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北京大学学报（医学版） ›› 2020, Vol. 52 ›› Issue (2): 290-297. doi: 10.19723/j.issn.1671-167X.2020.02.016

• 论著 • 上一篇    下一篇

中青年股骨颈骨折内固定术后发生缺血性股骨头坏死的相关因素

刘冰川,孙川,邢永,周方,田耘(),姬洪全,张志山,郭琰,吕扬,杨钟玮,侯国进,高山   

  1. 北京大学第三医院骨科,北京 100191
  • 收稿日期:2019-01-06 出版日期:2020-04-18 发布日期:2020-04-18
  • 通讯作者: 田耘 E-mail:tiany@bjmu.edu.cn

Analysis of risk factors for necrosis of femoral head after internal fixation surgery in young and mid-aged patients with femoral neck fracture

Bing-chuan LIU,Chuan SUN,Yong XING,Fang ZHOU,Yun TIAN(),Hong-quan JI,Zhi-shan ZHANG,Yan GUO,Yang LV,Zhong-wei YANG,Guo-jin HOU,Shan GAO   

  1. Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
  • Received:2019-01-06 Online:2020-04-18 Published:2020-04-18
  • Contact: Yun TIAN E-mail:tiany@bjmu.edu.cn

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摘要：

目的 通过回顾性研究分析中青年股骨颈骨折患者内固定术后发生缺血性股骨头坏死(avascular necrosis of femoral head, ANFH)的危险因素.方法: 对北京大学第三医院2007年1月至2017年12月期间采用骨折复位内固定术治疗的中青年(18~60岁)股骨颈骨折患者进行回顾性研究.记录患者的性别,年龄,体重指数(body mass index, BMI),美国麻醉协会分级(American Society of Anesthesiology,ASA),受伤原因,骨折侧别,受伤至手术间隔时间,骨折线部位,Garden分型,Pauwels分型,复位方式(切开或闭合),内固定方式及复位质量等资料.依据患者随访的X线及MRI影像资料明确ANFH的诊断.内固定方式采用空心加压螺钉(cannulated compression screw, CCS)或动力髋螺钉(dynamic hip screw, DHS,加或不加抗旋转螺钉).采用单因素卡方检验及Logistic回归方程分析各因素与术后发生ANFH的相关性.结果: 纳入研究的患者共113例,包括男性63例,女性50例,平均年龄(43.17±12.34)岁,平均随访时间(25.08±16.17)个月.ASA分级包括Ⅰ级21例,Ⅱ级55例和Ⅲ级37例.受伤原因包括低能量创伤76例及高能量创伤37例.骨折侧别包括左侧61例,右侧52例.骨折线部位包括头下型37例,经颈型74例及基底型2例.Garden分型包括Ⅰ型3例,Ⅱ型46例,Ⅲ型39例及Ⅳ型25例.Pauwels分型包括Ⅰ型21例,Ⅱ型55例及Ⅲ型37例.患者受伤至手术间隔时间为(3.88±3.66) d,采用闭合及切开复位的患者分别有108例及5例,内固定采用CCS的患者63例,DHS的患者50例.骨折复位质量包括A级91例,B级18例,C级4例.术后共发生ANFH 18例,发生率为15.93%(18/113).单因素卡方检验结果显示受伤原因(OR=0.19, P < 0.01),Garden分型(OR=0.13, P < 0.01),Pauwels分型(OR=0.12, P = 0.02),内固定方式(OR=3.29, P = 0.04)及骨折复位质量(OR=0.33, P < 0.01)等5种因素与术后ANFH有显著相关性, 将这5种因素进一步纳入Logistic回归方程,结果显示受伤原因(OR=4.11, P = 0.03)与Garden分型(OR=4.85, P = 0.04)与术后ANFH有显著相关性.结论: 受伤原因,Garden分型,Pauwels分型,内固定方式及骨折复位质量等因素会增加中青年股骨颈骨折患者复位内固定术后发生ANFH的风险,其中受伤原因和骨折Garden分型的相关性更加显著.

关键词: 股骨颈骨折, 股骨头坏死, 危险因素

Abstract:

Objective: To retrospectively analyze the risk factors of avascular necrosis of femoral head (ANFH) after internal fixation in young and mid-aged adults.Methods: From January 2007 to December 2017, femoral neck fracture patients (18-60 years old) treated by reduction and internal fixation were retrospectively studied in Peking University Third Hospital. We recorded their gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) grade, reason of injury, fracture side, interval between injury and surgery, location of fracture line, Garden classification, Pauwels classification, reduction method (open or closed), internal fixation and reduction quality. The diagnosis of ANFH was confirmed based on X-ray and MRI images during the follow-up. The internal fixation method inclu-ded cannulated compression screw (CCS) or dynamic hip screw (DHS, with or without anti-rotation screw). χ 2 test and Logistic regression analysis were used to analyze the relationship between the various factors and postoperative ANFH. Results: A total of 113 patients were included in this study, including 63 males and 50 females with an average age of (43.17 ± 12.34) years. They were followed up by (25.08 ± 16.17) months. ASA grade included grade Ⅰ (21 cases), grade Ⅱ (55 cases) and grade Ⅲ (37 cases). The reasons of injury included low-energy trauma (76 cases) and high-energy (37 cases). The fracture line included subcapital type (37 cases), transverse type (74 cases) and basal type (2 cases). Garden classification included type Ⅰ (3 cases), type Ⅱ (46 cases), type Ⅲ (39 cases) and type Ⅳ (25 cases). Pauwels classification included type Ⅰ (21 cases), type Ⅱ (55 cases) and type Ⅲ (37 cases). Interval between injury and surgery was (3.88 ± 3.66) days, 108 patients and 5 patients performed closed and open reduction respectively. 63 patients performed CCS, and 50 patients performed DHS. The reduction quality included grade A (91 cases), grade B (18 cases) and grade C (4 cases). 18 patients developed ANFH after surgery, the incidence rate was 15.93%(18/113). The result of χ 2 test showed the reason of injury (OR=0.19, P < 0.01), Garden classification (OR=0.13, P < 0.01), Pauwels classification (OR=0.12, P = 0.02), internal fixation method (OR=3.29, P = 0.04) and reduction quality (OR=0.33, P < 0.01) were significantly associated with ANFH. These five factors were further included into the Logistic regression analysis, and its results showed that the reason of injury (OR=4.11, P = 0.03) and Garden classification (OR=4.85, P = 0.04) were statistically significant. Conclusion: The reason of injury, Garden classification, Pauwels classification, internal fixation and reduction quality may increase the risk of ANFH after surgery, and the reason of injury and Garden classification were much more significant.

Key words: Femoral neck fracture, Necrosis of femoral head, Risk factors

中图分类号: 

  • R683.4

表1

股骨颈骨折复位质量分级"

Classification Angle of deviationa Neck-shaft angle
A < 15° 125° - 140°
B 15° - 30° 120° - 140° or 140° -150°
C > 30° <125° or >150°

表2

股骨颈骨折内固定术后发生股骨头坏死的单因素卡方检验"

Parameter Total(n=113) Necrosis(n=18) Non-necrosis(n=95) OR P value 95%CI
Gender 1.29 0.62 0.46, 3.64
Male 63 11 52
Female 50 7 43
Age/years 0.91 0.86 0.33, 2.57
< 40 46 7 39
40-60 67 11 56
BMI/(kg/m2) 0.69 0.53 0.22, 2.18
≤25 88 13 75
>25 25 5 20
ASA gradea 0.24
Ⅰ 21 1 20 0.16 0.06 0.02, 1.37
Ⅱ 55 9 46 0.71 0.52 0.25, 2.05
Ⅲ 37 8 29
Reason of fracture 0.19 <0.01 0.06, 0.55
Low-energy trauma 75 6 69
High-energy trauma 38 12 26
Interval between injury and surgery 1.09 0.86 0.39, 3.07
≤ 3 d 67 11 56
>3 d 46 7 39
Side of fracture 0.63 0.38 0.23, 1.75
Left 61 8 53
Right 52 10 42
Location of fracture lineb 0.71
Subcapital 37 7 30 1.07 0.50 0.98, 1.17
Transverse 74 11 63 1.03 0.56 0.99, 1.08
Basal 2 0 2
Garden classification 0.13 <0.01 0.03, 0.59
Ⅰ and Ⅱ 49 2 47
Ⅲ and Ⅳ 64 16 48
Pauwels classificationc 0.02
Ⅰ 21 1 20 0.12 0.02 0.01, 0.99
Ⅱ 55 6 49 0.29 0.02 0.10, 0.87
Ⅲ 37 11 26
Reduction method 0.75 0.80 0.08, 7.10
Closed 108 17 91
Open 5 1 4
Internal fixation 3.29 0.04 1.01, 10.71
CCS 63 14 49
DHS 50 4 46
Reduction qualityd <0.01
A 91 9 82 0.33 0.34 0.03, 3.51
B 18 8 10 2.40 0.47 0.21, 27.72
C 4 1 3

表3

股骨颈骨折内固定术后股骨头坏死危险因素的多因素Logistic回归分析"

Parameter OR P value 95%CI
Reason of fracture 4.11 0.03 1.19, 14.24
Garden classification 4.85 0.04 1.08, 21.75
Pauwels classificationa
Ⅰ vs. Ⅲ 1.95 0.57 0.19, 20.05
Ⅱ vs. Ⅲ 1.65 0.45 0.45, 6.08
Internal fixation 0.28 0.06 0.07, 1.06
Reduction qualityb
A vs. C 2.13 0.56 0.16, 27.59
B vs. C 0.29 0.37 0.02, 4.54

图1

典型病例,患者男,55岁,左股骨颈骨折"

图2

典型病例,患者男,50岁,右股骨颈骨折"

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