van de Ree Cornelis L P, De Jongh Mariska A C, Peeters Charles M M, de Munter Leonie, Roukema Jan A, Gosens Taco
Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.
Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, the Netherlands.
Geriatr Orthop Surg Rehabil. 2017 Sep;8(3):173-180. doi: 10.1177/2151458517713821. Epub 2017 Jul 7.
Increasing numbers of patients with hip fractures also have advanced comorbidities. A majority are treated surgically. However, a significantly increasing percentage of medically unfit patients with unacceptably high risk of perioperative death are treated nonoperatively. Important questions about patients' prefracture quality of life (QOL) and future perspectives should be asked before considering different treatment options to assess what kind of treatment is advisable in frail elderly high-risk patients with a hip fracture.
The aim of this review was to provide an overview of differences in mortality, health-related QOL [(HR)QOL], functional outcome, and costs between nonoperative management (NOM) and operative management (OM) of hip fractures in patients above 65 years.
A systematic literature search was performed in EMBASE, OvidSP, PubMed, Cochrane Central, and Web of Science for observational studies and trials. Observational studies and randomized controlled trials comparing NOM with OM in hip fracture patients were selected. The methodological quality of the selected studies was assessed according to the Methodological Index for Nonrandomized Studies (MINORS) or Furlan checklist.
Seven observational studies were included with a total of 1189 patients, of whom 242 (20.3%) were treated conservatively. The methodological quality of the studies was moderate (mean: 14.7, standard deviation [SD]: 1.5). The 30-day and 1-year mortalities were higher in the nonoperative group (odds ratio [OR]: 3.95, 95% confidence interval [CI]: 1.43-10.96; OR: 3.84, 95% CI: 1.57-9.41). None of the included studies compared QOL, functional outcome, or health-care costs between the 2 groups.
This systematic review and meta-analysis demonstrated that only a few studies with small number of patients comparing NOM with OM were published. A significantly higher 30-day and 1-year mortality was revealed in nonoperatively treated hip fracture patients. No data were found examining (HR)QOL and costs. Further work is needed to enable shared decision-making and to initiate NOM in frail elderly patients with advanced comorbidity and limited life expectancy.
髋部骨折患者数量不断增加，同时合并症也日益严重。大多数患者接受手术治疗。然而，因围手术期死亡风险过高而不宜手术的患者接受非手术治疗的比例显著上升。在考虑不同治疗方案之前，应询问患者骨折前的生活质量（QOL）及未来前景等重要问题，以评估何种治疗方式适合体弱的老年髋部骨折高危患者。
本综述旨在概述65岁以上髋部骨折患者非手术治疗（NOM）与手术治疗（OM）在死亡率、健康相关生活质量（HR）QOL、功能结局及成本方面的差异。
在EMBASE、OvidSP、PubMed、Cochrane Central和Web of Science中进行系统文献检索，查找观察性研究和试验。选取比较髋部骨折患者NOM与OM的观察性研究和随机对照试验。根据非随机研究方法学指数（MINORS）或Furlan清单评估所选研究的方法学质量。
纳入7项观察性研究，共1189例患者，其中242例（20.3%）接受保守治疗。研究的方法学质量中等（均值：14.7，标准差[SD]：1.5）。非手术组30天和1年死亡率更高（优势比[OR]：3.95，95%置信区间[CI]：1.43 - 10.96；OR：3.84，95%CI：1.57 - 9.41）。纳入的研究均未比较两组之间的QOL、功能结局或医疗成本。
本系统综述和荟萃分析表明，仅有少数比较NOM与OM且患者数量较少的研究发表。非手术治疗的髋部骨折患者30天和1年死亡率显著更高。未找到关于（HR）QOL和成本的研究数据。需要进一步开展工作，以实现共同决策，并为合并症严重且预期寿命有限的体弱老年患者启动非手术治疗。
