Recommendations on hip fractures
老人髋部骨折的管理
Strength of Recommendation: Strong
区域镇痛可以改善髋部骨折患者的术前疼痛
推荐强度：强烈
3.PREOPERATIVE TRACTION 术前牵引 Moderate evidence does not support routine use of preoperative traction for patients with a hip fracture. Strength of Recommendation: Moderate 不支持对髋部骨折的病例常规行术前牵引
稳定的转子间骨折可使用髋关节滑动螺钉或近端髓内钉
推荐强度：中等
14.SUBTROCHANTERIC OR REVERSE OBLIQUITY FRACTURES 转子下骨折或反斜行骨折 Strong evidence supports using a cephalomedullary device for the treatment of patients with subtrochanteric or reverse obliquity fractures. Strength of Recommendation: Strong
移位性股骨颈骨折行髋关节置换选择后侧入路脱位率更高
推荐强度：中等
13.STABLE INTERTROCHANTERIC FRACTURES 稳定的转子间骨折 Moderate evidence supports the use of either a sliding hip screw or a cephalomedullary device in patients with stable intertrochanteric fractures. Strength of Recommendation: Moderate
联合使用甲状旁腺激素和辛伐他汀对去卵巢大鼠骨质疏松症的治疗有叠加效应
联合使用甲状旁腺激素和辛伐他汀对去卵巢大鼠骨质疏松症的治疗有叠加效应颜海彬;张炳云【摘要】目的探索联合使用甲状旁腺激素(PTH)和辛伐他汀(SIM)对去势大鼠骨质疏松的防治作用.方法 50只健康雌性SD大鼠随机行假手术(Sham,N=10)和切除双侧卵巢(OVX,N=40)手术后,OVX大鼠随机的分成4组:OVX组、SIM组、PTH 组、PTH+ SIM组.术后第1天开始给予药物治疗,SIM组:SIM灌胃(剂量5 mg/kg,每天1次),PTH组:PTH皮下注射(剂量60 μg/kg,每周3次),PTH+ SIM组:SIM灌胃和PTH皮下注射,剂量和用药频率和SIM组、PTH组相同,直至手术后12周为止,12时所有大鼠处死取胫骨行Micro-CT检测.结果结果表明SIM组、PTH组、PTH+ SIM组和OVX组相比,胫骨近端都有较高的BMD、BV/TV、Tb.Th、Tb.N、Conn.D和较低的Tb.Sp,其中PTH+ SIM组大鼠胫骨近端有最高的BMD、BV/TV、Tb.Th、Tb.N、Conn.D和最低Tb.Sp.SIM和PTH单独使用的效果明显低于他们联合使用对去卵巢大鼠骨质疏松的防治作用.结论联合使用甲状旁腺激素和辛伐他汀对去势大鼠骨质疏松的防治有叠加作用【期刊名称】《中国骨质疏松杂志》【年(卷),期】2016(022)003【总页数】4页(P300-303)【关键词】去势大鼠;骨质疏松症;甲状旁腺激素;辛伐他汀【作者】颜海彬;张炳云【作者单位】浙江省温岭市第一人民医院骨科,温岭317500;浙江省温岭市第一人民医院骨科,温岭317500【正文语种】中文【中图分类】R681随着世界人口老年化进一步加重，骨质疏松症已经成为一种严重危害老年人群生活质量的社会公害，其患病率预计在未来10年将显著增加。
骨质疏松症大大增加髋部的骨折发生率，相对于西方国家髋部的骨折发生率在下降，亚洲大部分国家髋部骨折发生率在明显增加[1]。
股骨颈骨折内固定治疗的挑战与应对
或 主 要 并 发 症 发 生 率 无 差 异 。这提示 我 们 髋 部 骨 折 手 术并非越早越好，寻找一个既不影响预后，又可以进 行 充 足 术 前 准 备 的 时 间 平 衡 点 ，或许对改善患者预后 有 着 积 极 作 用 。本期杨晨辉等对研究群体进行了补 充 ，重点研究了手术时机对儿童及青少年股骨颈骨折 非 急 诊 手 术 患 者 手 术 时 间 和 术 后 并 发 症 的 影 响 ，发现 受 伤 至 手 术 时 间 延 长 不 会 增 加 手 术 时 间 ，亦不会增加 患 者 术 后 ANFH等并发症的发生率。
二 、股骨颈及头骨折的术式选择和手术时机 股骨颈骨折的术式、尤其是选择切开复位还是闭 合复位仍存在争议，不同的研究结果也存在差异|14°51。 支持切开复位的学者认为切开可以更好地完成复位， 而复位质量直接影响预后。此 外 ，骨折导致的关节囊 内压升高，也 会 增 加 ANFH的发生可能。支持闭合复 位 的 学 者 认 为 切 开 复 位 存 在 破 坏 股 骨 头 血 运 、加重软 组织损伤 的可 能，进而增加 术后并 发症。切开复位和 闭合复位 各有优 、缺 点 ，孰优孰劣还需要更多的研究 证据。需要注意的是，即便是闭合复位，在内固定置入 过 程 中 ，关节囊也会通过钉道与外界沟通，从而平衡 关 节 囊 内 外 压 力 ，所 以 闭 合 复 位 是 否 会 通 过 关 节 囊 内 压 增 加 导 致 ANFH仍需进一步探索。同样，股骨头骨 折 最 佳 手 术 方 式 也 存 在 争 议 ，经典的手术入路包括 Koi.her-Langen丨)eck 入 路 、Smith-丨,etersen 入 路 、 Ganz 入 路 和 改 良 Heuter入 路 等 [161。本 期 孙 守 斌 等 分 析 了 Ganz入 路 内 固 定 治 疗 Pipkin IV型股骨头骨折的临床 效 果 ，认 为 Ganz入路具有骨折复位质量高及髋关节 功能恢复好等优点。 手术时机是影响股骨颈及头骨折预后的又一重 要 因 素 。国 内 指 南 建 议 ，对 于 股 骨 颈 骨 折 患 者 ，应尽早 手 术 治 疗 lu;也 有 国 外 研 究 建 议 髋 部 骨 折 应 在 受 伤 后 48 h 内进行手术，认为手术早晚与患者预后息息相关' 而Miller"71最近的研究显示在需要手术治疗的髋部骨 折 患 者 中 ， 6 h 内 加速 手术 与标 准 治疗9 0 d 内病死率
老年人慢性失眠症单一疗法及两种疗法联合的疗效
老年人慢性失眠症单一疗法及两种疗法联合的疗效许研杰;王锐;杨志强;郭江涛【摘要】目的观察认知行为疗法(cognitive-behavioral therapy,CBT)联合针刺疗法治疗老年人慢性失眠症患者的疗效.方法选择2017-07至2018-05北京市隆福医院及韶九、朝阳门社区老年慢性失眠患者86例,按随机数字表法分为试验组(CBT联合针刺疗法)和对照组(单纯CBT疗法),各43例,干预8周;通过睡眠日志、失眠严重程度指数量表(1SI)、焦虑自评量表(SAS)、抑郁自评量表(SDS)评价患者的睡眠、情绪等,并进行统计学分析.结果试验组临床总有效率(74.41％)高于对照组(48.84％),差异有统计学意义(P<0.05).试验组治疗后的入睡时间[(27.5±9.8)min]、睡眠效率[(80.5±6.6)％]均好于对照组[(38.3±13.1)min,(76.6±5.7)％],差异均有统计学意义(P<0.05).治疗后,试验组SAS、SDS评分均低于对照组[(54.3±5.5)比(58.9±5.7)分、(55.7±5.0)比(58.2±4.8)分],差异有统计学意义(P<0.05).结论 CBT联合针刺疗法对老年慢性失眠症具有较好的疗效.【期刊名称】《武警医学》【年(卷),期】2018(029)012【总页数】4页(P1125-1128)【关键词】老年慢性失眠症;认知行为疗法;针刺疗法【作者】许研杰;王锐;杨志强;郭江涛【作者单位】100010,北京市隆福医院神经内科;100010,北京市隆福医院神经内科;100010,北京市隆福医院神经内科;100010,北京市隆福医院神经内科【正文语种】中文【中图分类】R245慢性失眠症是老年人最常见的睡眠障碍，65岁以上人群患病率为20%～50%[1]。
失眠严重损害患者的身心健康，影响患者的生活质量，甚至会诱发交通事故等意外危及个人及公共安全[2]。
抗凝指南
中国骨科大手术静脉血栓栓塞症预防指南中华医学会骨科学分会通信作者：邱贵兴 E-mail:骨科大手术后静脉血栓栓塞症（venous thromboembolism，VTE）发生率较高，是患者围手术期死亡的主要原因之一，也是医院内非预期死亡的重要原因。
对骨科大手术患者施以有效的预防方法，不仅可以降低发生静脉血栓栓塞症的风险，减轻患者痛苦，大量的医药经济学研究证实还可降低医疗费用[1]。
为提高与骨科相关的静脉血栓栓塞症的预防水平、规范预防方法，特制订“中国骨科大手术静脉血栓栓塞症预防指南”。
本指南中的“骨科大手术”特指人工全髋关节置换术（total hip replacement，THR）、人工全膝关节置换术（total knee replacement，TKR）和髋部周围骨折手术（hip fractures surgery，HFS）[2]。
本指南仅为学术性指导意见，具体实施时必须依据患者的医疗情况而定。
一、概述1. 静脉血栓栓塞症：指血液在静脉内不正常地凝结，使血管完全或不完全阻塞，属静脉回流障碍性疾病[3]。
包括两种类型：深静脉血栓形成（deep vein thrombosis，DVT）和肺动脉血栓栓塞症（pulmonary thromboembolism，PTE），即静脉血栓栓塞症在不同部位和不同阶段的两种临床表现形式。
2. 深静脉血栓形成：可发生于全身各部位静脉，以下肢深静脉为多，常见于骨科大手术后。
下肢近端（腘静脉或其近侧部位）深静脉血栓形成是肺栓塞血栓栓子的主要来源，预防深静脉血栓形成可降低发生肺动脉血栓栓塞症的风险。
3. 肺动脉血栓栓塞症：指来自静脉系统或右心的血栓阻塞肺动脉或其分支导致的肺循环和呼吸功能障碍疾病[4,5]，是骨科围手术期死亡的重要原因之一。
4. 骨科大手术后静脉血栓栓塞症的流行病学：国外骨科大手术后静脉血栓栓塞症的发生率如表1所示[2]。
一项亚洲7个国家19个骨科中心407例人工全髋、人工全膝关节置换及髋关节周围骨折手术后深静脉血栓形成发生率调查研究[6]表明，经静脉造影证实深静脉血栓形成发生率为%（120/278）。
大腿骨和胯骨连接处骨折
大腿骨和胯骨连接处骨折英文回答：A fracture at the connection between the femur and the hip bone can be a serious injury. This type of fracture is commonly known as a hip fracture or a femoral neck fracture. It usually occurs in older adults due to weakened bones,but it can also happen in younger individuals due to high-impact trauma or accidents.Hip fractures can be categorized into different types based on the location and severity of the fracture. Themost common type is an intracapsular fracture, which occurs within the hip joint capsule. Another type is an extracapsular fracture, which occurs outside the capsule. These fractures can further be classified as displaced or non-displaced fractures.The symptoms of a hip fracture include severe pain in the hip or groin area, inability to bear weight on theaffected leg, swelling, bruising, and limited range of motion. It is important to seek immediate medical attention if a hip fracture is suspected.The diagnosis of a hip fracture usually involves a physical examination, imaging tests such as X-rays or MRI, and sometimes a bone scan. Treatment options for hip fractures depend on the type and severity of the fracture. Non-displaced fractures may be treated with immobilization using a cast or brace, while displaced fractures often require surgical intervention.Surgery for hip fractures may involve internal fixation, where screws, plates, or rods are used to stabilize the fracture, or it may require a hip replacement surgery. The choice of surgical procedure depends on various factorssuch as the patient's age, overall health, and the specific characteristics of the fracture.Recovery from a hip fracture can be a lengthy process and may require physical therapy to regain strength, mobility, and independence. Complications such as infection,blood clots, or pressure sores can also arise during the recovery period.In conclusion, a fracture at the connection between the femur and the hip bone can be a serious injury requiring immediate medical attention. The treatment and recovery process can be complex and may involve surgery and physical therapy. It is important to follow the medical advice and recommendations for the best possible outcome.中文回答：大腿骨和胯骨连接处的骨折是一种严重的损伤。
不同入路行人工髋关节置换术治疗老年髋部骨折的疗效比较
我国老年人群骨质疏松现象较为普遍，粗隆间骨折和股骨颈骨折发生率逐年升高，人工髋关节置换术在临床上有较为广泛的应用。
此次研究特就老年髋部骨折患者行不同入路人工髋关节置换术的临床治疗效果进行探讨。
资料与方法2014年3月-2017年7月收治老年髋部骨折患者108例，女63例，男45例；年龄61～89岁，平均(79.4±10.2)岁；患者入院后均接受MRI以及CT诊断，病情均获得确诊，其中粗隆间骨折29例，股骨颈骨折79例；合并下肢静脉曲张1例，合并高血压19例，合并心血管疾病15例，合并糖尿病10例。
根据治疗方式的不同将所选患者分为参照组和探究组，每组54例。
对比两组患者合并症等基本临床资料，差异无统计学意义(P＞0.05)。
方法：入院后给予患者常规检查并对其各种合并症采取对症治疗方式。
参照组均接受后外侧入路治疗方式，其中33例患者接受全髋关节置换术，21例患者接受人工股骨头置换术。
自髂后上棘下方、大粗隆上方4～5cm部位做大切口，沿肌纤维方向对臀大肌进行分离并分别向前后方进行牵拉，以使脂肪层下外旋肌群得到显露。
将髂胫束切开以使切口向大腿部位延长。
髋关节内旋位，将闭孔内肌、上下孖肌以及梨状肌做切断处理，避免对股方肌造成损伤。
关节囊得到清楚显露后，将关节囊切开并用剪刀将关节囊敞开[1]。
探究组均接受前方入路治疗方式，其中37例患者接受全髋关节置换术，17例患者接受人工股骨头置换术。
自髂前上棘至缝匠肌外侧部位做切口，避免对股外侧皮神经造成损伤。
沿缝匠肌和阔筋膜张肌间隙进行切开操作时股直肌以及髋关节前方关节囊得到充分显露，做T形切口，在髋臼侧靠近部位将股骨头圆韧带切断，然后将股骨头取出。
进行截骨处理后保留约1.5cm股骨矩。
采取全髋关节置换术的患者，应用髋臼锉以外翻40°、前倾15°角度对髋臼进行打磨，给予患者生物学或者骨水泥固定。
对手术术野进行调整，使股骨近端得到暴露，然后应用髓腔锉扩髓，应用骨水泥进行人工假体柄安装并复位骨折[2]。
Gamma3髓内钉在股骨粗隆间骨折中的应用
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云南医药 2013 年第 34 卷a3 髓内钉在股骨粗隆间骨折中的应用
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（ 德宏州人民医院 骨二科
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芒市 678400 ）
胸外科，云南
关键词：Gamma 钉；股骨粗隆间骨折；内固定 中图分类号：R683.42 文献标识码：B 文章编号：1006- 4141 （ 2013 ） 02- 0122- 02
[2]
人工全髋关节疗 效评分根据
例；年龄 53- 81 岁；左侧 12 例，右侧 23 例 . 骨 折按 Evans� Jensen 分型：Ⅱ型 3 例，Ⅲ型 24 例， Ⅳ型 8 例 . 骨折原因由车祸伤引起为 25 例，摔伤 10 例；合并心血管疾病 11 例，糖尿病 3 例. 患者 入院后给予患肢行皮肤牵引，完善术前检查，并 积极控制和治疗基础疾病 . 手术方法 所有患者完善常规检查后，无绝 对手术禁忌后给予实施手术治疗 . 患者连续硬膜 外麻 醉或全麻后取 平卧位， 固定于骨 科牵引床 ， 患侧肢体给予牵引接近解剖复位后 （ C 型臂 X 线 机监视下完成 ）. 在大粗隆顶点 上方做约 3 � 5cm 长纵 形切口，切开 皮肤 , 皮 下组织 以及阔筋 膜 . 分离至大粗隆顶端处，向内约 0.5cm，选择该处为 导针入点，将开口器开口只股骨近端髓腔，向股 骨髓腔内插入导针，并在引导下用软钻进行股骨 干和股骨近端髓腔的扩髓 .将主钉插入髓腔，在 C 臂透视下观察置钉深度并保证拉力螺钉位于合适 位置 .安装瞄准器，沿股骨颈轴线中心钻入导针， 保持 适当的前倾角 ，位置合 适后拧入 拉力螺钉 .
维生素D缺乏的女性髋部骨折患者中血清甲状旁腺素值与股骨颈骨密度的相关性
维生素D缺乏的女性髋部骨折患者中血清甲状旁腺素值与股骨颈骨密度的相关性YANG Kun【摘要】目的探讨维生素D缺乏的女性髋部骨折患者中血清甲状旁腺素(PTH)值与股骨颈骨密度(BMD)的相关性.方法将128例维生素D缺乏(血清25-羟基维生素D水平＜50 nmol/L)的女性髋部骨折患者根据血清PTH水平分为PTH正常组(n=86)和PTH升高组(n=42).测定股骨颈BMD、BMD(T值)及各临床指标.各临床指标与股骨颈BMD(T值)的相关性采用多元logistic回归分析.结果年龄、PTH:PTH正常组显著低于PTH升高组(P＜0.05).血磷、肾小球滤过率、BMD(T 值)、BMD:PTH正常组显著高于PTH升高组(P＜0.05).多元线性回归分析结果显示,血清PTH、年龄与股骨颈BMD呈负相关(P＜0.05),BMI与股骨颈BMD呈正相关(P＜0.05).PTH正常组中有52例(60.47％) BMD(T值)≤-2.5,PTH升高组中有30例(71.43％) BMD(T值)≤-2.5.多元logistic回归分析结果显示,血清PTH、BMI 是BMD(T值)≤-2.5的影响因素(P＜0.05).结论维生素D缺乏的女性髋部骨折患者中,PTH水平与股骨颈BMD密切相关.维生素D缺乏症的防治在血清PTH升高的女性髋部骨折患者中可能尤为重要.【期刊名称】《临床骨科杂志》【年(卷),期】2019(022)001【总页数】4页(P104-106,110)【关键词】髋骨折;甲状旁腺素;股骨颈骨密度;维生素D缺乏【作者】YANG Kun【作者单位】【正文语种】中文【中图分类】R683.3;R977.14;R591.44维生素D对骨组织的保护作用具有促进骨形成和骨吸收双相性[1]。
最近一项研究指出，补充维生素D可减少患者跌倒风险[2]；另一项研究则证实，维生素D可改善老年患者的骨质脆弱性[3]；而跌倒和骨质脆弱正是老年人骨质疏松性骨折的两个主要危险因素[4]。
坎贝尔第三卷(英文11版)-股骨粗隆间骨折
Canale & Beaty: Campbell's Operative Orthopaedics,11th ed.Elsevier Chapter 52 –Fractures and Dislocations of the HipDavid G. LaVelleFractures of the proximal femur and hip are relatively common injuries in adults. Several epidemiological studies have suggested that the incidence of fractures of the proximal femur is increasing, which is not unexpected because the general life expectancy of the population has increased significantly during the past fewdecades. More than 280,000 hip fractures occur in the United States every year, and this incidence is expected to double by 2050. These fractures are associated with substantial morbidity and mortality; 30% of elderly patients die within 1 year of fracture. After 1 year, patients seem to resume their age-adjusted mortality rate.Most proximal femoral fractures occur in elderly individuals as a result of only moderate or minimal trauma. In younger patients, these fractures usually result from high-energy trauma. Despite similar locations of the fracture, the differences in low-velocity and high-velocity injuries in older compared with younger patientsoutweigh the similarities. More often than not, high-velocity injuries are more difficult to treat and are associated with more complications than low-velocity injuries.This chapter discusses intertrochanteric and subtrochanteric femoral fractures, fractures of the head and neck of the femur, and dislocation and fracture-dislocation of the hip, including classification of fractures and some commonly used methods of operative management.HIP FRACTURESFractures of the proximal femur, generally referred to as fractures of the hip, are classified first according to their anatomical location. Isolated fractures of the lesser or greater trochanter are uncommon and rarely require surgery; they can be associated with pathological disease. Avulsions of the lesser trochanter occur inimmature children from the pull of the iliopsoas muscle and can be treated nonoperatively. Fractures of the greater trochanter often result from direct trauma to the trochanter, usually are minimally displaced, and can be treated nonoperatively with protected weight bearing on crutches until symptoms subside. If a fracture of the Hip fractures 3237Intertrochanteric femoral fractures 3239Classification 3239Nonoperative treatment 3240l i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c ogreater trochanter is obvious on routine radiographs, CT or MRI should be obtained to rule out an intertrochanteric element before the decision is made fornonoperative treatment. An unsuspected intertrochanteric fracture can drift into varus or displace completely without open reduction and internal fixation.Femoral neck fractures and intertrochanteric fractures occur with about the same frequency. Nearly nine of 10 hip fractures occur in patients older than 65 years old.Both fractures are more common in women than in men by a margin of three to one. Other risk factors include white race, neurological impairment, malnutrition,impaired vision, malignancy, and decreased physical activity. Osteoporosis, although present in the population at risk, has not been shown to be more prevalent in patients with fractures than in age-matched controls. Subtrochanteric fractures, which account for 10% to 15% of proximal femoral fractures, have a bimodaldistribution pattern, occurring commonly in patients 20 to 40 years old and in patients older than 60. Fractures in younger patients usually result from high-energy trauma. Hip fractures in elderly individuals are the result of falls about 90% of the time. Causes of falls include impaired ambulation before injury, decreased reaction time, and poor vision.The prognosis for each of the three major categories of hip fractures is entirely different. Intertrochanteric fractures usually unite if reduction and fixation are properly done, and although malunions may be a problem, late complications are rare. A wide area of bone is involved, most of which is cancellous, and both fragments are well supplied with blood. Fractures of the neck of the femur are intracapsular and involve a constricted area with comparatively little cancellous bone and aperiosteum that is thin or absent. Although the blood supply to the distal fragment is sufficient, the blood supply to the femoral head may be impaired or entirely lacking; for this reason, osteonecrosis and later degenerative changes of the femoral head or nonunion often follow femoral neck fractures. The substance of the bone in the subtrochanteric region changes consistency as it progresses from the vascular cancellous bone of the intertrochanteric region to the less vasculardiaphyseal cortical bone of the proximal shaft. Subtrochanteric fractures are associated with high rates of nonunion and implant fatigue failure because of the greater mechanical stresses in this region.If the diagnosis of a hip fracture is questionable in an acutely painful hip, bone scanning and MRI have shown excellent sensitivity in identifying these injuries (Fig.52-1). In a study by Quinn and McCarthy, T1-weighted MRI was found to be 100% sensitive in patients with equivocal radiographic findings. Traditionally, bone scan has been thought to be unreliable before 48 to 72 hours after fracture, but a study by Holder et al. found a sensitivity of 93% regardless of time from injury, including fractures less than 24 hours old.Reports and opinions on the effect of delay of operative treatment on patient mortality are conflicting. Many elderly patients have multiple medical problems, andspending 12 to 24 hours in medical evaluation and treatment before surgery is advantageous and well supported; however, excessive delay should not be tolerated.Zuckerman et al. found that delaying fixation for more than 3 days doubled the mortality rate within the first year after surgery. McGuire noted a 15% increase in immediate mortality in patients in whom fixation was delayed for more than 2 days compared with patients whose hips were fixed within 2 days.The general recommendation of using Buck traction has been shown by Jerre et al. to be unhelpful in reducing pain preoperatively and does not improve the ease of fracture reduction. In femoral neck fractures, traction may reduce blood flow to the femoral head preoperatively. These patients tolerate bed confinement poorly, and every effort should be made to fix the fracture operatively as soon as possible. Internal fixation can be done with the patient under general, spinal, or epiduralanesthesia, with no proven difference in perioperative mortality.The goal of treating hip fractures is to return patients to their prefracture levels of function without long-term disability and avoiding medical complications. In 1996,Koval et al. reported that positive predictors of independence after fracture included age younger than 85 years, three or fewer comorbidities, prefractureindependence, and ambulation with therapy on discharge. Koval et al. later found fracture type (classification) not to be a predictor of mortality or of ambulatory ability.Open reduction and internal fixation of hip fractures should be done with the aim of obtaining rigid and stable internal fixation that would permit patients to beambulatory and at least bearing some weight on their affected hip within a short period (usually the next day). Mobilization is advantageous in preventing pulmonary complications, venous thrombosis, pressure sores, and generalized deconditioning. Bony continuity should be reestablished so that the bone itself assumes asignificant portion of the load. Internal fixation devices should be inserted such that the construct of metal and bone is rigid. Rydell, Frankel and Burstein, and others showed that the forces applied to the femoral head and proximal femur with activities such as lifting the leg and getting on and off a bedpan often equal or exceed the load applied during protected ambulation. Experience has confirmed that when the fracture is well reduced and internally fixed, weight bearing can begin almost immediately. In a classic study of femoral neck fractures treated with multiple Knowles pins, Arnold found no adverse effects of early weight bearing on healing rates of fractures with acceptable reductions. Koval et al. measured actual amounts of weight placed on injured limbs and determined that patients voluntarily limited loading until fracture healing. Despite this information, many authors still advocate only touch-down or weight-of-leg weight bearing until radiographic signs ofhealing are evident. Nonoperative treatment of displaced hip fractures usually is reserved for patients who were nonambulatory before the fracture and who are experiencing only mild pain.Intertrochanteric Femoral FracturesIntertrochanteric femoral fractures have been estimated to occur in more than 200,000 patients each year in the United States, with reported mortality rates ranging from 15% to 30%. Most intertrochanteric femoral fractures occur in patients older than 70 years old. Hip fractures (intertrochanteric and femoral neck fractures)account for 30% of all hospitalized patients in the United States, and the estimated cost for treatment is approximately $10 billion a year.ClassificationAt our institution, Boyd and Griffin (1949) classified fractures in the peritrochanteric area of the femur into four types. Their classification, which included fractures from the extracapsular part of the neck to a point 5 cm distal to the lesser trochanter, follows (Fig. 52-2):Fig. 52-1Nondisplaced intertrochanteric fracture is not visible on anteroposterior radiograph (A), but can be identified on T1-weighted MRI (B).Type 1: Fractures that extend along the intertrochan-teric line from the greater to the lesser trochanter. Reduction usually is simple and is maintained withlittle difficulty. Results generally are satisfactory.Type 2: Comminuted fractures, the main fracture being along the intertrochanteric line, but with multiple fractures in the cortex. Reduction of thesefractures is more difficult because the comminution can vary from slight to extreme. A particularly deceptive form is the fracture in which ananteroposterior linear intertrochanteric fracture occurs, as in type 1, but with an additional fracture in the coronal plane, which can be seen on the lateralradiograph.Type 3: Fractures that are basically subtrochanteric with at least one fracture passing across the proximal end of the shaft just distal to or at the lessertrochanter. Varying degrees of comminution are associated. These fractures usually are more difficult to reduce and result in more complications atl i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oThe most difficult types to manage, types 3 and 4, accounted for only about one third of the trochanteric fractures in Boyd and Griffin's series.Evans devised a widely used classification system based on the division of fractures into stable and unstable groups (Fig. 52-3). He divided unstable fracturesfurther into those in which stability could be restored by anatomical or near-anatomical reduction and those in which anatomical reduction would not create stability.In an Evans type I fracture, the fracture line extends upward and outward from the lesser trochanter. In type II, reverse obliquity fracture, the major fracture lineextends outward and downward from the lesser trochanter. Type II fractures have a tendency toward medial displacement of the femoral shaft because of the pull of the adductor muscles.The AO group classified trochanteric fractures as described in Figure 52-4. A1 fractures are uncomminuted, A2 fractures have increasing comminution, and A3operation and during convalescence.Type 4: Fractures of the trochanteric region and the proximal shaft, with fracture in at least two planes, one of which usually is the sagittal plane and maybe difficult to see on routine anteroposterior radiographs. If open reduction and internal fixation are used, two-plane fixation is required because of thespiral, oblique, or butterfly fracture of the shaft.Fig. 52-2Types of trochanteric fractures.(From Boyd HB, Griffin LL: Classification and treatment of trochanteric fractures, Arch Surg 58:853, 1949.)Fig. 52-3Evans classification of intertrochanteric fractures based on direction of fracture (see text).(From DeLee JC: Fractures and dislocations of the hip. In Rockwood CA Jr, Green DP, eds: Fractures in adults, 2nd ed, Philadelphia, 1984, Lippincott.)l i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c ofractures have subtrochanteric extensions or reverse obliquity. AO fractures A1.1 through A2.1 are commonly described as stable, and fractures A2.2 through A3.3usually are unstable.Nonoperative TreatmentClosed methods of treatment of intertrochanteric fractures have largely been abandoned. In the 1960s, Horowitz reported a mortality rate of 34.6% for trochanteric fractures treated by traction and 17.5% for fractures treated by internal fixation. Rigid internal fixation of intertrochanteric fractures with early mobilization of the patient should be considered standard treatment. Medical complications after internal fixation are fewer and less serious than complications after nonoperative treatment. Only comfortable nonambulatory patients or patients with brief life expectancies should be treated nonoperatively.Operative TreatmentOne goal of operative treatment is strong, stable fixation of the fracture fragments. Kaufer, Matthews, and Sonstegard listed the following variables as those that determine the strength of the fracture fragment-implant assembly: (1) bone quality, (2) fragment geometry, (3) reduction, (4) implant design, and (5) implantplacement. Of these five elements of stable fixation, the surgeon can control only the quality of the reduction and the choice of implant and its placement.Because most patients with intertrochanteric fractures have considerable osteopenia, with the quality of bone for the purchase of fixation within the femoral head and neck less than desirable, it is important that the internal fixation device be placed in that part of the head and neck where the quality of bone is best. In 1838, Ward described the internal trabecular system of the femoral head (Fig. 52-5). The orientation of the trabeculae is along the lines of stress, with thicker trabeculae coming from the calcar and passing superiorly into the weight bearing dome of the femoral head. Smaller trabeculae extend from the inferior region of the foveal area across the head and the superior portion of the femoral neck and into the trochanter and to the lateral cortex. The calcar is a dense, vertical plate of bone extending from the posteromedial portion of the femoral shaft under the lesser trochanter and radiating laterally to the greater trochanter, reinforcing the femoral neckposteroinferiorly. The calcar is thickest medially and gradually thins as it passes laterally. The quality of bone for purchase within the head and neck varies from one quadrant to another. Although the optimal position of a compression screw within the head and neck is controversial, all agree that it should be central or slightly inferior and posterior. The bone of poorest quality is in the anterosuperior aspect of the head and neck. Optimal positioning of the device is controlled by thesurgeon. Baumgaertner et al. described the tip-apex distance as the sum of the distances from the apex of the femoral head to the tip of the lag screw onanteroposterior and lateral radiographs, correcting for magnification. In a series of 198 peritrochanteric fractures, they found that if this sum was less than 25 mm,there were no failures caused by cutting out of the lag screw (Fig. 52-6). Adams et al. showed that the tip-apex distance also is crucial when using intramedullary nails and compression hip screws to prevent cutout and loss of reduction.Fig. 52-4AO classification of trochanteric fractures. Group A1, simple two-part fracture; group A2, fracture extends over two or more levels of medial cortex; group A3, fracture extends through lateral cortex of femur.(Redrawn from Müller ME, Nazarian S, Koch P, et al: The comprehensive classification of fractures of long bones, Berlin, 1990, Springer-Verlag, p 121.)l i k u W w w .d o c u -t r a c k .c m C c t o b y NO !w w .d o c u -t r a c k .c oIt is important before treatment to distinguish by radiographs whether the intertrochanteric fracture is stable or unstable based on fracture geometry, and whether reduction can restore cortical contact medially and posteriorly. The status of the lesser trochanter is important in evaluating the stability of the reduction. If the lesser trochanter is displaced with a large fragment, a significant cortical defect is present posteromedially, and the fracture geometry indicates a potentially unstable reduction. The surgeon should carefully inspect the radiographs for this defect or palpate this region to feel for a defect. If the defect is seen on preoperativeradiographs, the decision may be made to change internal fixation devices from a plate to an intramedullary device.Reduction can be done by open or closed means; with either method, the objective is a stable reduction, whether anatomical or nonanatomical. Usually, closedreduction by manipulation should be attempted initially. In most fractures, an anatomical reduction with posteromedial apposition is possible. Fluoroscopy, with good-quality anteroposterior and lateral views, is used to evaluate the quality of the reduction, with special attention paid to the cortical contact medially and posteriorly. If good medial cortical contact is seen on the anteroposterior view, and good posterior cortical contact is seen on the lateral view, the fracture can be internally fixed in this position. If a gap or overlap exists medially or posteriorly, adjustments in the traction or rotation may correct the reduction to a stable anatomical position.Frequently, in comminuted fractures, the distal shaft fragment sags posteriorly and may be difficult to correct by closed manipulation. In such cases, openanatomical reduction should be considered, and the posterior sag may be corrected by lifting up with a hip skid under the fracture by an assistant. This position may need to be maintained during internal fixation to prevent recurrence of the deformity. In an in vitro biomechanical study of posterior sag of 30 degrees or more in two-part intertrochanteric fractures, Joseph et al. found no significant difference in construct strength or stability.If necessary, an open anatomical reduction of the medial and posterior cortical support usually can be accomplished by applying a bone-holding forceps across the fracture in an anteroposterior plane while adjusting the traction and rotation. When an anatomically stable reduction has been achieved, a compression hip screw or other device can be used to secure the reduction. In rare cases, if the fracture is severely comminuted, anatomical reduction even by open means is difficult, if not impossible. In such circumstances, it may be wise to accept the nonanatomical but stable reduction obtained by medial displacement techniques; however, areduction that is nonanatomical and unstable should not be accepted. Stable fractures are treated by internal fixation after anatomical reduction.Unstable fractures usually can be treated by anatomical reduction with the use of a collapsible fixation device, such as a hip compression screw or cephalomedullary nail. Such collapsible internal fixation devices permit the proximal fragment to collapse or settle onto the fixation device, seeking its own position of stability, with theshaft usually displacing medially (Fig. 52-7).Fig. 52-5Trabecular system of proximal femur.(From DeLee JC: Fractures and dislocations of the hip. In Rockwood CA, Green DP, Bucholz RW, et al, eds: Fractures in adults, 4th ed, Philadelphia, 1996, Lippincott.)Fig. 52-6Calculation of tip-apex distance (TAD). Distances from tip of implant to apex of femoral head on anteroposterior (left ) and lateral (right ) views are summed (X AP + X Lat ). TAD of less than 25 mm should be achieved.(Redrawn from Powell J, Dirschl DR: Fractures of the proximal femur. In Baumgaertner MR, Tornetta P, eds: OKU trauma 3, Rosemont, Ill, 2005, American Academy of Orthopaedic Surgeons; and Lindskog DM,Baumgaertner MR: Unstable intertrochanteric hip fractures in the elderly, J Am Acad Orthop Surg 12:179, 2004.)Some authors have suggested that unstable trochanteric fractures in patients with severely osteoporotic bone are best thought of as pathological fractures, and that the use of polymethyl methacrylate (PMMA) to augment the fixation can improve stability in these patients. Cheng et al. concluded that PMMA augmentationprovided early stability and allowed early mobilization of elderly patients, but when improperly used could cause late problems. They recommended PMMAaugmentation for unstable trochanteric fractures in elderly patients with severe osteoporosis for whom no better form of fixation is available, and the bone is too porotic to hold a screw. Some orthopaedic manufacturers have introduced “super lag” screws that have screw threads of an enlarged width to improve purchase in “soft” bone.We routinely use prophylactic antibiotics in the perioperative period. Generally, a first-generation cephalosporin is administered immediately before surgery and is continued for 24 hours after surgery. Gustilo reported a de-crease in infection from 3% to 5% without prophylactic antibiotics to less than 1% with antibiotics. Some form of prophylactic anticoagulation therapy also is indicated, such as ultra-low-molecular-weight heparin (enoxaparin) or warfarin (Coumadin); however, these are associated with complications of bleeding and postoperative hematomas. As of yet, there is no ideal prophylaxis for thromboembolism in these patients.Physical therapy is essential for successful restoration of mobility. The goal of physical therapy is a return to prefracture ambulation and overall function. In a study by Koval et al., 41% of patients returned to their prefracture ambulatory ability, and 40% remained community and household ambulators. Age younger than 85years and the absence of multiple comorbid conditions correlated with the resumption of prefracture ambulatory status. We routinely have patients ambulating the day after surgery. When stable fixation has been achieved, as is our goal, we allow weight bearing as tolerated or full weight bearing immediately. In this population,patients often do not have the upper body strength or balance to be less than full weight bearing.Implant SelectionTwo broad categories of internal fixation devices are commonly used for intertrochanteric femoral fractures: sliding compression hip screws with side plateassemblies (Fig. 52-8) and intramedullary fixation devices (Fig. 52-9). Sliding hip screws include traditional compression hip screws that provide compression in the intertrochanteric plane and compression plates that provide additional compression axially (Fig. 52-10). Intramedullary devices include cephalomedullary nails withtwo screws (Recon-type nails, Smith & Nephew, Memphis, Tenn) or compression-type screws (e.g., the Gamma [Stryker Orthopaedics, Kalamazoo, Mich] or intramedullary hip screw). The intramedullary compression-type screw may be short and end in the diaphyseal femur or long and end in the supracondylar region.Fig. 52-7 A, Unstable intertrochanteric fracture.B, After fixation with hip compression screw.C,Six months after fixation, with collapse and healing in position of stability.Fig. 52-8Richards hip compression screw.The preferred type of device is controversial. Intramedullary nails have a biomechanical and biologi-cal advantage over standard compression hip screws.Intramedullary nails can be inserted with less exposure of the fracture and less blood loss, although they require more fluoroscopic exposure and have beenassociated with fracture comminution. Biomechanically, nails allow for stable anatomical fixation of more comminuted fractures without shortening the abductor moment arm or changing the proximal femoral anatomy. These devices provide fracture stability by virtue of allowing the lateral aspect of the head and neck to come to rest against the nail in the medullary canal.In addition, intramedullary nailing is a more techni-cally demanding procedure. Goldhagen et al. compared the Gamma nail with a standard compression hip screw and found no differences in operative time, blood loss, or fluoroscopy exposure. Clinical rates of healing have been similar for the two devices, but a 3% to 6%incidence of secondary fracture of the femoral shaft at the tip of the short intramedullary device has been reported. Because of this complication, we prefer thelonger version of these implants, which extends to the supracondylar region of the femur (Fig. 52-11). Intramedullary nails seem to have some advantage in unstable fractures, especially fractures with reverse obliquity and subtrochanteric extension that cannot be treated easily with standard hip compression screws.Fig. 52-9 A, Subtrochanteric fracture.B,Fixation with Recon nail.Fig. 52-10Medoff sliding plate.(From OrthoMatrix Trauma Solutions, Collierville, Tenn, 2000.)Studies by Sadowski et al., Haidukewych et al., and others evaluated by Kregor et al. reported the results of unstable intertrochanteric fracture treated with 95-degree fixed-angle devices, compression hip screws, or intramedullary nails. These studies show worse results with extramedullary implants than intramedullary nails (e.g., 35% failure of sliding screws in the study by Sadowski et al.). Our results in these fractures have been similar, so unstable intertrochanteric fractures,reverse obliquity, and fractures with a significant subtrochanteric extension (AO A2.2 through A3.3) usually are treated with an intramedullary device at ourinstitution. Stable fractures (AO A1.1 through A2.1) may be treated by either device, but the literature does not support the routine use of intramedullary nails in stable fractures because of concerns over the added complexity of the procedure and added expense of the intramedullary implants.Fixation with Sliding Compression Hip Screw DevicesIn the 1970s, sliding compression screw assemblies were introduced to allow compression of some intertrochanteric fractures. The depth to which the lag screwfixation is inserted into the head is crucial for maximal purchase on the proximal fragment; the screw should be inserted to within 1 cm of the subchondral bone. The optimal angle between the barrel and the side plate of a hip compression screw is controversial. Many authors have argued that 150-degree plates are preferable because the angle of the lag screw more closely parallels the compressive forces within the femoral neck. Theoretically, this should lead to less binding of the screw within the barrel of the side plate and less chance of failure of the implant from bending. In clinical studies, however, no difference has been found in thecompression ability of 135-degree hip compression screws and 150-degree devices. Plate fracture secondary to failure in a bending mode has been reported only rarely in true intertrochanteric fractures. More problematic is the placement of 150-degree lag screws in the center of the femoral head because they tend towardsuperior placement within the head, leading to a higher chance of screw cutout. Because the 135-degree devices are easily placed and because their clinical results are similar to those for the 150-degree plates, the higher angle plates are only rarely indicated for extremely valgus femoral necks and more distal fractures.In the past, with fixation devices that did not allow collapse, medial displacement osteotomy was performed more frequently. Cheng et al. compared the results of sliding compression hip screw fixation with anatomical reduction with the results of fixation with medial displacement osteotomy to enhance bony contact, asadvocated by Dimon and Hughston. They found that in four-part intertrochanteric fractures, anatomical reduction with the sliding hip screw, regardless of thepresence of a posteromedial fragment, provided significantly higher compression across the calcar region and significantly lower tensile strain on the side plate than did medial displacement osteotomy. Desjardins et al. compared unstable intertrochanteric fractures treated with anatomical reduction and a hip compression screw with fractures treated with medial displacement osteotomy and found no significant differences in eventual healing or walking ability, although surgery time and blood loss were higher in the osteotomy group. In a study by Hopkins, Nugent, and Dimon, 97% of anatomically reduced unstable intertrochanteric fractures healeduneventfully, with medial displacement of the distal fragment by controlled collapse in 89%. These researchers concluded that there was no advantage to medial displacement osteotomy in these fractures. A short-barrel side plate often is needed with this technique to prevent impingement of the compression screw against the barrel in the neck of the femur with this configuration. With current designs of compression hip screws, we rarely perform medial displace-ment osteotomies in extensively comminuted fractures. McLoughlin et al. have found that two-hole side plates are as stable as four-hole side plates (DHS; Synthes, Paoli, Penn) in vitro.New plate designs have been proposed. The Vari-Angle Hip Screw (VHS; EBI Biomet, Parsippany, NJ) has an adjustable barrel that allows the plate's neck-shaftangle to be changed to maximize stability and minimize hospital inventory. Disadvantages include a larger plate profile and the possibility of mechanical failure of the angle-locking mechanism. Madsen et al. thought that a trochanteric lateral buttress plate is superior to a compression hip screw to support the lateral aspect of the greater trochanter in unstable fractures. This aids in resisting lateral sliding of the proximal fragment and maintaining an anatomical reduction (Fig. 52-12). Bong et al. contended that this alters hip mechanics less than techniques that call for a more medial position of the femoral shaft, but this has not been shown in clinical studies. The current version of this device allows for sliding of the screw in the barrel and is applied on top of a compression hip screw. This technique adds to surgical time, blood loss, and amount of dissection needed to apply the device. Gottfried introduced a compression plate that is inserted percutaneously. The twobarrels and screws are inserted in the head of the femur, and all screws are inserted percutaneously. We have limited experience with these devices, and the literature has not supported their widespread use.Fig. 52-11Fracture of femoral shaft occurred during insertion of intramedullary hip screw and was treated with side plate, screws, and bone grafting.(From Hardy DCR, Descamps PY, Krallis P, et al: Use of an intramedullary hip screw compared with a compression hip screw with a plate for intertrochanteric femoral fractures, J Bone Joint Surg 80A:618, 1998.)。
髋部骨折-中英文混合版--陈芒芒
Displaced Femoral Neck Fractures Strong evidence supports arthroplasty for patients with unstable (displaced) femoral neck fractures.
单极，双极。 Moderate evidence 对于移位的不稳定的股骨颈骨折，无区别。一般 推荐。 be sensitive to patient prefidogrel Limited evidence。 无需为此延误手术。
麻醉 脊髓，全身麻醉一样。
Stable Femoral Neck Fractures Operative fixation Implication: Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.
骨质疏松的评估和治疗 中度推荐：
一般推荐----it is critical that treatment be predicated on外科医生的经验. Although THA may offer improved function and longterm results in select patients, 但是需要考虑缺点。。。 后侧入路，容易脱位。 推荐使用前外侧入路。但是，更需要考虑医生的习惯和 经验。 不推荐使用前方入路。
手术方法：讨论半髋还是全髋。 Cemented stems？ 一般推荐---优先使用骨水泥型。 supports both the preferential use of 骨水泥in patients undergoing 关节成形术and reports similar outcomes 报道了使用双极和单极的相 同疗效。 推荐使用骨水泥型，.和手术者的经验有关。
抗凝指南
中国骨科大手术静脉血栓栓塞症预防指南中华医学会骨科学分会通信作者：邱贵兴 E-mail: ****************骨科大手术后静脉血栓栓塞症（venous thromboembolism，VTE）发生率较高，是患者围手术期死亡的主要原因之一，也是医院内非预期死亡的重要原因。
对骨科大手术患者施以有效的预防方法，不仅可以降低发生静脉血栓栓塞症的风险，减轻患者痛苦，大量的医药经济学研究证实还可降低医疗费用[1]。
为提高与骨科相关的静脉血栓栓塞症的预防水平、规范预防方法，特制订“中国骨科大手术静脉血栓栓塞症预防指南”。
本指南中的“骨科大手术”特指人工全髋关节置换术（total hip replacement，THR）、人工全膝关节置换术（total knee replacement，TKR）和髋部周围骨折手术（hip fractures surgery，HFS）[2]。
本指南仅为学术性指导意见，具体实施时必须依据患者的医疗情况而定。
一、概述1. 静脉血栓栓塞症：指血液在静脉内不正常地凝结，使血管完全或不完全阻塞，属静脉回流障碍性疾病[3]。
包括两种类型：深静脉血栓形成（deep vein thrombosis，DVT）和肺动脉血栓栓塞症（pulmonary thromboembolism，PTE），即静脉血栓栓塞症在不同部位和不同阶段的两种临床表现形式。
2. 深静脉血栓形成：可发生于全身各部位静脉，以下肢深静脉为多，常见于骨科大手术后。
下肢近端（腘静脉或其近侧部位）深静脉血栓形成是肺栓塞血栓栓子的主要来源，预防深静脉血栓形成可降低发生肺动脉血栓栓塞症的风险。
3. 肺动脉血栓栓塞症：指来自静脉系统或右心的血栓阻塞肺动脉或其分支导致的肺循环和呼吸功能障碍疾病[4,5]，是骨科围手术期死亡的重要原因之一。
4. 骨科大手术后静脉血栓栓塞症的流行病学：国外骨科大手术后静脉血栓栓塞症的发生率如表1所示[2]。
基于CICARE沟通模式的赋能护理模式对老年髋骨骨折患者术后恐动症及跌倒恐惧心理的影响
基于CICARE 沟通模式的赋能护理模式对老年髋骨骨折患者术后恐动症及跌倒恐惧心理的影响郭茜1，李明朴1，吴昌霞1，史利霞2西安国际医学中心医院骨科1、老年病科2，陕西西安710054【摘要】目的探究基于CICARE 沟通模式的赋能护理模式对老年髋骨骨折患者术后恐动症及跌倒恐惧心理的影响。
方法选择2019年1月至2022年1月在西安国际医学中心医院就诊的84例老年髋骨骨折患者为研究对象，按随机数表法分为观察组和对照组各42例。
对照组患者采用常规护理方式，观察组患者采用基于CICARE 沟通模式的赋能护理模式，两组均进行3个月护理。
比较两组患者护理前后的术后患者恐动症评分量表(TSK)评分、国际跌倒效能感量表(FES-I)评分、Berg 平衡量表(BBS)评分、汉密尔顿焦虑评分表(HAMA)评分、一般自我效能感量表(GSES)评分、改良Barthel 指数评定量表(MBI)评分及护理满意度，记录患者术后并发症发生情况。
结果护理后，观察组患者的FES-I 、TSK 及HAMA 评分分别为(10.04±3.18)分、(29.49±4.38)分、(8.72±1.45)分，明显低于对照组的(12.73±3.01)分、(34.15±5.27)分、(10.58±2.01)分，差异均有统计学意义(P <0.05)；护理后，观察组患者BBS 、GSES 及MBI 评分分别为(49.33±7.15)分、(35.42±3.37)分、(78.06±8.65)分，明显高于对照组的(42.84±6.56)分、(28.16±4.51)分、(71.22±8.14)分，差异均有统计学意义(P <0.05)；护理后，观察组患者护理满意度中的情志护理、护理技术、护理态度、健康教育评分分别为(23.06±1.24)分、(22.43±1.08)分、(21.72±0.94)分、(23.21±0.87)分，明显高于对照组的(20.18±1.52)分、(19.59±1.26)分、(18.91±1.52)分、(22.06±1.13)分，差异均有统计学意义(P <0.05)；观察组和对照组患者术后并发症总发生率分别为7.14%、14.29%，差异无统计学意义(P >0.05)。
地舒单抗在骨质疏松症临床合理用药的中国专家建议
DOI：10.3969/j.issn.1674-2591.2020.06.002•指南与共识•地舒单抗在骨质疏松症临床合理用药的中国专家建议中华医学会骨质疏松和骨矿盐疾病分会［摘要］骨质疏松症已成为我国重要的公共健康问题。
地舒单抗作为一种具有较广抗骨折谱的抗骨质疏松药物，在国外应用已超过10年，大量的临床证据显示其可持续增加绝经后骨质疏松症的骨密度，并降低椎体、非椎体及髓部骨折的风险。
地舒单抗在国内上市为骨质疏松症的治疗提供了一种新“武器”，但我国临床工作者对地舒单抗的应用经验尚不多。
为此，中华医学会骨质疏松和骨矿盐疾病分会组织专家，在充分复习汇总循证医学证据的基础上，对地舒单抗在骨质疏松症中的临床合理用药提出建议，以供参考。
［关键词］地舒单抗；骨质疏松症；骨密度；骨折中图分类号：R683；R589.5文献标志码：AChinese expert recommendations on the clinical rationaluse of denosumab in osteoporosisChinese Society of Osteoporosis and Bone Mineral ResearchCorresponding author：XIA Wei-bo，E-mail:xiaweibo8301@,Department of Endocrinology，Peking Union Medical College Hospital，Chinese Academy of Medical Sciences&Peking Union Medical College，Beijing100730，China[Abstract]Osteoporosis has become a significant public health problem in China.Denosumab has been used abroad for more than10years as an anti-osteoporosis drug with a broad spectrum of anti-fracture efficacy.Abundant clinical evidence has demonstrated that denosumab can consistently increase bone mineral density in postmenopausal women with osteoporosis and reduce the risk of vertebral，nonvertebral，and hip fractures.Denosumab has recently been approved for the treatment of postmenopausal osteoporosis in China.However，practitioners in China have little experience in the clinical application of denosumab.Therefore，after a comprehensive review of relevant evidence，experts organized by the Chinese Society of Osteoporosis and Bone Mineral Research proposed recommendations on the clinical rational use of denosumab in osteoporosis.[Key words]denosumab；osteoporosis；bone mineral density；bone fracture骨质疏松症是一种以骨量减少，骨组织微结构破坏，导致骨脆性增加，易发生骨折为特征的全身性疾病［1］。
2014+SOGC临床实践指南：更年期骨质疏松症
SOGC CLINICAL PRACTICE GUIDELINEAbstractObjective: To provide guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis.Outcomes: Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response tomanagement, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis.Evidence: Published literature was retrieved through searches of PubMed and The Cochrane Library on August 30 and September 18, 2012, respectively. The strategy included the use ofappropriate controlled vocabulary (e.g., oteoporosis, bone density, menopause) and key words (e.g., bone health, bone loss, BMD). Results were restricted to systematic reviews, practice guidelines, randomized and controlled clinical trials, and observational studies published in English or French. The search was limited to the publication years 2009 and following, and updates were incorporated into the guideline to March 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.Values: The quality of the evidence was rated using the criteriadescribed by the Canadian Task Force on Preventive Health Care (Table 1).Sponsors: The Society of Obstetricians and Gynaecologists of Canada.RECOMMENDATIONS For Postmenopausal Women1. Health care providers should be aware that the goals ofosteoporosis management include assess m ent of fracture risk and prevention of fracture. (I-A) 2. Health care providers should understand that a stable orincreasing bone mineral density reflects a response to therapy in the absence of low-trauma fracture or height loss due to vertebral-compression fracture. A pro g ressive decrease in bone mineral density, with the magnitude of bone loss being greater than the precision error of the density assessment, indicates a lack of response to current ther a py. Management should be reviewed and modified appropriately. (I-A)No. 312, September 2014 (Replaces No. 222, January 2009)Osteoporosis in MenopauseThis clinical practice guideline has been prepared by the Menopause and Osteoporosis Working Group, reviewed by the Clinical Practice Gynaecology and Family Physician Advisory Committees, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.PRINCIPAL AUTHORS Aliya Khan, MD, Hamilton ON Michel Fortier, MD, Quebec QC MENOPAUSE AND OSTEOPOROSIS WORKING GROUPMichel Fortier, MD (Co-Chair), Quebec QC Robert Reid, MD (Co-Chair), Kingston ON Beth L. Abramson, MD, Toronto ON Jennifer Blake, MD, Toronto ON Sophie Desindes, MD, Sherbrooke QC Sylvie Dodin, MD, Quebec QC Lisa Graves, MD, Toronto ON Bing Guthrie, MD, Yellowknife NT Shawna Johnston, MD, Kingston ON Aliya Khan, MD, Hamilton ON Timothy Rowe, MB BS, Vancouver BC Namrita Sodhi, MD, Toronto ON Penny Wilks, ND, Dundas ON Wendy Wolfman, MD, Toronto ONDisclosure statements have been received from all contributors.The literature searches and bibliographic support for this guideline were undertaken by Becky Skidmore, MedicalResearch Analyst, Society of Obstetricians and Gynaecologists of Canada.Key Words : Osteoporosis, prevention, treatment, diagnosis, bone mineral density, dual energy x-ray absorptiometry, bone turnover markers, vertebral fractures, fragility fractures, antiresorptive, hormone therapy, selective estrogen-receptor modulator, bisphosphonates, calcitonin, anabolic, bone forming agentJ Obstet Gynaecol Can 2014;36(9 eSuppl C):S1–S15SOGC CLINICAL PRACTICE GUIDELINE3. Health care providers should identify the absolute fracture riskby integrating the key risk factors for fracture; namely, age,bone mineral density, prior fracture, and glucocorticoid use.These risk factors allow estimation of fracture risk using the tool of the Canadian Association of Radiologists and Osteoporosis Canada. (I-A)4. The Fracture Risk Assessment tool of the World HealthOrganization (FRAX) has now been validated in a Canadianpopulation and may also be used and incorporates additionalrisk factors; namely, low body mass index, parental history offracture, smoking status, alcohol intake, and the presence ofsecondary causes of osteoporosis. (I-A)5. Health care providers should be aware that a fragility fracturemarkedly increases the risk of a future fracture and confirms the diagnosis of osteo p orosis irrespective of the results of the bone density assessment, (I-A) and that the presence of a low-trauma fracture of a vertebra or hip or more than 1 fragility fractureconfirms a high fracture risk regardless of the bone mineraldensity. (I-A)6. Treatment should be initiated according to the results of the10-year absolute fracture risk assessment. (I-A)Calcium and Vitamin D7. Adequate calcium and vitamin D supplementation is keyto ensuring prevention of progressive bone loss. Forpostmenopausal women a total daily intake of 1200 mg ofelemental calcium from dietary and supplemental sourcesand daily supplementation with 800 to 2000 IU of vitamin Dare recommended. Calcium and vitamin D supplementationalone is insufficient to prevent fracture in those withosteoporosis; however, it is an important adjunct topharmacologic intervention with antiresorptive and anabolictherapy. (I-B)Hormone Therapy8. Hormone therapy should be prescribed for symptomaticpostmenopausal women as the most effective option formenopausal symptom relief. (I-A) It represents a reasonablechoice for the prevention of bone loss and fracture in this patient population. (I-A)9. Physicians may recommend low- and ultralow-dosage estrogentherapy to symptomatic women for relief of menopausalsymptoms (I-A) but should inform their patients that, despitethe fact that such therapy has demonstrated a beneficial effectin osteoporosis preven t ion, (I-A) no data are yet available onreduction of fracture risk.Bisphosphonates10. Alendronate, risedronate, and zoledronic acid are valuablefirst-line agents of choice in the treatment of postmenopausalosteoporosis and should be considered to decrease the risk ofvertebral, non-vertebral, and hip fractures. (I-A)11. Etidronate is a weak antiresorptive agent and is notrecommended as a first-line agent of choice for the treatmentof osteoporosis. (I-D)RANKL Inhibitor12. Denosumab is an effective antiresorptive agent, shown toreduce the risk of vertebral, non-vertebral, and hip fractures, (I-A) and should be considered as a first-line agent of choice in thetreatment of postmenopausal osteoporosis in women at a highfracture risk. (I-A)Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health CareQuality of evidence assessment*Classification of recommendations†I: Evidence obtained from at least one properly randomizedcontrolled trialA. There is good evidence to recommend the clinical preventive actionII-1: Evidence from well-designed controlled trials withoutrandomizationB. There is fair evidence to recommend the clinical preventive actionII-2: Evidence from well-designed cohort (prospective or retrospective) or case–control studies, preferably from more than one centre or research group C. The existing evidence is conflicting and does not allow to make arecommendation for or against use of the clinical preventive action;however, other factors may influence decision-makingII-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results inuncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category D. There is fair evidence to recommend against the clinical preventive actionE. There is good evidence to recommend against the clinical preventiveactionIII: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees L. There is insufficient evidence (in quantity or quality) to makea recommendation; however, other factors may influencedecision-making*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.89†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.89ABBREVIATIONSAFF atypical femoral fractureBMD bone mineral densityET estrogen therapyFIT Fracture Intervention TrialHR hazard ratioHT hormone therapyONJ osteonecrosis of the jawRANKL receptor activator of nuclear factor kappa-B ligandRCT randomized controlled trialSERM selective estrogen-receptor modulatorWHI Women’s Health InitiativeOsteoporosis in MenopauseSelective Estrogen-Receptor Modulators13. Treatment with raloxifene may be considered to decrease the riskof vertebral fractures, bearing in mind that this agent has not been shown to be effective in reducing the risk of non-vertebral or hipfractures. (I-A)Parathyroid Hormone14. Treatment with teriparatide should be considered to decrease therisk of vertebral and non-vertebral fractures in postmenopausalwomen with severe osteoporosis (I-A) and should also beconsidered in postmenopausal women experiencing bone loss ora new fracture despite antiresorptive therapy. (I-A) INTRODUCTIONO steoporosis is defined as an impairment in bone strength due to an abnormal quantity and/or quality of bone. Quantity is evaluated by measuring BMD. Quality is affected by many factors, including the degree of mineral i zation, the rate of bone remodelling, the connectivity of the bony trabeculae, the quality of the collagen fibres, and the health of the bone cells. The 3 types of bone cells are osteoblasts, osteoclasts, and osteocytes. The osteocytes function as “mechanostats”, sensing the degree of microdamage and triggering remodelling in areas of stress and strain, thus allowing continual renewal, repair, and replacement of bone. This process of remodelling maintains bone strength.Adequate calcium and vitamin D intake is necessary to attain and maintain normal bone quantity and quality and thus achieve optimal bone strength. Early assessment of skeletal health and then initiation of appropriate calcium and vitamin D supplementation and an exercise program are essential in the prevention and treatment of osteoporosis. Individuals at increased risk for fracture should also be offered pharmacologic therapy in order to reduce the fracture risk. Absolute frac t ure risk is identified by integrating age and BMD with other key risk factors for fracture including prior fracture history and use of glucocorticoid therapy. The decision to treat is based on the risk of fracture, and the quantification of absolute fracture risk enables targeting of treatment to those at greatest risk.RISK ASSESSMENT AND MANAGEMENTBone strength is determined by both bone quantity and bone quality. Bone densitometry provides information on BMD, which is a reflection of bone quantity. Bone quality is determined by a number of factors, including the rate of remodelling, bone mineralization, function of the bone cells, and quality of the collagen fibres. It is necessary to identify risk factors for fracture that may be present and the risk of falls. The timed “get up and go” test is valuable in assessing gait stability and is a reflection of fall risk. Risk factors for osteoporosis have been identi fi ed (Table 2),1 and the presence of risk factors in a postmenopausal woman justifies bone densitometry.2In 2005 Osteoporosis Canada recommended identifying absolute fracture risk by integrating the key risk factors for fracture; namely, age, BMD, prior fracture, and glucocorticoid use.3 The 10year risk of fragility fractures is thus determined (Figure)1and defined as high if it is greater than 20%, moderate if it is 10% to 20%, and low if it is less than 10%.4 The additional effect of a preexisting fragility fracture or glucocorticoid use moves the patient 1 risk category higher. These guidelines were based on Swedish data and have been recalibrated using Canadian hip fracture data. The version developed by the Canadian Association of Radiologists and Osteoporosis Canada4 has now been validated in 2 Canadian cohorts and has close to 90% agreement with the FRAX5 score (the FRAX tool can be downloaded from the Osteoporosis Canada website, http://www.osteoporosis.ca). The presence of a vertebral or hip fracture or more than 1 fragility fracture increases the fracture risk to high. Fracture risk is evaluated on the basis of femoral neck BMD and age and is modified by the presence of prior fragility fracture or the use of glucocorticoid therapy (7.5 mg for 3 months or longer); these modifiers increase the fracture risk to the next risk category.1 A BMD Tscore of −2.5 or less at either the lumbar spine or the femoral neck denotes at least a moderate risk of fracture.1 Height should be measured annually, and a decrease in measured height of more than 2 cm should be further evaluated by radiographs of the thoracic and lumbar spine with exclusion of vertebral fractures.6A more comprehensive calculation of the 10year absolute fracture risk, now available from the World Health Organization, incorporates additional risk factors: parental history of hip fracture, current tobacco smoking, rheumatoid arthritis or other secondary causes of bone loss, and alcohol intake of 3 or more units daily.5It is recommended that absolute fracture risk be calculated using the tool of either the Canadian Association of Radiologists and Osteoporosis Canada or FRAX and the decision to treat be based on the absolute fracture risk. Younger individuals at a low risk of fracture are appropriately managed with lifestyle changes and strategies designed to prevent bone loss.Osteoporosis is diagnosed in a postmenopausal woman on the basis of a BMD Tscore of less than −2.5 at theSOGC CLINICAL PRACTICE GUIDELINElumbar spine, hip (femoral neck or total hip), or radius (distal third). Clinically it is diagnosed in a postmenopausal woman in the presence of a lowtrauma fracture. In a premenopausal woman osteoporosis is diagnosed only in the presence of fragility fractures; BMD alone cannot be used for diagnosis.7In premenopausal women a normal BMD is defined as being within 2 standard deviations of the agematched reference mean. Comparison with the agematched reference range is represented by the Z score, and in premenopausal women Z scores should be used instead of T scores. Low bone density is defined as a BMD Z score 2 or more standard deviations below the mean agematched reference value.7Pharmacologic therapy is considered in postmenopausal women after exclusion of secondary causes of low bone density. If the 10year absolute fracture risk is greater than 20% (high), then drug therapy is advised. In those with a moderate risk (10% to 20%), management decisions are indi v idualized. Those with a low fracture risk (< 10%) can be treated conservatively after exclusion of secondary causes of bone loss with prevention strategies based on ensuring adequate calcium and vitamin D supplementation. It is also important to emphasize regular exercise and reduced con s umption of alcohol (fewer than 2 drinks/d) and coffee (fewer than 4 cups/d). Smoking cessation should also be strongly advised.Failure of therapy is confirmed by the development of a lowtrauma fracture or significant bone loss despite pharmacologic therapy for 2 years. In these individuals it is necessary to ensure that there are no secondary causes of bone loss. It is also important to ensure adequate adherence to therapy.8ADVANCES IN PHARMACOLOGIC THERAPYIn addition to adequate calcium, vitamin D, and exercise, options for the prevention and treatment of osteoporosis include antiresorptive and anabolic agents.9 Antiresorptive (anticatabolic) agents inhibit osteoclast activity and reduce bone turnover.9,10 The various agents have different mechanisms of action. Bisphosphonates reduce the rate of bone turnover, providing a longer time for bone to mineralize. Bisphosphonate therapy is thus associated with modest increases in BMD. Estrogen acts through the estrogen receptors on both osteoblasts and osteoclasts, suppressing receptor activator of nuclear factor κB ligand (RANKL)induced osteoclast differentiation and thereby decreasing bone remodeling.11 Raloxifene, a SERM, can bind to estrogen receptors, with tissuespecific agonist or antagonist effects. Raloxifene decreases bone remodelling in addition to its extraskeletal effects. Osteoclastic bone resorption is also inhibited by calcitonin acting on calcitonin receptors. Denosumab is a monoclonal antibodyTable 2. Risk factors for osteoporosis: indications for measuring BMDOlder adults (age ≥ 50 years)Younger adults (age < 50 years)Age ≥ 65 years (both women and men) Fragility fractureClinical risk factors for fracture(menopausal women and men age 50 to 64 years)Prolonged use of glucocorticoids* Fragility fracture after age 40 years Use of other high-risk medications†Prolonged use of glucocorticoids*Hypogonadism or premature menopause(age < 45 years)Use of other high-risk medications Malabsorption syndromeParental hip fracture Primary hyperparathyroidismVertebral fracture or osteopenia identified on radiography Other disorders strongly associated with rapid bone loss and/or fractureCurrent smokingHigh alcohol intakeLow body weight (< 60 kg) or major weight loss(> 10% of body weight at age 25 years)Rheumatoid arthritisOther disorders strongly associated withosteoporosis*At least 3 months’ cumulative therapy in the previous year at a prednisone-equivalent dose ≥ 7.5 mg daily.†For example, aromatase inhibitors or androgen deprivation therapy.Reproduced with permission of the Canadian Medical Association from Papaioannou A et al.1Osteoporosis in Menopauseto RANKL (receptor activator of nuclear factor κB) and binds to RANKL, lowering values to premenopausal levels. This results in a decrease in the formation, function, and survival of osteoclasts.Antiresorptive agents are effective in reducing frac t ure risk by approximately 30% to 68% in postmenopausal women. However, fractures may still occur, and anabolic therapy can complement antiresorptive therapy in the prevention of further fractures. Anabolic therapy can result in new bone formation, with increases in cortical thickness and trabecular connectivity, leading to major improvements in the quality and quantity of bone. Anabolic therapy can increase the production of new bone matrix by enhancing osteoblast function. Teriparatide (recombinant human parathyroid hormone, amino acid sequence 1 through 34) decreases the release of sclerostin from osteocytes. Sclerostin is a protein that decreases bone formation by inhibiting the Wnt signalling pathway in the osteoblast. With a decrease in this inhibitor of bone formation, there is an increase in new bone formation. Teriparatide, 20 μg daily, has been shown to reduce the risks of vertebral and nonvertebral fragility fractures by approximately 65% and 53%, respectively, over 18 months in postmenopausal women with osteoporosis.12 Teriparatide is the only anabolic agent available in Canada.CALCIUM AND VITAMIN D SUPPLEMENTATION The effectiveness of calcium and vitamin D supplementation in preventing hip fractures was evaluated in the WHI.13 The trial involved 36 282 postmenopausal women who daily received either 1000 mg of elemental cal c ium as calcium carbonate and 400 IU of vitamin D, or a placebo, for an average of7 years. Patients were allowed to take additional daily supplements of up to 1000 mg of cal c ium and 600 IU of vitamin D; approximately 38% of subjects took more than 1200 mg of elemental calcium daily. Personal use of bisphosphonates, calcitonin, SERMs, and ET was also permitted. The calcium and vita m in D study arm overlapped with the HT arm; thus, approximately 51% of women were receiving estrogen.Treatment compliance was poor: by the end of the study, only 59% of the women were taking 80% or more of their supplements. As compared with those taking placebo, the women taking 1000 mg of calcium and 400 IU of vitamin D daily showed a 1.06% increase in hip BMD (P < 0.01). In the treatmentcompliant group, the HR for hip fracture was 0.71 (95% CI 0.52 to 0.97), representing a statistically significant 29% reduction in hip fracture risk among the women taking 80% or more of their calcium and vitamin D supplements. Estrogen use was associated with a 42% Assessment of basal 10-year risk of fracture with the 2010 tool of the Canadian Association of Radiologist and Osteoporosis Canada.Reproduced with permission of the Canadian Medical Association from Papaioannou A et al.1The T-score for the femoral neck should be derived from the National Health and Nutrition Education Survey III reference database for white women. Fragility fracture after age 40 or recent prolonged use of systemic glucocorticoids increases the basal risk by one category (ie, from low to moderate or moderate to high). This model reflects the theoretical risk for a hypothetical patient who is treatment-naive; it cannot be used to determine risk reduction associated with therapy. Individuals with fragility fracture of a vertebra or hip and those with more than one fragility fracture are at high risk of an additional fracture.WomenLow risk (< 10%)High risk (> 20%)Moderate riskAge (year)T–score,femoralneck0.0–1.0–2.0–3.0–4.050 55 60 65 70 75 80 85MenLow risk (< 10%)High risk (> 20%)Moderate riskAge (year)T–score,femoralneck0.0–1.0–2.0–3.0–4.050 55 60 65 70 75 80 85SOGC CLINICAL PRACTICE GUIDELINEreduction in hip fracture risk. A small but significant 17% increase in the risk of renal stones was noted in the treatment group as compared with the placebo group: the HR was 1.17 (95% CI 1.02 to 1.34). Inadequate blood levels of vitamin D were also noted in the WHI study and may have contributed to the findings. In the nested case–control study, the mean serum 25hydroxy vitamin D level at baseline was 46.0 nmol/L in the women who had sustained hip fractures as compared with 48.4 nmol/L in their control subjects (P = 0.17). Vitamin D supplementation of more than 600 IU daily may have reduced the fracture risk, as has been demonstrated in other clinical trials.Calcium supplements have been linked to a possible increase in the risk of cardiovascular events.14 A recent 5year RCT of 1200 mg of elemental calcium carbonate daily versus placebo in 1460 postmenopausal women did not demonstrate any difference in rates of death or hospitalization due to coronary events.15 In the EPIC study of 23 980 people between the ages of 35 and 64 years followed for 11 years with questionnaires, those with a calciumenriched diet had a lower risk of myocardial infarction (HR 0.69; 95% CI 0.5 to 0.94), whereas those using a calcium supplement had a higher risk (HR 1.86; 95% CI 1.17 to 2.96).16Data from the WHI among those not using personal calcium or vitamin D supplements at baseline did not show an adverse effect of such supplementation on the risk of myocardial infarction, coronary heart disease, total heart disease, stroke, or overall cardiovascular disease.17 These RCT data are the best evidence currently available and do not support an increased risk of coronary events with calcium and vitamin D supplementation.It is recommended that the daily calcium requirement of 1200 mg be met ideally from dietary sources; if this is not possible, then supplements may be safely used. Calcium carbonate and calcium citrate are the supplements of choice.Ensuring adequate vitamin D supplementation is a key component of the prevention and treatment of osteoporosis. Although it might not be sufficient as the sole means of therapy for osteoporosis, routine supplementation with calcium (1000 mg/d) and vitamin D 3 (800 to 2000 IU/d) is still recommended as a mandatory adjunct to the main pharmacologic agents (antiresorptive and anabolic drugs). Vitamin D in doses of 800 IU daily has been shown to be effective in reducing the risk of falls by 49% over a 12week period of therapy.18 Vitamin D supplementation at a dose of 10 000 IU once weekly has been suggested for women unable to take daily supplements in areas wheresuch a preparation is available. Doses of 100 000 IU ofvitamin D 3 given orally every 4 months have been shownto be effective in reducing the risk of osteoporotic fractures.19Vitamin D levels depend on a number of factors, including dietary intake, sun exposure, skin pigmentation, body mass index, and smoking status.20 Extraskeletal benefits are currently being evaluated and may include a reduction in the risk of certain malignant diseases as well as autoimmune disorders.HORMONE THERAPYEstrogen has significant antiresorptive effects. Spe c ifically, it enhances the osteoblastic production of osteoprotegerin, which has antiosteoclastic properties because of its ability to bind to RANKL and subsequently to block the RANKL/RANK interaction required for osteoclast recruitment and activation.21,22 Estrogen also decreases RANKL expression from the osteoblast. In the WHI, a pri m ary prevention trial, the estrogenonly arm demonstrated a 30% to 39% reductionin fracture rates.23 This trial theref ore confirmed the antifracture effects of ET suggested by previous clinical trials.24,25The combined estrogen/progestogen arm of the WHI had similar results: an increase in total hip BMD, together with a 34% reduction in hip and vertebral fractures and a 24% reduction in total osteoporotic fractures.26 In earlypostmenopausal women, the combined therapy resulted in increases in BMD of 2% to 3% at the hip and spine over 2 years of therapy.24 A decline in the markers of bone turnover in response to HT was also seen in earlypostmenopausal women.25HT (with estrogen alone or combined with a progestogen) is still considered the most effective therapy for the medical management of meno p ausal symptoms. Bone protection with HT at a usual dosage is considered an added benefit. Recent studies designed to test various dosages of estrogen for bone pro t ection have shown a linear dose response of the skeleton from the lowest to the highest dosages tested.24,27,28 These RCTs have shown that lowdosage ET can prevent postmenopausal osteoporosis, and ultralowdosage ET has beneficial skeletal effects. However, no fracture trial has yet been carried out with low and ultralowdosage HT. A low dose is 0.3 mg of conjugated estrogen or its equivalent (e.g., 0.5 mg of micronized estradiol); half this amount is considered ultralow.29SERM THERAPYSERMs have demonstrated tissuespecific estrogenagonistic or estrogenantagonistic effects.30 In the Multiple。
美国对粗隆间骨折固定物选取的调查
Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States?A Survey of Orthopaedic SurgeonsEmily Niu MD,Arthur Yang MS,Alex H.S.Harris PhD,Julius Bishop MDReceived:21February2015/Accepted:15July2015ÓThe Association of Bone and Joint Surgeons12015AbstractBackground The best treatment for intertrochanteric hip fractures is controversial.The use of cephalomedullary nails has increased,whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedul-lary nails are more effective.As current orthopaedic trainees receive less exposure to sliding hip screws,this may con-tinue to perpetuate the preferential use of cephalomedullary nails,with important implications for resident education, evidence-based best practices,and healthcare cost. Questions/purposes We asked:(1)What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons?(2)Do surgical prac-tice patterns differ based on surgeon characteristics,practice setting,and other factors?(3)What is the rationale behind these surgical practice patterns?(4)What postoperative approaches do surgeons use for intertrochanteric fractures? Methods A web-based survey containing20questions was distributed to active members of the American Acad-emy of Orthopaedic Surgeons.Three thousand seven-hundred eighty-six of10,321invited surgeons participated in the survey(37%),with a97%completion rate(3687of 3784responded to all questions in the survey).The survey elicited information regarding surgeon demographics, preferred management strategies,and decision-making rationale for intertrochanteric fractures.Results Surgeons use cephalomedullary nails most fre-quently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only19%primarily use sliding hip screws,and the remaining13%use cephalomedullary nails and sliding hip screws with equal frequency.The cephalomedullary nail was the dominant approach regardless of experience level or practice setting.Surgeons who practiced in a nonaca-demic setting(71%versus58%;p\0.001),did not supervise residents(71%versus61%;p\0.001),or treated more thanfive intertrochanteric fractures a month(78% versus67%;p\0.001)were more likely to use primarily cephalomedullary nails.Of the surgeons who used only cephalomedullary nails,ease of surgical technique(58%) was cited as the primary reason,whereas surgeons who used only sliding hip screws cite familiarity(44%)and improved outcomes(37%)as their primary reasons.Of those who use only short cephalomedullary nails,ease of technique(59%)was most frequently cited.Postopera-tively,67%allow the patient to bear weight as tolerated. Nearly all respondents(99.5%)use postoperative chemical thromboprophylaxis.Conclusions Despite that either sliding hip screw or cephalomedullary nailfixation are associated withEach author certifies that he or she,or a member of his or her immediate family,has no funding or commercial associations(eg, consultancies,stock ownership,equity interest,patent/licensing arrangements,etc)that might pose a conflict of interest in connection with the submitted article.All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1editors and board members are onfile with the publication and can be viewed on request.Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.Electronic supplementary material The online version of this article(doi:10.1007/s11999-015-4469-5)contains supplementary material,which is available to authorized users.E.Niu(&),A.Yang,A.H.S.Harris,J.BishopDepartment of Orthopaedic Surgery,Stanford University,450 Broadway Street,M/C6342,Redwood City,CA94063,USAe-mail:eniu@equivalent outcomes for most intertrochanteric femur fractures,the cephalomedullary nail has emerged as the preferred construct,with the majority of surgeons believing that a cephalomedullary nail is easier to use,associated with improved outcomes,or is biomechanically superior to a sliding hip screw.The difference between what is evi-dence-based and what is done in clinical practice may be attributed to several factors,includingfinancial consider-ations,educational experience,or inability of our current outcomes measures to reflect the experiences of surgeons. The educators,researchers,and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care.Level of Evidence Level V,therapeutic study. IntroductionGeriatric hip fractures are an increasing epidemic in the United States as the population ages,with an anticipated incidence of500,000fractures per year by2040[17]. Intertrochanteric fractures comprise approximately50%of these.Historically,a sliding compression screw has been the preferred implant[19,28,30,34];however,cephalo-medullary nailing has become an increasingly popular fixation technique for these fractures since its introduction in the1980s[2,7,12].Cephalomedullary nailing has theoretical advantages of being less invasive and biome-chanically superior,providing a buttress to limit fracture collapse[21].Multiple clinical trials and meta-analyses have directly compared the two techniques for treatment of these fractures[3,18–20,27,28,30,34].Particular frac-ture patterns,such as those with reverse obliquity, subtrochanteric extension,fracture extension into the lat-eral wall,or greater trochanteric avulsion[23,26,33],have lower rates of failure and reoperation when treated with a cephalomedullary nail than a sliding hip screw.However, to our knowledge,no study has found one construct to be clearly superior in the treatment of commonly encountered conventional obliquity fracture patterns,and controversy over the optimal treatment strategy persists[3,5,25,27, 28,30,32].There is difficulty reaching a consensus based on available evidence given the heterogeneity of fracture patterns and implant designs reported in the literature[3, 18,27,30,34].Despite this uncertainty,data collected between1999and2006indicated that cephalomedullary nailing was overtaking use of sliding hip screws as the preferred technique forfixation of these fractures,partic-ularly among younger surgeons[2].We therefore wished to investigate current practice patterns among orthopaedic surgeons in the treatment of intertrochanteric fractures and the rationale behind decision-making.In particular,we hoped to identify the impetus for changing practice pat-terns.As the aging population strains our available healthcare resources,it is becoming increasingly important to deliver evidence-based and cost-effective care.Specifically,we asked:(1)What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons?(2)Do surgical practice patterns differ based on surgeon characteristics,practice setting,and other factors?(3)What is the rationale behind these surgical practice patterns?(4)What postoperative approaches do surgeons use for intertrochanteric fractures? Materials and MethodsWe conducted a cross-sectional survey study of current practices and opinions of orthopaedic surgeons in the treatment of standard obliquity intertrochanteric fractures. We developed a survey using previous literature and expert opinion(level V evidence).Thefinal questionnaire con-sisted of20questions that were divided into three broad categories:surgeon demographics and training background (years in practice and practice type,number of inter-trochanteric fractures treated),operative considerations in the treatment of intertrochanteric fractures including the rationale for decision-making(preference of cephalome-dullary nails versus sliding hip screws,rationale for choosing one implant instead of the other),and postoper-ative management of weightbearing precautions and use of chemical thromboprophylaxis(Appendix1.Supplemental material is available with the online version of CORR1.). The question regarding the number of years in practice of the respondent featured an open answerfield.The remainder of the questions offered close-ended,multiple choice-type responses.Questions pertaining to rationale for decision making included‘‘Other’’with an open response commentfield as one of the multiple choice answers.The survey was distributed by email to current North American members of the American Academy of Ortho-paedic Surgeons(AAOS).Resident,nonpracticing,and retired members were excluded,as were international members.We targeted a broad demographic because these fractures are treated by orthopaedic surgeons with diverse backgrounds and practice settings.After the initial email,we sent two reminder emails each spaced2weeks apart.The total collection period spanned3 months.We designed the survey to maximize response and completion rates.The purpose of the study was clearly stated,questions were designed to be relevant and easy toNiu et al.Clinical Orthopaedics and Related Research1answer,the sequence of questions was logical,and a web-based survey engine allowed respondents to be directed to certain questions based on their answers to previous questions,optimizing efficiency.Respondents were not allowed to advance to the next page until all questions on a given page were answered with the goal of maintaining a high completion rate.Responses were collected and reviewed by one reviewer (EN).The variables studied included surgeon training background including fellowship and current practice set-ting.Surgeons also were asked about their rationale for decision-making,specifically in deciding between use of sliding hip screws and cephalomedullary nails and use of short versus long cephalomedullary nails.No detailed description or classification of the fracture or injury radiographs were provided.Rather surgeons were given the opportunity to respond‘‘depends on fracture pattern’’. Surgeons also were asked about their postoperative man-agement regarding weightbearing restrictions and venous thromboembolism prophylaxis.A total of3786of10,321(37%)invited surgeons completed the survey,with a97%completion rate(3687of 3784).All survey respondents(3786)answered the ques-tions pertaining to demographics(Table1).The average number of years in practice was17(range,6months to57 years).Ninety-four percent(3568)of the respondents were male and6%(218)were female.There were notable variations in training and practice patterns.Seventeen percent(644)worked in an academic practice,whereas 83%(3142)worked in nonacademic settings.Thirty per-cent(1126)of respondents supervised residents and70%(2660)did not.Ten percent(363)completed a trauma fellowship,56%(2131)completed a nontrauma fellowship, and34%(1292)did not complete a fellowship.Seventy-five percent(2854)treated between zero andfive inter-trochanteric fractures a month,20%(746)treated more thanfive intertrochanteric fractures a month,and5%(186) stated that they do not commonly treat intertrochanteric fractures.In comparison to the AAOS2014census[1],our respondents were representative of the general AAOS membership,with an average age of practicing orthopae-dists of54.76years,92%male,and16%in an academic setting.Our survey respondents featured a larger propor-tion of trauma-specialized surgeons compared with the AAOS membership(10%vs5%),as expected given the subject matter.Categorical data were summarized using percentages. Trends in preferences and practice patterns were analyzed and response distributions determined.Odds ratios(OR) and95%CIs were used to determine statistical differences between proportions,with a p value less than0.05used to define statistical significance.Surgeons were stratified based on experience(number of years in practice,\2years [n=337];2to5years[n=464];6to10years[n=578];11 to20years[n=1055];21to30years[n=903];and[30 years[n=437])(Fig.1),to determine the proportions who use sliding hip screws and cephalomedullary nails in their training and current practice.The surgeons with fewer than 10years in practice were stratified into more groups owing to their large numbers and to determine whether there were any practice differences seen in the most recent residency graduates.Logistic regression analysis was performed to determine whether there was a correlation between surgeon experience and use of sliding hip screws versus cephalo-medullary nails in training and in practice.ResultsIn training,the majority of surgeons(55%;2088of3786) were taught using primarily sliding hip screws,compared with33%who trained using primarily cephalomedullary nails(1262of3786,OR,2.46;95%CI,2.24–2.70;p\ 0.001)(Fig.2A).Surgeons use cephalomedullary nails most frequently in their current practice for treatment of Table1.Demographics of the survey respondents and the AAOS 2014Census[1]Variable Intertrochantericfracture surveyAmericanAcademyof OrthopaedicSurgeons2014census Average years in practice17years(range,6months–57years)Not askedAverage age Not asked54.8years(range,22–98years) SexMale94%92%Female6%8%Practice settingAcademic17%16% Nonacademic83%84%Supervise residents Not askedYes30%No70%SpecializationTrauma10%5% Nontrauma56%81%None34%14%Number of fracturestreated/monthNot askedDid not commonly treat5%0–575%[520%Treatment of Intertrochanteric Hip FracturesNiu et al.Clinical Orthopaedics and Related Research1intertrochanteric hip fractures (Fig.2B).Although 68%(2533of 3712)currently use primarily cephalomedullary nails,only 19%(698of 3712)use primarily sliding hip screws to treat intertrochanteric fractures (OR,9.28;95%CI,8.33–10.33;p \0.001).The remaining 13%(481of 3712)use cephalomedullary nails and sliding hip screws equally in current practice (Fig.2B).Among surgeons who use cephalomedullary nails,29%(1029of 3548)use only long cephalomedullary nails,whereas 3%(97of 3548)use only short cephalomedullary nails,with the remaining 68%(2422of 3548)using long and short cephalomedullary nails.Surgeons with more years in practice were more likely to have trained using sliding hip screws (Fig.1A;OR of primarily using sliding hip screws in training with each increasing year in practice,1.007;95%CI,1.00to 1.01;p =0.046),however greater than 60%of surgeons currently use primarily cephalomedullary nails regardless of the number of years in practice (Fig.1B).There was no correlation found between the number of years in practice and use of sliding hip screws versus cephalomedullary nails in current practice.Surgeons with less than 2years in practice were more likely to use both constructs with equal frequency compared with other experience levels (Fig 1C)(\2years,22%[73of 330];all other experience levels,12%[404of 3371];OR,2.09;95%CI,1.58–2.76;p \0.001).We found that practice setting and training background affected surgeon use of cephalomedullary nails versus sliding hip screws.Surgeons who practiced in a nonaca-demic setting were more likely to use primarily cephalomedullary nails compared with those in an aca-demic setting (72%[2029of 2814]versus 58%[357of 615],respectively;OR, 1.87;95%CI, 1.56–2.24;p \0.001).Similarly surgeons who did not supervise residents (71%[1859of 2614]versus 61%[674of 1098];OR,1.55;95%CI,1.34–1.80;p \0.001)or treated more than five intertrochanteric fractures a month (78%[576of 741]versus 66%[1957of 2971];OR,1.81;95%CI,1.50–2.18;p \0.001)were more likely to use primarily cephalome-dullary pared with other surgeons,surgeons who completed a trauma fellowship (16%[57of 360]versus 35%[1176of 3352];OR,0.35;95%CI,0.26–0.47;p \0.001),practiced in an academic setting (13%[80of 615]versus 38%[1076of 2814];OR,0.24;95%CI,0.19–0.31;p \0.001),or supervised residents (19%[204of 1098]versus 39%[1029of 2614];OR,0.35;95%CI,0.35–0.42;p \0.001)were less likely to use a single construct (only cephalomedullary nails or only sliding hip screws)exclu-sively.Surgeons were more likely to use only long cephalomedullary nails if they completed a trauma fel-lowship (42%[149of 359]versus 27%[880of 3252];OR,1.91;95%CI,1.52–2.39;p \0.001),practiced in an aca-demic setting (41%[244of 601]versus 26%[701of 2739];OR,1.99;95%CI,1.65–2.39;p \0.001),or supervised residents (37%[396of 1079]versus 25%[633of 2532];OR,1.74;95%CI,1.49–2.03;p \0.001).The polled surgeons who favor cephalomedullary nails perceive them to be superior to sliding hip screws,whereas those who favor sliding hip screws did so because of their familiarity with the construct.Of the surgeons who use cephalomedullary nails exclusively (1106),the ease of surgical technique (58%;646of 1106),improved outcomes compared with sliding hip screws (16%;178of 1106),biomechanical superiority (15%;163of 1106),and famil-iarity with technique (10%;106of 1106)were identified as the primary reasons.Patient comorbidities (1%;13of 1106)and perceived cost (0of 1106)were not important influences on decision-making.Surgeons who use only sliding hip screws (127)chose familiarity with technique (44%;56of 127),perceived improved or equivalent out-comes to cephalomedullary nails (38%;48of 127),and surgical ease (16%;20of 127)as their reasons for favoring the sliding hip screws.Perceived cost (1%;two of 127)and patient comorbidities (1%;one of 127),were not primary factors in decision making.Of respondents who use only long cephalomedullary nails (1029),decreased risk of periimplant fracture (75%;767of 1029),biomechanical superiority (18%;181of 1029),and patient comorbidities (7%;72of 1029)served as the rationale.Five respondents chose ‘‘familiarity with technique’’,and four chose ‘‘other’’,with responses including:‘‘all of the above’’,‘‘peer pressure’’,‘‘dogma’’,and ‘‘I would use a DHS (dy-namic hip screw)instead of a short nail because it is cheaper’’.Of respondents who use only short cephalome-dullary nails (97),ease of technique (59%;57of 97),and perceived equivalency of outcomes to a long nail (31%;30of 97)drove decision-making.Decreased risk of intraop-erative fracture (5%;five of 97),cost (3%;three of 97),and patient comorbidities (2%;two of 97)were less-important factors.Postoperatively,67%(2457of 3687)allow the patient to bear weight as tolerated,29%(1060of 3687)allow toe-touch or partial weightbearing,and 2%(60of 3687)do not allow weightbearing.The remaining 3%(110of 3687)determine weightbearing precautions based on fracture pattern,with the majority selecting partial weightbearingFig.1A–C Rates of cephalomedullary nail (CMN)use were strati-fied across surgeon experience.Respondents were stratified by years in practice (\2,2-5,6-10,11-20,21-30,[30).The proportion who use primarily sliding hip screws (SHS)(those who responded ‘‘SHS only’’or ‘‘mostly SHS’’),primarily cephalomedullary nails (re-sponded ‘‘CMN only’’or ‘‘mostly CMN’’),and both (responded ‘‘I use SHS and CMN equally’’)were calculated for training and current practice in each experience group.The percentages of respondents who use primarily (A )sliding hip screws,(B )cephalomedullary nails,and (C )sliding hip screws and cephalomedullary nails equally in training versus in current practice are presented.b Treatment of Intertrochanteric Hip Fracturesfor more comminuted or unstable fracture patterns and weightbearing as tolerated for stable patterns.Surgeons who use primarily cephalomedullary nails were more likely to allow full weightbearing immediately after surgery (70%;1759of 2522)than those who use sliding hip screws (55%;381of 689;OR,1.86;95%CI,1.57–2;p \0.001).For venous thromboembolism prophylaxis,only 0.5%(17of 3687)of those surveyed use mechanical prophylaxis alone.Fifty-five percent (2024of 3687)use enoxaparin,16%(596of 3687)use warfarin,10%(375of 3687)use rivaroxaban,and 9%(317of 3687)use aspirin.Ten percent (358of 3687)use another form of chemical thrombopro-phylaxis.Fifty-five percent (2035of 3674)use chemical thromboprophylaxis for 2to 4weeks,26%(958of 3674)1to 2weeks,14%(528of 3674)greater than 4weeks,and 4%(153of 3674)use it for less than 1week.DiscussionDespite extensive research and debate devoted to the sub-ject [3,5,18–20,25,27,28,30,32,34],neither cephalomedullary nails nor sliding hip screws have been established as the definitively superior construct for the treatment of intertrochanteric hip fractures.However,cephalomedullary nails are the most commonly used con-struct in the current treatment of intertrochanteric hip fractures,despite the lack of evidence and increased cost [32].We conducted a survey to identify sources for the discrepancy between what is supported in the literature and what is used in practice.These findings may reflect factors that have not been widely recognized or studied,but that are important to surgeons,such as ease of surgical tech-nique.We found that the cephalomedullary nail is the favored implant by surgeons across all experience levels.Surgeons in a nonacademic setting,who do not work with residents,and treat a higher volume of hip fractures areeven more likely to use cephalomedullary nails.Ease of surgical technique was the most frequently cited reason for use of cephalomedullary nails.Our study has some limitations.The low response rate,although consistent with other surgical surveys [4,14,20],could introduce responder bias.Our data may not be gen-eralizable to the entire practicing population in the country;however,the survey does reflect the current treatment practices and perceptions of nearly 4000surgeons.The demographics of our respondents also closely match the demographics of the current AAOS membership,based on 2014census data [1],suggesting that we succeeded in achieving a broad and representative sampling of currently practicing orthopaedic surgeons.In addition,not all of the surgeons who were sampled are likely to treat hip fractures,which further offsets our responder bias limitation.Our survey did not detail particular fracture patterns or provide radiographs when querying surgeons about implant choice.Although a previous study polling surgeons showed there is no standard classification system that is used to define stable versus unstable fractures and no widely accepted treatment algorithm [20],we recognize that fracture pattern is an important consideration to many surgeons when they are selecting an implant and that the cephalomedullary nail can be used for certain fracture patterns (reverse obliquity,lateral wall involvement,subtrochanteric extension)where a sliding hip screw cannot be used.We addressed this by including the answer choice ‘‘depends on fracture pattern’’in our questions regarding the rationale for treatment strategies.This answer option was not chosen frequently,which suggests that other factors are more important in guiding treatment.Similarly,we did not specifically ask surgeons about their practices with a geriatric patient population,but given that the majority of patients with intertrochanteric fractures are elderly,we think it is safe to apply data generated by our survey to this population.The survey design is reliant on self-reported data.WeattemptedFig.2A–B Use of cephalomedullary nails (CMN)and sliding hip screws (SHS)in training and current practice are shown.The graphs show responses to the most common implant used (A )for treatment of intertrochanteric fractures by the surgeon while in training,and (B )by the surgeon in current practice.There is a notable shift toward the use of cephalomedullary nails in current practice.Both =SHS and CMN are used with equal frequency.Niu et al.Clinical Orthopaedics and Related Research 1to control for this by using close-ended,multiple choice-type questions to allow for comparability.However,this type of question limits the ability of respondents to report responses that did not appear on the survey.We offered commentfields after the majority of questions to address this limitation but these were used infrequently and did not significantly affect the results of our study.Additionally, we primarily used single-selection questions to elicit only the most relevant option for each scenario.Finally,because of the large number of responses,small but statistically significant differences may not always be clinically rele-vant.However,our reported comparison statistics all have a difference of10%or greater.Ourfinding that the majority of surgeons currently use cephalomedullary nails is in agreement with the literature showing that the popularity of the cephalomedullary nails is steadily increasing[2,7,12].Anglen and Weinstein[2] conducted a study of candidates participating in the American Board of Orthopaedics oral boards and found the use of cephalomedullary nails increased from3%to65% from1999to2006by newly practicing orthopaedic sur-geons.A study of treatment of intertrochanteric fractures in Medicare beneficiaries showed that the use of cephalome-dullary nails more than doubled between2000and2002 [12].We found that surgeons across all experience levels preferentially use cephalomedullary nails in their current practice,suggesting that this trend is not only the result of an influx of younger surgeons using primarily cephalo-medullary nails.Rather,even more experienced surgeons are favoring cephalomedullary nails.This reflects an overall shift in practice paradigm—one that does not appear to be supported by the current literature.We found that surgeons at academic centers or who supervise residents were more likely to use both constructs. Ourfindings are in contrast to those of Forte et al.[11]who found,in a study conducted between2000and2002on Medicare beneficiaries,that teaching hospital status and resident assistance during surgery are associated with increased cephalomedullary nail use.It remains to be seen whether future generations of surgeons will continue the trend in preferentially using cephalomedullary nails despite exposure to both techniques,or whether lack of literature support for indiscriminant use of cephalomedullary nails will create enough momentum to swing the pendulum back toward use of sliding hip screws.Our data show that surgeons believe that cephalome-dullary nails are a superior construct to sliding hip screws, whether attributable to ease of technique,perceived improved outcomes,or biomechanical advantage.There continues to be controversy regarding the optimum treat-ment of intertrochanteric fractures[3,5,25,27,28,30,32]. Several large prospective randomized trials have directly compared sliding hip screws and contemporary cephalomedullary nail constructs and have shown similar outcomes between the two techniques[3,27,28,30,34]. The most recent Cochrane review on the topic[28]con-cluded that the sliding hip screw is the superior construct for treatment of intertrochanteric fractures because of the decreased rate of surgical complications compared with cephalomedullary nails,but additional studies are necessary to determine whether newer designs of cephalomedullary nails avoid the complications of older models,such as those used for periimplant fracture.In contrast to surgeon perception of technical ease,studies have shown there is a learning curve associated with cephalomedullary nails use [7,27].Parker et al.[27]found that the intramedullary nail had slightly increased operative and anesthesia time, increased radiographic screening time,and overall was more technically challenging with respect to placement of proximal and distal interlock screws.Their study calls into question the driving factors behind the changing practice pattern.Of the surgeons surveyed,nearly1.3use only long nails.Despite a lack of evidence,the risk of periimplant fracture still drove decision-making for these surgeons (74%).Short nail proponents chose ease of technique (59%)and equivalency of outcomes to a long nail(24%)as their reasons for using short cephalomedullary nails. Studies have suggested a higher risk of periimplant fracture with cephalomedullary nails compared with sliding hip screws[19,25,28],but Norris et al.[25]found that newer designs of cephalomedullary nails have a significantly decreased rate of periimplant fracture compared with their predecessors.Boone et al.[6]performed a retrospective study of intertrochanteric fractures treated with either a long or short cephalomedullary nail with minimum1-year followup,finding no difference in the rate of periimplant fracture.With use of short cephalomedullary nails,there was significantly lower blood loss and rate of transfusion and shorter operative time.Further studies are necessary to determine whether short cephalomedullary nails have a higher incidence of periimplant fracture in long-term fol-lowup and whether this theoretical risk outweighs potential benefits of ease of use and lower perioperative morbidity compared with long cephalomedullary nails.Although cost rarely was cited as an important decision-making factor by our cohort,it likely will become increasingly important as the economics of health care continue to evolve.A cephalomedullary nail costs approximately USD900to USD1500more than a sliding hip screw depending on region and institution[32].Swart et al.[32]performed a cost-effectiveness analysis and found that sliding hip screws are likely more cost-effective than cephalomedullary nails for stable intertrochanteric fractures and those of questionable stability(AO Type31-A1or A2),withfixation failure rate and implant cost being the most important factors in determining implantTreatment of Intertrochanteric Hip Fractures。
向皮特推荐中国针灸英语作文
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Recommendations on hip fracturesK. Wendt 1 · D. Heim 2 · C. Josten 3 · R. Kdolsky 4 · H.‑J. Oestern 5 · H. Palm 6 · J. B. Sintenie 7 · R. Komadina 8 · C. Copuroglu 9© The Author(s) 2016. This article is published with open access at 1.26 million; this is estimated to approximately double to2.6 million by 2025 and to 4.5 million by 2050 [5]. As advances in medicine and healthcare awareness increase, life expectancy at birth and lifetime spans will rise exponentially.Management of hip fractures requires a wide spectrum of approaches, from prevention to postoperative care [6]. The socioeconomic impact of hip fractures is increasing on a worldwide scale, and there is a need to develop pre-ventive strategies [5] as well as evidence-based treatment protocols to minimise the enormous social burden of these fractures.Given that hip fractures are common, costly injuries with a complex treatment journey that is complicated by comorbidities in the elderly patient group, building clinical recommendations is an important and challenging topic if one considers that infrastructures do vary among European countries. These recommendations are therefore proposals for medical treatment in typical situations, and do not con-stitute legally committing rules to be observed.IntroductionHip fractures among the elderly are one of the major fragil-ity fractures in terms of quality of life, health outcomes and medical costs [1]. Since mortality and morbidity are high, hip fractures have a direct impact on public health [2] and are one of the main reasons for disability [3].Increases in age-adjusted incidence of falls with accom-panying deterioration in age-adjusted bone quality may explain the reason for osteoporotic hip fractures among the elderly [2].According to United Nations records from 2009, the average lifetime of human beings was 56 years in 1970; by 2000 it rose to 65 and by the year 2050 it is expected to be 75.5 years (73.3 for men and 77.9 for women) [4]. According to some epidemiological studies, there were 1.66 million hip fractures worldwide in 1990. Epidemio-logical projections estimate these annual figures to rise to 6.25 million by 2050 [2]. In another epidemiological study, the total number of hip fractures in 1990 was found to be * K. Wendtk.w.wendt@umcg.nl1Trauma Surgery, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands 2Hohmad Privatklinik Thun, Hohmaddstrasse 1, 3600 Thun, Switzerland3Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätskliniken Leipzig, Leibigstrasse 20, 04103 Leipzig, Germany4Departmernt for Emergency Surgery, Medical University of Vienna, AKH Wien, Währinger Gürtel 18-20, 1090 Vienna, Austria5 Schubertstrasse 12, 29223 Celle, Germany6Department of Orthopaedics, University Hospital Hovidovre, Kettegard Alle 30, 2650 Hovidovre, Denmark 7Department of Surgery, Elkerliek Ziekenhuis locatie Helmond, Wesselmanlaan 25, 5797 HA Helmond, The Netherlands8Department of Surgery, Teaching and General Hospital Celje, Oblakova Ulica 5, 3000 Celje, Slovenia9Department of Orthopaedics and Traumatology, Faculty of Medicine, Trakya University, Balkan Yerleskesi, 22030 Edirne, TurkeyK. Wendt et al.ESTES study group, proximal femurCem Copuroglu TurkeyDominik Heim SwitzerlandChristoph Josten GermanyRichard Kdolsky AustriaRadko Komadina SloveniaHans-Jörg Oestern GermanyHenrik Palm DenmarkJan Bernard Sintenie The NetherlandsKlaus Wendt The NetherlandsThe European Society for Trauma and Emergency Surgery (ESTES) Study Group was formed in 2014 with the aim of developing ESTES recommendations on proximal hip frac-tures. After a review of the recent literature and already existing guidelines in several European countries the members of the study group wrote a concept of the different parts of the rec-ommendations. On a consensus meeting in September 2014 in Frankfurt a definitive version of the recommendations was for-mulated and agreed by all study group members. The recom-mendations on hip fractures are approved by the ESTES board. Patient group and aimsThese recommendations focus on elderly people with a minor trauma of the proximal femur:1. Extra-articular pertrochanteric/subtrochanteric frac-tures (AO classification 31 A1–3).2. Femoral neck fractures (AO classification 31 B1–3).Minor trauma can be a fall indoors or outdoors from a standing height. Restoring the level of activity is the main treatment goal. To reach this goal a multidisciplinary approach is necessary. A trauma (orthopaedic) surgeon, anaesthetist, geriatrician and emergency physician can be part of the team. The coordinator should be a trauma (orthopaedic) surgeon [7]. He has the ability to overview the whole process. This means that a care pathway for this patient group should be established [8, 12].HistoryNot every elderly patient is able to answer questions ade-quately. For further information the family, nursing home staff and paramedics are important. Be aware of legal responsibilities and patient treatment limitations.DiagnosticsKey points: physical examination, basic lab, X-ray.Basic steps in this process are:1. General physical examination (documentation: decubi-tus, mental state, dehydration)2. Registration of fracture signs3. Basic lab: haemoglobin, electrolytes, renal functionand coagulation4. ECG5. Thoracic X-ray (starting point)6. AP pelvic X-ray and a lateral view if possible [13].CT-scan is indicated if the X-rays show no fracture but there is a high index of suspicion at physical examination [14, 15]. An MRI is optional for pathological fractures [16].The differential diagnosis should include:1. Hip contusion2. Pelvic fracture (pubic branch)3. Fracture of the acetabulum4. Fracture of the femoral head5. Fracture of the greater trochanterPreoperative workupKey points: management of pain, decubitus, delirium.At least a trauma (orthopaedic) surgeon, anaesthetist and geriatrician should be involved. Depending on the local situ-ation, one of these medical specialists has to coordinate the workup. Clear interdisciplinary agreements are necessary [8].Pain management is very important [17, 18]. Apart from analgesic drugs there are several options:1. Regional block, for example fascia iliaca compartmentblock [19]2. Traction splint3. Urinal catheterDecubitus prevention has to start at admission. A pres-sure-relieving mattress is necessary in bed-bound patients [20]. The state of the skin has to be monitored on a daily basis.Early prophylaxis, diagnosis and treatment of delirium are important [21, 22]. The mental status has to be moni-tored on a daily basis. One option is using the delirium observational scale (DOS).Recommendations on hip fracturesTo avoid electrolyte disorders and dehydration, fluid management has to start early [23].Many elderly persons take anticoagulant drugs. Be aware of coagulation disorders. This has to be addressed preoperatively.Operation Key points: conservative treatment, endoprosthesis, intramedullary device, DHS.Conservative treatment There might be an option for nonoperative treatment in case of a valgus-impacted femoral neck fracture in a vital The choice between regional and general anaesthesia shows no influence on the incidence of perioperative blood loss, postoperative respiratory insufficiency, myocardial infarction, myocardial insufficiency, renal insufficiency or cerebrovascular deficits [28, 29]. Regional anaesthesia in proximal femoral fractures diminishes the risk of thrombo-sis [30].Antibiotic prophylaxis has to start 30 min prior tothe operation [31]. The operative treatment of femoral neck and pertrochanteric fractures is discussed contro-versially. The following recommendation is based on the article ‘A new algorithm for hip fracture surgery’ byPalm et al. from Copenhagen and on the German guide-lines for femoral neck and pertrochanteric fractures [32, 33].patient without severe osteoporosis [10]. Depending on pain, weight-bearing has to start early. Before discharge an X-ray control of the hip is advisable [24, 25].In pertrochanteric fractures there are hardly any indica-tions for conservative treatment. Exceptions are patients with a severe general condition, like ASA 5 patients.Operative treatmentThe operation should be performed during the daytime by a dedicated team [26]. Especially for head-preserving pro-cedures it should take place within 24 h. Most important is the general condition of the patient. In patients with a severe general condition the preoperative workup may take more than 24 h. Fasting time should be as short as possible [27].Femoral neck fracturesA femoral neck fracture in a head-preserving procedure must be reduced anatomically.Nondisplaced fractures (Garden 1 and 2, <20° posterior tilt)• Osteosynthesis: dynamic hip screw, cannulated screws or Hansson pins.Displaced fractures (Garden 3 and 4, >20° posterior tilt)• Prosthesis; the choice between a total hip prosthesis and a hemiarthroplasty depends on the age and general con-dition of the patient.Patients from nursing homes with nosocomial infec-tions colonised with MRSA of ESBL have a higher risk ofK. Wendt et al.postoperative infection. In these patients with a displaced femoral neck fracture an osteosynthesis can be considered [34–36].Pertrochanteric fractureStable fractures (AO/OTA type A.1 and A.2.1).• Dynamic hip screw.Unstable fractures (AO/OTA type A.2.2, A.2.3 and A.3).• Antegrade intramedullary nail.The aim of all procedures is early full weight-bearing.Postoperative treatmentKey points: avoid pulmonary embolism, hypoxemia, delir-ium, decubitus.All hip fracture patients should be clustered in one nurs-ing ward in order to increase the experience of the nursing staff, thus improving the quality of care for the patients, and paying special attention to the care of elderly patients (early start of rehabilitation, adequate diet, pressure ulcer prevention).Multidisciplinary teamwork is generally considered effec-tive in hip fracture rehabilitation. At least a trauma (ortho-paedic) surgeon, geriatrician, dietician and physiotherapistRecommendations on hip fracturesshould be involved. During the stay at the nursing ward the patients should be visited routinely by the geriatrician [8].The incidence of thrombosis and pulmonary embolism after a hip fracture is high. The incidence of symptomatic venous thromboembolism is low (1.34 %) in patients given pharmacological thromboprophylaxis [13, 37, 38]. Sequen-tial compression and arterial venous foot impulse systems can reduce the risk of DVT [13, 39]. Mechanical prophylaxis is labour-intensive and poorly tolerated. There is no good evidence that compression stockings reduce the incidence of venous thromboembolism [13, 39]. Pharmacological proph-ylaxis is recommended [40]. In the majority of cases low molecular-weight heparin (LMWH) is given for 4–6 weeks. Other choices, like coumarin or fondaparinux, are an option.Adequate pain relief is associated with reduced cardiovas-cular, respiratory and gastrointestinal problems and a lower incidence of delirium. Several drugs can be used for pain relief. The choice depends on the circumstances in the specific country and hospital. Pain intensity should be scored with the aid of a visual analog scale (V AS score) on a regular basis.Hypoxemia is a serious postoperative problem and can persist several days after the operation. Routine use of pulse oxymetry can reduce the incidence of hypoxemia. Supplemental oxygen should be given in the first postop-erative hours and as long as hypoxemia persists [13, 41].Fluid and electrolyte management should be monitored routinely [23]. Malnutrition occurs frequently in the elderly. Poor nutrition can lead to mental apathy, muscle wasting and weakness, impairs cardiac function, and lowers immunity to infection. The nursing staff has to assess the nutritional sta-tus with the aid of a malnutrition score such as the MUST score. A dietician should be involved. Oral protein feeds pro-vide protein, energy, some vitamins and minerals, and may have a positive impact on postoperative morbidity [42].Delirium is a serious and frequent postoperative com-plication and a negative prognostic factor for the outcome. Prophylaxis should start early. Mental state should be mon-itored frequently with the aid of a delirium attention pro-tocol. Pharmacological treatment has to be started when delirium occurs.Decubitus prophylaxis has to start early. The patient should be transferred on a pressure-relieving mattress at admission [20]. The nursing staff should estimate pressure sore risk with the aid of a decubitus score.A urinary catheter should be removed as early as possible.Early mobilisation can prevent decubitus, thromboem-bolism and pneumonia. The patient should be mobilised within 24 h [43]. If possible, full weight-bearing should be achieved. Balance and gait are essential components of mobility. Activities of daily living such as transferring, washing, dressing and toileting should be trained. A physi-otherapist should be involved in the treatment.Discharge, nursing home and outpatient clinicKey points: early planning, co-working, prevention.To prevent delay, discharge procedures have to start early. Cooperation with nursing homes and geriatric reha-bilitation units should be considered. A nursing home physician should be involved early. The rehabilitation pro-grams of hospitals and rehabilitation units should be coor-dinated [8].After a hip fracture the risk of another fracture increases considerably. The multidisciplinary team has to advice and initiate osteoporotic diagnosis and treatment [9, 11, 44, 45]. This depends on the local situation and on who is in charge. Bone density measurement is recommended. In patients above 80 years of age with prevalent hip fracture, the WHO does not advice densitometry to initiate osteoporotic treatment.Results of fall prevention programs are controversial. Hip protectors are not recommended, as the incidence rate of hip fractures in protected vs. unprotected hips among nursing home residents did not differ (3.1 vs. 2.5 %) [46].According to Masud’s multifactorial interdisciplinary prevention programmes in the late 90s, post-fall and post-fracture strategies currently focus on multifactorial inter-ventions with osteoporosis and sarcopenia treatment [36, 47]. Lean-mass DXA measurement correlates with body composition DXA scans and depicts the loss of muscle mass [48].Compliance with ethical standardsConflict of interest Klaus Wendt, Dominik Heim, Christoph Josten, Richard Kdolsky, Hans-Jörg Oestern, Henrik Palm, Jan Bernard Sin-tenie, Radko Komadina and Cem Copuroglu declare that they have no conflict of interest.Open Access This article is distributed under the terms of the Crea-tive Commons Attribution 4.0 International License (/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.References1. Chang KP, Center JR, Nguyen TV, Eisman JA. Incidence of hipand other osteoporotic fractures in elderly men and women: Dobbo Osteoporosis Epidemiology Study. J Bone Miner Res.2004;19(4):532–6.2. Kannus P, Parkkari J, Sievänen H, Heinonen A, Vuori I,Järvinen M. Epidemiology of hip fractures. Bone 1996;18(1 Suppl):57S–63S.3. Tuzun C, Tikiz C. Hip fractures in elderly and problems duringrehabilitation. Turk J Geriatr. 2006;9(2):108–16.4. Gullberg B, Johnell O, Kanis JZ. World-wide projections for hipfracture. Osteoporos Int. 1997;7(5):407–13.K. Wendt et al.5. United Nations Population Division. World population pros-pects: the 2008 revision population database. / UNPP/p2k0data.asp. Accessed 24 Feb 2010.6. Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mor-tality following hip fracture: trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157–63.7. Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip frac-ture management: tailoring care for the older patient. JAMA.2012;307(20):2185–94.8. Flikweert ER, Izaks GJ, Knobben BA, Stevens M, Wendt KM.The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results ofa clinical trial. BMC Musculoskelet Disord. 2014;30(15):188.doi:10.1186/1471-2474-15-188.9. Slovenian recommendations for hip fracture treatment in elderly2012.10. Richtlijn Behandeling van de proximale femurfractuur bij deoudere mens, The Netherlands 2008.11. Komadina R. Hip, osteoporosis: new paradigm. Eur J TraumaEmerg Surg 2008.12. Saltvedt I, Prestmo A, Einarsen E, Johnsen LG, Helbostad JL,Sletvold O. Development and delivery of patient treatment in the Trondheim hip fracture trial. A new geriatric in-hospital pathway for elderly patients with hip fracture. BMC Res Notes.2012;5:355.13. Management of hip fracture in older people. A national clinicalguideline, Scotland 2009.14. Heikal S, Riou P, Jones L. The use of computed tomography inidentifying radiologically occult hip fractures in the elderly. Ann R Coll Surg Engl. 2014;96(3):234–7.15. Jordan R, Dickensen E, Westacott D, Baraza N, Srinivasan K. Avast increase in the use of CT scans for investigating occult hip fractures. Eur J Radiol. 2013;82(8):e356–9.16. Blain-Paré E, Ehlinger M, Dosch JC, Moser T. Rapid osteolysisof the femoral neck: consequence of an insufficiency fracture of the hip? Skelet Radiol. 2013;42(8):1089–95.17. Gille J, Gille M, Gahr R, Wiedemann B. Acute pain manage-ment in proximal femoral fractures: femoral nerve block (cath-eter technique) vs. systemic pain therapy using a clinic internal organisation model. Anaesthesist. 2006;55(4):414–22.18. Roberts KC, Brox WT, Jevsevar DS, Sevarino K. Managementof hip fractures in the elderly. J Am Acad Orthop Surg. 2015. 19. Mouzopoulos G, Vasiliadis G, Lasanianos N, NikolarasG, Morakis E, Kaminaris M. Fascia iliaca block prophy-laxis for hip fracture patients at risk for delirium: a rand-omized placebo-controlled study. J. Orthopaed Traumatol.2009;10:127–33.20. Rich SE, Shardell M, Hawkes WG, Margolis DJ, Amr S, MillerR, Baumgarten M. Pressure-redistributing support surface use and pressure ulcer incidence in elderly hip fracture patients. J Am Geriatr Soc. 2011;59(6):1052–9.21. Robles MJ, Formiga F, Vidán MT. Delirium preventionand treatment in elderly hip fracture. Med Clin (Barc).2014;142(8):365–9.22. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, EgbertsTC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-con-trolled study. J Am Geriatr Soc. 2005;53(10):1658–66.23. Ollivere B, Rollins K, Brankin R, Wood M, Brammar TJ, Wim-hurst J. Optimising fast track care for proximal femoral fracture patients using modified early warning score. Ann R Coll Surg Engl. 2012;94(4):267–71.24. Buord JM, Flecher X, Parratte S, Boyer L, Aubaniac JM, Argen-son JN. Garden I Femoral neck fractures in patients 65 years old and older: is conservative functional treatment a viable option?Orthop Traumatol Surg Res. 2010;96(3):228–34.25. Taha ME, Audigé L, Siegel G, Renner N. Factors predict-ing secondary displacement after non-operative treatment of undisplaced femoral neck fractures. Arch Orthop Trauma Surg.2015;135(2):243–9. doi:10.1007/s00402-014-2139-9(Epub 2014 Dec 31).26. Chacko AT, Ramirez MA, Ramappa AJ, Richardson LC,Appleton PT. Rodriguez EK Does late night hip surgery affect outcome? J Trauma. 2011;71(2):447–53. doi:10.1097/ TA.0b013e3182231ad7(discussion 453).27. Bjorkelund KB, Hommel A, Thorngren KG, Lundberg D, Lars-son S. The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture. AANA J.2011;79(1):51–61.28. Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hipfracture surgery in adults. Cochrane Database Syst Rev.2004;4(4):CD000521.29. White SM, Griffiths R, Holloway J, Shannon A. Anaesthe-sia for proximal femoral fracture in the UK: first report from the NHS Hip Fractures Anaesthesia Network. Anaesthesia.2010;65(3):243–8.30. Martin VC. Hypoxaemia in elderly patients suffering from frac-tured neck of femur. Anaesthesia. 1977;32(9):852–67.31. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for sur-gery for proximal femoral and other closed long bone fractures.Cochrane Database Syst Rev. 2010;17(3):CD000244.32. Palm H, Krasheninnikoff M, Halck K, Lemser T, Bang Foss N,Jacobsen S, Kehlet H, Gebuhr P. A new algorithm for hip frac-ture surgery. Reoperation rate reduced from 18% to 12% in 2,000 consecutive patients followed for 1 year. Acta Orthopae-dica 2012.33. German Guideline Hip Fractures DGU, Leitlinien Unfallchirur-gie—überarbeitete Leitlinie S2-e, AWMF-Nr. 012—001/012-002, 2014.34. Eseonu KC, Middleton SD, et al. A retrospective study of riskfactors for poor outcomes in methicillin-resistant staphylococcus aureus (MRSA) infection in surgical patients. J Orthop Surg Res.2011;6:25.35. Duckworth AD, Phillips SA, et al. Deep infection afterhip fracture surgery: predictors of early mortality. Injury.2012;43(7):1182–6.36. Masud T, Morris RO. Epidemiology of falls. Age Ageing.2001;30:2–7.37. Rosencher NVC, Emmerich J, Fagnani F, Samama CM, TheESCORTE group. Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study. J Thromb Haemost.2005;3(9):2006–14.38. Handoll H, Farrar M, McBirnie J, Tytherleigh-Strong G, MilneA, Gillespie W. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pul-monary embolism following surgery for hip fractures. Cochrane Libr. 2006;4:CD000305.39. Sobieraj DM, Coleman CI, Tongbram V, Chen W, Colby J, LeeS, Kluger J, Makanji S, Ashaye A, White CM. Comparative effectiveness of low-molecular-weight heparins versus other anticoagulants in major orthopaedic surgery: a systematic review and meta-analysis. Pharmocotherapy. 2012;32(9):799–808.40. Carpintero P, Caeiro JR, Carpintero R, Morales A, Silva S, MesaM. Complications of hip fractures: a review. World J Orthop.2014;5(4):402–11.41. Hedström M, Ljungqvist O, Cederholm T. Metabolism andcatabolism in hip fracture patients: nutritional and anabolic inter-vention—a review. Acta Orthop. 2006;77(5):741–7.42. Keehan R, Rees D, Kendrick E, Bradshaw C, Flavell E,Deglurkar M. Enhanced recovery for fractured neck of femur: a report of 3 cases. Geriatr Orthop Surg Rehabil. 2014;5(2):37–42.doi:10.1177/2151458513520167.Recommendations on hip fractures43. Kiel DP, et al. Efficacy of a hip protector to prevent hip fracturein nursing home residents: the HIP PRO randomized controlled trial. JAMA. 2007;298:413–22.44. Queally JM, Kiernan C, Shaikh M, Rowan F, Bennett D. Initia-tion of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial. Osteoporos Int. 2013;24(3):1089–94.45. Edwards C, Counsell A, et al. Early infection after hip fracturesurgery. Risk factors, costs and outcome. J Bone Joint Surg Br.2008;90B:770–7.46. Bell K, Strand H, Inder WJ. Effect of a dedicated osteoporosishealth professional on screening and treatment in outpatients presenting with acute low trauma non-hip fracture: a systematic review. Arch Osteoporos. 2014;9(1):167.47. Buehring B, Kirchner E, Sun Z, Calabrese L. The frequency oflow muscle mass and its overlap with low bone mineral den-sity and lipodystrophy in individuals with HIV-a pilot study using DXA total body composition analysis. J Clin Densitom.2012;15(2):224–32.48. Binkley N, Krueger D, Buehring B. What’s in a namerevisited:should osteoporosis and sarcopenia be considered components of “dysmobility syndrome”? Osteoporos Int.2013;24(12):2955–9.。