不稳定股骨粗隆间骨折PFNA-Ⅱ术后效果的影响因素分析

蒋臻; 郑明军; 赵小波; 鲍涛; 李城女

doi:10.16766/j.cnki.issn.1674-4152.002224

不稳定股骨粗隆间骨折PFNA-Ⅱ术后效果的影响因素分析

doi: 10.16766/j.cnki.issn.1674-4152.002224

1.
浙江省人民医院淳安分院骨科，浙江杭州 311700
2.
浙江省人民医院淳安分院麻醉科，浙江杭州 311700

基金项目:

浙江省医药卫生科技计划项目 2018KY149

详细信息

通讯作者:
蒋臻，E-mail：zjjiangz1974@163.com

中图分类号: R683.42 R687.4
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- 文章访问数: 165
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- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2020-12-25
- 网络出版日期: 2022-03-02

Analysis of influencing factors of the postoperative effect of unstable intertrochanteric fractures of PFNA-Ⅱ

1.
Department of Orthopaedics, Chun'an Branch of Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 311700, China

摘要

摘要: 目的探讨不稳定股骨粗隆间骨折PFNA-Ⅱ术后效果的影响因素。方法选取2016年1月—2019年1月于浙江省人民医院淳安分院行PFNA-Ⅱ的不稳定股骨粗隆间骨折患者63例，术后随访1年，根据术后髋关节Harris功能评分，分为优良组(Harris评分≥80分)和不良组(Harris评分＜80分)，对比2组患者一般资料及手术相关指标的差异，并行多因素logistic回归分析。结果随访过程中有1例患者失访，剩余62例患者末次随访时，42例Harris评分≥80分列为优良组，其余20例Harris评分＜80分列为不良组，术后髋关节功能不良率为32.26%(20/62)；比较2组BMI(25.31±4.63 vs. 27.96±4.72)、骨质疏松比例(47.62% vs. 85.00%)、尖顶距[(24.43±1.65)mm vs. (26.84±2.18)mm]、外侧壁分型(Ⅰ~Ⅲ型，分别为61.90%、33.33%、4.76% vs. 30.00%、40.00%、30.00%)、外侧壁厚度[(2.43±0.39)mm vs. (2.05±0.31)mm]，差异均有统计学意义(均P < 0.05)；多因素logistic回归分析结果显示：尖顶距、外侧壁分型、外侧壁厚度(均P＜0.05)可能是PFNA-Ⅱ术后髋关节功能的独立影响因素。结论尖顶距大、外侧壁完整性差及外侧壁薄是不稳定股骨粗隆间骨折PFNA-Ⅱ术后髋关节功能不良的独立危险因素。
- 股骨粗隆间骨折 /
- 不稳定 /
- 股骨近端防旋转髓内钉 /
- 髋关节功能
Abstract: Objective To explore the factors affecting the effect of PFNA-Ⅱ after unstable femoral intertrochanteric fractures. Methods A total of 63 patients with unstable femoral intertrochanteric fractures who underwent PFNA-Ⅱ at the Chun'an Branch of Zhejiang Provincial People's Hospital from January 2016 to January 2019 were followed up for 1 year. According to the Harris function score of the hip joint after surgery, the patients were divided into the good group (Harris score ≥ 80 points) and poor group (Harris score < 80 points). The differences in general information and surgery-related indicators between the two groups were compared, and multivariate logistic regression analysis was performed. Results During the follow-up, 1 patient was lost to follow-up. At the last follow-up of the remaining 62 patients, 42 patients with Harris score ≥ 80 were classified as the good group, and the remaining 20 patients with Harris score < 80 were classified as the poor group. The rate of postoperative hip dysfunction was 32.26% (20/62). There were significant differences in BMI (25.31±4.63 vs. 27.96±4.72), osteoporosis ratio (47.62% vs. 85.00%), apex distance [(24.43±1.65) mm vs. (26.84±2.18) mm], lateral wall classification (type Ⅰ-Ⅲ, fractions are 61.90%, 33.33%, 4.76% vs. 30.00%, 40.00%, 30.00%), thickness of outer wall [(2.43±0.39) mm vs. (2.05±0.31) mm] between the two groups (all P < 0.05). The results of multivariate logistic regression analysis showed that the apex distance, lateral wall type and lateral wall thickness were independent influencing factors of hip joint function after PFNA-Ⅱ operation (all P < 0.05). Conclusion The large apex distance, poor integrity of the lateral wall and thin lateral wall are independent risk factors for hip dysfunction after PFNA-Ⅱ operation for unstable femoral intertrochanteric fractures.
- Intertrochanteric fractures /
- Instability /
- Proximal femoral nail antirotation /
- Hip function

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图 1 典型病例1的手术前后影像资料

注：A为术前；B为术后1 d；C为术后7个月；D为术后1年。

下载: 全尺寸图片幻灯片

图 2 典型病例2的手术前后影像资料

注：A为术前；B为术后1 d；C为术后6个月；D为术后1年。

下载: 全尺寸图片幻灯片

表 1 2组骨折患者一般资料对比

组别	例数	性别[例(%)]		年龄 (x±s，岁)	BMI (x±s)	糖尿病史[例(%)]		高血压史[例(%)]
组别	例数	男性	女性	年龄 (x±s，岁)	BMI (x±s)	否	是	否	是
优良组	42	17(40.47)	25(59.52)	70.32±9.31	25.31±4.63	31	11	33(78.57)	9(21.43)
不良组	20	9(45.00)	11(55.00)	68.75±8.48	27.96±4.72	15	5	12(60.00)	8(40.00)
统计量		0.114^a		0.638^b	-2.094^b	0.010^a		2.348^a
P值		0.736		0.526	0.041	0.920		0.125

组别	例数	慢性肾病史[例(%)]		长期吸烟[例(%)]		长期饮酒[例(%)]		骨质疏松[例(%)]
组别	例数	否	是	否	是	否	是	否	是
优良组	42	36(85.71)	6(14.29)	29	13	32(76.19)	10(23.81)	22(52.38)	20(47.62)
不良组	20	15(75.00)	5(25.00)	11	9	11(55.00)	9(45.00)	3(15.00)	17(85.00)
统计量		0.458^a		1.168^a		2.862^a		7.867^a
P值		0.499		0.280		0.091		0.005
注：^a为χ²值, ^b为t值。

下载: 导出CSV

表 2 2组骨折患者手术相关指标对比

组别	例数	尖顶距 (x±s，mm)	外侧壁分型[例(%)]			外侧壁厚度 (x±s，mm)	刀片位置[例(%)]		颈干角 (x±s)	ASA分级[例(%)]
组别	例数	尖顶距 (x±s，mm)	Ⅰ	Ⅱ	Ⅲ	外侧壁厚度 (x±s，mm)	正中	其他	颈干角 (x±s)	Ⅰ/Ⅱ	Ⅲ/Ⅳ
优良组	42	24.43±1.65	26(61.90)	14(33.33)	2(4.76)	2.43±0.39	30(71.43)	12(28.57)	131.73±8.32	33(78.57)	9(21.43)
不良组	20	26.84±2.18	6(30.00)	8(40.00)	6(30.00)	2.05±0.31	13(65.00)	7(35.00)	133.56±9.17	12(60.00)	8(40.00)
统计量		-4.836^a	2.801^b			3.816^a	0.263^c		-0.783^a	2.348^c
P值		< 0.001	0.005			＜0.001	0.610		0.436	0.125
注：^a为t值，^b为U值，^c为χ²值。

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表 3 PFNA-Ⅱ术后髋关节功能多因素分析的赋值情况

变量	变量名	赋值
X1	BMI	连续变量，实测值
X2	骨质疏松	是=1；否=0
X3	尖顶距	连续变量，实测值
X4	外侧壁分型	Ⅰ型=1；Ⅱ型=2；Ⅲ型=3
X5	外侧壁厚度	连续变量，实测值
Y	功能不良	是=1；否=0

下载: 导出CSV

表 4 PFNA-Ⅱ术后髋关节功能的多因素分析

因变量	B	SE	Wald χ²	P值	OR值	95% CI
BMI	0.166	0.108	2.359	0.125	1.181	0.955~1.460
尖顶距	0.619	0.256	5.836	0.016	1.857	1.124~3.069
外侧壁厚度	-3.808	1.715	4.934	0.026	0.022	0.001~0.639
骨质疏松	-0.146	1.169	0.016	0.901	0.865	0.088~8.541
外侧壁分型	2.213	0.813	7.408	0.006	9.139	1.858~44.962

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参考文献(20)

[1]	ZHAO K, ZHANG J, LI J, et al. Treatment of unstable intertrochanteric fractures with proximal femoral nailing antirotation: Traction table or double reverse traction repositor[J]. J Invest Surg, 2020, 4(12): 1-7.
[2]	HONG J B, DAN Y, OUYANG L, et al. Biomechanical study on different lengths of PFNA fixation for unstable intertrochanteric femoral fractures[J]. J Musculoskelet Neuronal Interact, 2017, 17(4): 299-302.
[3]	CHEN J, MA J X, WANG Y, et al. Finite element analysis of two cephalomedullary nails in treatment of elderly reverse obliquity intertrochanteric fractures: Zimmer natural nail and proximal femoral nail antirotation-Ⅱ[J]. J Orthop Surg Res, 2019, 14(1): 422-425. doi: 10.1186/s13018-019-1468-3
[4]	STENICKA S, HANREICH C, BABELUK R, et al. High revision rates of a cementless beta-titanium alloy stem with contamination-free roughened surface in primary total hip arthroplasty[J]. J Clin Med, 2020, 9(7): 1-6.
[5]	HECKMANN N, HILL J R, VAKHSHORI V, et al. Increased pulmonary complications associated with intramedullary fixation of intertrochanteric fractures: An analysis of 13, 276 hips[J]. J Am Acad Orthop Surg, 2019, 27(18): 690-695. doi: 10.5435/JAAOS-D-17-00921
[6]	SHIN W C, SEO J D, LEE S M, et al. Radiographic outcomes of osteosynthesis using proximal femoral nail antirotation (PFNA) system in intertrochanteric femoral fracture: has PFNA Ⅱ solved all the problems?[J]. Hip Pelvis, 2017, 29(2): 104-112. doi: 10.5371/hp.2017.29.2.104
[7]	SOCCI A R, CASEMYR N E, LESLIE M P, et al. Implant options for the treatment of intertrochanteric fractures of the hip: Rationale, evidence, and recommendations[J]. Bone Joint J, 2017, 99-B(1): 128-133. doi: 10.1302/0301-620X.99B1.BJJ-2016-0134.R1
[8]	LENGUERRAND E, WHITEHOUSE M R, BESWICK A D, et al. Risk factors associated with revision for prosthetic joint infection following knee replacement: An observational cohort study from England and Wales[J]. Lancet Infect Dis, 2019, 19(6): 589-600. doi: 10.1016/S1473-3099(18)30755-2
[9]	刘永起. PFNa与股骨近端解剖型锁定钢板治疗老年股骨粗隆间骨折的临床研究[J]. 中国全科医学, 2019, 22(S02): 93-95. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX2019S2032.htm
[10]	SINGH N K, SHARMA V, TRIKHA V, et al. Is PFNA-Ⅱ a better implant for stable intertrochanteric fractures in elderly population? A prospective randomized study[J]. J Clin Orthop Trauma, 2019, 10(Suppl1): S71-S76.
[11]	ZHANG H, ZENG X, ZHANG N, et al. INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis[J]. J Int Med Res, 2017, 45(4): 1297-1309. doi: 10.1177/0300060517710584
[12]	SAKAGOSHI D, SAWAGUCHI T, SHIMA Y, et al. A refined definition improves the measurement reliability of the tip-apex distance[J]. J Orthop Sci, 2016, 21(4): 475-480. doi: 10.1016/j.jos.2016.03.001
[13]	NAYAK M, YADAV R, GANESH V, et al. An unusual case of femoral head perforation following fixation with proximal femoral nail antirotation (PFNA-Ⅱ) for an unstable intertrochanteric fracture: Case report and literature review[J]. Trauma Case Rep, 2019, 20(3): 100178.
[14]	DURAMAZ A, LTER M H. The impact of proximal femoral nail type on clinical and radiological outcomes in the treatment of intertrochanteric femur fractures: A comparative study[J]. Eur J Orthop Surg Traumatol, 2019, 29(7): 1441-1449. doi: 10.1007/s00590-019-02454-y
[15]	苏启旭, 巴黎, 王松. PFNA治疗老年股骨粗隆间骨折的效果及影响因素[J]. 中国老年学杂志, 2020, 40(6): 1234-1236. doi: 10.3969/j.issn.1005-9202.2020.06.038
[16]	KIM S S, KIM H J, LEE C S, Clinical outcomes of PFNA-Ⅱ in the Asian intertrochanteric fracture patients: Comparison of clinical results according to proximal nail protrusion[J]. Injury, 2020, 51(2): 361-366. doi: 10.1016/j.injury.2019.11.040
[17]	周钰卓, 齐宇新, 马腾洋, 等. 老年股骨粗隆间骨折PFNA失败的危险因素分析[J]. 中国矫形外科志, 2020, 28(4): 292-296. https://www.cnki.com.cn/Article/CJFDTOTAL-ZJXS202004003.htm
[18]	陈述祥, 刘彦, 区文欢, 等. 体质量指数对高龄股骨转子间骨折PFNA内固定术后疗效的影响[J]. 中华肥胖与代谢病电子杂志, 2017, 3(3): 138-142. doi: 10.3877/cma.j.issn.2095-9605.2017.03.006
[19]	向云. PFNA微创治疗老年骨质疏松性股骨粗隆间骨折的效果研究[J]. 中国伤残医学, 2019, 27(7): 35-36. https://www.cnki.com.cn/Article/CJFDTOTAL-YIYA201512038.htm
[20]	李大鹏, 黄永辉, 沈铁城, 等. DHS与PFNA治疗骨质疏松性股骨粗隆间骨折疗效分析[J]. 临床医学工程, 2012, 19(3): 364-365. doi: 10.3969/j.issn.1674-4659.2012.03.0364