股骨转子间骨折手术治疗后骨折不愈合的危险因素分析

Risk factors of nonunion after surgical treatment of femoral intertrochanteric fractures

目的探究股骨转子间骨折经动力髋螺钉内固定(dynamic hip screw,DHS)手术治疗后骨折不愈合的危险因素。方法回顾性分析我院2014年1月至2016年6月期间因股骨转子间骨折住院且接受DHS治疗的病人368例,年龄为(57.4±13.2)岁(34~79岁);其中,男192例,女176例。对性别、年龄、身体质量指数(BMI)、骨折类型(稳定型或不稳定型)、Signh分级、是否合并糖尿病、螺钉位置、螺钉深度、是否纠正髋内翻、Garden对线指数、颈干角、不负重活动时间以及负重活动时间等指标进行二分类量化,并通过单因素分析和Logistic多因素回归分析进行危险因素分析。结果 349例骨折愈合,19例骨折不愈合,骨折不愈合的发生率为5.16%。单因素分析结果显示:年龄、骨折类型、Signh分级、螺钉位置、螺钉深度、Garden对线指数、颈干角以及不负重活动时间对术后骨折不愈合的发生有影响,差异均具有统计学意义(P均<0.05)。Logistic多因素回归分析显示股骨转子间DHS手术治疗后骨折不愈合的独立危险因素有:年龄≥60岁[OR=3.694,95%CI(2.247,3.942)];不稳定型骨折[OR=3.214,95%CI(3.081,5.637)];Signh分级为Ⅰ~Ⅲ级[OR=4.267,95%CI(4.060,7.532)];螺钉位置不理想[OR=5.124,95%CI:4.635,8.421];螺钉深度不到位[OR=3.284,95%CI(2.427,7.392)];Garden对线指数不理想[OR=4.268,95%CI(3.629,5.484)]以及颈干角不正常[OR=11.426,95%CI(6.427,20.424)]。结论在股骨转子间骨折的DHS治疗中,对于高龄、不稳定型骨折以及可能合并有骨质疏松的病人应注意减少手术创伤,改善其营养状况;同时在手术过程中需要注意把握进钉位置、深度,保证骨折断端的对线以及颈干角的恢复。

Objective To explore the risk factors of nonunion after dynamic hip screw （DHS） surgery of intertrochanteric fractures. Methods A retrospective analysis on 368 cases of intertrochanteric fracture of femur hospitalized and treated with DHS from January 2014 to June 2016 in our hospital. The age was （57.4±13.2） years （range, 34-79 years）, including 192 males and 176 females. Gender, age, body mass index, fracture type （stable or unstable）, Signh classification, diabetes mellitus, screw position, screw depth, correction of coxa varus, Garden alignment index, cervical trunk angle, duration of non-weight-bearing activity and duration of weight-bearing activity were quantified by binary classification and single-factor analysis. Logistic regression analysis was used to analyze the risk factors. Results There were 349 cases of fracture healing and 19 cases of nonunion （5.16%）. Univariate analysis showed that age （＞60 years）, unstable fracture, Signh grade Ⅰ-Ⅲ, poor screw position, poor screw depth, Garden alignment index, and abnormal cervical shaft angle had significant effects on postoperative nonunion （P＜0.05 for all）. Logistic multivariate regression analysis showed that age ＞60 years [OR=3.694, 95%CI（2.247, 3.942）], unstable fracture [OR=3.214, 95%CI（3.081, 5.637）], Signh grade Ⅰ-Ⅲ [OR=4.267, 95%CI（4.060, 7.532）], unideal screw position [OR=5.124, 95%CI（4.635, 8.421）], screw depth not in place [OR=3.284, 95%CI（2.427, 7.392）], garden alignment index [OR=4.268, 95%CI（3.629, 5.484）] and abnormal cervical shaft angle [OR=11.426, 95%CI（6.427, 20.424）] were independent risk factors for fracture nonunion after intertrochanteric DHS. Conclusion In the DHS treatment of intertrochanteric fracture of the femur, the surgical trauma should be reduced, and the nutritional status should be improved in the elderly patients with unstable fracture and osteoporosis; at the same time, in the operation process, we should pay attention to grasp the position and depth of the screw, to ensure the fracture end of the line and the recovery of the neck shaft angle.