Janssen Stein J, Kortlever Joost T P, Ready John E, Raskin Kevin A, Ferrone Marco L, Hornicek Francis J, Lozano-Calderon Santiago A, Schwab Joseph H
From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA.
J Am Acad Orthop Surg. 2016 Jul;24(7):483-94. doi: 10.5435/JAAOS-D-16-00043.
Proximal femoral fractures resulting from metastatic disease often require surgical management. Few studies have compared surgical techniques, and physicians' preferred strategies vary. This study compared revision and complication rates among surgical strategies.
The study consisted of a retrospective review of electronic medical records of 417 consecutive patients with proximal femoral metastasis or multiple myeloma who underwent intramedullary nailing (n = 302), endoprosthetic reconstruction (n = 70), and open reduction and internal fixation (n = 45) between 1999 and 2014 at two orthopaedic oncology centers. Primary outcome measures were revisions and 30-day systemic complications. Secondary outcome measures were total estimated blood loss, anesthesia time, duration of hospital admission, and 30-day survival.
Revision rates did not differ between strategies (5.3% after intramedullary nailing, 11% after endoprosthetic reconstruction, and 13% after open reduction and internal fixation; P = 0.134). When reasons for revision were assessed separately, fixation failure was most common after open reduction and internal fixation (13% versus 3.0% after intramedullary nailing and none after endoprosthetic reconstruction; P < 0.001), whereas deep infection was most common after endoprosthetic reconstruction (8.6% versus 2.0% after intramedullary nailing and none after open reduction and internal fixation; P = 0.010). Overall systemic complication rates did not differ between strategies (8.3% after intramedullary nailing, 14% after endoprosthetic reconstruction, and 11% after open reduction and internal fixation; P = 0.268).
Implant-specific complications and their timing should be considered in the choice of surgical strategy. Analysis of secondary outcomes and risk factors for systemic complications could aid in surgical decision making.
Therapeutic Level III.
转移性疾病导致的股骨近端骨折通常需要手术治疗。很少有研究比较手术技术，医生的首选策略也各不相同。本研究比较了不同手术策略的翻修率和并发症发生率。
本研究对1999年至2014年期间在两个骨肿瘤中心接受髓内钉固定（n = 302）、人工关节置换重建（n = 70）和切开复位内固定（n = 45）的417例连续性股骨近端转移瘤或多发性骨髓瘤患者的电子病历进行回顾性分析。主要观察指标为翻修率和30天全身并发症发生率。次要观察指标为总估计失血量、麻醉时间、住院时间和30天生存率。
不同手术策略的翻修率无差异（髓内钉固定后为5.3%，人工关节置换重建后为11%，切开复位内固定后为13%；P = 0.134）。当分别评估翻修原因时，切开复位内固定后固定失败最为常见（13%，而髓内钉固定后为3.0%，人工关节置换重建后无；P < 0.001），而人工关节置换重建后深部感染最为常见（8.6%，而髓内钉固定后为2.0%，切开复位内固定后无；P = 0.010）。不同手术策略的总体全身并发症发生率无差异（髓内钉固定后为8.3%，人工关节置换重建后为14%，切开复位内固定后为11%；P = 0.268）。
在选择手术策略时应考虑植入物特异性并发症及其发生时间。对次要观察指标和全身并发症危险因素的分析有助于手术决策。
治疗性III级。
