合并肺栓塞髋部骨折患者手术与非手术治疗的疗效比较

Efficacy comparison between operation and non-operation treatment for hip fractures patients complicated with pulmonary embolism

目的探讨合并肺栓塞髋部骨折患者的手术与非手术治疗的疗效。方法采用回顾性病例对照研究分析2017年5月— 2019年1月浙江省东阳市人民医院治疗的18例术前合并肺栓塞髋部骨折患者临床资料,其中男11例,女7例;年龄59~96岁[(80.0±9.3)岁]。股骨转子间骨折10例,股骨转子下骨折1例,股骨颈骨折7例。诊断肺栓塞后予以低分子肝素抗凝治疗至少1周后复查示肺栓塞吸收好转、D-二聚体无二次升高。11例选择手术治疗(手术治疗组),予以髓内钉内固定术或人工髋关节置换术;7例选择非手术治疗(非手术治疗组),予以皮牵引治疗。比较两组患者髋关节功能Harris评分,采用视觉模拟评分(VAS)评估髋关节疼痛情况。末次随访观察骨折愈合、肺栓塞转归情况及3个月内病死率。结果患者均获随访3~22个月[(11.2±6.0)个月]。末次随访时,手术治疗组与非手术治疗组Harris评分分别为(92.1±2.2)分、(28.8±18.8)分(P<0.01);VAS分别为0(0,1)分、3(1,3)分(P<0.01)。末次随访时,手术治疗组5例内固定患者骨折均愈合,6例人工关节置换患者除1例死亡外,其余5例髋关节功能良好。末次随访两组肺栓塞均吸收,无肺栓塞复发。手术治疗组3个月内无一例死亡,非手术治疗组3个月内病死率为14%(1/7)。结论对于诊断为肺栓塞的髋部骨折患者,与非手术治疗比较,手术治疗利于恢复髋关节功能,缓解疼痛;手术治疗3个月内病死率更低。术前充分抗凝治疗1~2周后复查如肺栓塞吸收好转、D-二聚体无二次升高,可选择手术治疗。

Objective To investigate efficacy of operation and non-operation treatment for hip fractures patients complicated with pulmonary embolism. Methods A retrospective case control study was conducted to analyze the clinical data of 18 hip fracture patients complicated with pulmonary embolism admitted to Dongyang People's Hospital from May 2017 to January 2019. There were 11 males and seven females, aged 59 to 96 years[(80.0±9.3)years]. There were 10 patients with intertrochanteric fractures, one with femoral subtrochanteric fracture and seven with femoral neck fractures. After diagnosis of pulmonary embolism, the patients were given anticoagulant therapy with low molecular weight heparin for at least one week. The re-examination showed that pulmonary embolism absorption improved and D-dimer did not increase. Eleven patients chose surgical treatment (operation group) with intramedullary nail internal fixation or artificial hip replacement. Seven patients chose non-surgical treatment (non-operation group) with skin traction. The Harris score of hip function was compared between the two groups. Visual analogue scale (VAS) was used to evaluate hip joint pain. At the last follow-up, fracture healing, prognosis of pulmonary embolism and mortality within 3 months were recorded. Results All the patients were followed up for 3-22 months [(11.2±6.0)months]. At last follow-up, the Harris score was (92.1±2.2)points in the operation group and (28.8±18.8)points in the non-operation group (P<0.01);the VAS was 0 point (0-1 point) in the operation group and 3 points (1-3 points) in the non-operation group (P<0.01). At the last follow-up in the operation group, five patients obtained fracture healing after internal fixation, and among the six patients receiving artificial joint replacement, five patients recovered well except for one deceased patient. At the last follow-up, pulmonary embolism was absorbed and no recurrence of pulmonary embolism was found. None of the patients died within 3 months in operation group, while 14% of the patients (1/7) in the non-operation group died within 3 months. Conclusions For hip fracture patients complicated with pulmonary embolism, compared with non-operation treatment, operation treatment is more beneficial to restore hip function and relieve pain, with lower mortality rate within 3 months. Operation treatment is feasible for patients who showed improved absorption of pulmonary embolism and no secondary increase of D-dimer after one to two weeks of full anticoagulation treatment before operation.