髓内钉或滑动髋螺钉治疗髋关节囊外骨折后髋关节置换的转化率无差异：19604 例个体的观察性队列研究。
No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals.
机构信息
Department of Orthopaedics, Skåne University Hospital & Faculty of Medicine, Lund University, Malmö, Sweden.
Western Hospital Group, Region Västra Götaland & Faculty of Medicine, Lund University, Lund, Sweden.
出版信息
J Bone Joint Surg Am. 2022 Oct 5;104(19):1703-1711. doi: 10.2106/JBJS.22.00316. Epub 2022 Jul 25.
BACKGROUND
The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures.
METHODS
In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years.
RESULTS
We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants.
CONCLUSIONS
Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying.
LEVEL OF EVIDENCE
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
背景
与滑动髋螺钉（SHS）相比，髓内钉（IMN）在关节囊外髋部骨折（AO/OTA 31-A1、31-A2、31-A3）中的广泛应用受到质疑，尽管最近的植入物设计和学习曲线可能改善了结果，但并发症发生率仍然较高。本研究旨在调查在 IMN 或 SHS 固定关节囊外髋部骨折后的前 5 年内，是否存在与关节置换或任何再手术相关的累积发生率的差异。
方法
在这项全国性观察性队列研究中，年龄≥60 岁的患者在 2012 年至 2018 年期间因关节囊外骨折而在瑞典骨折登记处（SFR）登记，并主要接受 IMN 或 SHS 治疗，在 SFR 和瑞典关节置换登记处（SAR）中随访至少 1 年。主要结局是关节置换的累积发生率（转化率）。次要结局是所有再手术的累积发生率（再手术率）。在第 1 年内，通过竞争风险分析计算这两个结局。
结果
共纳入 19604 例患者（70%为女性），中位年龄为 85 岁（范围：60-107 岁）。最常见的是 31-A2 骨折（52%），其次是 31-A1 骨折（28%）。IMN 或 SHS 使用后 1 年的转化率（31-A1 骨折中为 1.0%比 0.9%，31-A2 骨折中为 1.7%比 1.3%，31-A3 骨折中为 1.3%比 1.5%）或 1 年再手术率（31-A1 骨折中为 1.9%比 1.9%，31-A2 骨折中为 3.4%比 2.5%，31-A3 骨折中为 4.0%比 5.2%）无显著差异。仅在 31-A2 骨折中，IMN 使用 2 年和 5 年后的再手术更多（p < 0.05）。1 年粗死亡率为 26.4%（19604 例中的 5178 例），不同植入物之间无显著差异。
结论
就关节置换而言，IMN 和 SHS 的总体表现相当。在 31-A2 骨折中，IMN 的再手术率高于 SHS。然而，从临床角度来看，两种植入物之间的差异很小，特别是在考虑死亡的竞争风险时。
证据水平
预后 III 级。请参阅作者指南，以获取完整的证据水平描述。
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