股骨颈骨折的治疗：半髋还是全髋？

Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture

股骨颈骨折的治疗：半髋还是全髋？

译者：张峻

Background: Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty.

背景：从全世界范围来看，髋部骨折是导致成人致残疾病的十大原因之一。对于移位的股骨颈骨折，半髋和全髋关节置换术的效果哪个更好仍然有争议。

Methods: We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points.

方法：我们随机将1495例＞50岁的移位的股骨颈骨折随机分为半髋治疗组和全髋治疗组。所有入组病人在骨折之前都可以独立正常行走。主要观察终点是随访24个月内的第二次髋关节手术。次要观察终点包括死亡，严重不良事件，髋关节相关并发症，生命健康相关质量，功能和全身健康终点。

Results: The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty.

结果：主要观察终点在全髋置换组发生率为7.9%（57/719），在半髋置换组发生率为8.3%（60/723），HR=0.95；95% CI=0.64-1.40；P=0.79。髋关节脱位或不稳在全髋置换组发生率为4.7%（34/719），在半髋置换组发生率为2.4%（17/723），HR=2；95% CI=0.97-4.09。髋关节功能评估采用WOMAC评分，疼痛评分，僵硬评分，功能评分，显示全髋置换组稍优于半髋置换组。死亡率两组没有差别（全髋组14.3%，半髋组13.1%，P=0.48）。严重不良事件在全髋置换组发生率为41.8%（300/719），在半髋置换组发生率为36.7%（265/723）。

Conclusions: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.).

结论：在术前能够独立正常行走的股骨颈骨折病人中，髋关节二次手术发生率在全髋置换组和半髋置换组没有显著差异。随访24个月后，全髋置换组病人在的功能和生活质量方面稍优于半髋置组。

表1 病人基线资料

表2 试验观察终点

表3 严重不良事件

表4 生命健康相关质量评分，功能和全身健康评分

图1 主要观察终点K a p l an – M e i e r 曲线

文献出处：HEALTH Investigators, Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, Frihagen F, Guerra-Farfán E, Kleinlugtenbelt YV, Poolman RW, Rangan A, Bzovsky S, Heels-Ansdell D, Thabane L, Walter SD, Devereaux PJ. Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. N Engl J Med. 2019 Dec 5;381(23):2199-2208. doi: 10.1056/NEJMoa1906190. Epub 2019 Sep 26. PMID: 31557429.