本文選題：PFNA + 股骨粗隆間骨折　； 參考：《青島大學》2017年碩士論文

【摘要】：目的:評估股骨粗隆間骨折防旋髓內(nèi)釘治療術后骨折不愈合相關因素,并評估每個可能因素的風險。方法:對2012年1月至2016年1月期間在威海市立醫(yī)院確診并經(jīng)PFNA治療的140例股骨粗隆間骨折進行回顧性研究分析。納入研究的患者依據(jù)內(nèi)固定器械的成功與否分為兩組。對分組患者的術前X片的粗隆部外側壁厚度、AO/OTA分組及術后骨折復位質量,股骨頸干角,螺旋刀頭在股骨頭內(nèi)的位置(尖端-頂點距離和克利夫蘭區(qū))等影像學指標進行測量,對偏態(tài)分布連續(xù)變量采用Mann-Whitney U檢驗分析,對分類變量使用Fisher確切概率檢驗或連續(xù)校正卡方檢驗分析,對有統(tǒng)計差異的變量進行Logistic回歸分析,回歸模型擬合用Hosmer-Lemeshow擬合優(yōu)度估計并對建立的Logistic模型計算預測概率,使用最大似然方法導出調(diào)整的優(yōu)勢比(OR)和95%置信區(qū)間(CI),以P0.05為差異有統(tǒng)計學意義。結果:本研究共納入140例患者,男性62例,女性78例,平均連續(xù)隨訪20.3個月(6-46)。其中內(nèi)固定失敗9例(6.4%),并發(fā)癥中發(fā)生股骨頭切割最為常見,共5例(55.6%),螺旋刀片軸向移位2例(股骨頭內(nèi)側穿出1例,螺旋刀片退出1例),主釘末端股骨干骨折1例,遠端鎖定斷裂1例。內(nèi)固定器械失效患者的股骨粗隆部外側壁厚度平均為21.7mm,明顯低于內(nèi)固定有效組的27.5mm,差異有統(tǒng)計學意義(P0.05),且經(jīng)Logistic回歸分析發(fā)現(xiàn)其是內(nèi)固定失敗最重要的危險因素;螺旋刀片的TAD值在20-30mm無一例出現(xiàn)內(nèi)固定失敗,TAD20mm或TAD30mm內(nèi)固定失敗風險顯著增高,TAD是內(nèi)固定失敗第二相關因素;骨折復位后頸干角130°患者失敗率明顯高于頸干角130°患者,兩組間差異有明顯(P0.05),故應避免骨折在內(nèi)翻位進行固定;良好的骨折復位可提供穩(wěn)定的支撐,復位良好同復位質量差的患者組統(tǒng)計分析也存在明顯差異(P0.05);而患者的年齡、性別、骨折分類及螺旋刀片頭端在股骨頭內(nèi)象限分布無明顯統(tǒng)計學意義。內(nèi)固定失敗相關因素是:股骨近端外側厚度、骨折復位質量、螺旋刀頭在股骨頭內(nèi)的位置及復位后股骨頸干角,其中股骨近端外側壁厚度是最重要的危險因素。結論:股骨近端外側壁的厚度,TAD20mm或TAD30mm,骨折復位不理想,復位后頸干角130°可能是防旋髓內(nèi)釘治療粗隆間骨折術后發(fā)生內(nèi)固定失敗的相關因素,其中股骨粗隆部外側壁質量對內(nèi)固定失敗與否最為關鍵,TAD的影響位于其次。而患者年齡、性別、骨折類型及螺旋刀片頭端所在股骨頭象限內(nèi)分布對內(nèi)固定是否失敗影響相對較小。
[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 擄angle of cervical trunk after fracture reduction was significantly higher than that of patients with 130 擄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 擄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.
【學位授予單位】：青島大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R687.3

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