"Y"型软骨未闭合儿童股骨颈骨折术后股骨近端骺板早闭的风险因素分析

Risk factors for premature proximal femur physeal closure after femoral neck fractures in children treated surgically

目的探讨"Y"型软骨未闭合儿童股骨颈骨折术后股骨近端骺板早闭(premature proximal femur physeal closure,PPC)的风险因素。方法回顾性分析2010年3月至2017年5月采用手术治疗的106例"Y"型软骨未闭合股骨颈骨折患儿资料,记录患儿的年龄、性别、侧别、受伤机制、骨折分型、移位程度、手术时机、固定方式、有无过骺板固定、复位方式、复位质量和末次随访时有无股骨头坏死等可疑风险因素。术后6~12个月通过X线片评估有无PPC的发生。结果106例患儿均得到随访,随访时间(20.4±13.3)个月(范围6~86个月)。其中39例患儿股骨颈骨折术后发生PPC,发生率为36.8%(39/106)。发生PPC的患儿39例,男25例,女14例;年龄(9.7±3.6)岁(范围3~15岁);左侧23例,右侧16例;交通伤5例,高处坠落伤21例,运动伤12例,其他类型损伤1例;DelbetⅠ型2例,Ⅱ型26例,Ⅲ型11例;移位程度Ⅱ度26例,Ⅲ度13例;受伤至手术时间(3.3±2.8)d(范围1~14 d);克氏针固定2例,螺钉固定35例,钢板固定2例;过骺板固定2例,未过骺板固定37例;闭合复位15例,开放复位24例;解剖复位14例,可接受复位24例,不可接受复位1例;末次随访时24例出现股骨头坏死,余15例无股骨头坏死。统计学分析显示,有PPC的患儿年龄(t=3.875,P<0.001)、移位程度(Z=-2.118,P=0.034)和股骨头坏死的发生率(χ^2=42.280,P<0.001)均大于无PPC的患儿,差异均有统计学意义;其余各因素两者比较差异均无统计学意义。Logistic回归分析结果显示,年龄(OR=1.288,P=0.011)和股骨头坏死(OR=40.336,P<0.001)是儿童股骨颈骨折术后发生PPC的独立风险因素。ROC曲线分析提示年龄>10岁会增加PPC的风险。年龄≥10岁的患儿PPC发生率(63.6%,21/33)高于年龄<10岁的患儿(24.7%,18/73)(χ^2=14.848,P<0.001)。结论年龄≥10岁和股骨头坏死是"Y"型软骨未闭合儿童股骨颈骨折术后股骨近端骺板早闭的风险因素。

Objective To identify the risk factors for premature proximal femur physeal closure(PPC)in children treated surgically for femoral neck fractures.Methods Data of 106 children with an open triradiate cartilage who were treated surgically for a femoral neck fracture were retrospectively analyzed.Age,gender,laterality,mechanism of injury,the type of fracture,initial displacement,time to reduction,fixation method,whether the implant crossed the physeal plate,reduction method,reduction quality and development of femoral head avascular necrosis(AVN)were collected.PPC of the proximal femur was assessed through postoperative 6-12 months radiographs.Results A total of 106 patients with an open triradiate cartilage were followed up,with an average duration of 20.4±13.3 months(range,6-86 months).The overall rate of PPC following paediatric femoral neck fractures treated surgically was 36.8%(39/106).Among the 39 patients with PPC,25 were males and 14 were females;the average age at the time of injury was 9.7±3.6 years(range,3-15 years);23 patients were involved in left hips and 16 were in right;the mechanisms of injury included motor vehicle accident in 5 fractures,falling injury in 21,sports-related injury in 12 and other causes in 1 fracture;two hips were Delbet type I,and 26 hips and 11 hips were Delbet type II and III,separately;type II and III of initial displacement were involved in 26 and 13 patients,separately;the mean duration from injury to surgery was 3.3±2.8 d(range,1-14 d);2 hips were treated with Kirschner wires,35 hips with screw fixation,and the remaining 2 hips underwent screw and plate fixation;2 hips had the hardware crossing the proximal femoral growth plate,and the remaining 37 hips didn’t;15 hips were treated by closed reduction and internal fixation,and the other 24 hips underwent open reduction and internal fixation;anatomical reduction was achieved in 14 patients,acceptable reduction in 24 hips and unacceptable reduction in 1 hip;24 hips developed AVN at the latest follow-up and the remaining 15 hips didn’t.Statistical analysis indicated that age(t=3.875,P<0.001),the severity of initial displacement(Z=-2.118,P=0.034)and the rate of AVN(χ^2=42.280,P<0.001)in patients with PPC were significantly higher than those in patients without;Logistic regression analysis confirmed age(OR=1.288,P=0.011)and AVN(OR=40.336,P<0.001)as risk factors for PPC.ROC curve analysis indicated 10 years was the cut off age to significantly increase the rate of PPC.The rate of PPC in patients aged over 10 years(63.6%,21/33)was significantly higher than that(24.7%,18/73)in those aged less than 10 years(χ^2=14.848,P<0.001).Conclusion Age over 10 years and AVN are risk factors for PPC in children with femoral neck fractures treated surgically.