InterTan髓内钉与AFHR对老年股骨粗隆间骨折患者疗效的影响及术后死亡的因素分析

Effects of InterTan intramedullary nailing and AFHR on efficacy of femoral intertrochanteric fracture in elderly patients and analysis of risk factors for postoperative mortality

目的探讨InterTan髓内钉与人工股骨头置换术(AFHR)对老年股骨粗隆间骨折患者疗效的影响。方法前瞻性选择河北省沧州中西医结合医院接受治疗的92例股骨粗隆间骨折患者,其中男性51例,女性41例;年龄80~89岁,平均年龄84.4岁;骨折AO分型A1型32例,A2型60例。依据随机数字表法分为InterTan髓内钉组和AFHR组,分别为53例和39例。InterTan髓内钉组采用InterTan髓内钉固定治疗,AFHR组采用AFHR治疗。比较两组患者的临床疗效、临床相关指标、髋关节功能恢复情况及术后并发症,随访所有患者1年生存情况,比较两组患者30 d、1年的死亡率,并分析术后死亡危险因素。结果InterTan髓内钉组临床有效率(81.1%)与AFHR组(79.5%)比较,差异无统计学意义(χ^(2)=0.039,P>0.05)。InterTan髓内钉组患者手术时间[(52.9±20.7)min]和切口长度[(5.2±1.0)cm]均明显短于AFHR组[(67.5±15.9)min,(13.1±1.2)cm],且术中出血量[(125.3±43.5)mL]明显少于AFHR组[(198.7±52.6)mL](t=3.677、34.388、7.316,P<0.05);而AFHR组患者的下床活动时间[(6.7±1.8)d]明显早于InterTan髓内钉组[(14.9±2.2)d],且住院时间[(14.1±2.6)d]明显短于InterTan髓内钉组[(18.7±3.2)d](t=19.046、7.362,P<0.05)。术后3个月,AFHR组Harris评分[(79.6±10.6)分]明显优于InterTan髓内钉组[(66.5±11.6)分](t=5.550,P<0.05),而术后6个月、12个月比较,差异无统计学意义(P>0.05)。术后随访3个月内InterTan髓内钉并发症发生率(7.5%)与AFHR组(7.7%)比较,差异无统计学意义(P>0.05)。InterTan髓内钉组患者术后30 d、1年死亡率(5.7%,11.3%)与AFHR组(5.1%,12.8%)比较,差异无统计学意义(χ^(2)=0.012、0.048,P>0.05)。单因素分析显示术后死亡的影响因素为冠心病、合并内科疾病数量、入院时血红蛋白及白蛋白水平;多因素分析显示术后死亡的独立危险因素为合并2种以上内科疾病和入院时白蛋白<35 g/L。结论InterTan髓内钉与AFHR均能有效治疗老年股骨粗隆间骨折,InterTan髓内钉具有手术时间短、切口短小、出血量少等优势,而AFHR能明显缩短患者住院时间、加快早期负重训练,合并多种内科疾病或白蛋白水平较低患者术后死亡率较高,因此应综合患者实际病情,选择合适的手术方式,并在围手术期加强风险管控,改善临床愈后。

Objective To explore effects of InterTan intramedullary nailing and artificial femoral head replacement(AFHR)on efficacy of femoral intertrochanteric fracture in elderly patients.Methods A total of 92 patients with femoral intertrochanteric fracture were enrolled,which included 51 males and 41 females;aged 80-89 years old with mean age of 84.4 years old.Based on fracture AO classification,patients were classified into 32 cases of A1 type and 60 cases of A2 type.According to random number table,all of them were divided into InterTan intramedullary nail group(n=53,treated with InterTan intramedullary nail)and AFHR group(n=39,treated with AFHR).The clinical efficacy,clinical related indicators,hip joint function recovery and postoperative complications between 2 groups were compared.The 1-year survival status of all patients was followed up,the 30-day and 1-year mortality rates between 2 groups were compared,and the risk factors of postoperative mortality were analyzed.Results There was no significant difference in clinical efficacy between InterTan group(81.1%)and AFHR group(79.5%)(χ^(2)=0.039,P>0.05).The operation time[(52.9±20.7)minutes],incision length[(5.2±1.0)cm]in InterTan group were significantly shorter than those in AFHR group[(67.5±15.9)minutes,(13.1±1.2)cm],and intraoperative blood loss[(125.3±43.5)mL]was significantly less than that in AFHR group[(198.7±52.6)mL](t=3.677,34.388,7.316,P<0.05);While ambulation time in AFHR group[(6.7±1.8)days]was significantly earlier than that in InterTan group[(14.9±2.2)days],and hospitalization time[(14.1±2.6)days]in AFHR group was significantly shorter than that in InterTan group[(18.7±3.2)days](t=19.046,7.362,P<0.05).Three months after operation,the Harris score[(79.6±10.6)scores]of AFHR group was significantly better than that of InterTan group[(66.5±11.6)scores](t=5.550,P<0.05),but there was no significant difference in Harris score 6 months and 12 months post operation between 2 group(P>0.05).During 3 months follow-up,there was no significant difference in incidence of postoperative complications between InterTan group(7.5%)and AFHR group(7.7%)(P>0.05).There was no significant difference in mortality at 30-day and 1-year after surgery between InterTan group(5.1%,11.3%)and AFHR group(5.1%,12.8%)(χ^(2)=0.012,0.048,P>0.05).The univariate analysis showed that coronary atherosclerotic heart disease,number of comorbidities,preoperative hemoglobin and albumin levels were the influencing factors of postoperative mortality(P<0.05);Multivariate analysis showed that combined more than 2 medical diseases,and preoperative albumin(<35 g/L)were the independent risk factors of postoperative mortality(P<0.05).Conclusion It is demonstrated that InterTan and AFHR could effectively treat femoral intertrochanteric fracture in elderly patients.InterTan has the advantages of shorter operation time,less incision and bleeding,AFHR can reduce hospitalization time,carry out early weight-bearing exercise.As patients with multiple medical diseases or low albumin levels have higher postoperative mortality,appropriate surgical methods should be selected based on patient condition,and risk management during perioperative period should be strengthened to im-prove clinical outcomes.