Swart Eric, Roulette Paulvalery, Leas Daniel, Bozic Kevin J, Karunakar Madhav
1Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts 2Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina 3Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas.
J Bone Joint Surg Am. 2017 Jan 4;99(1):65-75. doi: 10.2106/JBJS.16.00406.
The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario.
A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis.
THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs.
Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group.
Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
对于65岁及以下移位型股骨颈骨折患者，决定采用切开复位内固定术（ORIF）还是关节成形术具有挑战性。两种选择都有潜在的缺点；如果采用ORIF治疗的骨折未能愈合，可能需要进行翻修手术，而接受关节成形术的相对年轻患者可能在其一生中需要翻修。本研究的目的是运用决策分析建模技术，在这种临床情况下生成基于证据的治疗建议。
创建一个马尔可夫决策分析模型，以模拟40至65岁移位型股骨颈骨折患者接受ORIF、全髋关节置换术（THA）或半髋关节置换术后的结果。模型中的变量采用来自具有高级别证据的研究以及文献中报道的国家登记数据的值。该模型用于估计THA成为更优策略的阈值年龄。使用敏感性分析和概率统计分析对结果进行检验。
对于年龄大于54岁的健康患者、合并轻度疾病且年龄大于47岁的患者以及合并多种疾病且年龄大于44岁的患者，THA被发现是治疗移位型股骨颈骨折的一种具有成本效益的选择。40至65岁患者的THA和ORIF的平均临床结果相似，尽管基于初始固定的成功或失败，ORIF的结果变异性更大。对于所有年龄和病例，半髋关节置换术的结果更差且成本更高。
与ORIF相比，初次THA对于45至65岁移位型股骨颈骨折患者可能是一种具有成本效益的治疗方法，随着内科合并症和ORIF固定失败风险的增加，倾向于THA的年龄界限降低。半髋关节置换术结果更差且成本更高，不推荐用于该年龄组。
经济和决策分析III级。有关证据水平的完整描述，请参阅作者须知。
