全程管理在类风湿关节炎患者脆性骨折中的应用研究

Application of full management in the treatment fragility fractures in patients with rheumatoid arthritis

目的探讨疾病全程管理对类风湿关节炎(rheumatoid arthritis,RA)患者骨密度及脆性骨折发生率的影响。方法选取2013-2017年我科住院的RA患者108例,随机分为试验组54例(全程管理组)和对照组54例(常规管理组),随访1年,分别于基线时与12个月结束时测量腰椎、髋部及前臂骨密度,测定血清25-羟维生素D3水平,同时记录两组骨折发生情况。结果(1) 108例RA患者,合并脆性骨折者32例,发生率为29. 6%,其中女性31例,男性1例;椎体骨折7例,非椎体骨折25例,足/踝骨折发生率最高(37. 5%),其次为椎体骨折(21. 9%);(2) RA患者中无脆性骨折和有脆性骨折患者在年龄、病程和糖皮质激素累积量上差异有统计学意义(P<0. 05或P<0. 01),而在DAS28和糖皮质激素使用时间上差异无统计学意义(P>0. 05),合并脆性骨折的RA患者股骨颈及前臂的骨密度低于无脆性骨折组,差异有统计学意义(P<0. 05),但两者间腰椎骨密度比较差异无统计学意义(P>0. 05)。(3)随访1年后,试验组股骨颈骨密度的增长显著高于对照组,差异有统计学意义(P<0. 05);(4)随访1年后,常规管理组患者新发骨折8例,发生率为14. 8%,全程管理组患者新发骨折1例,发生率为1. 9%,显著低于常规管理组患者,差异有统计学意义(P<0. 05)。结论与常规管理相比,全程管理可显著增加RA患者骨密度,并降低RA患者脆性骨折的发生率,具有一定的临床价值。

Objective To investigate the effect of disease management model on bone mineral density and fracture incidence in patients with rheumatoid arthritis(RA). Methods A total of 108 RA patients were enrolled in our hospital from 2013 to 2017. They were randomly divided into experimental group(n=54) and control group(n=54). The patients were followed up for 1 year. At baseline and 12 months, bone density of lumbar vertebrae, hip and forearm and serum 25-hydroxyvitamin D3 levels were measured. The incidence of fractures was recorded. Results(1) In the 108 patients with RA, 32 patients had fragility fracture, including 1 male and 31 females, thus the incidence rate was 29.6%. There were 7 vertebral fractures, and 25 non-vertebral fractures. The incidence of foot/ankle fracture was the highest(37.5%), followed by vertebral fracture(21.9%).(2) The differences in age, disease duration, and glucocorticoid accumulation in RA patients with and without fragility fracture were statistically significant(P<0.05 or P<0.01), but there was no significant difference in the time of using DAS28 and glucocorticoids(P>0.05). Bone density of femoral neck and forearm of RA patients with fragility fracture was lower than that of RA patiens without fracture, the difference was statistically significant(P<0.05), but there was no significant difference in lumbar spine bone mineral density between the two groups(P>0.05).(3) After 1 year of follow-up, the increase in femoral neck bone mineral density in the experimental group was significantly higher than that in the control group, the difference was statistically significant(P<0.05).(4) After 1 year of follow-up, 8 patients had new fractures in the conventional management group, with an incidence rate of 14.8%. One patient had a new fracture in the full management group, with an incidence rate of 1.9%, which was significantly lower than that in the conventional management group(P<0.05). Conclusion Compared with the conventional management model, the full management model could significantly increase bone mineral density and reduce the incidence of osteoporotic fractures in RA patients, which has certain clinical promotion value.