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中华老年骨科与康复电子杂志 ›› 2025, Vol. 11 ›› Issue (03) : 129 -138. doi: 10.3877/cma.j.issn.2096-0263.2025.03.001

髋部骨折

不稳定老年股骨粗隆间骨折PFNA内固定术后颈干角丢失原因分析及处理策略
张超1, 吴雨桐1, 杨子飞1, 杨鹤1,()   
  1. 1. 671003 大理,解放军陆军第七十五集团军医院骨科
  • 收稿日期:2024-01-25 出版日期:2025-06-05
  • 通信作者: 杨鹤
  • 基金资助:
    大理州(市)科技计划项目(批号:20242901A020010)

Cause analysis and management strategy of neck shaft angle loss after PFNA internal fixation for unstable elderly intertrochanteric femoral fractures

Chao Zhang1, Yutong Wu1, Zifei Yang1, He Yang1,()   

  1. 1. Department of Orthopaedics,75th Army Hospital of the PLA Joint Logistic Support Force,Dali 671003,China
  • Received:2024-01-25 Published:2025-06-05
  • Corresponding author: He Yang
引用本文:

张超, 吴雨桐, 杨子飞, 杨鹤. 不稳定老年股骨粗隆间骨折PFNA内固定术后颈干角丢失原因分析及处理策略[J/OL]. 中华老年骨科与康复电子杂志, 2025, 11(03): 129-138.

Chao Zhang, Yutong Wu, Zifei Yang, He Yang. Cause analysis and management strategy of neck shaft angle loss after PFNA internal fixation for unstable elderly intertrochanteric femoral fractures[J/OL]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2025, 11(03): 129-138.

目的

分析不稳定老年股骨粗隆间骨折PFNA 内固定术后颈干角丢失的原因及处理策略。

方法

选取2021 年1 月至2023 年1 月于我院接受PNFA 内固定手术治疗的患者126 例,其中男69 例,女57例。术后颈干角丢失组(31例),未丢失组(95例)。通过SPSS 23.0统计软件进行数据统计分析,收集患者临床资料、手术指标及术后恢复情况等资料。通过有序Logistic回归分析影响因素与患者术后颈干角丢失的关系。分层交互分析Harris评分对患者术后颈干角丢失的影响作用。通过潜在类别分析(LCA)比较因素分布特征的差异。

结果

(1)丢失组患者的手术时间与住院时间显著长于未丢失组,术中出血量显著高于研究组(P<0.001),两组在骨折复位质量、内固定质量、螺旋刀片置入精确度方面差异显著(P<0.001)。(2)两组患者在术后7 d、术后1个月、术后3个月、术后6个月、术后12个月的Harris评分有显著差异(P<0.001)。(3)Singh指数、骨质疏松、股骨近端外侧壁厚度、骨折复位质量、内固定质量、螺旋刀片置入精确度均是发生术后颈干角丢失的重要影响因素(P<0.001)。(4)分层交互检验结果显示,调整因素前后,不同Harris评分下,Singh指数、骨质疏松、股骨近端外侧壁厚度、骨折复位质量、内固定质量、螺旋刀片置入精确度与患者术后颈干角丢失的关系存在(均P<0.05)。交互检验作用(Pinteraction)表明Harris评分不能影响上述指标与患者术后颈干角丢失的关系。(5)LCA显示Singh指数、骨质疏松、股骨近端外侧壁厚度、骨折复位质量、内固定质量、螺旋刀片置入精确度对术后颈干角丢失的影响具有异质性。

结论

Singh指数、骨质疏松、股骨近端外侧壁厚度、骨折复位质量、内固定质量及螺旋刀片置入精确度,均为影响不稳定老年股骨粗隆间骨折PFNA内固定术后颈干角丢失的关键因素。

Objective

To analyze the causes and management strategies of neck shaft angle loss in elderly patients with unstable intertrochanteric fractures after PFNA internal fixation.

Methods

A total of 126 patients (69 males and 57 females) who received PNFA internal fixation in our hospital from January 2021 to January 2023 were selected. Postoperative dry neck angle loss group (31 cases), no loss group (95 cases).SPSS 23.0 statistical software was used for data statistical analysis,and clinical data,surgical indicators and postoperative recovery of patients were collected. Ordered Logistic regression was used to analyze the relationship between the influencing factors and the loss of neck shaft angle.The effect of Harris score on postoperative loss of neck shaft angle was analyzed by stratified interaction.Differences in factor distribution characteristics were compared by latent class analysis (LCA).

Results

(1) The operative time and hospital stay in the lost group were significantly longer than those in the non-lost group,and the amount of intraoperative blood loss was significantly higher than that in the study group(P<0.001).There were significant differences between the two groups in fracture reduction quality, internal fixation quality, and helical blade placement accuracy(P<0.001).(2)There were significant differences in Harris scores between the two groups at 7 days, 1 month, 3 months, 6 months and 12 months after surgery (P<0.001). (3) Singh index, osteoporosis,thickness of proximal femoral lateral wall,quality of fracture reduction,quality of internal fixation,and accuracy of helical blade placement were all important influencing factors of postoperative neck shaft angle loss(P<0.001).(4)The results of hierarchical interaction test showed that Singh index,osteoporosis,thickness of proximal femoral lateral wall, quality of fracture reduction, quality of internal fixation, and accuracy of helical blade placement were related to the loss of neck shaft angle after operation under different Harris scores before and after adjustment (all P<0.05). Pinteraction test showed that Harris score did not affect the relationship between the above indicators and postoperative neck shaft angle loss. (5) LCA showed that the effects of Singh index, osteoporosis, proximal femoral lateral wall thickness, fracture reduction quality, internal fixation quality,and helical blade placement accuracy on postoperative neck shaft angle loss were heterogeneous.

Conclusion

Singh index,osteoporosis,thickness of proximal femoral lateral wall,quality of fracture reduction, quality of internal fixation and accuracy of helical blade insertion are the key factors affecting the loss of neck shaft angle after PFNA internal fixation for unstable intertrochanteric fractures in the elderly.

图1 ~2 患者女性,59岁,老年股骨粗隆间骨折闭合复位PFNA内固定手术前后X线片
表1 两组不稳定股骨粗隆间骨折患者临床资料比较[例(%),±s
表2 两组不稳定股骨粗隆间骨折患者手术相关指标比较(±s
表3 两组不稳定股骨粗隆间骨折患者手术前后髋关节功能比较(分,±s
表4 两组不稳定股骨粗隆间骨折患者术后颈干角丢失的多因素Logistic回归分析
表5 分层交互分析Harris评分对患者术后颈干角丢失的影响作用
项目 模型 Harris 评分≥70 分 P Harris 评分<70 分 P P interaction
β(95%CI β(95%CI
Singh 指数 未调整 2.214(1.792,2.480) 0.014 2.458(2.036,2.868) 0.007 0.374
模型1 2.505(2.160,2.812) 0.017 2.752(2.249,3.129) 0.015 0.216
模型2 2.583(2.112,2.917) 0.012 2.894(2.387,3.347) 0.022 0.143
骨质疏松 未调整 2.698(2.415,2.937) 0.020 2.973(2.585,3.462) 0.008 0.385
模型1 2.450(2.153,2.887) 0.035 2.468(2.050,2.833) 0.016 0.076
模型2 2.532(2.174,2.856) 0.016 2.559(2.154,2.857) 0.004 0.162
股骨近端外侧壁厚度 未调整 2.525(2.192,2.784) 0.024 2.718(2.238,3.345) 0.010 0.271
模型1 2.749(2.460,3.422) 0.036 2.772(2.354,3.029) 0.013 0.387
模型2 2.483(2.032,2.817) 0.022 2.547(2.206,2.956) 0.007 0.156
骨折复位质量 未调整 2.428(2.173,2.841) 0.022 2.554(2.341,2.982) 0.008 0.367
模型1 2.482(2.120,2.782) 0.018 2.652(2.338,3.141) 0.021 0.200
模型2 2.641(2.324,3.168) 0.033 2.740(2.372,3.364) 0.017 0.165
内固定质量 未调整 2.437(2.121,2.738) 0.024 2.586(2.183,2.977) 0.026 0.446
模型1 2.572(2.361,2.971) 0.025 2.642(2.227,3.124) 0.015 0.295
模型2 2.612(2.341,3.167) 0.020 2.655(2.274,2.978) 0.013 0.374
螺旋刀片置入精确度 未调整 2.826(2.677,3.318) 0.014 2.790(2.348,3.372) 0.015 0.125
模型1 2.831(2.512,3.382) 0.008 2.886(2.538,3.374) 0.010 0.152
模型2 2.935(2.735,3.281) 0.006 2.894(2.613,3.402) 0.007 0.147
表6 基于LCA模型分析因素
表7 术后脊柱内镜类脊髓高压综合征影响因素LCA分析指标比较
表8 术后颈干角丢失影响因素的条件概率和LCA概率
图3 术后颈干角丢失的2个LCA条件概率分布
1
Yıldırım C,Muratoğlu OG,Turan KY,et al.The intra-and interobserver reliability of five commonly used intertrochanteric femur fracture classification systems[J].Jt Dis Relat Surg,2022,33(1):187-192.
2
Durgut F, Şahin E, Çiftçi S, et al. Proximal femoral nail antirotation versus cemented calcar-replacement hemiarthroplasty for unstable intertrochanteric fracture in elderly: an overall survival study [J]. Turk J Med Sci,2022,52(2):463-466.
3
Lil NA,Makwana VR,Patel TD,et al.Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and withoutdistalinterlockingscrews[J].WorldJOrthop,2022,13(3):267-277.
4
Cheng YX, Sheng X. Optimal surgical methods to treat intertrochanteric fracture:a Bayesian network meta-analysis based on 36 randomized controlled trials[J].J Orthop Surg Res,2020,15(1):402.
5
Al-Ani ZM,Bindumadhavan S,Sharif K,et al.Can an inferior calcar stabilising antirotation screw improve stability in unstable a2 inter trochanteric fractures when fixed with a dynamic hip screw? [J]. J Coll Physicians Surg Pak,2022,32(11):1474-1477.
6
Jin ZZ, Xu SY, Yang Y, et al. Cemented hemiarthroplasty versus proximal femoral nail antirotation in the management of intertrochanteric femoral fractures in the elderly: a case control study [J]. BMC Musculoskelet Disord,2021,22(1):846.
7
Wang J, Ma JX, Lu B, et al. Comparative finite element analysis of three implants fixing stable and unstable subtrochanteric femoral fractures: Proximal Femoral Nail Antirotation (PFNA), Proximal Femoral Locking Plate (PFLP), and Reverse Less Invasive Stabilization System (LISS) [J]. Orthop Traumatol Surg Res, 2020, 106(1):95-101.
8
Guo YL,Wu H,Fan SG,et al.Evaluate the outcomes of senile femoral intertrochanteric fractures treated with proximal femoral nail Anti-Rotation internal fixation to those treated with prosthetic femoral head replacement[J].Altern Ther Health Med,2023,29(8):26-29.
9
Bi CQ,Zhao Y,Ma ZL,et al.Comparison of proximal Anti-Rotation intramedullary nail and femoral head replacement for the treatment of femoral intertrochanteric fractures in elderly patients [J]. Altern Ther Health Med,2023,29(5):268-273.
10
Okkaoglu MC,Ozdemir E,Yaradilmis U,et al.Is radiographic osteoporotic hip morphology a predictor for high mortality following intertrochanteric femur fractures?: Osteoporotic Hip Morphology&Mortality[J].Injury,2022,53(6):2184-2188.
11
中华人民共和国国家卫生健康委员会医政司.老年髋部骨折诊疗与管理指南(2022 年版)[J].中华创伤骨科杂志,2023,25(4):277-283.
12
Zora H, Bayrak G, Bilgen ÖF. A novel interfragmentary technique vs.a conventional posterolateral approach for unstable femoral intertrochanteric fractures in the elderly: a retrospective cohort study [J].Medicina(Kaunas),2025,61(4):605-614.
13
Ghalenavi E, Mirfeizi Z, Hashemzadeh K, et al. Diagnostic value of radiographic singh index compared to Dual-Energy X-Ray absorptiometry scan in diagnosing osteoporosis: a systematic review [J].Arch Bone Jt Surg,2024,12(1):1-11.
14
中华医学会骨质疏松和骨矿盐疾病分会.原发性骨质疏松症诊疗指南(2022)[J].中华骨质疏松和骨矿盐疾病杂志,2022,15(6):573-611.
15
Li FZ,Zhu LX,Geng YN,et al.Effect of hip replacement surgery on clinical efficacy,VAS score and Harris hip score in patients with femoral head necrosis[J].Am J Transl Res,2021,13(4):3851-3855.
16
Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures:a comparison of intraoperative fluoroscopy and post-operative three dimensional computerised tomography Reconstruction [J]. Int Orthop, 2018, 42(1): 183-189.
17
张朕,刘华水,段升军,等.机器人辅助PFNA与传统手术治疗股骨粗隆间骨折的疗效比较[J].中华老年骨科与康复电子杂志,2020,6(1):25-30.
18
Jia X, Qiang M, Zhang K, et al. Accuracy of detecting burst of the lateral wall in intertrochanteric hip fractures with plain radiographs:is postoperative CT necessary?[J].Heliyon,2024,10(3):e25389.
19
Pang Y,He QF,Zhu LL,et al.Loss of reduction after cephalomedullary nail fixation of intertrochanteric femoral fracture: a brief report[J].Orthop Surg,2020,12(6):1998-2003.
20
Sermon A,Slock C,Coeckelberghs E,et al.Correction to:quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus[J].Arch Osteoporos,2022,17(1):70.
21
Bozgeyik B, Buyukbebeci O, Guner S, et al. Evaluation of the effect of proximal femur geometry on results of geriatric intertrochanteric fracture surgery.Proksimal femur geometrisinin geriatrik intertrokanterik kırık cerrahisi sonuçlarına etkisinin değerlendirilmesi [J]. Ulus Travma Acil Cerrahi Derg,2022,28(12):1723-1730.
22
Tucker A, Donnelly KJ, McDonald S, et al. The changing face of fractures of the hip in Northern Ireland: a 15-year review [J]. Bone Joint J,2017,99-B(9):1223-1231.
23
Fischer CS, Ittermann T, Hannemann A, et al.Are there associations between hip geometry and bone quality?An analysis on 3074 adults from a general population [J].Arch Orthop Trauma Surg, 2024, 144(1):81-90.
24
Fang L,Qi J,Wang Z,et al.Inverse relationship between femoral lateralization and neck-shaft angle is a joint event after intramedullary nailing of per trochanteric fractures[J].Sci Rep,2023,13(1):10999-11008.
25
Sun DW,Wang CL,Chen YH,et al.A meta-analysis comparing intramedullary with extramedullary fixations for unstable femoral intertrochanteric fractures [J]. Medicine (Baltimore), 2019, 98(37):e17010.
26
Pang Y,He QF,Zhu LL,et al.Loss of reduction after cephalomedullary nail fixation of intertrochanteric femoral fracture: a brief report[J].Orthop Surg,2020,12(6):1998-2003.
27
Ding XB, Chen YK, Guo CC, et al. Mutations in ARHGEF15 cause autosomal dominant hereditary cerebral small vessel disease and osteoporotic fracture[J].Acta Neuropathol,2023,145(5):681-705.
28
Chen HY, Avgerinou C. Association of alternative dietary patterns with osteoporosis and fracture risk in older People: a scoping review[J].Nutrients,2023,15(19):4255.
29
Cannarella R, Barbagallo F, Condorelli RA, et al. Osteoporosis from an Endocrine Perspective:The Role of Hormonal Changes in the Elderly[J].J Clin Med,2019,8(10):1564.
30
Bover J, Ureña-Torres P, Laiz Alonso AM, et al. Osteoporosis, bone mineral density and CKD-MBD (II): Therapeutic implications [J].Nefrologia(Engl Ed),2019,39(3):227-242.
31
Thirunthaiyan MR, Mukherjee K, Prashanth T, et al. Predicting the anatomical location of neck of femur fractures in osteoporotic geriatric Indian population[J].Malays Orthop J,2022,16(1):103-111.
32
Muñoz M,Robinson K,Shibli-Rahhal A.Bone health and osteoporosis prevention and treatment [J]. Clin Obstet Gynecol, 2020, 63(4):770-787.
33
Papaioannou I, Pantazidou G, Baikousis A, et al. Femoral bowing and femoral Neck-Shaft angle evaluation can reduce atypical femoral fractures in osteoporotic patients: a scientific report [J]. Cureus,2020,12(10):e10771.
34
Gumuchdjian DA, Waltenspül M, Dietrich M, et al. Hip axis length and femoral neck-shaft angle as risk factors for proximal femur fractures in octogenarians to centenarians [J]. J Clin Med, 2024, 13(14):4071-4079.
35
Chen JM,Yue C,He PL,et al.Comparison of clinical outcomes with hip replacement versus PFNA in the treatment of intertrochanteric fractures in the elderly: A systematic review and meta- analysis(PRISMA)[J].Medicine(Baltimore),2021,100(9):e24166.
36
Shi ZM, Qiang MF, Jia XY, et al.Association of the lateral wall integrity with clinical outcomes in older patients with intertrochanteric hip fractures treated with the proximal femoral nail anti-rotation-Asia[J].Int Orthop,2021,45(12):3233-3242.
37
Wang W, Ni B, Shen H, et al. Meta-analysis of InterTan, PFNA and PFNA-II internal fixation for the treatment of unstable intertrochanteric fractures in elderly individuals [J].Acta Orthop Belg, 2023, 89(1):51-58.
38
Mu JX, Xiang SY, Ma QY, et al. Selection of internal fixation method for femoral intertrochanteric fractures using a finite element method[J].World J Clin Cases,2021,9(22):6343-6356.
39
Huang CY, Xu WQ,Ye X, et al. Changes in nail position and antirotation blade angles on the risk of femoral head varus in PFNA fixed patients: a clinical review and comprehensive biomechanical research[J].Eur J Med Res,2024,29(1):336.
40
Guo Y,Yang HP,Dou QJ,et al.Efficacy of femoral nail anti-rotation of helical blade in unstable intertrochanteric fracture [J]. Eur Rev Med Pharmacol Sci,2017,21(3 Suppl):6-11.
41
Lilly RJ, Koueiter DM, Graner KC, et al. Computer-assisted navigation for intramedullary nail fixation of intertrochanteric femur fractures:A randomized,controlled trial[J].Injury,2018,49(2):345-350.
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