一例老年股骨粗隆间骨折患者的循证治疗_《中国循证医学杂志》

作者：

邓洲铭 ,  蔡林

武汉大学中南医院骨外科（武汉 430071）;

关键词：

老年患者股骨粗隆间骨折循证治疗

DOI：

10.7507/1672-2531.20100533

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的为1例股骨粗隆间骨折的老年患者确定循证治疗方案。
方法根据患者的具体情况，提出所要解决的临床问题，全面检索美国国家指南交换中心NGC（2000～2009）、Cochrane图书馆（2009年第4期）、TRIP Database、PubMed（1966～2009）及中国生物医学文献数据库（1978～2009），以获得相关的证据。依据循证医学三结合原则（最佳研究证据、医师的临床经验和病人的意愿相结合）制定治疗方案。
结果共纳入3篇临床指南、14篇系统评价/Meta分析和2篇RCT。当前证据表明：对于老年患者的不稳定型股骨粗隆间骨折应首选手术治疗；不同的手术内固定方式相比较，滑动髋螺钉（SHS）的疗效最佳，尚无足够证据支持手术后伤口常规放置闭合引流；早期手术能够缩短住院时间，降低死亡率；术前预防应用抗生素能减少术后感染的发生率；为预防深静脉血栓形成，药物预防应自入院起就开始应用，术后应辅助物理预防；住院期间高营养饮食有助于促进患者康复；术后应尽早进行康复训练。参照指南及相关证据，并根据患者的具体情况，制定合理的治疗方案。经过3个月随访，证实该方案适合本患者。
结论应用循证医学的方法，采用高质量的证据为患者制定个性化治疗方案，能显著提高治疗效果，改善患者的预后。

引用本文： 邓洲铭,蔡林. 一例老年股骨粗隆间骨折患者的循证治疗. 中国循证医学杂志, 2010, 10(8): 1004-1008. doi: 10.7507/1672-2531.20100533 复制

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6.	Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2008, (3): CD000093.
7.	Ding XF, Pei GX, Lin J, et al. [Postoperative implant-related complications after treatment of intertrochanteric fracture by gamma nail or by sliding hip screw: a meta-analysis]. Zhonghua Yi Xue Za Zhi, 2008, 88(33): 2364-2368.
8.	刘嵬, 雪原, 赵宏, 等. 我国高龄不稳定型转子问骨折经人工关节置换术与内固定术治疗的Meta分析. 天津医科大学学报, 2009, 15(1): 70-73.
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11.	Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies. Injury, 1999, 30(3): 157-163.
12.	Parker MJ, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev, 2007, (3): CD001825.
13.	Clifton R, Haleem S, McKee A, et al. Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials. Int Orthop, 2008, 32(6): 723-727.
14.	Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth, 2008, 55(3): 146-154.
15.	Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am, 2008, 90(7): 1436-1442.
16.	Southwell-Keely JP, Russo RR, March L, et al. Antibiotic prophylaxis in hip fracture surgery: a meta analysis. Clin Orthop Relat Res, 2004, (419): 179-184.
17.	Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev, 2001, (1): CD000244. .
18.	中华医学会. 中国骨科大手术静脉血栓栓塞症预防指南. 中华骨科杂志, 2009, 29(6): 602-604.
19.	Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med, 2007, 146(3): 204-210.
20.	Segal JB SM, Hofmann LV, Thornton K, et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med, 2007, 146(3): 211-222.
21.	Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev, 2006, (4): CD001880.
22.	Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg, 2006, 76(7): 607-611.

1. Guyatt GH, Rennie D, Editors. The Evidence-Based Medicine Working Group.Users’Guides to the Medical literature:A Mannual for Evidence-Based Clinical Practice. Chicago. AMA Press 2002.
2. 杨学宁, 吴一龙. 临床证据水平分级和推荐级别. 循证医学, 2003, 3(2): 111-113.
3. 米登海, 姜雷, 杨克虎, 等. 一例广泛期小细胞肺癌的循证治疗. 中国循证医学杂志, 2009, 9(4): 4884-4488.
4. Scottish intercollegiate guideline network management of hip fracture in older people. scottish intercollegiate guideline network 2009 (cited 2009 dec 29 ). Available from :URL : http://www.sign. ac.uk/pdf/sign111.pdf.
5. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev, 2008(3): CD000337.
6. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2008, (3): CD000093.
7. Ding XF, Pei GX, Lin J, et al. [Postoperative implant-related complications after treatment of intertrochanteric fracture by gamma nail or by sliding hip screw: a meta-analysis]. Zhonghua Yi Xue Za Zhi, 2008, 88(33): 2364-2368.
8. 刘嵬, 雪原, 赵宏, 等. 我国高龄不稳定型转子问骨折经人工关节置换术与内固定术治疗的Meta分析. 天津医科大学学报, 2009, 15(1): 70-73.
9. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2006, (2): CD000086.
10. Parker MJ, Handoll HH. Extramedullary fixation implants for extracapsular hip fractures. Cochrane Database Syst Rev, 2002, (2): CD000339.
11. Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies. Injury, 1999, 30(3): 157-163.
12. Parker MJ, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev, 2007, (3): CD001825.
13. Clifton R, Haleem S, McKee A, et al. Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials. Int Orthop, 2008, 32(6): 723-727.
14. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth, 2008, 55(3): 146-154.
15. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am, 2008, 90(7): 1436-1442.
16. Southwell-Keely JP, Russo RR, March L, et al. Antibiotic prophylaxis in hip fracture surgery: a meta analysis. Clin Orthop Relat Res, 2004, (419): 179-184.
17. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev, 2001, (1): CD000244. .
18. 中华医学会. 中国骨科大手术静脉血栓栓塞症预防指南. 中华骨科杂志, 2009, 29(6): 602-604.
19. Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med, 2007, 146(3): 204-210.
20. Segal JB SM, Hofmann LV, Thornton K, et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med, 2007, 146(3): 211-222.
21. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev, 2006, (4): CD001880.
22. Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg, 2006, 76(7): 607-611.

《中国循证医学杂志》

一例老年股骨粗隆间骨折患者的循证治疗

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一例老年股骨粗隆间骨折患者的循证治疗

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