Download CURRICULUM VITAE

彰化縣醫師公會醫師繼續教育課程
一、時間：99 年 1 月 24 日（星期日）13:30-18:00
二、地點：彰化縣農會 14 樓會議室(彰化市中山路二段 349 號)
三、主辦單位：彰化縣醫師公會
四、指導單位：彰化縣衛生局
五、協辦單位：台灣諾華股份有限公司
彰化縣防癌協會
六、課 程 表：
時
間
13:30～13:55
報
內
到
13:55～14:00
致
詞
14:00～15:00
骨鬆患者之全方面治療與
預防
15:00～16:00
16:00～17:00
17:00～18:00
容
Female pelvic floor:
function, dysfunction
and management
如何處理乳癌病人的骨質
健康問題
骨折內固定之選擇與運用
主 持
人 ／ 講 師
彰化縣醫師公會
蔡明忠 理事長
財團法人彰化基督教醫院骨科
于振東醫師
財團法人彰化基督教醫院婦產部
黃志成醫師
秀傳醫療社團法人秀傳紀念醫院
乳房外科 王馨鎂主任
秀傳醫療社團法人秀傳紀念醫院
榮譽院長暨骨科總監
李土生醫師
于振東醫師學經歷
學歷：國立陽明醫學院醫學系學士
中國醫藥大學臨床醫學研究所碩士
經歷：台北榮民總醫院骨科部住院醫師，總醫師
台北榮民總醫院骨科部主治醫師
花蓮鳳林榮民醫院骨科主任
健保局東區審核委員
彰化基督教醫院二林分院急診室主任
紐約 Beth Israel Medical Center 膝關節重建進修
法國 Clinique d’Argonay 髖關節重建進修
2003-2006
大葉大學機械及自動化工程學系暨研究所兼任助理教授
現任： 財團法人彰化基督教醫院骨科部主治醫師
長榮大學臨床教授
研究：高彎曲型人工膝關節之動作分析，早期膝關節壞死之治療，人工膝關節暨
髖關節手術，骨質疏鬆之治療與防治
骨鬆患者之全方面治療與預防
Providing Effective Therapy across a Broad Spectrum of Osteoporosis Patients
Yu chen-tung MD. MSc
Changhua Christian Hospital
Osteoporosis is a disease characterized by low bone mass and bone
structural deterioration, which results in increased bone fragility and
fracture susceptibility. Fractures, the most important consequence of
osteoporosis, are associated with enormous costs and substantial
morbidity and mortality. The most typical sites of fractures related to
osteoporosis are the spine, hip, and wrist. In Taiwan, one in three women
and one in five men over age 50 will have an osteoporosis-related fracture
in her/his remaining lifetime. The rate of hip fractures is two to three
times higher in women than men; however, the one-year mortality following
a hip fracture is much higher in males (15% vs. 22%).
A number of therapeutic agents are available to treat osteoporosis;
bisphosphonates remain the main stream of them. Several bisphosphonates
(BPs) are available; with oral and intravenous modes of administration
formulated for varying dosing frequencies Each BP has its unique profile
and different indications for osteoporosis. More information about the
chemistry, pharmacology, and clinical applications of BPs will be
presented and discussed.
黃志成醫師學經歷
學歷：高雄醫學院
經歷：彰化基督教醫院婦產科住院醫師及總醫師
彰化基督教醫院婦產科主治醫師 1996~
台灣婦產科專科醫師
台北馬偕醫院婦產科研究員
淡水馬偕醫院羊水實驗室研究
中華民國婦產科內視鏡醫學會會員
中華民國婦女泌尿暨骨盆鬆弛醫學會會員
專長：尿動力檢查
婦女尿失禁評估，藥物及治療
子宮，膀胱及直腸脫垂等骨盆鬆弛手術及治療
婦科腫瘤,藥物及腹腔鏡手術治療
一般婦科,更年期,月經異常
一般產科
The Female Pelvic Floor Function, Dysfunction and Management
Static anatomy outline

Static anatomy

Pelvic with organs and connective tissues

Pelvic with organs and muscles

Relationship of the pelvic muscles to organ, ligament and fascia
Dynamic anatomy outline

Functional anatomy

Continence and micturition
The integral theory





Symptoms of stress, urge, and abnormal emptying mainly derive
From laxity
In the vagina
Its supporting ligaments
A result of altered connective tissue
Endopelvic fasciaViscero-fascial layer







Top layer of the pelvic floor
Endopelvic fascia
Endopelvic fascia attach to the uterus
Parametrium
Cardinal and uterosacral ligaments
Endopelvic fascia attach to the vagina
Paracolpium
Endopelvic fascia





The upper two thirds of the vagina
Suspended and attached to the pelvic walls by the paracolpium
after hysterectomy
Paracolpium has two portion
Level I
Upper portion

Relative long sheet of tissue

Suspend the vagina by attaching it to the pelvic wall
Endopelvic fascia

Level II

Mid-portion

Attach the vagina laterally and more directly to the
pelvic wall

Stretches the vaginal transversely between the bladder
and rectum


Pubocervical fascia
A combination of the anterior vaginal wall and its
attachments to the pelvic wall

Support the bladder
Endopelvic fascia



Level II
Rectovaginal fascia
A combination of the posterior vaginal wall and
endopelvic fascia

Blocking formation of a rectocele
Endopelvic fascia









Level III
The distal vagina
Directly attached to surrounding structures without any
intervening paracolpium
Anterior
Fuse with the urethra
Posteriorly
Fuse with perineal body
Laterally
Fuse with levator ani muscles
The dynamics of urethral opening and closure-urethral perspective

Urethral closure or opening is determined by

Contraction or relaxation of one muscle


Pubococcygeus
Stretch and close the proximal urethral cavity to “C”

Forward muscles PCM



Backward acting muscles LP and LMA
Open the urethral cavity to “O”
Relaxation of PCM

LP and LMA to stretch
The dynamics of urethral closure and opening – vaginal perspective


During effort
Distal vagina

Stretched forward by PCM

Upper vagina and bladder base


Stretched down and back by LP and LMA
PCM and LP contract against


PUL
LMA contracts against

USL
The dynamics of urethral closure and opening – vaginal perspective


During micturition
PCM relaxes

Stretch receptors activate the micturition reflex

The whole system is stretched down and back by LP
and LMA

Opening out the outflow tract

Detrusor contracts to expel urine
The biomechanics of the vagina

The vagina stretches

To transmit muscle forces for urethral opening and closure

Counteracts the hydrostatic pressure at the bladder base

Prevents displacement of the stretch receptors

Which initiate the micturition reflex
Pelvic diaphragm




Below the viscero-fascial layer
Levator ani group of muscles
Pelvic diaphragm
Together with superior and inferior fasciae of the levator ani
and the levator ani muscles
Pelvic diaphragm
Functional anatomy
Pelvic diaphragm



Levator ani
Pubovisceral muscle (a thick U-shape muscle)
Puboccocygeus and puborectalis



Sling-like arrangement
Iliococcygeus muscle
Horizontal sheet

A shelf on which the organs may rest
Pelvic diaphragm

Pubococcygeus muscle

Most cephalic portion of the levator

Connects tow relatively immovable structures


Pubic and coccyx
Could not be expected to contribute substantially to
supporting the pelvic organs
Pelvic diaphragm



Puborectalis portion of the pubovisceral m
Lateral vaginal walls are attached to it
The fibres between the vagina and pubic bone




Pubovaginalis muscle
Responsible for elevating the urethra during
pelvic muscle contraction
Continues dorsally
Some fibres insert into the rectum between the
internal and external sphincter

Others pass behind the ano-rectal junction
Pelvic diaphragm

Urogenital hiatus is bounded

Ventrally (anteriorly) by the pubic bones

Laterlly by the levator muscles

Dorsally (posteriorly) by the perineal body and external anal
sphincter
Pelvic diaphragm

Pelvic floor muscles and the supportive ligaments

The interaction is critical to pelvic organ support

If the pelvic floor muscles do not close the pelvic floor


The connective tissue must carry this load for long
periods of time
Eventually fail to hold the vaginal in place
Perineal membrane and external genital meuscles

Perineal membrane (urogenital diaphragm)

A dense triangular-shaped membrane

In anterior portion of the pelvis

Below the pelvic diaphragm

Contaning a central opening

Lies at the level of the hymenal ring

Attches the urethra, vagina, and perineal body to the
ischiopubic rami
Functional anatomy of the lower urinary tract
Conservative treatment
Pelvic floor re-education in urogynecology
Pelvic floor muscle training





Striated urethral rhabdosphincter fibers
Mainly: slow-twitch fibers
Fast-twitch fibers only in
Compressor urethrae
Fast contraction of the pelvic floor muscles

Elevate the bladder neck

Clamping the urethra

Pressing it against the pubic symphysis
Pelvic floor muscle training


Regular training
Increase the number of

Activated motor unit potentials

The frequency (neural adaptation)

Volume (hypertrophy) of excitations
Pelvic floor muscle training


Consensual protocols
Three sets of 8 to 12 slow-velocity maximal contractions

Sustained for 6 to 8 seconds

Three to four times a week

Continued for at least 4 to 5 months
Pelvic floor muscle training

Often supplemented with

Biofeedback

Intravaginal resistance devices

Vaginal cones

Electrical stimulation

Bladder retraining
Biofeedback






Are used to increase
The patients’s awareness of
The intensity and the frequency of pelvic floor muscle
contractions
Approach
One or two fingers to palpate the levator muscles
Special device consisting of a vaginal or anal probe with
electromyographic sensors
Biofeedback


Different perineometer devices are used
Surface electromyography electrodes

The vaginal surface electrode is now placed 3 cm from the
introitus

Record of pelvic floor muscle activity during
contraction
Intravaginal resistance devices

Devices (air- or water-inflated balloons or perineometers)

Inserted into the vagina

Pulled out of the vagina with a pulley system

Applies gradually increasing force
Vaginal cones




Ranging from 20 to 100 gm
Inserted into the vagina
Once the patient can hold the 20-gm cone for 20 minutes on two
occasions
The next heaviest cone is used
王馨鎂醫師學經歷
學歷：
台北醫學院醫學系學士
現任：
秀傳醫療社團法人秀傳紀念醫院乳房外科主任
資歷：
馬偕醫院一般外科主治醫師
耕莘醫院乳症特別科主治醫師
專長：
乳房手術、乳癌化學治療及荷爾蒙治療、乳癌篩檢、乳房超音波等。
如何處理乳癌病人的骨質健康問題
抗荷爾蒙治療是預防乳癌再發的重要方式之一.
其中，使用芳香環轉化酶( Aromatase Inhibitor)可以達到良好
的治療效果。
然而女性病人在身體裡雌激素濃度下降之後,會出現骨質流失的
問題，使得骨折的危險性上升.
因此，定期追蹤骨密度，建議病人經常運動,服用鈣片及維生素 D，
或使用雙磷酸鹽藥物都可以讓病患骨折的機會降低，提升生活品質。
李土生醫師學經歷
現任：秀傳紀念醫院 榮譽院長暨骨科總監
經歷：台中榮民總醫院 骨科部 部主任
德國柏林大學醫學博士
台灣骨科創傷醫學會 理事長
國際內固定研究學會 台灣分會會長
台中榮總 骨科 科主任
台北榮總 骨科 主治醫師
專長：人工膝關節置換、人工髖關節置換、肌肉及筋膜之疼痛治療、骨折、外傷
骨折內固定之選擇與應用
彰濱秀傳紀念醫院 骨科部 李土生
Life is movement
Movement is life
The principles of fracture management
and internal fixation
w Fracture reduction and fixation to
restore anatomical relationships.
w Stability by fixation or splintage, as the
personality of the fracture and the injury requires.
w Preservation of the blood supply to soft tissue and
bone by careful handling and gentle reduction
technique.
w Early and safe mobilization of the part and the
patient.
Fracture and Blood Supply
w Although a fracture is a purely mechanical
process, it triggers important biological
reactions such as bone resorption and
bone (callus) formation
w These two processes depend on the
blood supply
Factors may damage the blood
supply
w The accident
w The transportation
w The surgical approach
w The implant
w Elevated intra-articular pressure reduces the
epiphyseal bone circulation, especially in
young patients
Implants and Materials in
Fracture Fixation
w General requirement
w Special requirement (stiffness, strength, ductility,
corrosion, resistence, surface structure …)
w Biocompatibility
w Near metalic implant material (high strength alloys,
shape memory alloys)
w Biodegrable implant
w Implant materials for filling defect
w Glue
Implants and materials in
fracture fixation
w Only metal offer high stiffness and strength,
good ductility, and biocompatibility at the
same time
w Today’s metal implant are made either of
stainless steel or tatanium
w Osteosynthesis restores bone stiffness
temporarily, while fracture healing restores
it permanently
Reduction Technique (1)
w Direct reduction : The fracture area is
exposed surgically or is already widely
open.
w Indirect reduction : The fracture lines
are not directly exposed and seen, and
that the fracture area remains covered
by the surrounding soft tissue.
Reduction Technique (2)
w Indirect reduction techniques offers
enormous advantages because they add
minimal surgical damage to tissues
already traumatized by the fracture.
Surgical Reduction (1)
w The aim of reduction is to restore, as
precisely as possible, the overall length
of the bone, as well as the axial and
rotational alignment
w Fracture reduction requires a variety of
technique and flexibility of approach
Surgical Reduction (2)
w In the articular segment, to avoid
post-traumatic osteoarthritis,
anatomical reduction of the joint
surface, with elevation of the
impacted area, is mandatory.
Implants in fracture treatment
w Screw
w Plate
w Wire
w Pin
w Intramedullary nail
w External fixators
Implant Function
in
Internal Fixation
Fixation Technique
w Technique of absolute stability
‧ Lag screw
‧ Plates
‧ Tension band principle
w Technique of relative stability
‧ Intramedullary nailing
‧ Bridge plating
‧ External fixation
w Internal Fixator : a new technology
Technique of absolute stability
w Lag screw
w Plates
w Tension band principle
Principles of lag screw:
proximal 4.5mm
distal 3.2mm drill bit
Shaft screw provide
better compression
Lag screw fixation
Lag screw combine buttress
plate fixation
Lag screws with neutralization plate
Different function of plates
w Neutralization plate
w Buttress plate
w Tension band plate
w Bridge plate
Tension band principle
w The tension band convert tensile forces into
compression forces
w In the diaphysis angular deformity
(convexity) indicates the tension side
w The opposite cortex should be able to
withstand compression forces
Tension band plate
w A plate under tension is much stronger than
under bending forces
Cortical defect,
plate under bending
No cortical defect,
plate under tension
Tension band principle
The application of a tension band will neutralize the forces and
even convert them into compression when the joint is flexed
Fixation Technique
w Technique of absolute stability
‧ Lag screw
‧ Plates
‧ Tension band principle
w Technique of relative stability
‧ Intramedullary nailing
‧ Bridge plating
‧ External fixation
w Internal Fixator : a new technology
Fracture with flexible surgical
fixation
w Intramedullary nail
w External fixators
w Bridging plate
w Internal fixators (Locked plate screws)
Intramedullary nailing
w Nailing of disphyseal fractures is standard
w Interlocking increases stability of fixation and
widens the indication for nailing
w A solid nail is less susceptible to infection than a
tubular nail
w Damage to endosteal blood supply after reaming
w In severe trauma may cause respiratory distress
Unreamed nail
Solid nail
Contraindication for
intramedullary nailing
w Infection
w Femoral fractures in the multiply injuried
patient with pulmonary trauma, where
temporary stabilization by external fixator
is advocated
w Metaphyseal fractures: malalignment may
occur
Bridge plating
w The plate acts as an extramedullary
splint
w Biological plating combines adequate
stability with uncompromised biology
Bridge plate with ext. fixator
Comminuted
fracture
Bridge
plate
Medial buttress
Ext. Fixator
Fixation Technique
w Technique of absolute stability
‧ Lag screw
‧ Plates
‧ Tension band principle
w Technique of relative stability
‧ Intramedullary nailing
‧ Bridge plating
‧ External fixation
w Internal Fixator : a new technology
w Much of the vascular supply to the callus area
derives from the surrounding soft tissue, a reason
not to strip any soft tissue!
w Internal fixation of fracture alters the biology of
fracture healing
w Reaming does result in a delayed return of blood
flow in cortical bone
w The least damage to the blood supply, however,is
done by the use of external or internal fixators
Biological problems in
Conventional Internal Fixation (1)
Biological problems in
Conventional Internal Fixation (2)
w Plating :
‧ Compromise to cortical blood supply
w Nailing :
‧ Damage to endosteal blood supply
The principle of preserving
blood supply to bone, must
be addressed in every phase
of fracture management.
Recent Developments in Internal
Fixation Technology (1)
w Minimal invasive technique
‧ Nailing : The damage of endosteal blood
supply, can be reduced by avoiding
reaming
‧ Plating : Conventional plating is been
increasing replaced by using internal
fixator
Recent Developments in Internal
Fixation Technology (2)
w Unreamed solid nail with locking
w Internal fixator (uni- or bi-cortical fixation)
‧ Locked screw-plate
‧ PC-Fix
‧ LISS
w Increase stability of fixation & widens
the indication of nailing
w Limited damage of endosteal blood
supply and less susceptable to infection
Unreamed nailing with locking
Unreamed nail
Solid nail
Unreamed nailing
with locking
Internal fixator: a new
technology
w Prevent the pressure of
a plate against bone
w Function as a subcutaneous or submuscular
external fixator
w Use of locked screw and unicortical fixation
New design plate
w LC-DCP ( Limited contact-DCP)
w PC- Fix ( Point contact fixator) &
LCP plate
w LISS (Less invasive stabilization
system)
PC-Fix & LCP
w The first implant designed to fulfill the new
requirements was the small PC-Fix for
forearm fracture
w Limited application in metaphyseal and
epiphyseal area
LCP - Locked screws and plate
Compare between conventional DCP and LCP plate
Compare between DCP and LC-DCP
(a)
(b)
(c)
PC-Fix
LISS
w LISS was designed for the distal femur and
proximal tibia, to be inserted by minimal
invasive technique
New LISS plate
Choice of internal fixation
w Patient’s condition
w Soft tissue condition
w Location of fracture: articular, metaphysis,
diaphysis
w Goal of fixation: absolute stability or
flexible fixation
Articular fractures: principles
w Repair of adult articular cartilage depends
on exact reconstruction, rigid fixation, and
early motion
w Continuous passive motion (CPM) after
anatomical reduction and rigid fixation can
lead to hyaline cartilage healing
w Timing of surgery depends on soft-tissue
condition
Articular fractures: principles
w Perfect anatomical restoration and
freedom of joint motion can only be
obtained by internal fixation
(Sir John Charnley)
Intraarticular fracture need lag screw
for absolute stability
Metaphyseal fracture : principles
w Bone defect must be filled with autogenous
bone or a substitute
w Axial alignment is more important than
anatomical reduction
w Buttress of the metaphysis can be done by
plate or external fixators
Intraarticular depression
fracture need elevation
and buttress plate fixation
Technique error
Dual plate for medial buttress
Medial buttress
Tension plate with no medial buttress :
implant failure
Cortical defect
Diaphyseal fractures: principles
w Bone quality influences the choice of
fixation technique
w Fracture type and displacement are good
predictors of soft-tissue damage
w History of accident indicates the
amount of energy involved
w Arterial injury dominates decision making
Diaphyseal fractures: principles
w Exact anatomical reconstruction of the
diaphysis is not necessary for normal limb
function (humerus)
w Radius and ulnar demand anatomical
reduction similar to a joint
w Joint must be in their original axial
relationship
Unstable fracture with nonunion
Implant selection error
Too large gap and unstable fixation
Inadequate fixation :
plate too short
Neutralization plate without lag screw
fixation may fail
Dynamization of interlocking nail
cause bone union
Correct alignment
Dynamization
Static locking screw
Varus deformity
Tension bend principle
External fixator act as tension band
Wrong application
Unnecessary plating
Gap
Summary
w The pursuit of absolute stability, original
proposed for almost all fracture, is mandatory
only for joint and certain related fracture
recently.
w When clinical situation favor, the use of
plate, proper planning & the current
technique for minmal access and fixation
have been designed to minimize any insult to
the bloody supply of the bony fragment and
soft tissue
Summary
w Articular fracture - anatomical reduction and
rigid fixation (screw, plate, etc)
w Fr. of patella, olecranon, avulsion Fr. - tension
band principle (pin, wire, plate)
w Simple diaphyseal fracture - flexible fixation
(plate, nail with locking or without locking,
unreamed nail with locking)
w Multifragmental fracture - splintage fixation
(locking nail or bridging plate)
Summary
w Fracture of forearm diaphysis - anatomical
reduction with fixation (DCP, LC-DCP,
PC-Fix)
w Femoral supracondylar or proximal tibial
fr. - flexible fixation (DCS, DCP, locked
screw-plate, LISS)
Thanks for your attention !