Uhler Lauren M, Schultz W Randall, Hill Austin D, Koenig Karl M
Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas.
Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas; Texas Orthopedics, Austin, Texas.
J Arthroplasty. 2017 May;32(5):1434-1438. doi: 10.1016/j.arth.2016.11.051. Epub 2016 Dec 14.
Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates.
We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters.
In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%.
We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.
65岁及以上患者股骨颈骨折的治疗方法各异，许多外科医生更倾向于半髋关节置换术（HA）而非全髋关节置换术（THA）。有证据表明，THA可能带来更好的功能预后，尽管其死亡风险和脱位率也更高。
我们创建了一个马尔可夫决策模型，以检验早期HA（在48小时内进行）与延迟THA（在48小时后进行）治疗老年股骨颈骨折患者的预期健康效用。模型输入数据来自文献。健康效用数据来自先前60岁以上的合适患者。对死亡率和脱位率进行敏感性分析，以检验模型参数不确定性的影响。
在基础病例中，HA组2年的平均累积效用为0.895，THA组为0.994。在敏感性分析中，直到THA的30天和1年死亡率增加到基础病例率的1.3倍之前，THA都比HA更受青睐。直到HA的健康效用达到THA的98%之前，THA都比HA更受青睐。当将THA患者的脱位累积发生率从基础病例的4.4%提高到26.1%时，THA仍然是首选策略。
我们发现，对于老年股骨颈骨折患者，尽管延迟手术会增加30天和1年死亡率，但延迟THA比早期HA具有更高的健康效用。未来的研究应探讨THA治疗股骨颈骨折的成本效益。
