目的: 比較兩種微創手術方式(MIDHS與Gamma-3 nail)在治療老年髖關節轉子間骨折的手術預後及醫療耗用差異。
方法:利用病例回溯性研究，研究族群來自高雄某區域教學醫院，年齡在65歲以上，90歲以下被診斷為髖關節轉子間骨折且有接受微創手術治療患者。比較病人的基本資料、手術紀錄結果、住院期間及後續門診追蹤紀錄，分析病人手術後一年追蹤之患肢的功能恢復程度及利用X光判斷骨折有無癒合。使用描述性統計、獨立樣本t檢定、單因子變異數分析與迴歸分析進行資料處理分析。
結果:研究族群總共收錄了165人，採用MIDHS手術方式者有79人，採用Gamma-3 nail固定方式有86人。在手術結果比較方面，採用MIDHS患者有較短手術時間、較小手術傷口及術後血色素降低較少；兩種手術的術後患肢功能及X光骨折癒合率沒有差異。使用Gamma-3 nail來治療髖關節轉子間骨折有較多的醫療花費；使用MIDHS治療能讓醫療院所在健保定額給付下獲得較多的利潤。
結論:使用MIDHS方式來治療老年髖關節轉子間骨折對於身體傷害較低，較不易增加老年患者手術風險。兩種微創手術的術後功能預後及骨折癒合率無明顯差別。採用MIDHS的總醫療花費金額較低，在台灣健保定額給付政策下能使醫療院所的利潤提高。

Objective: To compare the prognosis and medical cost of two minimally invasive surgeries (the minimally invasive Dynamic Hip Screw (MIDHS) vs. Gamma3 nail) to treat elderly intertrochanteric fractures.
Method: This retrospective case study was carried out at a regional teaching hospital in Kaohsiung, Taiwan. Patients aged 65 to 90 years old with hip intertrochanteric fractures received minimally invasive surgery within three days of the injury. Basic patient characteristics were collected and compared, as well as surgical records and follow-up records from the hospital and medical clinics. The Harris Hip Score was used to analyze the functional recovery of the affected limb, and an X-ray was used to assess fracture healing. Descriptive statistics, an independent sample t-test, single factor variation analysis, and regression analysis were used for data processing analysis.
Result: A total of 165 people were in the study group, 79 of whom were treated with MIDHS and 86 of whom were treated with the Gamma3 nail. Patients with a MIDHS have a shorter surgical time, smaller surgical wounds, and higher hemoglobin levels after surgery. There was no difference in affected limb function and fracture healing rate between the two procedure groups. The Gamma3 nail has a higher medical cost. The MIDHS treatment is more profitable under the Tw-DRGs fixed payment in Taiwan.
Conclusion: The use of a minimally invasive Dynamic Hip Screw (MIDHS) to treat elderly hip intertrochanteric fractures results in a shorter surgical time, smaller surgical wounds, and higher hemoglobin levels after surgery. There was no significant difference in functional prognosis and fracture healing rate between the two procedures. MIDHS has a relatively low medical expenses, which can increase profits under the Tw-DRGs fixed payment policy.

學位論文審定書 i
誌謝 ii
摘要 iii
Abstract iv
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻探討 4
第一節 骨質疏鬆症及髖關節轉子間骨折介紹 4
第二節 各國在治療髖關節轉子間骨折的醫療耗用現況 23
第三節 小結 26
第三章 研究方法 28
第一節 研究設計與研究架構 28
第二節 研究對象與資料來源 29
第三節 研究變項操作型定義 30
第四節 資料處理及統計分析 34
第四章 研究結果 36
第一節 研究族群基本特徵、手術結果及預後追蹤分析 36
第二節 治療髖關節轉子間骨折之醫院獲利(虧損)因素分析 46
第三節 影響醫院獲利(虧損)影響因素複迴歸分析 52
第五章 討論與建議 57
第一節 採用微創手術治療老年髖關節轉子間骨折的手術預後比較 57
第二節 不同微創手術來治療老年髖關節轉子間骨折的醫療經濟 59
第三節 研究限制 61
第四節 研究貢獻 61
第五節 後續研究之建議 62
參考文獻 63
附錄一:CCI與ICM-9-CM、ICM-10-CM對應表 70

圖目錄
圖 2 1 近端股骨生理結構。(摘錄至NETTER氏圖譜 中文版) 6
圖2 2 股骨頭血液供應，摘錄至ORTHOPEDIC IMAGING A PRACTICAL APPROACH,4TH EDITION,P234。 7
圖 2 3 近端股骨骨小樑線分布，摘錄至ORTHOPEDIC IMAGING A PRACTICAL APPROACH,4TH EDITION,P235 9
圖 2 4 髖關節骨折X-光。 9
圖2-5 BOYD & GRIFFIN 分類。摘錄至ROOKWOOD AND GREEN’S FRACTURES IN ADULES,7ED,2010 10
圖 2 6 THE MÜLLER AO CLASSIFICATION OF FRACTURES。摘錄至OKU9, P405。 11
圖 2 7 骨骼牽引示意圖。摘錄至ESSENTIAL ORTHOPAEDICS,2010,P590。 12
圖 2 8 內固定X光示意圖。 13
圖 2 9 動態型髖關節骨釘組，摘錄至鄭浩任,2009。 14
圖 2 10病患於骨折床上擺位姿勢圖。摘錄至AO PRINCIPLES OF FRACTURE MANAGEMENT, P446。 15
圖 2 11 近端股骨手術示意圖。摘錄至KEY TECHNIQUES IN ORTHOPAEDIC SURGERY，P137-8。 15
圖 2 12 MIDHS手術示意圖。摘錄至WONG ET AL.,2009 文獻附圖。 17
圖 3 1 研究架構 28

表目錄
表 2 1 CDHS與MIDHS歷年文獻比較 17
表 2 2 使用CDHS與GAMMA NAIL歷年文獻比較 20
表 3 1 CCI-Q 合併罹病症指數(參考鄒怡真，2011)。 31
表 4 1 研究族群基本特徵分析 38
表 4 2 手術治療資訊比較 41
表 4 3 醫療經濟比較 43
表 4 4 手術品質比較 45
表 4 5 病人基本特徵與醫院獲利(虧損)相關性分析 48
表 4 6 手術因素與醫院獲利(虧損)相關性分析 51
表 4 7 多變量線性回歸 52
表 4 8 醫院盈餘(虧損)金額相關因子複迴歸分析 54
表 4 9 醫院盈餘(虧損)金額相關因子的羅吉斯迴歸分析 56

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