談?wù)劺夏牦y部骨折患者手術(shù)治療的幾個(gè)問題

吳新寶 楊明輝

. 述評(píng) Editorial .

談?wù)劺夏牦y部骨折患者手術(shù)治療的幾個(gè)問題

吳新寶 楊明輝

髖部骨折；老年人；治療結(jié)果；骨質(zhì)疏松；合作行為

隨著我國人口老齡化的日益加重，老年骨質(zhì)疏松性骨折患者逐漸增多。其中髖部骨折對(duì)老年患者的生活質(zhì)量有嚴(yán)重影響，甚至?xí)＜吧黐1]。隨著老年骨折逐漸成為創(chuàng)傷骨科面臨的重要疾病類型，如何更好地治療老年髖部骨折，成為骨科醫(yī)生面臨的一項(xiàng)重要工作。

一、老年髖部骨折患者治療的目的是盡快恢復(fù)其活動(dòng)能力

老年人發(fā)生髖部骨折后，治療的目的是盡快恢復(fù)患者的活動(dòng)能力，避免臥床以及由此所帶來的并發(fā)癥，例如墜積性肺炎、褥瘡、泌尿系統(tǒng)感染等。對(duì)其中絕大多數(shù)身體狀況較好的患者，手術(shù)治療是首選。為了達(dá)到前述的治療目的，老年髖部骨折的手術(shù)應(yīng)該允許患者術(shù)后即可開始患側(cè)肢體的活動(dòng)和負(fù)重。

二、適應(yīng)證選擇

1. 內(nèi)固定是粗隆間骨折的首選治療方法：老年髖部骨折主要包括股骨頸骨折和粗隆間骨折，粗隆下骨折少見。對(duì)粗隆間骨折，內(nèi)固定是治療的首選方法，根據(jù)骨折線形態(tài)、粉碎情況和骨折穩(wěn)定性可選擇髓內(nèi)或髓外固定[2]。針對(duì)股骨近端鎖定鋼板治療粗隆間骨折的臨床研究雖然不少，但它仍不是主流的固定方式，推薦用于謹(jǐn)慎選擇的病例。人工關(guān)節(jié)置換僅適用于少數(shù)存在特殊情況的粗隆間骨折，如初次內(nèi)固定后失敗病例或嚴(yán)重粉碎的病例。

2. 空心釘內(nèi)固定是穩(wěn)定股骨頸骨折的首選治療方法：對(duì)無移位或外展嵌插的穩(wěn)定股骨頸骨折，多數(shù)醫(yī)生建議手術(shù)治療，空心釘內(nèi)固定是首選的治療方式。對(duì)移位的股骨頸骨折，建議進(jìn)行人工關(guān)節(jié)置換術(shù)。根據(jù)患者的年齡、身體狀況、傷前活動(dòng)能力等綜合評(píng)估，對(duì)有選擇的患者進(jìn)行全髖關(guān)節(jié)置換會(huì)獲得更好的效果。在選擇人工股骨頭置換時(shí)，雙動(dòng)頭和單動(dòng)頭的效果無明顯差別。在選擇股骨側(cè)假體時(shí)，水泥型假體優(yōu)先于非水泥型假體。對(duì)股骨頸骨折進(jìn)行人工關(guān)節(jié)置換時(shí)，選擇后入路會(huì)有更高的關(guān)節(jié)脫位概率[2]。

三、老年髖部骨折的手術(shù)治療宜盡早進(jìn)行

老年髖部骨折的一個(gè)重要特點(diǎn)，是患者常常存在較多的基礎(chǔ)病，手術(shù)前需進(jìn)行相應(yīng)的檢查、評(píng)估和治療。何時(shí)進(jìn)行手術(shù)在老年髖部骨折的治療中是一個(gè)重要課題。目前多數(shù)研究認(rèn)為盡早手術(shù)可有效地縮短住院時(shí)間，降低并發(fā)癥發(fā)生率，同時(shí)不會(huì)增加患者病死率，有的研究甚至發(fā)現(xiàn)盡早手術(shù)可降低病死率[3-4]。因此，很多國家的指南建議盡可能在患者住院 48 h 內(nèi)完成老年髖部骨折的手術(shù)治療，并將此作為考核老年髖部骨折治療的重要指標(biāo)之一[2,5]。

四、多科協(xié)作制訂有針對(duì)性的臨床路徑和流程可有效改善預(yù)后

要盡快完成老年髖部骨折的手術(shù)，需要骨科、老年科、麻醉科等相關(guān)科室組成協(xié)作治療組，同時(shí)要有專門針對(duì)老年髖部骨折的臨床路徑。有針對(duì)性的臨床路徑和流程可以讓患者縮短術(shù)前檢查的時(shí)間，盡快完成術(shù)前準(zhǔn)備，及時(shí)安排手術(shù)室，盡早完成手術(shù)治療。治療相關(guān)科室的緊密協(xié)作能統(tǒng)一治療理念和標(biāo)準(zhǔn)，縮短患者合并癥的評(píng)估和調(diào)整時(shí)間，降低患者進(jìn)入手術(shù)室后又停掉手術(shù)的概率。這需要相關(guān)科室的醫(yī)生均能理解老年髖部骨折的治療理念：老年髖部骨折手術(shù)不是常規(guī)的擇期手術(shù)，而是相對(duì)緊急的手術(shù)，需要盡快把老年人的身體狀況調(diào)整或改善到最佳狀態(tài)，而不是逐步、緩慢地進(jìn)行內(nèi)科相關(guān)疾病的治療。

在這一理念的基礎(chǔ)上，就需要骨科醫(yī)生對(duì)患者合并癥和基礎(chǔ)用藥的常規(guī)處理方法進(jìn)行反思和研究。針對(duì)有些內(nèi)科疾病進(jìn)行深入檢查和評(píng)估，是否有助于進(jìn)行相應(yīng)的治療，以調(diào)整改善患者的術(shù)前狀況？這些檢查和治療是否優(yōu)先于老年髖部骨折的治療？肺部感染是進(jìn)行多數(shù)外科手術(shù)的禁忌，但對(duì)老年髖部骨折患者，骨折手術(shù)利于患者坐起及下床活動(dòng)，有助于肺部感染的治療。因此對(duì)合并肺部感染的老年髖部骨折患者，不是一律不能手術(shù)，而是要綜合考慮手術(shù)的風(fēng)險(xiǎn)和收益。針對(duì)老年人術(shù)前服用的抗凝藥物，阿司匹林、華法林、氯吡格雷等。這些藥物對(duì)手術(shù)時(shí)機(jī)及圍手術(shù)期出血的影響已受到廣泛關(guān)注。多數(shù)研究發(fā)現(xiàn)對(duì)這些患者盡早進(jìn)行髖部骨折手術(shù)并不會(huì)明顯增加出血的風(fēng)險(xiǎn)及病死率[6]。

很多研究和指南建議老年科醫(yī)生加入老年髖部骨折治療組，骨科和老年科協(xié)作治療可縮短患者住院時(shí)間，降低院內(nèi)病死率?？捎卸喾N協(xié)作方式，最常見的方式是患者住在骨科病房，老年科醫(yī)生會(huì)診。少數(shù)醫(yī)院是患者住在老年科病房，骨科醫(yī)生會(huì)診。目前有研究發(fā)現(xiàn)，成立專門的老年骨折病房，由骨科和老年科醫(yī)生共同管理，會(huì)進(jìn)一步提高治療效率，改善治療效果。

總之，老年髖部骨折的治療目標(biāo)是使患者盡可能恢復(fù)到受傷前的活動(dòng)能力和功能狀況，避免再次摔倒和骨折的發(fā)生。要達(dá)到這一目標(biāo)，除了盡快完成手術(shù)治療，還需要康復(fù)科的參與和配合、骨質(zhì)疏松的評(píng)估和治療、針對(duì)患者跌倒的評(píng)估、圍手術(shù)期血栓的預(yù)防和治療等。

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( 本文編輯：李慧文 )

My view on several problems in surgical treatment of geriatric hip fracture

WU Xin-bao, YANG Ming-hui. Beijing Jishuitan Hospital, Beijing, 100035, China

With the development of society, the incidence of geriatric hip fractures is increasing as the aging population is growing in our country. Because of the unique pathophysiological characteristics, there are still many challenges in the management of geriatric hip fractures, which are closely related to the elderly patients with medical comorbidities, poor pre-injury function status, osteoporosis, etc. Geriatric fractures have become an important type of disease in the fi eld of traumatic orthopedics, and how to better treat geriatric hip fractures is an important task that orthopedic surgeons are facing. Therefore, it is necessary to understand the problems in the management of geriatric hip fractures, such as when to perform the surgery and how to cooperate among the surgeons of orthopedics, geriatrics, anesthesia and other relevant departments to complete the surgery as soon as possible. The problems should be focused on, such as how to plan for the clinical pathway of geriatric hip fractures, what is the conventional treatment method for the patients’ comorbidities and basic medicine, whether in-depth examination and evaluation of certain medical diseases is helpful for the corresponding treatment and further to adjust and improve the patients’ preoperative status, and whether these examinations and treatments should be performed before the management of geriatric hip fractures. We also need to know the new progress, and furthermore make greater efforts and more contributions for the management of geriatric hip fractures in China.

Hip fractures; Aged; Treatment outcome; Osteoporosis; Cooperative behavior

10.3969/j.issn.2095-252X.2017.03.001

R683.3

北京市醫(yī)院管理局重點(diǎn)醫(yī)學(xué)專業(yè)發(fā)展計(jì)劃 ( ZYLX201506 )

100035 北京積水潭醫(yī)院

2016-11-09 )