2016-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/646222摘要：肩峰鎖骨關節傷害是一種年輕族群最常見的肩關節運動傷害，尤以從事高強度運動之選手更容易有肩峰鎖骨關節脫位的風險；其主要原因為維持肩峰鎖骨關節的喙突鎖骨韌帶及肩峰鎖骨韌帶因創傷導致程度不等的撕裂。肩峰鎖骨關節傷害第三型及其以上的傷害以保守治療方法之療效均不甚理想，大多需手術治療。目前治療肩峰鎖骨關節脫位的主要手術方式為「鈎狀骨板固定術」及「經關節鏡肌腱雙懸吊鈕喙鎖關節固定術」。「鈎狀骨板固定術」具有成功率高、操作簡單、療效可靠、可早期復健等優點，故逐漸成為治療肩峰鎖骨關節脫位的主流。然而鈎狀骨板的原理是以鋼板鈎鈎住肩峰下緣以復位脫位的關節，過去文獻顯示鈎狀骨板術後常見併發症如植入物旁鎖骨骨折、肩峰骨折及肩峰下磨損等，所以一般建議患者需要二次手術移除鈎狀骨板。然而即使在骨板移除後，病患還是常併發肩峰下夾擠症候群、肩峰鎖骨關節炎及肩旋轉肌腱斷裂等後遺症。另一方面，「經關節鏡肌腱雙懸吊鈕喙鎖關節固定術」具有傷口小、精準的解剖性復位及不須二次手術移除內置物等優點，近幾年逐漸被發展來治療肩峰鎖骨關節脫位。然而，相較於鈎狀骨板固定術，其手術時間較長，技術上也較困難；短期追蹤報告成功率與鈎狀骨板固定手術相當，然而中長期的臨床結果尚無定論。研究文獻中發現，鈎狀骨板固定後的病患肩胛骨運動的變化與肩峰下夾擠症候群患者相當類似，然而，對於骨板移除後病患卻仍然發生肩關節病灶的現象則無法解釋；而經關節鏡肌腱雙懸吊鈕喙鎖關節固定術後是否能夠以精準的解剖性復位改善鈎狀骨板固定手術的後遺症，目前也未有解答。本研究預計利用兩年計畫時間，收取並追蹤鈎狀骨板術治療、經關節鏡肌腱雙懸吊鈕喙鎖關節固定術治療以及正常受試者各15 名。利用雙平面透視攝影動態X 光 (Biplane Fluoroscopy) 影像對位技術，求得第三型以上肩峰鎖骨關節脫位病患於兩種不同治療方法術後之精確三維肩關節運動學，並量化肌肉活動程度與關節活動範圍的大小。每位接受手術治療者將施以每月一次的復健訓練，並以臨床量表評估主觀之癒後成效。第一年針對鈎狀骨板術治療與經關節鏡肌腱雙懸吊鈕喙鎖關節固定術治療二個族群之受試者治療開始後三個月與六個月時於不同功能動作之肩部運動學，藉由雙平面透視動態攝影分析技術客觀量化，並輔以X 光檢測癒後狀況，正常受試者作為對照比較，鈎狀骨板組病患於手術後第六個月，即第二次影像分析後手術移除骨板。第二年針對受試者於治療開始後十二個月與十八個月作後續追蹤，量測肩部運動功能，以比較不同手術治療之復原情形。以次分組分析比較鈎狀骨板固定術病患於骨板移除前與移除後的變化。另分析比較鈎狀骨板移除後的病患與經關節鏡肌腱雙懸吊鈕喙鎖關節固定術及正常受試者肩關節生物力學之不同。統計分析方面，本計畫擬採用雙因子重複量測混合設計變異數分析(two-way ANOVA mixed model)，探討族群間、不同手術治療以及時間參數影響之特性分析，找出導致併發症的主要原因，即可得知預防併發症的方法。<br> Abstract: Acromioclavicular injury is the most common orthopedic injuries to the shoulder in young athlete population.Surgical treatment is indicated for advance acromioclavicular injury, including Rockwood type III, type IVand type V acromioclavicular injury.Hook plate is designed for treatment of this injury and alternatively for communition distal clavicle fracture.It is the most commonly used implants for acromioclavicular injury and distal clavicle fracture in this decadebecause of the promising result and less technical demanding surgical procedure. However, complicationssuch as peri-implant fracture, sub-acromion erosion and shoulder joint stiffness after this procedure werereported and therefore implants removal was suggested. However, sequela developed even after implantsremoval, such as acromioclavicular osteoarthritis, scapular dyskinesia and sub-acromion impingement.Arthroscopy-assisted coracoclavicular fixation using double flip buttons was developed for the treatment ofacromioclavicular injury in recent years. Arthroscopic techniques allow very accurate coracoclavicular andacromioclavicular anatomic reduction. Short term results of this procedure were reported to be comparable tohook plate fixation. However, arthroscopy-assisted coracoclavicular fixation has long learning course and isrelatively technical demanding with less promising result.Literatures reported the acromioclavicular injury patients with retention of hook plate have similarly scapularmotion to those with sub-acromion impingements. The etiology of compilations developed even after hookplate removal was not known. Current prevailing thought is that mechanical alteration of the shoulder girdlemotion may further result in soft tissues pathologies. However, the kinematic change of shoulder joints aftersurgical treatments of this injury was not studied before. The effect of accurate anatomic reduction ofarthroscopy-assisted coracoclavicular fixation using double flip buttons to shoulder girdle motion was notreported either.This project aims to apply the technique of biplane 2D-fluoroscopy to investigate the effect of two differentsurgical methods on the functional performance and kinematics of type III, type IV, type V or type VIacromioclavicular injury patients’ shoulder girdle, and compare with the follow-up X-ray imaging betweenthese groups.In the current study, 45 participants will be recruited in total. Acromioclavicular injury patients whounderwent surgical treatment with hook plate fixation and arthroscopy-assisted coracoclavicular fixationusing double flip buttons were compared to a normal control group. Fifteen subjects were be recruited in eachgroup. Clinical tables are applied to evaluate the subjective treatment effects. Hook plates will be surgicallyremoved 6th months after the primary surgery. Biplane 2D-fluoroscopy method is used to quantify thekinematic parameters during different functional movements of the shoulder complex. All measuredkinematic parameters are analyzed using repeated measured design, two-way ANOVA mixed model toevaluate the performances in different groups. This project will be carried out in two years with the followingspecific tasks and goals:1st year study： To develop a complete procedure of biomechanical analysis of different surgical methods (hook platefixation and arthroscopy-assisted coracoclavicular fixation using double flip buttons) on the functionalperformance and kinematics of patients' shoulder girdle. To perform the measurements of the scapular retraction/protraction, lateral/medial rotation andanterior/posterior tilt relative to trunk of different operative patients and control normal group. Use the technique of biplane 2D-fluoroscopy method to measure the kinematics data and the functional表CM02 共 3 頁 第 3 頁performance. To compare the biomechanics and X-ray imaging difference between three groups in 3rd months and 6thmonths after treatment. To evaluate the treatment effects on different operative treatments and control normal group. Implants removal will arrange for patients with treatment of hook fixation after 2nd biomechanicssurvey (6th months after primary surgery)2nd year study： To perform experiment of sternoclavicular joint angles, acromioclavicular joint angles, scapulothoracicjoint angles on 12th and 18th months after primary surgery. To compare the kinematic change between before and after implants removal of hook plate fixationpatents. To compare shoulder kinematic change between patents after hook plate removal, patients witharthroscopy-assisted coracoclavicular fixation using double flip buttons and normal controls.