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。

关键词:股骨粗隆间骨折;股骨近端抗旋转髓内钉(PFNA);失败;危险因素;预测

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.

Key words:femoral intertrochanteric fracture; proximal femoral nail anti-rotation (PFNA); failure; risk factors; prediction