高龄股骨颈骨折患者人工双极股骨头置换术后死亡危险因素分析

Risk factors for mortality after bipolar femoral head replacement in elderly patients with femoral neck fractures

目的探讨高龄股骨颈骨折患者行人工双极股骨头置换术后死亡的危险因素。方法选择2011年1月—2015年12月间在江苏省江阴市青阳医院行人工双极股骨头置换术的80岁以上股骨颈骨折患者114例。通过查阅病历系统收集患者的一般资料(包括年龄、性别、受伤至手术时间、ASA分级、贫血、低白蛋白血症、合并症),住院时间,手术时间,术中出血量,术后不良反应,假体固定方式。收集随访时患者术后康复训练、假体翻修手术情况,评估术前和术后患者行走能力,以及死亡患者的死亡时间和原因。采用单因素和多因素Cox生存风险回归模型对各变量进行分析。采用Kaplan-Meier(K-M)法对术后患者进行生存分析,绘制生存曲线。结果114例患者中失访10例,最后有104例患者纳入研究,其中女83例、男21例,年龄为(83.3±2.7)岁,受伤至手术的时间为(2.5±1.3)d;住院时间为(7.2±2.1)d,手术时间为(48.9±19.6)min,术中出血量为(189±52)mL,ASA分级Ⅲ级以下68例(65.4%)、Ⅲ级及以上36例(34.6%);贫血(血红蛋白80~<110 g/L)38例(36.5%),低白蛋白血症(白蛋白<35 g/L)39例(37.5%);合并症<3种83例(79.8%)、≥3种21例(20.2%)。术后随访时间为50.38(41.26,58.45)个月。术后1、6个月和1、3年的全因死亡率分别为3.8%(4/104)、7.7%(8/104)、10.6%(11/104)和17.2%(18/104)。5年累积生存率为54.4%。单因素分析结果显示,贫血(HR=2.33,95%CI为1.19~4.55,P=0.014)、男性(HR=2.05,95%CI为1.00~4.20,P=0.049)、术前合并症≥3种(HR=4.15,95%CI为2.09~8.25,P<0.001)、合并慢性肺部疾病(HR=3.02,95%CI为1.17~7.80,P=0.023)和合并慢性肾衰竭(HR=2.27,95%CI为1.03~6.91,P=0.044)是术后死亡的危险因素。多因素回归分析结果显示,高龄(HR=1.12,95%CI为1.01~1.24,P=0.025)、男性(HR=2.87,95%CI为1.27~6.48,P=0.011)、术前合并症≥3种(HR=5.57,95%CI为2.41~12.87,P<0.001)、合并慢性肾衰竭(HR=6.45,95%CI为1.28~32.55,P=0.024)是患者术后死亡的独立危险因素。6例患者在随访期内进行假体翻修手术,其中髋臼磨损3例,反复脱位、股骨假体周围骨折、关节假体周围感染各1例。术前能独立行走患者62例,拄拐杖行走29例,室内独立行走11例,室内拄拐杖行走2例;术后1年能独立行走患者38例,拄拐杖行走32例,室内独立行走15例,室内拄拐杖行走4例,不能行走4例。结论高龄、男性和术前合并症≥3种是高龄股骨颈骨折患者手术后死亡的独立危险因素,在临床治疗中需加以重视,及时干预,以降低术后死亡率。

Objective To analyze risk factors for mortality after bipolar hemiarthroplasty for femoral neck fractures in elderly patients.Methods A total of 114 patients aged over 80 years who underwent bipolar hemiarthroplasty in our hospital between January 2011 and December 2015 were collected in this retrospective study.Age,gender,injury-surgery interval,American Society of Anesthesiologists(ASA)score,hemoglobin level,albumin level,comorbidities,hospital stay,operation time,intraoperative blood loss,postoperative complications,and prosthesis fixation were recorded.A follow-up was conducted on rehabilitation training,revisions,ambulatory status,and mortality.Univariate and multivariate analysis of Cox proportional hazard regression(HR)were used to evaluate risk factors.Kaplan-Meier analysis was applied for survival analysis,and a survival curve was drawn.Results Eventually,104 patients were followed up and enrolled in this study.There were 83 females and 21 males,with a mean age of(83.3±2.7)years.The mean duration from injury to operation was(2.5±1.3)d.The mean hospital stay was(7.2±2.1)d.The mean operation time was(48.9±19.6)min.The mean intraoperative blood loss was(189±52)ml.ASA grade was less thanⅢin 68 patients(65.4%),and gradeⅢor above in 36 patients(34.6%).There were 38 patients(36.5%)with anemia(hemoglobin 80-<110 g/L)and 39 patients(37.5%)with hypoalbuminemia(albumin<35 g/L).There were 83 patients(79.8%)with less than 3 kinds of comorbidities and 21 patients(20.2%)with 3 or more comorbidities.The duration of follow-up was 50.38(41.26,58.45)months.The mortality was 3.8%(4/104),7.7%(8/104),10.6%(11/104)and 17.2%(18/104)30 days,6 months,1 year and 3 years after operation,respectively.The 5-year cumulative survival rate was 54.4%.Univariate analysis showed that anemia(HR=2.33,95%CI:1.19-4.55,P=0.014),male(HR=2.05,95%CI:1.00-4.20,P=0.049),preoperative comorbidities≥3(HR=4.15,95%CI:2.09-8.25,P<0.001),chronic lung disease(HR=3.02,95%CI:1.17-7.80,P=0.023),and chronic renal failure(HR=2.27,95%CI:1.03-6.91,P=0.044)were the risk factor for postoperative death.Multivariate regression analysis showed that advanced age(HR=1.12,95%CI:1.01-1.24,P=0.025),male(HR=2.87,95%CI:1.27-6.48,P=0.011),preoperative comorbidities≥3(HR=5.57,95%CI:2.41-12.87,P<0.001)and chronic renal failure(HR=6.45,95%CI:1.28-32.55,P=0.024)were risk factors for postoperative death.Six patients received revision surgery during follow-up,including 3 cases of acetabular wear,1 case of repeated dislocation,1 case of periprosthetic fracture and 1 case of periprosthetic infection.Before operation,62 patients were able to walk independently,29 patients were able to walk with walking stick,11 patients were able to walk independently indoors,and 2 patients were able to walk with walking stick indoors.One year after operation,38 patients were able to walk independently,32 patients were able to walk with walking stick,15 patients were able to walk independently indoors,4 patients were able to walk with walking stick indoors,and 4 patients were unable to walk.Conclusion Advanced age,males and comorbidities≥3 are independent risk factors for mortality after bipolar hemiarthroplasty for femoral neck fractures in elderly patients:we should pay attention to these risk factors and give timely treatment to decrease mortality.