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研究生：	王郁智 Wang, Yu-Chih
論文名稱：	三維有限元素分析：肱骨大結節骨折施以不同修復方式之力學探討 Finite Element Analysis of Mechanics about Different Fixations for Greater Tuberosity Fractures of the Humerus
指導教授：	葉明龍 Yeh, Ming-Long
共同指導教授:	蘇維仁 Su, Wei-Ren
學位類別：	碩士 Master
系所名稱：	工學院 - 生物醫學工程學系 Department of BioMedical Engineering
論文出版年：	2014
畢業學年度：	102
語文別：	英文
論文頁數：	58
中文關鍵詞：	肱骨大節結骨折、骨釘、縫線鉚釘、骨密度、有限元素分析
外文關鍵詞：	Greater tuberosity fracture, Bone screw, Suture anchor, Bone mineral density, Finite element method
相關次數：	點閱：176 下載：5
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肱骨大節結(Greater tuberosity)骨折的發生率占了肱骨近端的骨折的14%到25%左右，而目用於前臨床的治療有骨釘直接固定或縫線鉚釘縫合大節結碎片。文獻指出對於年長或是骨鬆患者使用骨釘固定法修復，其再位移的機率會增加，而對於此類病患則縫線鉚釘法修復法有較佳的結果。然而，使用縫線鉚釘法修復則因內側鉚釘穿過棘上肌肌腱(Supraspinatus tendon)，可能會對於肌腱造成微小撕裂傷。本研究之目的是為了調查不同的骨質下，使用不同的修復方式對其修復強度、以及軟組織的應力分布的影響。
我們根據近期臨床提供的肱骨大節結骨折修復方法，建立了三維有限元素分析模型包含雙骨釘(Two screw fixation)、縫線縫合橋(Suture-bridge)、雙排縫線(Double-row)、與單排縫線(Single-row)等四種固定方法。並施以三種不同的骨質密度與0˚外展附載力探討其生物力學的影響。
本篇研究結果包含了不同骨密度下四種大節結骨折修復方法之修復強度, 及其應力作用於棘上肌肌腱的大小。結果顯示：骨密度(Bone Mineral Density)小於0.1 g/cm3 時，使用骨釘修復的強度會大大降低，而在骨密度大於 0.8 g/cm3 的情況下雙骨釘(Two screw fixation)與其他三種縫線鉚釘(Suture anchor) 修復法的修復強度沒有太大的差異。在相同的骨密度(0.8 g/cm3) 與力量 370 N 的附載下，雙排縫線(Double-row)會在內側的縫線處對棘上肌產生最大von-Mises 應力 57.68 MPa，縫線縫合橋(Suture-bridge)產生16.69 MPa次之，單排縫線(Single-row)產生8.43 MPa最小。而雙骨釘(Two screw fixation)則對棘上肌肌腱無直接影響，其最大應力 6.24MPa與本實驗之對照組相同。
根據本篇實驗結果，我們建議肱骨大節結的修復在骨釘與縫線鉚釘的選擇上，如果其骨質密度小於0.1 g/cm3則使用縫線鉚釘修復其強度較為理想。而在各種臨床縫線鉚釘修復方法的選擇上，雙排縫線(Double-row)相較於其他的修復方法強度較強，但其內排縫線會在肌腱內側產生一個較大的集中應力，增加對棘上肌肌腱產生傷害的可能。

Isolated greater tuberosity (GT) fractures of the humerus are common. The rates of incidence have been reported in 14% to 25% among proximal humeral fractures. Either open surgeries or percutaneous techniques using screws or suture anchors are well accepted for the reduction and fixation of GT fractures. Bone screws are the common tool generally described for fixation of GT fractures in both open and arthroscopic surgeries. Previous studies suggested that surgeons should exercise caution using screw fixation for GT fractures in older and osteoporotic bones because the screw provides suboptimal fixation in osteopenia bone of the GT fragments and lead to further damage the fracture fragments. In such scenarios, the suture anchor fixations might be the superior options. Using suture anchor repair techniques can provide a better outcome to the older or osteoporosis patients, but these procedures might damage the rotator cuff because the medial anchor is inserted through an intact cuff attached to the greater tuberosity fragment. Therefore, our purpose was to investigate the strength of different fixation constructs, using suture anchors or screws under different bone mineral densities (BMD) and which kind of suture anchor techniques had the maximum stress appeared on tendon.
To investigate the strength of different GT fracture fixation techniques, a finite element GT fracture model was built. It consisted of four different fixations: Two screw (TS), Suture-bridge (SB), Double-row (DR) and Single-row (SR) fixations. All of these fixation conditions were provided a 370 N loading under different bone qualities at 0˚ abduction.
Resulting stresses at the supraspinatus tendon and comparisons of different fixation strength from different BMD were studied. The definition of fixation strength was the migration of GT fragment relative to the humerous. Among all of these groups, the TS fixation strength was the weakest when the BMD was under 0.1 g/cm3. And the Double-row fixation had a superior strength in the entire suture groups. Additionally, the maximum von-Mises stress of DR technique was 57.68 MPa, which is more than the other fixations under a 370 N loading at 0˚ abduction.
In our study, we suggest that the suture anchor construct was the superior option when BMD is less than 0.1 g/cm3. Additionally, Double-row fixation has some negative effects that would cause a large stress concentration at the medial row and damage the rotator cuff tendon.

Contents
中文摘要	I
Abstract	III
致謝	V
Contents	VIII
Figure lists	XI
Table lists	XIV
Chapter 1.	Introduction	1
1.	The anatomy of the proximal humerus and the shoulder joint	2
1.1.	The anatomy of shoulder	2
1.2.	Muscles Crossing the Shoulder Joint: Movements of the Arm	3
2.	Greater tuberosity fracture	4
2.1.	The frequency of isolated dislocation	4
2.2.	The Classification of the proximal humerus fracture	6
3.	Different fixation types of Greater Tuberosity fracture	7
3.1.	Suture bridge technique	8
3.2.	Double-row suture fixation	9
3.3.	Single-row suture fixation	10
3.4.	Bone screw fixation	11
4.	The comparison between bone screw and suture anchor fixation	11
4.1.	The results of biomechanical studies	12
5.	Osteoporosis and bones’ marital properties	13
6.	Finite Element Analysis (FEA)	14
7.	Motivation and Purpose	14
Chapter 2.	Materials and Methods	17
1.	Flow chart	17
2.	Creating the finite element models of different fixations (suture anchor versus screw fixation) for greater tuberosity fractures	18
2.1.	Constructing the 3D humerous model and post-operation procedures	18
2.2.	Constructing the 3D supraspinatus tendon model and post-operation procedures	19
2.3.	Constructing the 3D Screw Fixation Model and Suture-Anchor Models	20
3.	Boundary Condition Setting: Material Properties, Loading Conditions, and Contact	22
3.1.	Material properties	22
3.2.	Loading Conditions (Verification and evaluation)	24
3.3.	Contact Conditions	25
4.	Elements	29
5.	Evaluation factor	29
Chapter 3.	Results	31
1.	The strength of different fixations under different BMD	31
2.	Supraspinatus tendon stress distribution	33
2.1.	Control group	33
2.2.	Two Screw Fixation group	34
2.3.	Suture Bridge group	35
2.4.	Single-row group	35
2.5.	Double-row group	36
3.	Convergence test	37
4.	Summary	40
Chapter 4.	Discussion	43
1.	The Finite Element models	45
1.1.	The entire groups	45
1.2.	The supra tendon shapes	46
1.3.	The material properties of bones	46
1.4.	The contact conditions:	47
2.	The strength of different fixations under different BMD	47
2.1.	Validation	47
3.	Supraspinatus tendon stress distribution	49
4.	Limitation and future works	51
Conclusions	52
References	53

                                    

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校內：2015-09-02公開
校外：2015-09-02公開

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