Aleem Ilyas S, Karanicolas Paul J, Bhandari Mohit
Departments of Surgery, McMaster University, Hamilton, Ontario, Canada.
Ortop Traumatol Rehabil. 2009 May-Jun;11(3):233-41.
The optimal surgical management of displaced femoral neck fractures in the elderly remains controversial. Treatment alternatives include arthroplasty and internal fixation. Options for arthroplasty include total hip arthroplasty and hemiarthroplasty, whereas options for internal fixation include multiple screws and sliding hip screws. We sought to compare arthroplasty and internal fixation alternatives and determine the key factors influencing final outcomes using a clinical decision analysis.
We constructed a decision analytic model representing potential outcomes after arthroplasty and internal fixation alternatives. Probabilities of events following each procedure were systematically derived from a literature review. Relative outcome preferences were estimated using health utility questionnaires with surgeons and lay persons. Sensitivity analyses determined threshold values that would alter the preferred decision.
In the arthroplasty comparison, patients treated with total hip arthroplasty achieved higher expected utility values than patients treated with hemiarthroplasty (0.80 versus 0.74). In the internal fixation analysis, sliding hip screw fixation yielded higher expected utility values than multiple screws (0.76 versus 0.73). Overall, total hip arthroplasty achieved higher expected utility values than either approach to internal fixation. The superiority of arthroplasty over internal fixation was maintained over a wide range of probabilities and utilities.
When outcomes and their values are considered in a systematic manner, arthroplasty results in better patient outcomes when compared to internal fixation in the management of displaced hip fractures in the elderly.
老年移位型股骨颈骨折的最佳手术治疗方案仍存在争议。治疗选择包括关节置换术和内固定术。关节置换术的选择包括全髋关节置换术和半髋关节置换术，而内固定术的选择包括多枚螺钉和滑动髋螺钉。我们试图通过临床决策分析比较关节置换术和内固定术，并确定影响最终结果的关键因素。
我们构建了一个决策分析模型，以呈现关节置换术和内固定术替代方案后的潜在结果。每个手术步骤后事件的概率是通过系统的文献综述得出的。使用健康效用问卷对外科医生和普通民众进行相对结果偏好评估。敏感性分析确定了会改变首选决策的阈值。
在关节置换术的比较中，接受全髋关节置换术的患者获得的预期效用值高于接受半髋关节置换术的患者（0.80对0.74）。在内固定分析中，滑动髋螺钉固定产生的预期效用值高于多枚螺钉（0.76对0.73）。总体而言，全髋关节置换术获得的预期效用值高于任何一种内固定方法。在广泛的概率和效用范围内，关节置换术优于内固定术的优势得以保持。
当系统地考虑结果及其价值时，在老年移位型髋部骨折的治疗中，与内固定术相比，关节置换术能带来更好的患者预后。
