Inter-Tan髓内钉固定治疗老年股骨转子间骨折术后内固定相关并发症发生的危险因素分析

Risk factors of complications related to internal fixation after Inter‑Tan intramedullary nail fixation for intertrochanteric fractures in elderly patients

目的探讨Inter-Tan髓内钉固定治疗老年股骨转子间骨折术后内固定相关并发症发生的危险因素。方法采用回顾性队列研究分析2016年1月至2020年12月中国人民解放军总医院第七医学中心收治的314例老年股骨转子间骨折患者的临床资料,其中男100例,女214例;年龄60~98岁[(80.2±8.2)岁]。患者均行Inter-Tan髓内钉内固定治疗。根据2018年AO/OTA分型标准,103例为稳定型骨折,211例为不稳定型骨折,再按随访期间患者是否发生内固定并发症分别分为并发症组和无并发症组。稳定型骨折中6例(5.8%)出现内固定相关并发症,其中骨折不愈合4例,头钉切出2例。不稳定型骨折中28例(13.3%)出现内固定相关并发症,其中骨折不愈合5例,头钉切出20例,头钉切入1例,头钉断裂2例。以术后内固定相关并发症作为因变量,将性别、年龄、合并症[高血压病、冠心病、心律失常、肺部感染、慢性阻塞性肺疾病(COPD)、肾功能不全、糖尿病]、骨密度、手术等待时长、麻醉方式、复位方法、复位质量、尖顶距、头钉位移等影响因素作为自变量,分别对稳定型骨折和不稳定型骨折进行单因素和多因素Logistic回归分析,筛选内固定相关并发症发生的独立危险因素。结果稳定型骨折患者的单因素分析结果显示,并发症组与无并发症组骨密度、复位质量差异均有统计学意义(P<0.05或0.01);多因素Logistic回归分析结果表明,骨密度T值≤-3.0 SD(OR=33.17,95%CI 2.40,457.82,P<0.01)和复位质量差(OR=71.38,95%CI 3.58,1422.02,P<0.01)与术后内固定相关并发症发生显著相关。不稳定型骨折患者的单因素分析结果显示,并发症组与无并发症组年龄、复位质量、骨密度、尖顶距和头钉位移差异均有统计学意义(P<0.05或0.01);多因素Logistic回归分析结果表明,年龄>80岁(OR=2.82,95%CI 1.01,7.93,P<0.05)、骨密度T值≤-3.0 SD(OR=6.10,95%CI 2.06,17.51,P<0.01)、复位质量差(OR=12.25,95%CI 2.90,51.79,P<0.01)、尖顶距≥25 mm(OR=3.65,95%CI 1.20,11.08,P<0.05)和头钉位移<4 mm(OR=7.26,95%CI 2.54,20.81,P<0.01)与术后内固定相关并发症发生显著相关。结论Inter-Tan髓内钉固定治疗老年股骨转子间骨折,骨密度低和复位质量差是稳定型骨折患者术后内固定相关并发症发生的独立危险因素;高龄、骨密度低、复位质量差、尖顶距大和头钉位移是不稳定型骨折患者术后内固定相关并发症发生的独立危险因素。

Objective To explore the risk factors for complications related to internal fixation after Inter-Tan intramedullary nail fixation in the treatment of intertrochanteric fractures in elderly patients.Methods A retrospective cohort study was conducted to analyze the clinical data of 314 elderly patients with intertrochanteric fractures admitted to the Seventh Medical Center of the Chinese PLA General Hospital from January 2016 to December 2020,including 100 males and 214 females,aged 60-98 years[(80.2±8.2)years].All the patients underwent Inter-Tan intramedullary nail fixation.According to the 2018 AO/OTA classification,103 patients were with stable fractures and 211 with unstable fractures.The patients were further divided into complication groups and non-complication groups according to the presence of the complications during the follow-up.Six patients(5.8%)with stable fractures had the complications including nonunion in 4 and cut-out in 2.Twenty-eight patients(13.3%)with unstable fractures developed the complications,including nonunion in 5,cut-out in 20,cut-through in 1,and broken nails in 2.With the internal fixation-related complications after surgery as dependent variables,and gender,age,complications[hypertension,coronary heart disease,arrhythmia,pulmonary infection,chronic obstructive pulmonary disease(COPD),renal insufficiency,diabetes],bone density,waiting time for surgery,anesthesia method,reduction method,reduction quality,tip-apex distance,head screw displacement and other influencing factors as independent variables,univariate and multivariate Logistic regression analyses were conducted on the patients with stable fractures and unstable fractures separately to screen the independent risk factors of internal fixation-related complications.Results For the patients with stable fractures,the univariate analysis indicated significant differences in bone density and reduction quality between the complication group and non-complication group(P<0.05 or 0.01);the multivariate Logistic regression analysis showed that bone density T value≤-3.0 SD(OR=33.17,95%CI 2.40,457.82,P<0.01)and poor reduction quality(OR=71.38,95%CI 3.58,1422.02,P<0.01)were significantly correlated with the incidence of the postoperative complications.For the patients with unstable fractures,the univariate analysis indicated significant differences in age,reduction quality,bone density,tip-apex distance,and screw displacement between the complication group and non-complication group(P<0.05 or 0.01);the multivariate Logistic regression analysis showed that age>80 years(OR=2.82,95%CI 1.01,7.93,P<0.05),bone density T value≤-3.0 SD(OR=6.10,95%CI 2.06,17.51,P<0.01),poor reduction quality(OR=12.25,95%CI 2.90,51.79,P<0.01),tip-apex distance≥25 mm(OR=3.65,95%CI 1.20,11.08,P<0.05),and head screw displacement<4 mm(OR=7.26,95%CI 2.54,20.81,P<0.01)were significantly correlated with the postoperative complications.Conclusion For Inter-Tan intramedullary nail fixation of intertrochanteric fractures in elderly patients,low bone density and poor reduction quality are independent risk factors for the postoperative complications in patients with stable intertrochanteric fractures;old age,low bone density,poor reduction quality,tip-apex distance,and head screw displacement are independent risk factors for the postoperative complications in patients with unstable fractures.