【摘要】：目的：隨著全球老齡化加劇及人均壽命的延長(zhǎng),老年人骨折發(fā)生率逐年升高,針對(duì)老年不穩(wěn)定型股骨粗隆間骨折患者,手術(shù)治療已成為首選治療方案,而手術(shù)內(nèi)固定材料的選擇仍存在爭(zhēng)論。DHS可進(jìn)行動(dòng)力加壓,力學(xué)強(qiáng)度可靠,固定牢固可為患者的功能康復(fù)創(chuàng)造條件,但其術(shù)后并發(fā)癥發(fā)生率高；PFNA具有操作簡(jiǎn)單、創(chuàng)傷小、出血量少等特點(diǎn),但研究發(fā)現(xiàn)髓內(nèi)釘固定與髖關(guān)節(jié)螺釘治療髖關(guān)節(jié)囊外骨折比較,前者術(shù)后移位的發(fā)生率高；因次本研究通過(guò)對(duì)PFNA與DHS兩種內(nèi)固定手術(shù)方式治療的臨床療效進(jìn)行系統(tǒng)評(píng)價(jià),以期為臨床決策提供循證依據(jù)。方法：制定納入標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn),確定檢測(cè)指標(biāo),通過(guò)計(jì)算機(jī)及手工兩種檢索方式檢索出完全符合納入標(biāo)準(zhǔn)和排除標(biāo)準(zhǔn)的文獻(xiàn)研究,計(jì)算機(jī)檢索中文數(shù)據(jù)庫(kù)包括萬(wàn)方醫(yī)學(xué)、中國(guó)知網(wǎng)、維普醫(yī)藥及中國(guó)生物醫(yī)學(xué),英文數(shù)據(jù)庫(kù)包括Cochrane Library、Embase.Medline、PubMed,手工檢索國(guó)內(nèi)近五年收集的雜志,包括《中華外科雜志》、《中華骨科雜志》、《中華創(chuàng)傷雜志》、《中華創(chuàng)傷骨科雜志》、《中國(guó)骨與關(guān)節(jié)損傷雜志》、《中國(guó)矯形外科雜志》和《昆明醫(yī)科大學(xué)學(xué)報(bào)》等。對(duì)納入本研究的文獻(xiàn)由兩名評(píng)價(jià)者獨(dú)立采用改良的Jadad評(píng)分系統(tǒng)及最新的質(zhì)量評(píng)價(jià)方法進(jìn)行方法學(xué)質(zhì)量評(píng)價(jià)和數(shù)據(jù)收集,若意見(jiàn)不統(tǒng)一時(shí),由兩名評(píng)價(jià)者討論或由第三方專(zhuān)家決定,最后對(duì)收集的數(shù)據(jù)運(yùn)用RevMan5.3專(zhuān)用系統(tǒng)評(píng)價(jià)軟件進(jìn)行Meta分析。結(jié)果：依據(jù)制定的納入標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn),共有10篇文獻(xiàn)研究納入本次研究,其中包括1篇英文文獻(xiàn)和9篇為中文文獻(xiàn),總共納入患者715例,其中PFNA組366例,DHS組349例,根據(jù)改良的Jadad質(zhì)量評(píng)分,1篇為高質(zhì)量研究,9篇為低質(zhì)量研究,Meta分析結(jié)果示,兩組在平均手術(shù)時(shí)間方面比較差異具有統(tǒng)計(jì)學(xué)意義(MD=-24.79,95% CI:-35.07～14.51,P0.00001)；在平均術(shù)中出血量方面比較差異具有統(tǒng)計(jì)學(xué)意義(MD=-201.28,95% CI:-229.13～-173.43,P0.00001)；在手術(shù)切口長(zhǎng)度方面比較差異具有統(tǒng)計(jì)學(xué)意義(MD=-7.80,95% CI:-8.58～7.01, P0.00001):在術(shù)后優(yōu)良率方面差異具有統(tǒng)計(jì)學(xué)意義(OR=4.90,95% CI: 2.89～8.32, P0.00001);在術(shù)后并發(fā)癥發(fā)生率方面差異具有統(tǒng)計(jì)學(xué)意義(OR=0.46,95% CI:0.26～0.80,P=0.006);在住院天數(shù)方面差異具有統(tǒng)計(jì)學(xué)意義(MD=-4.14,95% CI:-7.74～-0.53,P=0.02)。結(jié)論：通過(guò)對(duì)PFNA與傳統(tǒng)經(jīng)典手術(shù)DHS在治療老年不穩(wěn)定型股骨粗隆間骨折的平均手術(shù)時(shí)間、平均術(shù)中出血量、手術(shù)切口長(zhǎng)度、術(shù)后優(yōu)良率、術(shù)后并發(fā)癥發(fā)生率及住院天數(shù)方面指標(biāo)進(jìn)行檢測(cè)比較,結(jié)果顯示PFNA更具優(yōu)勢(shì),但是地區(qū)差異、術(shù)者技術(shù)差異及骨質(zhì)量程度差異等因素對(duì)檢測(cè)指標(biāo)有一定的影響,因此需要通過(guò)嚴(yán)格設(shè)計(jì)大樣本隨機(jī)對(duì)照試驗(yàn)、采用正確的隨機(jī)方法、分配隱藏、盲法,并對(duì)納入研究的對(duì)象長(zhǎng)期隨訪(fǎng),盡可能統(tǒng)一評(píng)價(jià)療效來(lái)進(jìn)一步研究。
[Abstract]:Objective: with the aggravation of global aging and the prolongation of life expectancy, the incidence of fracture in the elderly has increased year by year. Surgical treatment has become the first choice for the elderly patients with unstable intertrochanteric fracture of femur. However, the choice of internal fixation materials is still controversial. DHS can be used for dynamic compression, reliable mechanical strength, solid fixation can create conditions for the functional rehabilitation of patients, but the incidence of postoperative complications is high. PFNA has the characteristics of simple operation, less trauma and less bleeding. However, it is found that intramedullary nail fixation has a higher incidence of postoperative displacement than that of hip screw in the treatment of extracapsular hip fractures. In order to provide evidence-based basis for clinical decision-making, this study systematically evaluated the clinical efficacy of PFNA and DHS in the treatment of internal fixation. Methods: the inclusion criteria and exclusion criteria were formulated, the test indexes were determined, and the literature studies that fully met the inclusion criteria and exclusion criteria were retrieved by computer and manual retrieval methods. The Chinese computer retrieval database included universal medicine. Chinese Journal of surgery, Chinese Journal of Orthopaedics, Chinese Journal of Trauma, The Chinese Journal of Orthopedic Trauma, the Chinese Journal of Bone and Joint injury, the Chinese Journal of Orthopaedic surgery and the Journal of Kunming Medical University. The literature included in this study was independently evaluated and collected by two evaluators using the improved Jadad scoring system and the latest quality assessment methods. In the event of disagreement, It is discussed by two evaluators or decided by a third party expert. Finally, the collected data is analyzed by Meta using RevMan5.3 special system evaluation software. Results: according to the inclusion criteria and exclusion criteria, 10 literature studies were included in this study, including 1 English and 9 Chinese literature. A total of 715 patients were included in the study, including 366 patients in PFNA group and 349 in DHS group. According to the improved Jadad quality score, one study was of high quality and nine were of low quality. The results of Meta analysis showed that there was a statistically significant difference between the two groups in terms of average operative time (MD=-24.79,95% CI:-35.07~14.51,). P0.00001); There was significant difference in mean intraoperative bleeding volume (MD=-201.28,95% CI:-229.13~-173.43,P0.00001). The difference in the length of incision was statistically significant (MD=-7.80,95% CI:-8.58~7.01, P0.00001), and the difference in the excellent and good rate after operation was statistically significant (OR=4.90,95% CI: 2.89 8.32, P 0.00001). P0.00001); There was significant difference in the incidence of postoperative complications (OR=0.46,95% CI:0.26~0.80,P=0.006). The difference in hospitalization days was statistically significant (MD=-4.14,95% CI:-7.74~-0.53,P=0.02). Conclusion: the treatment of unstable intertrochanteric fracture of femur in elderly patients with PFNA and classical DHS was performed on the basis of mean operative time, average intraoperative bleeding, length of operative incision, excellent and good rate after operation. The incidence of postoperative complications and length of stay were compared. The results showed that PFNA had more advantages, but regional differences, technical differences and bone quality differences had some effects on the indexes. Therefore, it is necessary to study further by strictly designing large sample randomized controlled trials, using correct random methods, assigning hidden and blind methods, and following up the subjects involved in the study for a long time, and to evaluate the curative effect as uniformly as possible.
【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R687.3

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