一例老年股骨粗隆间骨折患者的循证治疗

目的为1例股骨粗隆间骨折的老年患者确定循证治疗方案。方法根据患者的具体情况,提出所要解决的临床问题,全面检索美国国家指南交换中心NGC（2000～2009）、Cochrane图书馆（2009年第4期）、TRIP Database、PubMed（1966～2009）及中国生物医学文献数据库（1978～2009）,以获得相关的证据。依据循证医学三结合原则（最佳研究证据、医师的临床经验和病人的意愿相结合）制定治疗方案。结果共纳入3篇临床指南、14篇系统评价/Meta分析和2篇RCT。当前证据表明：对于老年患者的不稳定型股骨粗隆间骨折应首选手术治疗;不同的手术内固定方式相比较,滑动髋螺钉（SHS）的疗效最佳,尚无足够证据支持手术后伤口常规放置闭合引流;早期手术能够缩短住院时间,降低死亡率;术前预防应用抗生素能减少术后感染的发生率;为预防深静脉血栓形成,药物预防应自入院起就开始应用,术后应辅助物理预防;住院期间高营养饮食有助于促进患者康复;术后应尽早进行康复训练。参照指南及相关证据,并根据患者的具体情况,制定合理的治疗方案。经过3个月随访,证实该方案适合本患者。结论应用循证医学的方法,采用高质量的证据为患者制定个性化治疗方案,能显著提高治疗效果,改善患者的预后。

Evidence-Based Treatment for an Elderly Patient with Intertrochanteric Fractures

Objective To identify an evidence-based treatment for an elderly patient with intertrochanteric fractures.Methods Clinical problems were presented on the basis of the patient＇s conditions,and evidence was collected from the NGC（2000 to 2009）,The Cochrane Library（Issue 4,2009）,TRIP Database,PubMed（1966 to 2009）and CBM（1978 to 2009）.Treating strategies were formulated in terms of the three-combination principle（best evidence,the doctor＇s professional knowledge and the patient＇s desire）.Results Three guidelines and sixteen studies were included.The current evidence indicated that surgery was the preferred solution to intertrochanteric fractures of the elderly patient.The sliding hip screw（SHS）appeared superior to others.There was insufficient evidence to support the routine use of closed suction drainage in orthopedic surgeries.Early surgery was associated with shorter hospital stay and improved mortality.Antibiotic prophylaxis significantly reduced infections.In order to lower the risk of venous thromboembolism,pharmacological prophylaxis should be carried out when the patient was admitted to hospital and be assisted with mechanical prophylaxis after surgery.Nutritional supplementation was conducive to the recovery of the patient.Rehabilitation ought to be performed as soon as possible.Considering the patient＇s condition,the treatment option was established according to the available evidence and guidelines.Short-term follow-up showed a good outcome.Conclusion Through the evidence-based method,an individual treatment plan could obviously improve the treatment effect and prognosis.