今日の臨床サポート

大腿骨転子部骨折

著者: 福田文雄 北九州総合病院 整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2021/06/02
参考ガイドライン:
  1. 大腿骨頚部/転子部骨折診療ガイドライン2021(改訂第3版)
患者向け説明資料

概要・推奨   

  1. 早期手術、早期荷重を推奨する(推奨度1 S/CSJ
  1. できるだけ早期に⼿術を⾏うべきである。早期⼿術は合併症が少なく、⽣存率が⾼く、⼊院期間が短い[1]
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
福田文雄 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント
  1. 大腿骨頚部/転子部骨折診療ガイドライン2021(改訂第3版)に基づき、エビデンスのシステマティックレビューと益と害のバランスなどを考慮した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 大腿骨近位部骨折は、2012年では約17.5万例(男性:37,600例、女性:138,100例)であり女性に多く70歳を過ぎると急激に増加し、団塊の世代の高齢化にともない今後さらに増加する[2][3]
  1. 2009 年〜2014 年の患者数の増加は男性では 85〜89 歳、⼥性では 90〜94 歳で最も⼤きかった[4]
  1. 大腿骨近位部骨折は、その骨折部位により、関節内骨折である頚部骨折と関節外骨折である転子部骨折、どちらにも分類できない頚基部骨折に分類される。頚部骨折より高齢者に起こることが多い。これらのうち、転子間骨折、転子貫通骨折を転子部骨折と呼ぶ。
 
大腿骨近位部骨折の分類

通常、関節包内骨折である頚部骨折と関節包外骨折である転子部骨折に分かれる。

 
  1. 頚部骨折
  1. 骨頭下骨折
  1. 中間部骨折
  1. 転子部骨折
  1. 転子間骨折(intertrochanteric fractures)
  1. 転子貫通骨折(pertrochanteric fractures)
  1. 骨粗鬆症を基盤として高齢者の転倒による低エネルギー外傷の結果として起こる。
  1. 若年者でも交通事故や転落など高エネルギー外傷として起こる。
  1. 高齢者に多い骨折であり、認知症、せん妄、深部静脈血栓症、肺塞栓症、肺炎予防のため早期離床目的に手術が行われる。
  1. 誤嚥性肺炎や肺塞栓症による死亡など生命予後に影響を及ぼす骨折である。
問診・診察のポイント  
問診:
  1. 転倒など外傷歴を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

著者: H Orimo, T Hashimoto, K Sakata, N Yoshimura, T Suzuki, T Hosoi
雑誌名: J Bone Miner Metab. 2000;18(3):126-31.
Abstract/Text The third nationwide survey for hip fracture incidence was conducted in 1997 following the first such survey in 1987 and the second in 1992. The purpose of this study was to investigate the trends in the incidence and regional distribution of this disease during 10 years. Of 10271 orthopedic institutions in Japan, 4503 were selected as subjects for the study using the optimum allocation method. Questionnaires concerning new patients with hip fracture were mailed. The replies were obtained from 2930 institutions by the end of December 1998; the response rate was 65.1%. The number of new patients was estimated to be 89900-94900 [mean, 92400; 20100-21400 (20800) men and 69600-73600 (71600) women]. The number of cases in 1997 was about 1.7 times higher than that in the first survey and 1.2 times higher than that in the second survey. The age-specific incidence (per 10000 per year) in men and women in 1997 was 0.30 and 0.13, respectively, for age under 40 years; 0.91 and 0.60, 40-49 years; 2.00 and 2.39, 50-59 years; 5.12 and 9.07, 60-69 years; 17.3 and 40.8, 70-79 years; 57.4 and 147.8, 80-89 years; and 128.9 and 281.0, for age over 90 years. The incidence was increased compared with that of the first survey, and similar to the second survey, excepting that of women aged 80 years or older. Concerning regional differences, hip fracture incidence was relatively low in the eastern area compared to the western area in Japan, which was a trend identical to that in the previous nationwide surveys.

PMID 10783845  J Bone Miner Metab. 2000;18(3):126-31.
著者: H Orimo, Y Yaegashi, T Hosoi, Y Fukushima, T Onoda, T Hashimoto, K Sakata
雑誌名: Osteoporos Int. 2016 May;27(5):1777-84. doi: 10.1007/s00198-015-3464-8. Epub 2016 Jan 5.
Abstract/Text UNLABELLED: We estimated the number of hip fracture patients in 2012 in Japan and investigated the trends in incidence during a 25-year period from 1987 to 2012. Despite the increasing number of patients, the incidence of hip fracture in both men and women aged 70-79 years showed the possibility of decline.
INTRODUCTION: The objectives of this study were to estimate the number of hip fracture patients in 2012, to investigate the trends in incidence during a 25-year period from 1987 to 2012, and to determine the regional differences in Japan.
METHODS: Data were collected through a nationwide survey based on hospitals by a mail-in survey. Hip fracture incidences by sex and age and standardized incidence ratios by region were calculated.
RESULTS: The estimated numbers of new hip fracture patients in 2012 were 175,700 in total (95 % CI 170,300-181,100), 37,600 (36,600-38,600) for men and 138,100 (134,300-141,900) for women. The incidence rates in both men and women aged 70-79 years were the lowest in the 20-year period from 1992 to 2012. The incidence was higher in western areas of Japan than that in eastern areas in both men and women; however, the difference in the incidence of hip fracture between western and eastern areas is becoming smaller.
CONCLUSIONS: Despite the increasing number of new patients, the incidence of hip fracture in both men and women aged 70-79 years showed the possibility of decline. The exact reasons for this are unknown, but various drugs for improving bone mineral density or preventing hip fracture might have influenced the results. A decrease in the differences in nutrient intake levels might explain some of the change in regional differences in Japan.

PMID 26733376  Osteoporos Int. 2016 May;27(5):1777-84. doi: 10.1007/s0・・・
著者: Hiroshi Hagino, Naoto Endo, Atsushi Harada, Jun Iwamoto, Tasuku Mashiba, Satoshi Mori, Seiji Ohtori, Akinori Sakai, Junichi Takada, Tetsuji Yamamoto
雑誌名: J Orthop Sci. 2017 Sep;22(5):909-914. doi: 10.1016/j.jos.2017.06.003. Epub 2017 Jul 17.
Abstract/Text BACKGROUND: A nationwide survey of hip fractures by the Japanese Orthopaedic Association (JOA) from 1998 to 2008 found a drastic increase in incidence. The aims of this study were to elucidate the status of hip fractures from 2009 to 2014 and to survey the causes for delayed surgery.
METHODS: A tally of all hip fractures that occurred in patients from 2009 to 2014 was conducted in hospitals authorized by the JOA or in clinics with inpatient facilities of the Japanese Clinical Orthopaedic Association (JCOA). A survey of the causes for delay in surgery was conducted at 849 sites and 526 sites participated.
RESULTS: A total of 488,759 hip fractures were registered. Increases in incidence from 2009 to 2014 were prominent in the 90-94-year-old age group among women and the 85-89-year-old age group among men. More trochanteric fractures than neck fractures occurred; however, the neck/trochanter ratio increased over time. The mean duration of preoperative hospital stay was 4.8 and 4.5 days, and the mean duration of hospitalization was 40.5 and 36.8 days in 2009 and 2014, respectively. There were significant differences between patients who waited for surgery up to 3 days and those who waited longer than 3 days in date of hospitalization, fracture type, comorbidities, anticoagulant use, surgical procedure, type of physician who administered anesthesia, type of anesthesia, and operating room schedule. Physicians in charge of each patient who waited for surgery for more than 3 days most frequently cited difficulties in securing operating rooms as the cause for delayed surgery.
CONCLUSION: A drastic increase occurred in the number of patients with hip fractures with time in Japan. One problem in the treatment of hip fractures is the long waiting time from hospitalization to surgery resulting from difficulties in securing operating rooms.

Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
PMID 28728988  J Orthop Sci. 2017 Sep;22(5):909-914. doi: 10.1016/j.jo・・・
著者: J Fairclough, E Colhoun, D Johnston, L A Williams
雑誌名: J Bone Joint Surg Br. 1987 Mar;69(2):251-3.
Abstract/Text Of 693 elderly patients admitted with suspected hip fractures, 43 had normal radiographs and were investigated by isotope bone scan. The 30 patients (70%) with normal scans were mobilised and none developed a fracture. All 13 of the patients with specific bone scan abnormalities were subsequently proved to have fractures, five of which became displaced. Clearly conventional radiography does not exclude fracture of the femoral neck in elderly patients; bone scanning is advisable in doubtful cases.

PMID 3818756  J Bone Joint Surg Br. 1987 Mar;69(2):251-3.
著者: P F Rizzo, E S Gould, J P Lyden, S E Asnis
雑誌名: J Bone Joint Surg Am. 1993 Mar;75(3):395-401.
Abstract/Text Sixty-two consecutively seen patients in whom a fracture about the hip was clinically suspected, but in whom the radiographic findings were negative, were examined with both magnetic resonance imaging and bone-scanning. The magnetic resonance-imaging studies, consisting of T1-weighted coronal sections, were done within twenty-four hours after admission to the hospital, and the bone scans, within seventy-two hours after admission. There were twenty-three men and thirty-nine women. Thirty-six patients who had evidence of a fracture on the magnetic resonance-imaging study also had a positive bone scan initially. Twenty-three patients who had a negative finding on the magnetic resonance-imaging study had a corresponding negative bone scan. Two additional patients had evidence of avascular necrosis of the femoral head on both the magnetic resonance image and the bone scan, and they were managed non-operatively. One patient had a positive magnetic resonance image and a negative bone scan twenty-four hours after admission. A repeat bone scan, which was made six days later, was positive for a fracture of the femoral neck and the patient was managed with internal fixation. Magnetic resonance imaging was as accurate as bone-scanning in the assessment of occult fractures of the hip. The magnetic resonance imaging took less than fifteen minutes to perform, and it was tolerated well by the patient. Magnetic resonance imaging provides an early diagnosis of occult fractures about the hip and may decrease the length of the stay in the hospital by expediting definitive treatment.

PMID 8444918  J Bone Joint Surg Am. 1993 Mar;75(3):395-401.
著者: Joanne Guay, Martyn J Parker, Richard Griffiths, Sandra L Kopp
雑誌名: Anesth Analg. 2018 May;126(5):1695-1704. doi: 10.1213/ANE.0000000000002489.
Abstract/Text BACKGROUND: This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic.
METHODS: Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale.
RESULTS: Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, -1.41 (95% confidence interval [CI], -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used (P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38-1.27; I statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19-0.89; I statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 [95% CI, 5-72]; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, -11.25 hours (95% CI, -14.34 to -8.15 hours; I statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, -3.48 (95% CI, -4.23 to -2.74; moderate quality of evidence).
CONCLUSIONS: There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks).

PMID 28991122  Anesth Analg. 2018 May;126(5):1695-1704. doi: 10.1213/A・・・
著者: Anne Marie Nyholm, Kirill Gromov, Henrik Palm, Michael Brix, Thomas Kallemose, Anders Troelsen, Danish Fracture Database Collaborators
雑誌名: J Bone Joint Surg Am. 2015 Aug 19;97(16):1333-9. doi: 10.2106/JBJS.O.00029.
Abstract/Text BACKGROUND: We hypothesized that undergoing surgery as soon as possible reduces early mortality in patients with a proximal femoral fracture. Our aim was to evaluate the association between surgical delay and early mortality in these patients.
METHODS: We performed a retrospective analysis of prospectively collected data from the Danish Fracture Database and the Civil Registration System on patients who were fifty years of age or older and had undergone surgery for a proximal femoral fracture. Femoral head fracture (classified as OTA/AO 31C per the OTA/AO classification system), high-energy trauma, pathological fractures, multiple fractures, and surgeries performed with implants not commonly used were excluded. End points were adjusted odds ratios for thirty-day and ninety-day mortality.
RESULTS: For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality.
CONCLUSIONS: In this study, a surgical delay of more than twelve hours significantly increased the adjusted risk of thirty-day mortality and a surgical delay of more than twenty-four hours significantly increased the adjusted risk of ninety-day mortality. The adjusted risk of both thirty-day and ninety-day mortality increased significantly when the education level of the surgeon was below that of an attending surgeon. The study findings challenge orthopaedic departments to facilitate fast surgical treatment supported by attending orthopaedic surgeons.

Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
PMID 26290084  J Bone Joint Surg Am. 2015 Aug 19;97(16):1333-9. doi: 1・・・
著者: María T Vidán, Elisabet Sánchez, Yassira Gracia, Eugenio Marañón, Javier Vaquero, José A Serra
雑誌名: Ann Intern Med. 2011 Aug 16;155(4):226-33. doi: 10.7326/0003-4819-155-4-201108160-00006.
Abstract/Text BACKGROUND: The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.
OBJECTIVE: To assess the effect of surgical delay on hospital outcomes according to the cause of delay.
DESIGN: Prospective cohort study.
SETTING: A hip fracture unit in a university hospital in Spain.
PATIENTS: 2250 consecutive elderly patients with hip fracture.
MEASUREMENTS: Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.
RESULTS: Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.
LIMITATION: This was a single-center study without postdischarge follow-up.
CONCLUSION: The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.
PRIMARY FUNDING SOURCE: None.

PMID 21844548  Ann Intern Med. 2011 Aug 16;155(4):226-33. doi: 10.7326・・・
著者: Philip J Belmont, E'Stephan J Garcia, David Romano, Julia O Bader, Kenneth J Nelson, Andrew J Schoenfeld
雑誌名: Arch Orthop Trauma Surg. 2014 May;134(5):597-604. doi: 10.1007/s00402-014-1959-y. Epub 2014 Feb 26.
Abstract/Text STUDY DESIGN: Retrospective review of prospectively collected data.
OBJECTIVE: To describe the impact of patient demographics, injury-specific factors, and medical co-morbidities on outcomes after hip fracture using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB).
METHODS: The 2008 NSP-NTDB was queried to identify patients sustaining hip fractures. Patient demographics, co-morbidities, injury-specific factors, and outcomes (including mortality and complications) were recorded and a national estimate model was developed. Unadjusted differences for risk factors were evaluated using t test/Wald Chi square analyses. Weighted logistic regression and sensitivity analyses were performed to control for all factors in the model.
RESULTS: The weighted sample contained 44,419 incidents of hip fracture. The average age was 72.7. Sixty-two percent of the population was female and 80 % was white. The mortality rate was 4.5 % and 12.5 % sustained at least one complication. Seventeen percent of patients who sustained at least one complication died. Dialysis, presenting in shock, cardiac disease, male sex, and ISS were significant predictors of mortality, while dialysis, obesity, cardiac disease, diabetes, and a procedure delay of ≥2 days influenced complications. The major potential modifiable risk factor appears to be time to procedure, which had a significant impact on complications.
CONCLUSIONS: This is the first study to postulate predictors of morbidity and mortality following hip fracture in a US national model. While many co-morbidities appear to be influential in predicting outcome, some of the more significant factors include the presence of shock, dialysis, obesity, and time to surgery.
LEVEL OF EVIDENCE: Prognostic study, Level II.

PMID 24570142  Arch Orthop Trauma Surg. 2014 May;134(5):597-604. doi: ・・・
著者: M J Parker, H H Handoll, A Bhargara
雑誌名: Cochrane Database Syst Rev. 2000;(4):CD000337. doi: 10.1002/14651858.CD000337.
Abstract/Text BACKGROUND: Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest.
OBJECTIVES: To compare conservative with operative treatment for fractures of the proximal femur (hip) in adults.
SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register and bibliographies of published papers, and contacted trialists. Date of the most recent search: August 1999.
SELECTION CRITERIA: Randomised and quasi-randomised trials comparing these two treatment methods in adults with hip fracture. Outcomes sought fell into four categories: a) fracture fixation complications, b) post-operative or clinical complications, c) anatomical restoration and d) final outcome measures including mortality.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of an twelve item scale, and extracted data. Additional information was sought from trialists. After grouping by fracture type, comparable groups of trials were subgrouped by implant type and where appropriate, data were pooled using the fixed effects model.
MAIN RESULTS: The five randomised trials identified involved only 425 elderly patients. One small and potentially biased trial of 23 patients with undisplaced intracapsular fracture showed a reduced risk of non-union for those fractures treated operatively. The four identified studies on extracapsular fractures tested a variety of surgical techniques and implant devices and only one trial involving 106 patients can be considered to test current practice. In this trial, no differences were found in medical complications, mortality and long-term pain. However, operative treatment was more likely to result in the fracture healing without leg shortening, a shorter hospital stay and a statistically non-significant increase in the return of patients back to their original residence.
REVIEWER'S CONCLUSIONS: Given the lack of available evidence to inform practice and the continued variation in practice, good quality randomised trials of operative versus conservative treatment for undisplaced intracapsular fractures are warranted. The limited available evidence from randomised trials does not suggest major differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment appears to be associated with a reduced length of hospital stay and improved rehabilitation. However these results are derived mainly from one study. Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common. Although further randomised trials would provide more robust data, they may be difficult to mount.

PMID 11034683  Cochrane Database Syst Rev. 2000;(4):CD000337. doi: 10.・・・
著者: M J Parker, H H G Handoll
雑誌名: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD000168. doi: 10.1002/14651858.CD000168.pub2. Epub 2006 Jul 19.
Abstract/Text BACKGROUND: Following a hip fracture, traction may be applied to the injured limb before surgery.
OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.
SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1988 to 2006 Week 11), CINAHL (1982 to March 2006), the UK National Research Register (Issue 1, 2006), conference proceedings and reference lists of articles.
SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery.
DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled.
MAIN RESULTS: Ten randomised trials, mainly of moderate quality, involving a total of 1546 predominantly elderly patients with hip fractures, were identified and included in the review. Nine trials compared traction with no traction. Although limited data pooling was possible, overall this provided no evidence of benefit from traction, either in the relief of pain before surgery or ease of fracture reduction or quality of fracture reduction at time of surgery. One of these trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly.
AUTHORS' CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Further, high quality trials would be required to confirm or refute the absence of benefits of traction.

PMID 16855952  Cochrane Database Syst Rev. 2006 Jul 19;(3):CD000168. d・・・
著者: Boyuan Nie, Dou Wu, Zhaohui Yang, Qiang Liu
雑誌名: Medicine (Baltimore). 2017 Jul;96(27):e7446. doi: 10.1097/MD.0000000000007446.
Abstract/Text BACKGROUND: More and more studies conduct to compare intramedullary fixation (IMF) with arthroplasty in treating intertrochanteric hip fractures, but it remains controversy. The aim of this meta-analysis was to find out whether IMF or arthroplasty was more appropriate for treating intertrochanteric hip fractures in elderly patients.
METHODS: Relevant studies were searched in the electronic databases of PubMed, Embase, and The Cochrane Central Register of Controlled Trials from January 1980 to September 2016 with English language restriction. Surgical information and postoperative outcomes were analyzed using RevMan 5.3 version.
RESULTS: A total of 1239 patients from 11 studies which satisfied the eligibility criteria were included. Compared with IMF, the use of arthroplasty reduced implant-related complications (odds ratio [OR]: 2.05, P = .02) and reoperation rate (OR: 7.06, P < .001), and had similar length of hospital stay (weighted mean difference [WMD]: -0.41, P = .63). However, IMF reduced blood loss (WMD: -375.01, P = .001) and transfusion requirement (OR: 0.07, P < .001), shorter operation time (WMD: -18.92, P = .010), higher Harris hip score (WMD: 4.19, P < .001), and lower rate of 1-year mortality (OR: 0.67, P = .02) compared with arthroplasty.
CONCLUSION: The main treatment of intertrochanteric hip fractures is internal fixation using IMF. In the absence of concrete evidence, arthroplasty should be undertaken with caution in carefully selected patient and surgeon should be aware of the increased complexity of doing the arthroplasty in these elderly patients. Further high-quality randomized controlled trials (RCTs) are needed to provide robust evidence and evaluate the treatment options.

PMID 28682912  Medicine (Baltimore). 2017 Jul;96(27):e7446. doi: 10.10・・・
著者: Magnus Eneroth, Ulla-Britt Olsson, Karl-Göran Thorngren
雑誌名: Clin Orthop Relat Res. 2006 Oct;451:212-7. doi: 10.1097/01.blo.0000224054.86625.06.
Abstract/Text Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively.

PMID 16770284  Clin Orthop Relat Res. 2006 Oct;451:212-7. doi: 10.1097・・・
著者: Martyn J Parker, Helen H G Handoll
雑誌名: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000093. doi: 10.1002/14651858.CD000093.pub4. Epub 2008 Jul 16.
Abstract/Text BACKGROUND: Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants (e.g. the sliding hip screw).
OBJECTIVES: To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults.
SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to June week 3 2007), EMBASE (1988 to 2007 Week 27), the UK National Research Register, orthopaedic journals, conference proceedings and reference lists of articles.
SELECTION CRITERIA: All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures.
DATA COLLECTION AND ANALYSIS: Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled.
MAIN RESULTS: Predominantly older people with mainly trochanteric fractures were treated in the 36 included trials.Twenty-two trials (3871 participants) compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications.Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group; all cases of operative and later fracture of the femur occurred in this group. Results for post-operative complications, mortality and functional outcomes were similar in the two groups. Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) compared with the SHS. Single trials compared the Targon PF nail versus SHS (60 participants); experimental mini-invasive static intramedullary nail versus SHS (60 participants); Kuntscher-Y nail versus SHS (230 participants); Gamma nail versus Medoff sliding plate (217 participants); and PFN versus Medoff sliding plate (203 participants). These trials provided insufficient evidence to establish differences between these implants. Two trials (65 participants with reverse and transverse fractures at the level of the lesser trochanter) found intramedullary nails (Gamma nail or PFN) were associated with better intra-operative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar screw) for these fractures.
AUTHORS' CONCLUSIONS: Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures. Further studies are required to determine if different types of intramedullary nail produce similar results, or if intramedullary nails have advantages for selected fracture types (for example, subtrochanteric fractures).

PMID 18646058  Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000093. d・・・
著者: K H Stappaerts, J Deldycke, P L Broos, F F Staes, P M Rommens, P Claes
雑誌名: J Orthop Trauma. 1995;9(4):292-7.
Abstract/Text A prospective randomized study was set up, comparing a compression hip screw with the Vandeputte (VDP) endoprosthesis treatment for fresh, unstable peritrochanteric fractures, according to the Evans-Jensen and AO systems. Ninety patients, ages > or = 70 years, 47 of whom were treated with a compression hip screw and 43 with a VDP endoprosthesis, were included. All patients were being followed for 3 months. No difference between the two groups was found for operating time, wound complications, and mortality rate, but there was a higher transfusion need in VDP treatment. Severe fracture redisplacement or total collapse of the fracture occurred in 11 (26%) compression hip screw patients, two of whom had revision surgery. Only one patient needed reintervention after VDP treatment. Functional capacity of preoperative independent patients at hospital discharge did not differ for the two groups. In conclusion, the compression hip screw seemed to be an appropriate implant for most of the peritrochanteric fractures, but for very old patients with advanced osteoporosis, with a complex, unstable peritrochanteric fracture, and who are eligible for early mobilization, primary cemented endoprosthesis might be the best treatment.

PMID 7562150  J Orthop Trauma. 1995;9(4):292-7.
著者: K J Koval, K D Friend, G B Aharonoff, J D Zukerman
雑誌名: J Orthop Trauma. 1996;10(8):526-30.
Abstract/Text Five hundred ninety-six patients age > or = 65 with femoral neck or intertrochanteric fractures were allowed immediate unrestricted weight bearing after surgery and were prospectively followed. Follow-up data and hospital records were examined to identify those patients who required additional hip surgery owing to failure of fixation, nonunion, osteonecrosis, or prosthetic dislocation. Four hundred seventy-three patients were available for 1-year minimum follow-up; 16 patients (3.4%) required additional hip surgery. The revision surgery rate after intertrochanteric fracture due to loss of fixation was 2.9%. The revision surgery rate after internal fixation of the femoral neck from loss of fixation/nonunion was 5.3%; the revision rate from osteonecrosis for patients with 2-year follow-up was 5.4%. The revision rate after hemiarthroplasty due to prosthetic dislocation was 0.6%. These results support the use of unrestricted weight bearing in elderly patients after hip fracture surgery.

PMID 8915913  J Orthop Trauma. 1996;10(8):526-30.
著者: J A Valverde, M G Alonso, J G Porro, D Rueda, P M Larrauri, J J Soler
雑誌名: Clin Orthop Relat Res. 1998 May;(350):56-61.
Abstract/Text Fractures of the proximal femur are, more than ever, an important challenge in the field of traumatology. The Gamma nail, a combination of advantages of the sliding screw with the intramedullary nail, represents an efficient technique in the management of these fractures. A series of 224 fractures of the proximal femur in which this nail was used is reported. The average age of the patients was 79.2 years. The mean healing time was 68.2 days in 99.4% of the cases. The incidence of perioperative complications was 10.3% showing that, in most of the cases, the complications occurred because of poor technique. Postoperative complications occurred with an incidence of 14.1%. Seven cases of migration of a proximal screw, six shaft fractures, and one broken nail were the most important complications. The device allowed for early mobilization and full weightbearing of the affected hip regardless of the type of fracture. With adequate surgical technique and experience, the advantages of the Gamma nail increases as the complication rate diminishes.

PMID 9602800  Clin Orthop Relat Res. 1998 May;(350):56-61.
著者: Deting Xue, Fangcai Li, Gang Chen, Shigui Yan, Zhijun Pan
雑誌名: J Orthop Surg Res. 2014 Jun 5;9:45. doi: 10.1186/1749-799X-9-45. Epub 2014 Jun 5.
Abstract/Text BACKGROUND: Whether bisphosphonates affect indirect bone healing is still unclear.
METHOD: We carried out a comprehensive search strategy. Only randomized controlled trials were included. Two reviewers independently assessed methodological qualities and extracted outcome data. Analysis was performed with RevMan 5.2.
RESULTS: Eight eligible randomized controlled trials with 2,508 patients were included. Meta-analysis results showed that no statistically significant differences were founded in indirect bone healing in short time (within 3 months) (relative risk (RR) 1.40, relative the control group; 95% CI 0.36 to 5.49) and in long-term (more than 12 months) postoperation (RR 1.0; 95% CI 0.98 to 1.02) between bisphosphonates infusion groups and control groups. There were no statistically significant differences of indirect bone healing between early and delay bisphosphonates administration groups. Bisphosphonates infusion after lumbar infusion surgery could promote bone healing and shorten fusion time in 6 months postoperation (RR 1.35; 95% CI 1.11 to 1.66).
CONCLUSION: There was no clinically detectable delay to fracture healing via external callus formation following bisphosphonates treatment. Considering the benefit aspects of bisphosphonates for osteoporosis treatment, we recommend bisphosphonates infusion after fracture fixation surgery and lumbar fusion surgery.

PMID 24902588  J Orthop Surg Res. 2014 Jun 5;9:45. doi: 10.1186/1749-7・・・
著者: D Marshall, O Johnell, H Wedel
雑誌名: BMJ. 1996 May 18;312(7041):1254-9.
Abstract/Text OBJECTIVE: To determine the ability of measurements of bone density in women to predict later fractures.
DESIGN: Meta-analysis of prospective cohort studies published between 1985 and end of 1994 with a baseline measurement of bone density in women and subsequent follow up for fractures. For comparative purposes, we also reviewed case control studies of hip fractures published between 1990 and 1994.
SUBJECTS: Eleven separate study populations with about 90,000 person years of observation time and over 2000 fractures.
MAIN OUTCOME MEASURES: Relative risk of fracture for a decrease in bone mineral density of one standard deviation below age adjusted mean.
RESULTS: All measuring sites had similar predictive abilities (relative risk 1.5 (95% confidence interval 1.4 to 1.6)) for decrease in bone mineral density except for measurement at spine for predicting vertebral fractures (relative risk 2.3 (1.9 to 2.8)) and measurement at hip for hip fractures (2.6 (2.0 to 3.5)). These results are in accordance with results of case-control studies. Predictive ability of decrease in bone mass was roughly similar to (or, for hip or spine measurements, better than) that of a 1 SD increase in blood pressure for stroke and better than a 1 SD increase in serum cholesterol concentration for cardiovascular disease.
CONCLUSIONS: Measurements of bone mineral density can predict fracture risk but cannot identify individuals who will have a fracture. We do not recommend a programme of screening menopausal women for osteoporosis by measuring bone density.

PMID 8634613  BMJ. 1996 May 18;312(7041):1254-9.
著者: R A Merchant, K L Lui, N H Ismail, H P Wong, Y Y Sitoh
雑誌名: Ann Acad Med Singapore. 2005 Mar;34(2):163-8.
Abstract/Text INTRODUCTION: We studied the prevalence of postoperative complications in a series of consecutive patients who received surgery for hip fractures in a major public hospital in Singapore. We also studied the predictors for the occurrence of complications and the impact of these complications on patient outcomes.
MATERIALS AND METHODS: A retrospective chart review of patients admitted with hip fracture, from March to November 2001, was carried out. Patients were classified as having postoperative complications if they developed any of the following conditions after surgery: dislocation of prosthesis, deep vein thrombosis, postoperative confusion, foot drop, stroke, cardiac arrhythmias or acute myocardial infarctions, urinary retention, urinary tract infection, pneumonia, wound infection and incident pressure sores.
RESULTS: Of the 180 patients studied, 60 developed postoperative complications. Significant predictors of complications after logistic regression included being of female gender [odds ratio (OR), 2.79; 95% confidence interval (CI), 1.13 to 6.89] and pre-fracture mobility status (OR for independent ambulators 0.45; 95% CI, 0.23 to 0.87), but not the age of the patients. Postoperative complications significantly affected the length of stay within the acute hospital (beta coefficient, 6.42; 95% CI, 2.55 to 10.29), but were not associated with a decline in mobility status at 3 months post-fracture, eventual discharge destination or readmission within 1 year.
CONCLUSION: Postoperative complications are common after surgery for hip fractures and result in significantly longer hospitalisation periods. Significant predictors for such complications include being of female gender and pre-fracture mobility. Age, in itself, does not result in a higher risk of complications and should not preclude older hip fracture patients from surgical management.

PMID 15827663  Ann Acad Med Singapore. 2005 Mar;34(2):163-8.
著者: H H G Handoll, C Sherrington
雑誌名: Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001704. doi: 10.1002/14651858.CD001704.pub3. Epub 2007 Jan 24.
Abstract/Text BACKGROUND: Hip fracture mainly occurs in older people. Mobilisation strategies such as gait retraining and exercises are used at various stages of rehabilitation after surgery.
OBJECTIVES: To evaluate the effects of different mobilisation strategies after hip fracture surgery in adults.
SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE and other databases, conference proceedings and reference lists of articles, up to January 2006.
SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different mobilisation strategies after hip fracture surgery.
DATA COLLECTION AND ANALYSIS: The authors independently selected trials, assessed trial quality and extracted data. There was no data pooling.
MAIN RESULTS: Most of the 13 included trials (involving 1065 participants, generally over 65 years) were small and all had methodological limitations, including inadequate follow up. Seven trials evaluated mobilisation strategies started soon after hip fracture surgery. One historic trial found no significant differences in unfavourable outcomes for weight bearing started at two versus 12 weeks after internal fixation of a displaced intracapsular fracture. Two trials compared a more with a less intensive regimen of physiotherapy: one found no difference in recovery, the other found a higher level of drop-out in the more intensive group with no difference in length of hospital stay. One trial found short-term improvement in mobility and balance for a two-week programme of weight-bearing versus non-weight-bearing exercise. One trial found improved mobility in those given a quadriceps muscle strengthening exercise programme. One trial found no significant difference in recovery of mobility after a treadmill versus conventional gait retraining programme. One trial found a greater recovery of pre-fracture mobility after neuromuscular stimulation of the quadriceps muscle. Six trials evaluated strategies started after hospital discharge. Started soon after discharge, two trials found improved outcome after 12 weeks of intensive physical training and a home-based physical therapy programme respectively. Begun after completion of standard physical therapy, one trial found improved outcome after six months of intensive physical training whereas another trial found no significant effects of home-based resistance or aerobic training. One trial found improved outcome after home-based exercises started around 22 weeks from injury. One trial found home-based weight-bearing exercises starting at seven months produced no statistically significant differences aside for greater quadriceps strength.
AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to establish the effectiveness of the various mobilisation strategies used in rehabilitation after hip fracture surgery. Further research is required to establish the possible benefits of the additional provision of interventions, including intensive supervised exercises, primarily aimed at enhancing mobility.

PMID 17253462  Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001704. d・・・
著者: Michael Stenvall, Birgitta Olofsson, Lars Nyberg, Maria Lundström, Yngve Gustafson
雑誌名: J Rehabil Med. 2007 Apr;39(3):232-8. doi: 10.2340/16501977-0045.
Abstract/Text OBJECTIVE: To investigate the short- and long-term effects of a multidisciplinary postoperative rehabilitation programme in patients with femoral neck fracture.
DESIGN AND SUBJECTS: A randomized controlled trial in patients (n = 199) with femoral neck fracture, aged >or= 70 years.
METHODS: The primary outcomes were: living conditions, walking ability and activities of daily living performance on discharge, 4 and 12 months postoperatively. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. A geriatric team assessed those in the intervention group 4 months postoperatively, in order to detect and treat any complications. The control group followed conventional postoperative routines.
RESULTS: Despite shorter hospitalization, significantly more people from the intervention group had regained independence in personal activities of daily living performance at the 4- and 12-month follow-ups; odds ratios (95% confidence interval (CI) ) 2.51 (1.00-6.30) and 3.49 (1.31-9.23), respectively. More patients in the intervention group had also regained the ability to walk independently indoors without walking aids by the end of the study period, odds ratio (95% confidence interval) 3.01 (1.18-7.61).
CONCLUSION: A multidisciplinary postoperative intervention programme enhances activities of daily living performance and mobility after hip fracture, from both a short-term and long-term perspective.

PMID 17468792  J Rehabil Med. 2007 Apr;39(3):232-8. doi: 10.2340/16501・・・
著者: C Sherrington, S R Lord
雑誌名: Arch Phys Med Rehabil. 1997 Feb;78(2):208-12.
Abstract/Text OBJECTIVE: To determine the effect of a home exercise program on strength, postural control, and mobility following hip fracture.
DESIGN: Randomized controlled trial of 1 month's duration.
SETTING: Daily exercise carried out within the subjects' home environments.
PARTICIPANTS: Forty-two people 64 to 94 years of age, 35 of whom were living independently in the community and 7 of whom were residing in institutional care. Subjects were recruited on average 7 months after a fall-related hip fracture and randomly allocated to either the intervention or the control group (n = 21 each). The groups were well matched in terms of medical conditions, medication use, disability, and activity levels.
INTERVENTION: A "home-based" program of weight-bearing exercise established at a visit by a physiotherapist.
MAIN OUTCOME MEASURES: Quadriceps strength, postural sway, functional reach, weight-bearing ability, walking velocity, and self-rated fall risk. The subjects undertook these assessments at the beginning and end of the trial.
RESULTS: At pretest, exercisers and controls performed similarly in all tests. At the end of the trial, the intervention group showed significantly greater quadriceps strength in the affected (hip-fractured) leg and increased walking velocity. The intervention subjects also improved their weight-bearing ability and reported reduced subjective falls risk. In contrast, there were no significant improvements in any of the test measures in the controls. Within the intervention group, improvements in quadriceps strength were significantly associated with improved performances in the weight-bearing test measures and with increased walking velocity.
CONCLUSIONS: This exercise program improved strength and mobility following hip fracture. Further research is needed to ascertain whether the extent of this improvement in these fall risk factors is sufficient to prevent falls.

PMID 9041904  Arch Phys Med Rehabil. 1997 Feb;78(2):208-12.

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