股骨近端抗旋转髓内钉稳定评分系统的预测价值△

Predictive value of a scoring system for failure of proximal femoral nail anti- rotational used for femoral intertrochanter fractures

摘要:

[目的]探讨股骨近端抗旋转髓内钉（proximal femoral nail anti-rotation, PFNA）失败的危险因素，建立 PFNA 术后稳定性评分系统，并探讨其预测价值。[方法]2019 年 1 月—2022 年 1 月宁阳县第一人民医院收治的股骨转子间骨折（股骨粗隆间骨折）患者 164 例纳入本研究，根据随访结果将患者分为成功组、失败组。采用单因素及二元回归分析探讨导致固定失败的危险因素，依据危险因素建立 PFNA 术后稳定性评分表。采用受试者工作曲线 （ROC） 分析此评分预测失败的价值。[结果] 164 例患者中，共 38 例 PFNA 失败，失败率 23.2%。单项因素比较，失败组外侧壁完整 [例, 完整/不完整; (12/25) vs (93/33), P＜ 0.05]，Cal-TAD [例, ＜25 mm/≥25 mm; (9/29) vs (83/43), P＜0.05]，螺旋刀片位置 [例, 好/差; (13/25) vs (111/15), P＜0.05]，骨折分型 [例, 完整/危险/破裂; (5/12/21) vs (98/17/11), P＜0.05]，复位质量 [例, 优/良/差; (4/12/22) vs (81/29/16), P＜0.05]，皮质支撑 [例, 阳性/ 中性/阴性; (4/11/23) vs (82/29/15), P＜0.05] 显著差于成功组。逻辑回归分析表明，外侧壁完整差 （OR=12.118, P=0.007）、CalTAD 大 （OR=18.995, P=0.003）、螺旋刀片位置不佳 （OR=20.603, P=0.003）、骨折分型差 （OR=14.71, P=0.014）、内侧皮质阴性支撑（OR=16.068, P=0.01）、复位质量差（OR=45.598, P=0.001）是 PFNA 固定失败发生的独立危险因素。依据逻辑回归建议评分系统，ROC 分析显示，此评分系统预测固定失败的临界值为 6.5，曲线下面积 （AUC） 为 0.934，灵敏度及特异度为 94.7%、 73.0%。[结论]外侧壁完整差、螺旋刀片位置不佳、骨折分型差、内侧皮质阴性支撑、复位质量差是 PFNA 失败的危险因素， 据此建立的评分系统，对预测 PFNA 失败可能有一定临床意义。

Abstract:

[Objective] To explore the risk factors for failure of proximal femoral nail anti-rotation (PFNA), establish a scoring system for postoperative stability of PFNA, and explore its predictive value. [Methods] A total of 164 patients who received PFNA for femoral inter- trochanteric fractures in our hospital from January 2019 to January 2022 were included in this study. According to the follow-up results, the patients were divided into successful group and failure group. Univariate comparison and binary regression analysis were used to search the risk factors of PFNA failure. A scoring system was established according to the risk factors, its value for predicting PFNA failure was an- alyzed using receiver operating curve (ROC). [Results] Of the 164 patients, 38 patients were confirmed as PFNA failure, counting for 23.2%. As consequences of univariate comparison, the failure group was significantly inferior to the successful group in terms of that the lat- eral wall integrity [n, complete/incomplete; (12/25) vs (93/33), P＜0.05], calcar referenced tip-apex distance (Cal-TAD) [n, ＜25 mm /≥25 mm; (9/29) vs (83/43), P＜0.05], spiral blade position [n, good/poor; (13/25) vs (111/15), P＜0.05], fracture classification [n, complete/danger- ous/broken; (5/12/21) vs (98/17/11), P＜0.05], reduction quality [n, excellent/good/poor; (4/12/22) vs (81/29/16), P＜0.05], cortical support [n, positive/neutral/negative; (4/11/23) vs (82/29/15), P＜0.05]. Based on logistic regression analysis, poor lateral wall integrity (OR=12.118, P= 0.007), greater Cal-TAD (OR=18.995, P=0.003), poor spiral blade position (OR=20.603, P=0.003), and poor fracture classification (OR= 14.71, P=0.014), negative medial cortical support (OR=16.068, P=0.01) and poor reduction quality (OR=45.598, P=0.001) were indepen- dent risk factors for PFNA failure. According to the logistic regression, a scoring system was created, and ROC analysis showed that the crit- ical value for predicting fixed failure of this scoring system was 6.5, the area under the curve (AUC) was 0.934, and the sensitivity and speci- ficity were 94.7% and 73.0%. [Conclusion] Poor lateral wall integrity, poor spiral blade position, poor fracture classification, negative medi- al cortical support, and poor reduction quality are risk factors for PFNA failure. The scoring system established on this basis might have clinical significance for predicting PFNA failure in some extent.