股骨粗隆间骨折PFNA内固定失效手术因素分析

目的　探讨股骨粗隆间骨折PFNA内固定术后失效的手术相关因素。 方法　回顾性研究2015.09~2018.09期间因股骨粗隆间骨折在本院行股骨近端防旋髓内钉（proximal femoral nail anti-rotation，PFNA）内固定治疗的病例，筛选出内固定失效且病历资料完整的24例；观察其术前、术后及内固定失效复诊X线片，分析其术前外侧壁是否骨折，术后股骨粗隆内侧皮质的复位质量、正侧位X线片上螺旋刀所在区域并测量其尖顶距（tip apex distance，TAD）等指标。 结果　失效的24例病例，术前外侧壁骨折13例（54%），外侧壁有骨折倾向5例，外侧壁无骨折6例；内侧皮质复位阴性支撑16例（67%）、阳性支撑6例、中性支撑2例；TAD>25 mm 16例（67%），10~25 mm 6例，<10 mm 2例；X线正位片螺钉位于偏上19例（79%），中偏下3例，偏下2例；侧位片螺钉位于偏前17例（71%），偏后5例，中间2例。 结论　行PFNA内固定治疗股骨粗隆间骨折，如存在术前外侧壁骨折或骨折倾向、内侧皮质复位欠佳、TAD过大以及螺旋刀片位置不良等因素，均会增加术后内固定失效的风险。

Analysis of surgical factors of failure of PFNA after intertrochanteric fracture

Objective　To investigate the operative factors of failure in femoral intertrochanteric fractures treated with proximal femoral nail anti-rotation (PFNA).　Methods　The material of patients with intertrochanteric fracture who accepted fixation with PFNA were conducted from September 2015 to September 2018 in our hospital and were analyzed retrospectively. Patients who failed in PFNA fixation were 24. Preoperative lateral wall fracture, postoperative reduction mass of medial femoral trochanteric cortex, region of spiral blade located on X-ray film, and the tip-apex distance (TAD) were observed through the X-ray film of preoperative, postoperative and internal fixation failure.　Results　In the 24 cases who failed in PFNA fixation, 13 cases (accounting for 54%) had lateral wall fractures before operation, 5 cases had dangerous lateral wall fractures, and 6 cases had no lateral wall fractures. While there were 16 cases (accounting for 67%) of medial cortical reduction negative support, 6 cases of positive support and 2 cases of neutral support. At the same time, there were 16 cases (accounting for 67%) with TAD>25 mm, 6 cases with TAD between 10mm~25mm, 2 cases with TAD<10 mm. In the region of spiral blade located on the positive X-ray film, there were 19 cases (accounting for 79%) located on the upper side, 3 cases in the middle-lower side and 2 cases in the lower side. In addition, in the lateral X-ray film, there were 17 cases (accounting for 71%) located in the front side, 5 cases in the back side, and 2 cases in the middle side.　Conclusions　The risk of internal fixation increase when there were lateral wall fractures before operation, poor medial cortex reduction, oversize TAD and poor location of spiral blade on the X-ray film in the femoral intertrochanteric fracture fixed with PFNA.