臺灣博碩士論文加值系統

全人工膝關節置換後所併發的同側遠端股骨骨折（supracondylar fracture），目前治療方法分歧，無一定論，且內固定效果及其癒後通常滿意度低。此種病例約佔全人工膝關節置換人數的0.3％至2.5％，由於台灣地區全人工膝關節置換術的施行越來越普遍，此種病歷也隨之增加，預料將成為骨科手術所急欲解決的問題之一。
本研究針對此一問題，嘗試提出一解決方案，根據全人工膝關節置換術中股骨元件的特徵，設計出一個新型內固定器，以固定股骨元件及股骨幹，藉此能促進股骨髁骨折癒合及即早活動。新型內固定器與其他內固定器不同之處在於新內固定器與人工膝關節股骨元件是緊密鎖合在一起，使這兩部分之間沒有相對運動。
在實驗方面，利用已植入人工膝關節、並做出人造骨折的人造股骨，裝上新內固定器，固定股骨髁區不穩定的骨折。再建立生物力學測試模式，測試項目包括扭轉及軸向壓迫試驗，以得知骨折固定後整體剛性的提升程度。其結果再與傳統骨板式或是髓內釘固定方法比較，以比較其固定效能的優劣。
由實驗結果得知，在軸向壓迫測試方面，新設計與傳統骨板和骨髓內釘的固定效能無明顯差異，並且都可以達到未骨折時的水平。而在扭轉測試方面，雖然新設計與骨板、骨髓內釘的結果皆比未骨折時差，但是新設計的抗扭轉能力明顯比另兩種內固定器好。
本新型內固定器若能成功的提供骨科醫師使用，將對此類的臨床病患有相當的幫助。

The management of ipsilateral distal femoral (supracondylar) fracture after total knee arthroplasty (TKA) is still a controversial to the orthopaedic surgeon. Although there were some fixators for the stabilization of supracondylar femoral fracture and biomechanical test were investigated, there were few studies made with the fractures after TKA. This study had tried to design a new internal fixator for the fracture of distal femur after TKR. The biomechanical test was conducted to compare the mechanical properties (axial and torsional stiffness) of the femur which were restabilized by different fixators(DCP, GSH and new design).
The new fixator was designed with an intramedullary nail to be fixed on the femoral component of the total knee prosthesis. So there is no movement between the two pieces of the implants. Therefore, this new internal fixator could have greater structure stiffness by increasing the structure contact area. To test this improvement, the femoral component was implanted on the artificial composite bone (composite bone, SAWBONESR, USA) and made a mimic supracondylar femoral fracture(transverse pattern). The fractures were fixed with new designed fixator or traditional DCP plate or GSH nail(five samples in each group). The axial compression test and torsional test were done by the MTS Bionix858 to compare the mechanical stability of these fixators with intact bone(no fracture) and prosthesis implanted bone(no fracture).
There is no significant difference between each group in axial stiffness, which means that these three fixators can stabilize the fracture effectively in the longitudinal direction. All three fixation groups (Nail, Plate, New) are lower than the no fracture group (Intact, Prosthesis) with significant difference. But the torsional stiffness of the new designed foxator is higher than the DCP plate and GSH nail.

目錄
中文摘要………………………………………………………………….I
英文摘要…………………………………………………………………II
目錄……………………………………………………………………..III
圖目錄…………………………………………………………………...V
表目錄………………………………………………………………….VII
第一章 前言……………………………………………………………1
1-1 研究動機…………………………………………………………..1
1-2遠端股骨骨折……………………………………………………….2
1-2.1 骨骼肌肉之相對解剖位置…………………………………….2
1-2.2 傷害機轉……………………………………………………….4
1-2.3 遠端股骨骨折之分類…………………………………………5
1-2.4 治療方式………………………………………………………9
1-3 全人工膝關節至換後所併發之遠端股骨骨折…………………17
1-3.1 人工膝關節簡介…………………………………………….17
1-3.2 併發遠端股骨骨折的原因………………………………….19
1-3.3 處理方式…………………………………………………….19
1-4 文獻回顧…………………………………………………………21
1-5 研究目的…………………………………………………………23
第二章 研究方法與材料…………………………………………….24
2-1 新型內固定器的設計……………………………………………25
2-2 力學測試模式的建立……………………………………………29
2-2.1 測試用骨材料的選擇………………………………………..29
2-2.2 夾治具的設計與製作………………………………………..30
2-2.3 測試組別……………………………………………………..36
2-3 測試項目…………………………………………………………38
2-3.1 軸向壓迫測試………………………………………………..38
2-3.2 扭轉測試……………………………………………………..40
2-4 統計分析…………………………………………………………44
第三章 結果………………………………………………………….45
3-1 數據處理結果……………………………………………………45
3-2 軸向壓迫測試結果………………………………………………48
3-2 扭轉測試結果……………………………………………………51
第四章 討論………………………………………………………….54
4-1 新型內固定器設計及製作結果討論…………………………...54
4-2 夾治具設計及製作結果討論…………………………………...56
4-3 測試用骨材討論………………………………………………...58
4-4 軸向壓迫測試結果討論………………………………………...59
4-5 扭轉測試結果討論……………………………………...………62
第五章 結論………………………………………………………….64
第六章 未來工作…………………………………………………….65
參考文獻……………………………………………………………….66
圖目錄
圖1-1 遠端股骨位置圖……………………………………………….3
圖1-2 下肢骨骼排列圖……………………………………………….3
圖1-3 Neer氏分類……………………………………………………6
圖1-4 Sensheimer氏分類……….. …………………………………6
圖1-5 Müller氏分類……………………………………………..……8
圖1-6 95∘Condylar Blade Plate………………………………….10
圖1-7 95∘Condylar Blade Plate的插入位置…………………….10
圖1-8 95° blade plate 的固定……………………………………...11
圖1-9 Condylar compression screw system……………………..13
圖1-10 Compression screw與 side plate 的固定………………13
圖1-11 Condylar buttress plate……………………………………14
圖1-12 Retrograde nail……………………………………………..15
圖1-13 人工膝關節的各部分元件………………………………….18
圖2-1 研究方法流程圖…………………………………………… 24
圖2-2 新設計所用之股骨元件……………………………………...25
圖2-3 新設計所使用之骨髓內釘…………………………………...26
圖2-4 新設計的組成元件…………………………………………...26
圖2-5 新設計內固定器的組合圖…………………………………...27
圖2-6 新內固定器設計作用示意圖………………………………...28
圖2-7 包埋式夾治具示意圖………………………………………...31
圖2-8 機械式夾治具示意圖………………………………………...31
圖2-9 本研究夾治具設計概念草圖………………………………...32
圖2-10 夾治具全圖……………..…………………………………...32
圖2-11 夾治具下半部分設計圖…………………………………….33
圖2-12 夾治具上半部分設計圖…………………………………….33
圖2-13 夾治具上半部分設計圖…………………………………….34
圖2-14 夾治具夾片部分設計圖…………………………………….34
圖2-15 夾治具成品，下面部分…………………………………….35
圖2-16 夾治具成品，上面部分……………………………………..36
圖2-17 本研究實驗組的示意圖…………………………………….37
圖2-18 實驗裝置…………………………………………………….39
圖2-19 軸向壓迫測試流程………………………………………….39
圖2-20 步態週期中膝關節在冠狀面所受到的扭力……………….41
圖2-21 扭力測試流程圖…………………………………………….42
圖3-1 文獻上的軸向位移-軸向力或角位移-扭力關係圖………….45
圖3-2 軸向壓迫測試一次cycle收集到軸向位移-軸向力關係圖…46
圖3-3 扭轉測試一次cycle收集到角位移-扭力關係圖…………...46
圖3-4 軸向壓迫測試十次cycle所收集到力量與位移的關係圖…47
圖3-5 將圖3-4轉換成勁度對次數關係圖…………………………47
圖3-6 根據表3-1所做出的分佈圖………………………………….49
圖3-7 各實驗組的勁度平均值……………………………………...50
圖3-8 根據表3-3所做出的分佈圖…………………………………52
圖3-9 各實驗組的扭轉勁度平均值………………………………...53
圖４-1 不同實驗組的軸向位移-軸向力關係圖…………………….60
圖4-2 實驗初期所做出，偏高的勁度直……………………………61
圖4-3 不同實驗組別的角位移-扭力關係圖………………………..63
圖4-4 因夾治具的問題而導致內轉的扭轉勁度大於外轉………...63
表目錄
表3-1 每枝股骨第3到第7次cycle的軸向勁度平均值…………...48
表3-2 各實驗組的勁度平均值與統計結果………………………...49
表3-3 每枝股骨第3到第7次cycle的扭轉勁度平均值…………51
表3-4 各實驗組扭轉勁度的平均值與統計結果…………………...53
表4-1 文獻上所提出的股骨勁度與扭轉勁度值…………………...59

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