Butler Mary, Forte Mary, Kane Robert L, Joglekar Siddharth, Duval Susan J, Swiontkowski Marc, Wilt Timothy
Evid Rep Technol Assess (Full Rep). 2009 Aug(184):1-85, v.
To conduct a systematic review and synthesize the evidence for the effects of surgical treatments for subcapital and intertrochanteric/subtrochanteric hip fractures on patient-focused outcomes for elderly patients.
MEDLINE, Cochrane databases, Scirus, and ClinicalTrials.gov, and expert consultants. We also manually searched reference lists from relevant systematic reviews.
High quality quasi-experimental design studies were used to examine relationships between patient characteristics, type of fracture, and patient outcomes. Randomized controlled trials were used to examine relationships between type of surgical treatment and patient outcomes. Patient mortality was examined with Forest plots. Narrative analysis was used for pain, quality of life (QoL), and functional outcomes due to inconsistently measured and reported outcomes.
Mortality does not appear to differ by device class, or by devices within a class. Nor, on the whole, do pain, functioning, and QoL. Some internal fixation devices may confer earlier return to functioning over others for some patients, but such gains are very short lived. Very limited results suggest that subcapital hip fracture patients with total hip replacements have improved patient outcomes over internal fixation, but it is unclear whether these results would continue to hold if the analyses included the full complement of relevant covariates. Age, gender, prefracture functioning, and cognitive impairment appear to be related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Again, however, the observational literature does not include the full complement of potential covariates and it is uncertain if these results would hold.
Several factors limit our ability to definitively answer the key questions posed in this study using the existing literature. Limited perspectives lead to incomplete sets of independent variables included in analyses. Specific populations are poorly defined and separated for comparative study. Fractures with widely varying biomechanical problems are often lumped together. Outcome variables are inconsistently measured and reported, making it very difficult to aggregate or even compare results. If future high quality trials continue to support the evidence that differences in devices are short term at best, within the first few weeks to few months of recovery, policy implications involve establishing the value of a shorter recovery relative to the cost of the new device. As the literature generally focuses on community dwelling elderly patients, more attention needs to be directed toward understanding implications of surgical treatment choices for the nursing home population.
进行系统评价并综合分析针对老年患者股骨颈骨折和转子间/转子下骨折的手术治疗对以患者为中心的结局的影响的证据。
医学期刊数据库（MEDLINE）、考克兰数据库、Scirus和美国国立医学图书馆临床试验数据库（ClinicalTrials.gov），以及专家顾问。我们还手动检索了相关系统评价的参考文献列表。
采用高质量的准实验设计研究来检验患者特征、骨折类型与患者结局之间的关系。采用随机对照试验来检验手术治疗类型与患者结局之间的关系。使用森林图分析患者死亡率。由于结局测量和报告不一致，采用叙述性分析来分析疼痛、生活质量（QoL）和功能结局。
死亡率似乎不因器械类别或类别内的器械而有所不同。总体而言，疼痛、功能和生活质量也没有差异。对于一些患者，某些内固定器械可能比其他器械能使患者更早恢复功能，但这种改善非常短暂。非常有限的结果表明，接受全髋关节置换术的股骨颈骨折患者比接受内固定术的患者结局更好，但如果分析纳入全部相关协变量，这些结果是否仍然成立尚不清楚。年龄、性别、骨折前功能和认知障碍似乎与死亡率和功能结局有关。骨折类型似乎与患者结局没有独立关联。然而，同样地，观察性文献并未纳入全部潜在协变量，这些结果是否成立尚不确定。
几个因素限制了我们利用现有文献明确回答本研究中关键问题的能力。观点有限导致分析中纳入的自变量不完整。特定人群定义不明确且未分开进行比较研究。生物力学问题差异很大的骨折常常被归为一类。结局变量的测量和报告不一致，使得汇总甚至比较结果非常困难。如果未来的高质量试验继续支持这样的证据，即器械差异充其量只是短期的，在恢复的最初几周至几个月内，政策影响包括确定相对于新器械成本而言较短恢复时间的价值。由于文献通常关注社区居住的老年患者，需要更多关注了解手术治疗选择对养老院人群的影响。
