螺钉内固定和双极股骨头置换在治疗老年移位的股骨颈骨折中的比较

Internal Screw Fixation Compared with Bipolar Hemiarthroplasty for Treatment of Displaced Femoral Neck Fractures in Elderly Patients

背景：内固定和关节置换是治疗老年移位的股骨颈骨折的两种主要选择。最优选择仍存在争议。我们利用挪威髋部骨折记录，比较治疗移位的股骨颈骨折中股骨头置换和螺钉内固定的效果。方法：对4335例年龄超过70岁的有移位的股骨颈骨折患者治疗进行比较，其中1823例行内固定、2512例行股骨头置换，随访周期至少12个月。分别分析1年死亡率、再次手术例数以及第4和12个月患者疼痛、满意率和生活质量自我评估。另外，对认知障碍和行走能力下降的患者进行次级分析。结果：在股骨头置换组中，只应用同代的双极假体，其中现代柄和羟基磷灰石涂层的非骨水泥型假体占移植物的20．8％（522例）。两组一年死亡率无明显差别（内固定组27％，关节置换组25％，p=0．76）。在随访期内，内固定组412例（22．6％）接受二次手术，股骨头置换组72例（2．9％）接受二次手术。12个月后，内固定组相对股骨头置换组疼痛发生更高（平均分，29．9比19．2），手术满意度更差（平均分，38．9比25．7），生活质量更差（平均分，0．51比0．60）。所有差异均有统计学意义（p〈0．001）。对于认知障碍的患者，股骨头置换在第12个月时可以提供更好的功能结果（p〈0．05）（EuroQol主观视觉评分显示疼痛小，手术结果的高满意率和高质量的生活）。结论：老年有移位的股骨颈骨折应行股骨头置换治疗。

Background： Internal fixation and arthroplasty are the two main options for the treatment of displaced femoral neck fractures in the elderly. The optimal treatment remains controversial. Using data from the Norwegian Hip Fracture Register, we compared the results of hemiarthroplasty and internal screw fixation in displaced femoral neck fractures. Methods： Data from 4335 patients over seventy years of age who had internal fixation （1823 patients） or hemiarthroplasty （2512 pa- tients） to treat a displaced femoral neck fracture were compared at a minimum follow-up interval of twelve months. One-year mortali- ty, the number of reoperations, and patient self-assessment of pain, satisfaction, and quality of life at four and twelve months were analyzed. Subanalyses of patients with cognitive impairment and reduced walking ability were done. Results： In the arthroplasty group, only contemporary bipolar prostheses were used and uncemented prostheses with modern stems and hydroxyapatite coating accounted for 20.8% （522） of the implants. There were no differences in one-year mortality （27% in the osteosynthesis group and 25% in the arthroplasty group; p = 0.76）. There were 412 reoperations （22.6%） perfot3ned in the osteosynthesis group and seventy-two （2.9%） in the hemiarthroplasty group during the follow-up period. After twelve months, the osteosynthesis group reported more pain （mean score, 29.9 compared with 19.2）, higher dissatisfaction with the operation result （mean score, 38.9 compared with 25.7）, and a lower quality of life （mean score, 0.51 compared with 0.60） than the arthroplasty group. All differences were significant （p 〈 0.001）. For patients with cognitive impairment, hemiarthroplasty provided a better functional outcome （less pain, higher satisfaction with the result of the operation, and higher quality of life as measured on the EuroQol visual analog scale） at twelve months （p 〈 0.05）. Conclusions： Displaced femoral neck fractures in the elderly should be treated with hemiarthroplasty Level of Evidence： Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence