Evaluation for fracture risk in elderly patients after hemiarthroplasty

doi:10.3969/j.issn.2095-4344.2014.31.024

Abstract

Abstract:

BACKGROUND: For evaluation of risks of periprosthetic fractures in elderly patients aged > 75 years old after hemiarthroplasty, we should perform dynamic observation of postoperative physical health status, quality of life, hip function and bone mineral density. Presently, there is lack of general investigation.
OBJECTIVE: To provide references for clinical diagnosis and prediction of periprosthetic fractures after hemiarthroplasty in elderly patients.
METHODS: On the basis of arranging the exploration results of recent studies on risk factors for periprosthetic fractures of hip joint, we analyzed the monitoring method of scholars concerning fracture-associated risk factors. Simultaneously, in combination of the development of modern inspection sciences, the method was applied in the clinic. Thus, we summarized general evaluation methods with clinical significance for risk factors of prosthesis fracture in elderly patients after hemiarthroplasty.
RESULTS AND CONCLUSION: For elderly patients with femoral neck or intertrochanteric fracture combined with various medical illness, hemiarthroplasty is an effective manner presently. Fractures surrounding the prosthesis in elderly patients postoperatively gradually increased. Once fracture appeared, it would bring a great attack on patients’ spirit, economy and even life. Therefore, early evaluation on the risk factors for fractures surrounding the prosthesis is a necessary measure for preventing and saving this disastrous consequence by selecting general correct prevention and treatment strategies. This will greatly improve patients’ prognosis and elevated patient’s quality of life and survival rate. Present short-term small-sample prospective follow-up studies suggested that comprehensive dynamic evaluation possibly has a certain clinical significance for the evaluation of risks of fractures after hemiarthroplasty in elderly patients, and deserves further investigations.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: arthroplasty, replacement, hip, internal fixators, periprosthetic fractures, risk assessment

CLC Number:

R318

Hua Han-bing, Bi Zheng-gang. Evaluation for fracture risk in elderly patients after hemiarthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(31): 5062-5067.

Figures/Tables 3

2.1 风险因素 2.1.1 组织学因素自从半髋关节置换开展以来，学者们就坚持通过随访对置换后患者的并发症及风险因素各个方面进行评估和分析，其中包括南京医科大学范卫民等[2]的动物实验，在国内较早的证实了人工关节磨损后，产生大量的磨损微粒，微粒刺激组织细胞分泌肿瘤坏死因子等溶骨性因子，这些溶骨性因子直接或间接地激活破骨细胞，从而引起假体周围骨吸收、骨溶解，最终导致假体松动。假体松动后又可加重磨损，产生更多的微粒，形成恶性循环。 2.1.2 术中因素刘志宏等[3]学者对人工髋关节置换后失败的病例进行分析，对人工髋关节翻修手术35例 (36髋)总结经验，根据前次手术失败的原因进行分组并分析。结果根据病例统计，在同一失败病例中，失败的原因往往不止一个。最常见的原因是假体松动、假体周围骨溶解，并得出结论，人工髋关节置换作为髋关节重建的一种有效的治疗方法而得到广泛的应用，其长期可靠的疗效与严格掌握手术指征，假体的适当选择和手术中正确操作有关。 2.1.3 自身因素 Burghardt等[4]曾通过HR-pQCT成像，证实2型糖尿病的高龄患者由于骨量重新分配的效率减慢，致使以牺牲皮质骨小梁的骨密度为代价来适应骨骼所受的弯曲外力。Singh等[5]对置换后患者平均6.3年的随访，认为对性别、疾病和肥胖的风险因素采取有效的干预措施针和优化疾病管理可以减少术后骨折的发生率。因此综合性指标的调查和研究，对于高龄患者将更为科学。 2.2 评价指标 2.2.1 双能X射线双能X射线的临床应用使抽象的经验总结和动物实验对于临床工作中假体周围骨折的风险评估具体化，后在国内有学者临床放射学研究发现，股骨头假体置换后股骨周围常有骨质吸收现象并采用双能X射线骨密度测定及常规X射线检查对照方法，对12例股骨头置换患者术前、后假体周围骨量进行连续测定，认为双能X射线骨密度仪测定可作为人工股骨头或全髋置换后股骨假体松动的早期辅助诊断工具[6]。骨密度测定采用双能X射线骨密度仪并采用配套骨科分析软件进行分析按照Grune分7个测量兴趣区(region of interest，ROI)即将股骨柄假体从转子部到假体远端平均分为3等份，假体外侧从上到下分别为1区(ROI 1)、2区(ROI 2)、3 区(ROI 3)，假体远端2 cm区域为 4 区(ROI 4)，假体内侧从下到上分别为5区(ROI 5)、6区(ROI 6)和7区(ROI 7)。骨密度扫描时患者仰卧扫描床上，将膝及足固定标在标准位置以保持术肢内旋12°扫描时要避免因下肢旋转角度不良而致图像复制偏差。至今，通过使用双能X射线对髋关节置换后的患者进行假体周围骨密度动态观察[7-11]，已经成为一种重要的研究手段，随后在研究中加入了Harris评分等术后疗效观察指标，使患者治疗效果的随访评估更加完善。 2.2.2 疗效评分系统牛津髋关节评分系统：与以往的其他的人工髋关节置换评价体系不同，该评分系统属于医疗处置结果评估体系，是基于患者本人感觉的量表，该评价系统的可靠性和敏感性已被证实，问题简单易懂，适用于各种文化程度的患者，尤其是能以信件，电话的方式进行询问。特点是短小，灵活，方便，具有临床使用价值。采用世界卫生组织(WHO)推荐的“健康调查简易量表”(SF-36)：该量表由36个单项组成，包括8个维度，均按百分制进行评分：①体能。②精神影响。③社会活动。④心理健康。⑤体能影响。⑥精力。⑦身体疼痛。⑧一般健康。各维度计分采用累加法，按最后题值计算原始分数，再以标准公式计算转换分数，各维度得分为0分(最差)-100分(最好)[12]。日本有学者使用SF-36评分对肢体功能障碍术后患者的全身健康状态进行评估，证实了该评估手段与骨折风险的相关性。Baker等[13]在人身体质量指数对假体置换后功能性改进的实验中，通过体质量指数所反应的效应与SF-36所显示的一致。目测类比评分法：该法比较灵敏，有可比性。具体做法是：在纸上面划一条10 cm的横线，横线的一端为0，表示无痛；另一端为10，表示剧痛；中间部分表示不同程度的疼痛。让患者根据自我感觉在横线上划一记号，表示疼痛的程度。轻度疼痛平均值为2.57±1.04；中度疼痛平均值为5.18±1.41；重度疼痛平均值为8.41±1.35。测定可分别在假体置换后1周、3个月、6个月、1年时进行。因此综合全面量化统计将会成为评估未来髋关节置换后骨折风险的一个大体趋势，尤其是试用于高龄患者[14-15]。自行共病调查问卷(SCQ)：诸如Sangha等[16]所倡导的自行共病调查问卷和心理评估等等也可用于置换后患者的综合评估范围之内。Anderson等[17]在评价患者年龄在75岁以上全膝关节置换后功能结果和患者满意度时所采用的疗效评价方法，虽然只做了回顾性的分析但相对全面。其结论明确显示了，心理评估分数与患者置换后功能情况有明显的相关性。 Harris人工髋关节疗效评分：包括疼痛、功能性活动、髋关节活动度及畸形4 个组成部分。其中，疼痛和功能性活动在Harris评分法中比重较大[18]，两部分共计62分，因此无需再用日常生活能力评估量表(ADL)或功能独立性测量(FlM)等评估工具重复评定[4]。Harris 评分法在国内外髋关节置换疗效评价中都得到了一定的应用，国内有不少的髋关节置换疗效文献都使用了Harris评分法[19]。2.3 现状分析 Ethgen等[20]用Medline和EMBASE医疗文献数据库搜索，从1980年1月到2003年6月，识别相关的研究。研究资格审查是否符合以下标准：①语言是英语或法语。②至少一个有效的和自我报告健康相关生活质量的仪器。③一个前瞻性群组研究或设计使用。认为健康相关生活质量的数据是有价值的。而近年来，随着双能X射线的发展和普及，辐射小，价格低廉，成为研究骨量变化的重要检测手段[21]，例如Singh[22]和Korkosz等[23]对强直性脊柱炎患者骨密度的测定过程中，显著肯定了双能X射线吸收仪的优势。 2.3.1 临床资料哈尔滨医科大学附属第一医院2013年8月至12月对7例髋关节置换后的患者进行随访时获得数据，假体周围骨折的患者在翻修入院后测定。应用双能X射线骨密度仪等检查设备观察此后1年髋关节置换后的患者假体周围的骨密度。男6例，女1例，70-74岁，平均73岁，右髋4例，左髋3例，其中股骨头骨折患者6例，股骨头坏死1例，所有患者均无长期应用激素的病史，并排除所有其他代谢性骨病。所有患者均行髋关节置换，采用生物型髋关节假体，康复方法大致相同。分别于置换后1周、3个月、6个月、12个月行假体周围骨密度等指标的测定。 2.3.2 骨密度测量采用美国数字式双能X射线骨密度仪，及其附带的骨科分析软件，所有测量及分析工作均由同1人完成。对膝关节假体周围骨质进行分区测定。 2.3.3 骨密度扫描变异系数按Callaghan的方法计算变异系数[24]，连续2 d测量5例患者的骨密度，每天测定1次，计算所测各个兴趣区的变异系数。ROI1-7区的CV%为(0.6±0.11)%。 2.3.4 统计学处理分别将术后3，6，12个月时的骨密度检测值与术后1周时的骨密度检测值进行比较，采用单因素方差分析[25]，并计算术后3，6，12 个月时骨密度(骨密度)变化率。骨密度变化率= [(骨密度2-骨密度1)÷骨密度1]×100% 骨密度1为术后1周时的骨密度值；骨密度2为3，6，12个月时的骨密度值[26]。 2.3.5 结果所有患者均于1 周内完全负重，并暂时得到了3个月随访，术后无感染和假体松动现象，功能恢复良好。置换后假体周围骨密度测定结果：表1可见置换后3个月的骨密度均较置换后1周显著减少(P < 0.05)。置换后功能评分结果：表2可见置换后1个月的SF-36评分较置换后1周显著升高(P < 0.05)[27-30]。"

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