个体化围手术期方案在高龄股骨转子间骨折治疗中的应用

The clinical experience of the perioperative management of intertrochanteric fracture with elderly highrisk patients

目的分析个体化围手术期治疗方案在高龄转子间骨折治疗中的应用效果。方法回顾性分析南方医科大学南方医院2008年7月至2016年1月收治的87例复杂高龄(80岁以上)股骨转子间骨折患者的资料,入院后评估患者心肺及认知能力、术前活动能力、骨折类型、个体化制定手术放案(髓内钉,髓外固定或外固定架)及麻醉方案(腰麻或筋膜阻滞),如无法手术则行保守治疗,记录患者入院至手术时间、术中出血量、手术时间、并发症发生率、30 d内死亡率、1年内死亡率、术后Harris评分及SF-36评分等来总结个体化治疗高龄患者的应用效果。结果 78例患者接受手术治疗,平均受伤至手术时间为(35±8)h(12~78 h),平均手术时间为(63±14)min(15~98 min),平均术中失血量为(263±121)ml(47~795 ml)。随访1年,8例患者伤后30 d内死亡,30 d死亡率为9.2%,另15例患者伤后12个月内死亡,1年内死亡率为26.4%,15例患者死于肺部感染,5例心功能衰竭,2例泌尿系感染,1例肺栓塞;2例患者发生手术相关并发症从而导致内固定失效,无医源性骨折发生;术后1年平均Harris评分为(73±4)分(66~87分),SF-36评分较术前显著改善。结论高龄转子间骨折患者通过个体化术前合并症评估,制定个体化麻醉及手术方案,并尽可能伤后48 h内手术,有望降低死亡率并提高患者生存质量。

Objective To conclude clinical experience of the perioperative management of intertrochantericfracture with advanced patients. Methods Data of 87 elderly patients with intertrochanteric fracture（over 80 years old） admitted from July 2008 to January 2016 in Nanfang Hospital of Southern MedicalUniversity were analyzed. Cardiopulmonary and cognitive abilities, preoperative activities, fracture typewere carefully recorded, individualized surgical release （intramedullary nail, extramedullary fixation or externalfixator） and anesthesia program （spinal anesthesia or fascia block） were designed accordingly. If surgerywas not applicable conservative treatment would be used. The duration from to operation, blood loss, introoperativetime, mortality rate, complication rate, 30 d motality, 1 year motality, Harris score and SF-36 scorewere recorded for analysis. Results Seventy-eight cases were treated operatively, the average time from injuryto surgery is （35±8） h （12-78 h）. The average intro-operative time is （63±14） min （15-98 min）, bloodlose is （263±121） ml （47-795 ml）. Patients were followed up for 1 year, 8 patients died within 30 days afterinjury, the mortality rate was 9.2% after 30 days. The other 15 patients died within 12 months after injury, themortality rate within 1 year was 26.4%. Fifteen patients died of lung disease and 5 cases of heart failure, 2cases out of urinary tract infection and 1 case of pulmonary embolism. 2 patients had operation-related complicationsresulting in internal fixation failure and no iatrogenic fracture. The Harris score at 1 year after operationwas 66-87 points with an average of （73±4） points, SF-36 score was significantly improved comparedwith the preoperative. Conclusion Individualized preoperative comorbidities evaluation, individualized an- esthesia and surgical protocols and ensure surgery performing within 48 hours for elderly patients with intertrochantericfractures is possible to reduce mortality and improve patient quality of life.