal of Pediatric Orthopaedics, 2004. 24(4): p. 397-402.
50.Khoury, J.G., et al., Results of screw epiphysiodesis for the treatment of limb length discrepancy and angular deformity. Journal of Pediatric Orthopaedics, 2007. 27(6): p. 623-628.
51.Blount, W.P. and G.R. Clarke, CONTROL OF BONE GROWTH BY EPIPHYSEAL STAPLING - A PRELIMINARY REPORT. Journal of Bone and Joint Surgery-American Volume, 1949. 31-A(3): p. 464-478.
52. Jeffrey J. Cherian, et al., Mechanical, Anatomical, and Kinematic Axis in TKA: Concepts and Practical Applications. 2014 Jun; 7(2): 89–95
53. Patel K. Corrective Exercise: A Practical Approach. Routledge.