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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 老年患者髖部骨折是即刻還是延遲手術(shù)？2017年奧地利：手術(shù)時機(jī)對60歲或以上急性髖部骨折患者健康結(jié)果的影響 作者：Thomas Klestil, Christoph R?der, Christoph Stotter, Birgit Winkler, Stefan Nehrer, Martin Lutz, Irma Klerings, Gernot Wagner, Gerald Gartlehner, Barbara Nussbaumer-Streit 作者單位: Department of Orthopedic Surgery and Traumatology, LK Baden-M?dling-Hainburg, Waltersdorferstra?e 75, 2500, Baden, Austria. thomas.klestil@donau-uni.ac.at. 譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科） 摘要 背景：髖部骨折是老年人群的主要公共衛(wèi)生問題，并伴有高死亡率。手術(shù)時機(jī)是否對致殘率和死亡率有影響一直存在爭議，許多研究表明手術(shù)延遲會顯著增加致殘率和死亡率的風(fēng)險；其他人報告說，實現(xiàn)穩(wěn)定的生命狀況比早期手術(shù)更重要。我們系統(tǒng)評價的目的是評估手術(shù)時機(jī)對60歲或以上急性髖部骨折患者健康結(jié)果的影響。此外，我們將根據(jù)人口統(tǒng)計學(xué)特征、身體狀況和抗凝藥物的使用，調(diào)查患者亞組中手術(shù)時機(jī)的有益或有害影響的差異。 方法：我們將通過Ovid、Cochrane圖書館、Embase、PubMed和臨床試驗注冊中心（1997年至2017年）系統(tǒng)地搜索MEDLINE。此外，我們將搜索相關(guān)評論的參考列表、骨科學(xué)會年會檔案，并聯(lián)系專家。我們將納入隨機(jī)對照試驗和非隨機(jī)研究，以英文或德文發(fā)表，評估60歲或以上患者髖部骨折后手術(shù)時機(jī)的影響。我們感興趣的結(jié)果包括健康結(jié)果，例如死亡率、圍手術(shù)期并發(fā)癥、功能能力和生活質(zhì)量。如果我們至少有三項足夠相似的研究，我們計劃進(jìn)行薈萃分析。如果數(shù)據(jù)充足，我們將進(jìn)行亞組分析，測試年齡組、性別、用ASA（美國麻醉醫(yī)師協(xié)會）評分評估的患者身體狀況以及抗凝藥物的使用之間的差異。 討論：由于這是自2010年以來對該主題的第一次系統(tǒng)評價，我們的研究結(jié)果將有助于為有關(guān)髖部骨折手術(shù)時機(jī)的臨床實踐指南提供信息。此外，我們的研究結(jié)果可能有助于為不同組的急性髖部骨折患者確定手術(shù)的最佳時間段。 系統(tǒng)評價注冊：PROSPERO 2017 CRD42017058216。 關(guān)鍵詞：早期手術(shù)；老年；老年病學(xué);髖部骨折；發(fā)病率；死亡；手術(shù)延誤；手術(shù)時機(jī)。 討論 我們的方案介紹了系統(tǒng)評價的方法學(xué)方法，該方法將評估手術(shù)時間對老年急性髖部骨折患者的影響。此外，該綜述將重點關(guān)注手術(shù)時機(jī)對亞組的影響差異，例如使用抗凝藥物的患者或具有不同ASA身體狀態(tài)的患者。據(jù)我們所知，我們的綜述將是近十年來系統(tǒng)總結(jié)這些臨床相關(guān)問題的文獻(xiàn)的第一項研究。 老年患者急性髖部骨折后手術(shù)延遲很常見，這可歸因于幾個因素。例如，國家醫(yī)療保健系統(tǒng)和醫(yī)院基礎(chǔ)設(shè)施之間的差異會影響手術(shù)干預(yù)的時機(jī)[30]。具體而言，在擁有多個外科學(xué)科的醫(yī)院中，對有限的急性手術(shù)能力（例如，手術(shù)室）的競爭可能會決定手術(shù)的時機(jī)。全面的最新證據(jù)綜合可以為優(yōu)先考慮早期髖關(guān)節(jié)手術(shù)提供基礎(chǔ)。 導(dǎo)致手術(shù)延遲的另一個因素是抗凝藥物，尤其是新型口服抗凝劑(NOAC)。許多髖部骨折患者接受抗凝藥物治療[45-47]。對于一些NOAC，目前沒有可用的特定解毒劑來阻斷其活性[48-50]。因此，醫(yī)生通常更愿意等待這種藥物的效果消失后再對患者進(jìn)行手術(shù)。然而，這種方法是有爭議的，因為研究聲稱接受NOAC治療的患者在早期手術(shù)中存活下來，沒有任何不利的健康影響[51, 52]。我們希望我們的審查能夠更好地了解這一臨床上重要的問題。 最后，出現(xiàn)了各種評估患者健康狀況的方案[53, 54]。一些作者認(rèn)為，在進(jìn)行任何手術(shù)之前，健康狀況不佳的患者必須在醫(yī)學(xué)上穩(wěn)定下來，以避免手術(shù)干預(yù)造成的傷害[55]。迄今為止，尚不清楚延遲手術(shù)是否對身體狀況不佳的患者有益。 總體而言，我們相信，對老年髖部骨折患者手術(shù)時機(jī)的最佳現(xiàn)有證據(jù)的全面總結(jié)將對臨床實踐指南產(chǎn)生影響，并最終改善患者護(hù)理。 文獻(xiàn)出處：Thomas Klestil, Christoph R?der, Christoph Stotter, Birgit Winkler, Stefan Nehrer, Martin Lutz, Irma Klerings, Gernot Wagner, Gerald Gartlehner, Barbara Nussbaumer-Streit. Immediate versus delayed surgery for hip fractures in the elderly patients: a protocol for a systematic review and meta-analysis. Meta-Analysis, Syst Rev. 2017 Aug 15;6(1):164. doi: 10.1186/s13643-017-0559-7. Immediate versus delayed surgery for hip fractures in the elderly patients: a protocol for a systematic review and meta-analysis Abstract Background: Hip fractures are a major public health problem in elderly populations and are accompanied by high-mortality rates. Whether timing of surgery has an impact on morbidity and mortality has been discussed controversially, numerous studies suggest that the delay of surgery can significantly increase the risk of morbidity and mortality; others report that achieving a stable medical condition is more important than early surgery. The goal of our systematic review is to assess the impact of timing of surgery on health outcomes in patients aged 60 years or older with acute hip fracture. In addition, we will investigate differences in beneficial or harmful effects of timing of surgery in subgroups of patients based on demographic characteristics, physical status, and the use of anticoagulant medications. Methods: We will systematically search MEDLINE via Ovid, the Cochrane Library, Embase, PubMed, and clinical trial registries (from 1997 to 2017). In addition, we will search reference lists of pertinent reviews, archives of annual meetings of orthopaedic societies, and contact experts. We will include randomized controlled trials and non-randomized studies assessing the impact of timing of surgery after hip fracture in patients 60 years or older, published in English or German. Our outcomes of interest include health outcomes such as mortality, perioperative complications, functional capacity, and quality of life. We plan to perform meta-analyses if we have at least three sufficiently similar studies. If data are sufficient, we will conduct subgroup-analyses testing for differences between age groups, sex, patients' physical status as assessed with ASA (American Society of Anesthesiologists) scores, and the use of anticoagulation. Discussion: Since this is the first systematic review on this topic since 2010, our findings will help to inform clinical practice guidelines concerning timing of surgery in hip fractures. Furthermore, our findings could contribute to define an optimal time period for surgery for different groups of patients with acute hip fracture. Systematic review registration: PROSPERO 2017 CRD42017058216. Keywords: Early surgery; Elderly; Geriatric; Hip fractures; Morbidity; Mortality; Surgical delay; Timing of surgery. Discussion Our protocol presents the methodological approach of a systematic review that will assess the effect of timing of surgery in elderly patients with acute hip fractures. In addition, the review will focus on differences of the impact of timing of surgery in subgroups such as patients on anticoagulation medication or patients with different ASA physical statuses. To our knowledge, our review will be the first study that systematically summarizes the literature on these clinically relevant questions in almost a decade. Delays in surgeries after acute hip fracture in elderly patients are common and attributable to several factors. For example, differences between national healthcare systems and infrastructures of hospitals can influence timing of surgical interventions [30]. Specifically, in hospitals with several surgical disciplines, a competition for limited acute surgical capacities (e.g., operating rooms) may determine the timing of surgery. A comprehensive up-to-date evidence synthesis could provide the basis to prioritise early hip surgery. Another factor contributing to delayed surgery is anticoagulant medications, particularly new oral anticoagulants (NOACs). Many patients suffering from hip fractures are treated with anticoagulant medication [45–47]. For some NOACs, no specific antidotes to block their activity are currently available [48–50]. Doctors, therefore, often prefer to wait for the effects of this medication to wear off prior to operating on the patient. Such an approach, however, is controversial because studies have claimed that patients treated with NOACs survive early surgery without any adverse health effects [51, 52]. We hope that our review will provide better insight into this clinically important matter. Finally, various routines for assessing a patient’s health status have emerged [53, 54]. Some authors argue that patients with a poor health status must be medically stabilized before any surgery can be performed to avoid harm as a consequence of the surgical intervention [55]. To date, it remains unclear if delayed surgery is beneficial for patients with a poor physical status. Overall, we are confident that a comprehensive summary of the best available evidence on timing of surgery for elderly patients with hip fractures will have an impact on clinical practice guidelines and will ultimately improve patient care. Fig. 1 Analytic framework 圖1 分析框架 Table 1 Inclusion and exclusion criteria 表1 納入排除標(biāo)準(zhǔn)2022年01月17日
540
0
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骨折相關(guān)科普號
錢亞龍醫(yī)生的科普號
錢亞龍 主治醫(yī)師
北京大學(xué)人民醫(yī)院
脊柱外科
3786粉絲1.1萬閱讀
王海華醫(yī)生的科普號
王海華 副主任醫(yī)師
北京積水潭醫(yī)院
手外科
5260粉絲5.6萬閱讀
李政康醫(yī)生的科普號
李政康 副主任醫(yī)師
上海交通大學(xué)醫(yī)學(xué)院附屬第九人民醫(yī)院
眼科
6417粉絲27.1萬閱讀