股骨转子间骨折围手术期的并发症及死亡原因分析

Analysis of the causes of complications and death of the femoral intertrochanteric fracture during perioperative period

目的探讨股骨转子间骨折围手术期的并发症发生情况及死亡原因。方法回顾性分析2007年5月至2014年6月547例接受手术治疗股骨转子间骨折患者的病历资料，共499例符合条件纳入研究，男132例，女367例；年龄59～103岁，平均（78．3±7．3）岁。股骨转子间骨折根据Evans分型：Ⅰ型84例、Ⅱ型67例、Ⅲ型187例、Ⅳ型161例。将术前健康状况评估（APACHEⅡ评分系统）结果和预测死亡率分别与年龄、手术时间、出血量等相关因素进行统计学分析。对APACHEⅡ评分的有效性进行ROC曲线分析。结果围手术期间合并症或新出现并发症共354例次，依次是肺炎、泌尿系感染、下肢深静脉血栓、心脏事件。死亡30例，死亡率为6．0％。死亡原因依次为感染中毒性休克、呼吸功能衰竭、心脏事件、肾功能衰竭、肝破裂导致失血性休克。存活组和死亡组的APACHEⅡ评分分别是（12．0±5．2）分和（22．0±5．3）分，两组差异有统计学意义。多因素相关性分析显示，死亡组APACHEⅡ评分及预测死亡率与手术时间及出血量呈正相关，APACHEⅡ评分ROC曲线下面积为0．938，最佳截断值为17．5（约登指数为0．767），此时的敏感度为86．7％，特异度为90％。通过APACHEⅡ评分换算的死亡风险ROC曲线下面积为0．817，最佳截断值为16．765％（约登指数为0．483），此时的敏感度为93．3％，特异度为55．0％。结论股骨转子间骨折围手术期的并发症与合并症较多，死亡的主要原因是感染性休克。血红蛋白和手术时间与患者创伤的程度密切相关。APACHEⅡ评分系统被证实对股骨转子间骨折评估和预后具有一定的临床价值，值得推荐使用。

Objective To analyze the causes of complications and death of the femoral intertrochanteric fracture during perioperative period, and to assess the orthopedics surgery risk of aged. Methods 499 of 547 cases were retrospectively reviewed （132 male, 367 female）, who underwent operation from May 2007 to Jun 2014 in our hospital. Their age varied from 59 to 103 years old, with an average of 78.3±7.3 years old. According to Evans classification, there were 84 cases of type Ⅰ, 67 type Ⅱ, 187 type Ⅲ, and 161 type IV. The causes of death were analyzed and discussed. The factors including health assessment before operation, age, operating time and blood loss were studied statistically to find out their correlation with mortality of operation. Results There were altogether 354 complications, including pulmonary infection, urinary system infection, DVT, and cardiac events. There were 30 cases of death and the mortality was 6.0%. The major causes of death included infectious shock, pulmonary infection, cardiac events, kidney failure and hemorrhagic shock caused by hepatic rupture. Statistical results from the score of APACHE Ⅱ showed the factor which definitely influenced the mortality was the amount of blood loss during operation. APACHE Ⅱ scoring area under the ROC curve was 0.938, and the best cutoff value was 17.5 （about an index of 0.767）, with the sensitivity of 86.7% and specificity of 90%. The area of risk of death under the ROC curve by APACHE Ⅱ score was 0.817, the best cutoff value of 16.765% （about an index of 0.483）, and the sensitivity and specificity of 93.3% and 55.0%. Conclusion There were a lot of complications and accompanied diseases when femoral intertrochanteric fractures happened in aged patients. The main cause of death was septic shock. There were relationships between hemoglobin and the operating time and the degree of trauma. What＇ s more, it was confirmed that the APACHE Ⅱ scoring system was very useful to value the condition of the patients with femoral intertrochanteric fractures, which can be recommended.