PFNA治疗股骨粗隆间骨折内固定手术失败的原因分析

An analysis on failure of PFNA internal fixation for femoral intertrochanteric fracture

[目的]探讨PFNA治疗股骨粗隆间骨折内固定手术失败的原因。[方法]回顾性分析本院2013年1月～2017年1月收治的股骨粗隆间骨折行PFNA内固定失败病例12例。搜集初次行PFNA手术前后、随访复查的X线片及部分三维重建CT片,着重分析骨折类型、骨质情况、骨折复位情况、PFNA螺旋刀片在股骨头颈位置、尖顶距(TAD)值及翻修后伤口骨折愈合、髋关节功能、髋内外翻等情况。[结果] 12例手术失败患者中,病理性骨折1例,因置钉困难后更换手术方式;合并骨质疏松11例。12例中复位质量良8例,差4例。PFNA螺旋刀片在股骨头颈位置:TAD>30 mm 6例,其中螺旋刀片切割股骨颈4例,2例螺旋刀片退钉;TAD <30 mm 6例。所有12例患者随访11～19个月,平均(15.08±2.84)个月。无死亡病例。除3例改行关节置换、1例骨转移瘤改行钢板固定外,其他患者骨折均愈合,发生髋内翻畸形2例。术后12个月髋关节Harris评分标准评定髋关节功能:其中优4例,良3例,可2例,差3例,优良率58.33%。[结论]股骨粗隆间骨折PFNA内固定一旦失败,预后不佳。正确选择适应证,评价骨质疏况、骨折复位情况,以及准确的置钉位置,是预防失败的重要措施。

[Objective] To explore the failure reasons of proximal femoral nail anti-rotation（PFNA） for femoral intertrochanteric fracture. [Methods] A retrospective study was conducted in 12 patients who suffered from internal fixation failure of PFNA for femoral intertrochanteric fracture in our hospital from January 2013 to January 2017. The data, including radiographs and computer tomographic images before the primary internal fixation with PFNA, postoperatively and at the follows up, were collected and analyzed to evaluate the fracture type, bone quality, character of reduction, and the position of screw blade in femoral head-neck, such as tip apex distance（TAD）. In addition, the patients were evaluated for clinical outcomes after the secondary treatment, including bone healing, hip function and coxa varus or valgus. [Results] Of the 12 patients, 1 had metastatic cancer, which was turned to internal fixation with plate, and 11 had osteoporosis. In term of Baumgaertner criteria, the primary fracture reduction was graded as good in 8 and poor in 4 patients. Regarding to the position of screw blade in femoral head-neck,the TAD30 mm was noted in 6 patients, including the screw blade penetrated femoral head-neck in 4 patients and the screw blade back out in 2 patients, while the TAD30 mm was found in 6 patients. The duration of follow up lasted for 11 to 19 months with an average of（15.08±2.84） months. No death happened in any of them. Except 3 patients who revised by hip replacement and 1 with metastatic cancer, the remaining patients got bony healing eventually with coxa varus in 2 patients. At the latest follow up, the clinical outcomes were graded as excellent in 4, good in 3, fair in 2 and poor in 3 based on Harris scores, with excellent and good rate of 58.33%. [Conclusion] Once internal fixation with PFNA fails for intertrochanteric fracture, the prognosis is poor.Therefore, proper selection of indication, careful evaluation of accompanied osteoporosis or bone disorder, correct reduction and accurate placement of implant are key measures to prevent failure.