对于老年患者的 Garden Ⅰ型骨折，非手术治疗是否仍然相关？股骨颈压入角作为一个新的 CT 参数，用于确定非手术治疗的适应证。

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment.

机构信息

Service de chirurgie orthopédique, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France.

出版信息

Orthop Traumatol Surg Res. 2019 May;105(3):479-483. doi: 10.1016/j.otsr.2018.12.010. Epub 2019 Mar 8.

DOI:10.1016/j.otsr.2018.12.010

PMID:30858044

Abstract

BACKGROUND

The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over.

HYPOTHESIS

The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment.

METHODS

Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane.

RESULTS

After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04-45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90-0.97) and 0.9011 (95%CI, 0.83-0.94), respectively.

DISCUSSION

The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment.

LEVEL OF EVIDENCE

II, prospective cohort study.

摘要

背景

股骨颈无移位骨折的非手术治疗适应证存在争议。本研究的目的是评估在 65 岁及以上患者中，股骨颈挤压角（IA）和股骨颈后倾角（PTA）这两个 CT 参数是否能有效预测 Garden I 型股骨颈骨折非手术治疗后的继发性移位风险。

假设

本研究的工作假设为冠状位的 IA 和轴位的 PTA 可以预测 Garden I 型股骨颈骨折非手术治疗后的继发性移位，可以在 CT 扫描上重复且可靠地测量，并且可以识别 Garden I 型骨折在非手术治疗后有继发性移位的风险。

方法

本前瞻性单中心研究纳入了 49 例 65 岁及以上接受非手术治疗的 Garden I 型骨折患者。使用 CT 图像测量 IA，即骨折线在冠状位相对于股骨头的位置，以及 PTA，即股骨头中心在轴位相对于股骨颈轴线的位置。

结果

在非手术治疗后，22 例（45%）患者发生了继发性移位。继发性移位组与无继发性移位组的 PTA 无显著差异（p=0.62）。IA 值≤135°与继发性移位显著相关（优势比，11.73；95%置信区间 [95%CI]，3.04-45.28；p=0.004）。IA≤135°对预测继发性移位的敏感性为 72.73%，特异性为 81.48%。IA 测量具有可重复性，组内和组间 Cohen's kappa 值分别为 0.94（95%CI，0.90-0.97）和 0.9011（95%CI，0.83-0.94）。