构建股骨转子间骨折股骨近端防旋髓内钉内固定失效的风险预测模型  

Construction of a risk prediction model for failure of proximal femoral nail antirotation fixation in intertrochanteric fractures

作　　者：涂泽松[1] 徐大星[1] 罗洪斌[1] 王宇胜 冯兴伦[1] 彭仲华[1] 杜绍龙 Tu Zesong;Xu Daxing;Luo Hongbin;Wang Yusheng;Feng Xinglun;Peng Zhonghua;Du Shaolong(Department of Orthopedics,Sanshui Branch of Foshan Hospital of Traditional Chinese Medicine,Foshan 528100,Guangdong Province,China)

机构地区：[1]佛山市中医院三水医院骨科,广东省佛山市528100

出　　处：《中国组织工程研究》2025年第27期5845-5853,共9页Chinese Journal of Tissue Engineering Research

基　　金：佛山市自筹经费类科技创新入库项目(2220001004515),项目负责人:涂泽松;佛山市“十四五”高水平医学重点专科建设项目、佛山市“十四五”中医重点专科建设项目、三水区“十四五”医学重点专科建设项目(202KJS09,佛山市中医院三水医院中医骨伤科),项目负责人:涂泽松。

摘　　要：背景:股骨转子间骨折是主要的老年脆性骨折类型,股骨近端防旋髓内钉是首选手术方案,但术后内固定失效的相关因素尚存在争议。目的:通过术前评估患者影像学资料提出一种新的股骨转子间骨折“三柱”分类法,并分析其与术后内固定失效的交互关系,利用数字技术运算开发和验证风险预测模型,便于临床医生术前甄别并干预高风险患者。方法:选择2012年6月和2022年6月佛山市中医院三水医院收治的股骨转子间骨折患者,按照术后是否出现内固定失效结局,分为内固定失效组和内固定维持组。根据患者术前X射线片将股骨近端分为“三柱”:内侧柱、外侧柱及中柱,每柱均有不同的亚组分型。分析“三柱”的形态特征与股骨近端防旋髓内钉内固定术后复位失效的关系,通过先单因素后多因素logistics回归分析,筛选出引起内固定失效的独立风险因素,根据独立风险因素利用R语言软件构建风险预测模型。采用自助法重抽样1000次,使用受试者工作特征曲线下的面积、校准曲线、临床决策曲线评价模型的区分度、校准能力及临床应用价值。通过Youden指数确定预测模型的最佳风险分界值,据此将患者分为高、低风险组,根据模型风险预测能力的准确度来评价其稳定性和外延性。结果与结论:①利用“三柱”分型系统预测骨折术后内固定失效的4个独立风险因素,分别为内侧柱(小转子及股骨距粉碎性骨折)[优势比=5.385,95%CI(1.961,14.782),P=0.001]、中间柱(烟囱型)[优势比=2.893,95%CI(1.167,7.173),P=0.022]、外侧柱(外侧壁厚度<20.5 mm)[优势比=2.804,95%CI(1.078,7.297),P=0.035]及外侧柱(外侧壁骨折)[优势比=4.278,95%CI(1.670,10.959),P=0.012];②构建的风险预测模型表现出良好的区分度和准确度[受试者工作特征曲线下面积=0.852,95%CI(0.837,0.922)],校准曲线显示模型预测风险和实际发生风险有较好的一致性;�BACKGROUND:Intertrochanteric femoral fractures are the main type of fragility fracture in the elderly,and proximal femoral nail antirotation is the preferred surgical option,but the factors associated with postoperative internal fixation failure are controversial.OBJECTIVE:A new“three-column”classification of intertrochanteric femoral fractures was proposed by evaluating patients’imaging data preoperatively and analyzing its interaction with postoperative internal fixation failure.A risk prediction model was developed and validated by using numerical algorithms,which facilitates clinicians to identify and intervene in high-risk patients preoperatively.METHODS:Patients with intertrochanteric femur fractures in Sanshui Branch of Foshan Hospital of Traditional Chinese Medicine between June 2012 and June 2022 were selected.The patients were divided into the internal fixation failure group and the internal fixation maintenance group according to whether they had internal fixation failure after surgery.According to the preoperative radiographs,the proximal femur was divided into three columns:the medial column,the lateral column,and the middle column.Each column had different subgroups.The relationship between the morphological characteristics of the“three columns”and the failure of proximal femoral nail antirotation internal fixation was analyzed,and the independent risk factors for internal fixation failure were screened out by single and then multifactorial logistic regression analyses.A risk prediction model was constructed according to the independent risk factors using R language software.The Bootstrap method was used to resample 1000 times.The area under the curve,calibration curve,and clinical decision curve were used to evaluate the differentiation,calibration ability,and clinical application value of the model.The Youden index was used to determine the optimal risk cut-off value of the prediction model,according to which the patients were divided into high and low risk groups.The stability and exten

关 键 词：股骨转子间骨折 股骨近端防旋髓内钉 独立风险因素 内固定失效 分型系统 风险预测模型 骨科植入物 

分 类 号：R459.9[医药卫生—治疗学] R318[医药卫生—临床医学] R641