PFNA治疗股骨粗隆间骨折内固定失败的危险因素分析

发布时间：2018-07-06 14:20

本文选题：PFNA + 股骨粗隆间骨折　；参考：《青岛大学》2017年硕士论文

【摘要】：目的:评估股骨粗隆间骨折防旋髓内钉治疗术后骨折不愈合相关因素,并评估每个可能因素的风险。方法:对2012年1月至2016年1月期间在威海市立医院确诊并经PFNA治疗的140例股骨粗隆间骨折进行回顾性研究分析。纳入研究的患者依据内固定器械的成功与否分为两组。对分组患者的术前X片的粗隆部外侧壁厚度、AO/OTA分组及术后骨折复位质量,股骨颈干角,螺旋刀头在股骨头内的位置(尖端-顶点距离和克利夫兰区)等影像学指标进行测量,对偏态分布连续变量采用Mann-Whitney U检验分析,对分类变量使用Fisher确切概率检验或连续校正卡方检验分析,对有统计差异的变量进行Logistic回归分析,回归模型拟合用Hosmer-Lemeshow拟合优度估计并对建立的Logistic模型计算预测概率,使用最大似然方法导出调整的优势比(OR)和95%置信区间(CI),以P0.05为差异有统计学意义。结果:本研究共纳入140例患者,男性62例,女性78例,平均连续随访20.3个月(6-46)。其中内固定失败9例(6.4%),并发症中发生股骨头切割最为常见,共5例(55.6%),螺旋刀片轴向移位2例(股骨头内侧穿出1例,螺旋刀片退出1例),主钉末端股骨干骨折1例,远端锁定断裂1例。内固定器械失效患者的股骨粗隆部外侧壁厚度平均为21.7mm,明显低于内固定有效组的27.5mm,差异有统计学意义(P0.05),且经Logistic回归分析发现其是内固定失败最重要的危险因素;螺旋刀片的TAD值在20-30mm无一例出现内固定失败,TAD20mm或TAD30mm内固定失败风险显著增高,TAD是内固定失败第二相关因素;骨折复位后颈干角130°患者失败率明显高于颈干角130°患者,两组间差异有明显(P0.05),故应避免骨折在内翻位进行固定;良好的骨折复位可提供稳定的支撑,复位良好同复位质量差的患者组统计分析也存在明显差异(P0.05);而患者的年龄、性别、骨折分类及螺旋刀片头端在股骨头内象限分布无明显统计学意义。内固定失败相关因素是:股骨近端外侧厚度、骨折复位质量、螺旋刀头在股骨头内的位置及复位后股骨颈干角,其中股骨近端外侧壁厚度是最重要的危险因素。结论:股骨近端外侧壁的厚度,TAD20mm或TAD30mm,骨折复位不理想,复位后颈干角130°可能是防旋髓内钉治疗粗隆间骨折术后发生内固定失败的相关因素,其中股骨粗隆部外侧壁质量对内固定失败与否最为关键,TAD的影响位于其次。而患者年龄、性别、骨折类型及螺旋刀片头端所在股骨头象限内分布对内固定是否失败影响相对较小。
[Abstract]:Objective: to evaluate the factors associated with nonunion of intertrochanteric fractures and evaluate the risk of each possible factor. Methods: 140 cases of femoral intertrochanteric fractures diagnosed in Weihai City Hospital from January 2012 to January 2016 and treated with PFNA were analyzed retrospectively. The patients included in the study were divided into two groups according to the success of the internal fixation device. The thickness of the lateral wall of the trochanter and the reduction quality of the fracture, the angle of the femoral neck, the position of the helical head in the femoral head (tip-vertex distance and Cleveland area) were measured. Mann-Whitney U test was used to analyze the skewed continuous variables, Fisher exact probability test or continuous corrected chi-square test was used to analyze the classification variables, and logistic regression analysis was carried out on the variables with statistical differences. In regression model fitting, Hosmer-Lemeshow goodness of fit was used to estimate the prediction probability of Logistic model, and the adjusted odds ratio (OR) and 95% confidence interval (CI) were derived by maximum likelihood method. The difference was statistically significant with P0.05. Results: a total of 140 patients, 62 males and 78 females, were followed up for an average of 20.3 months (6-46). The internal fixation failure occurred in 9 cases (6.4%), the most common complication was femoral head cutting (55.6%), axial displacement of helical blade (1 case of medial femoral head perforation, 1 case of exiting screw blade), fracture of femoral shaft at the end of main nail (1 case), fracture of femoral shaft at the end of main nail (1 case), axial displacement of helical blade (1 case). Distal locking rupture in 1 case. The average thickness of lateral wall of trochanter of femur was 21.7 mm in patients with failure of internal fixation, which was significantly lower than that in effective group of internal fixation (27.5 mm) (P0.05). Logistic regression analysis showed that the thickness of lateral wall of trochanter was the most important risk factor for failure of internal fixation. There was no significant risk of failure of internal fixation in 20-30mm. TAD20mm or TAD30mm was the second related factor of the failure of internal fixation, and the failure rate of the patients with 130 掳angle of cervical trunk after fracture reduction was significantly higher than that of patients with 130 掳angle of the neck shaft, and the risk of failure of TAD20mm or TAD30mm was significantly higher than that of the patients with internal fixation failure. There were significant differences between the two groups (P0.05), so we should avoid the internal fixation of fractures; good reduction of fractures can provide stable support, and there are significant differences in statistical analysis of patients with good reduction and poor quality of reduction (P0.05). No statistical significance was found in the classification of fractures and the distribution of the head of the helical blade in the quadrant of the femoral head. The factors related to the failure of internal fixation were the thickness of proximal femur, the quality of fracture reduction, the position of helical head in the femoral head and the angle of femoral neck trunk after reduction, among which the thickness of lateral wall of proximal end of femur was the most important risk factor. Conclusion: the thickness of proximal lateral wall of femur is 20 mm or 30 mm of TAD, and the reduction of fracture is not ideal. The angle of cervical trunk 130 掳after reduction may be the related factor of failure of internal fixation after treatment of intertrochanteric fracture with anti-rotation intramedullary nail. The quality of lateral wall of femoral trochanter was the most important factor to the failure of internal fixation. However, age, sex, fracture type and distribution of femoral head quadrant at the head of screw blade had relatively little effect on failure of internal fixation.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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