术后早期应用唑来膦酸对骨质疏松性股骨转子间骨折高龄患者预后的影响

doi:10.3969/j.issn.1674-8115.2024.07.010

摘要/Abstract

摘要：

目的·探究在接受防旋股骨近端髓内钉（proximal femoral nail antirotation，PFNA）手术治疗的骨质疏松性股骨转子间骨折高龄患者中，术后早期应用唑来膦酸对骨折愈合的影响，以及其他可能的相关因素。方法·回顾性分析2016年1月至2022年2月于上海交通大学医学院附属瑞金医院行PFNA手术的80岁及以上的股骨转子间骨折患者174例，根据术后是否早期接受唑来膦酸治疗将患者分为实验组（n=26）和对照组（n=148），所有患者完成术后6周和12周2次随访。运用倾向性评分匹配（propensity score matching，PSM）法将实验组与对照组患者按照1∶3的比例进行匹配，匹配因素包括年龄、性别、骨折分型以及体质量指数（body mass index，BMI）。比较2组患者匹配后的一般资料，以及2次随访时的骨折愈合和功能恢复情况。采用Logistic回归分析探究患者术后12周骨折愈合的相关因素。结果·PSM法匹配后得到实验组患者25例和对照组患者65例，2组患者一般资料间差异均无统计学意义。实验组患者术后6周和12周的骨折愈合率分别为16.0%和96.0%，均显著高于对照组（分别为1.5%和73.8%，均P<0.05）；实验组患者术后12周时Harris髋关节功能评分显著高于对照组（P=0.019）。Logistic回归分析结果显示，良好的手术复位（OR=12.52，95%CI 2.67~58.74，P=0.001）、术后早期使用唑来膦酸（OR=10.14，95%CI 1.01~102.09，P=0.049）和更高的血清白蛋白水平（OR=1.15，95%CI 1.02~1.29，P=0.025）为骨折愈合的促进因素，而不稳定型骨折（OR=0.10，95%CI 0.03~0.31，P=0.000）为不利因素。结论·对于接受PFNA手术的骨质疏松性股骨转子间骨折高龄患者，术后早期使用唑来膦酸可以促进骨折愈合且使患者获得更好的功能恢复；除此之外良好的术中复位、更高的血清白蛋白水平是促进骨折愈合的有利因素，而不稳定型骨折为骨折愈合的阻碍因素。

关键词: 股骨转子间骨折, 唑来膦酸, 骨质疏松, 高龄

Abstract:

Objective ·To investigate the effect of early postoperative administration of zoledronic acid on fracture healing and functional recovery in elderly patients with osteoporotic femoral intertrochanteric fracture treated with proximal femoral nail antirotation (PFNA) surgery, and explore other potential prognostic factors. Methods ·A total of 174 patients with femoral intertrochanteric fractures of 80 years old or above who underwent PFNA treatment in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from January, 2016 to February, 2022, were divided into experimental group (n=26) and control group (n=148) according to whether they received zoledronic acid early after surgery. All patients were followed up twice at 6 weeks and 12 weeks after surgery. The patients in the experimental group were matched with the control group by propensity score matching (PSM) at a ratio of 1:3 (the matching factors included age, gender, fracture type, and body mass index). General characteristics, as well as fracture healing and functional recovery at the two follow-up visits were compared between the two groups after matching. Subsequently, Logistic regression was used to explore the potential prognostic factors on fracture healing at 12 weeks after surgery. Results ·PSM resulted in 25 patients in the experimental group and 65 patients in the control group, and there were no statistically significant differences in baseline characteristics between the two groups. The fracture healing rates at 6 weeks and 12 weeks after surgery in the experimental group (16.0% and 96.0%, respectively) were higher than those in the control group (1.5% and 73.8%), and the differences were statistically significant (P<0.05). Harris hip function score in the experimental group at 12 weeks was significantly higher than that of the control group (P=0.019). The results of Logistic regression analysis showed that good surgical reduction (OR=12.52, 95%CI 2.67?58.74, P=0.001), early postoperative administration of zoledronic acid (OR=10.14, 95%CI 1.01?102.09, P=0.049), and higher serum albumin level (OR=1.15, 95%CI 1.02?1.29, P=0.025) were the favorable factors of early fracture healing, while unstable fracture (OR=0.10, 95%CI 0.03?0.31, P=0.000) was the unfavorable factor. Conclusion ·For elderly patients with osteoporotic intertrochanteric femoral fractures treated with PFNA surgery, early postoperative administration of zoledronic acid can promote fracture healing and lead to better functional recovery; in addition, good surgical reduction and higher serum albumin levels are favorable factors for fracture healing, whereas unstable fracture presents as a hindrance to the healing process.

Key words: femoral intertrochanteric fracture, zoledronic acid, osteoporosis, elderly

中图分类号:

R683.42

王北辰, 杨耀琦, 鲍其远, 温竣翔, 张伟滨, 万荣. 术后早期应用唑来膦酸对骨质疏松性股骨转子间骨折高龄患者预后的影响[J]. 上海交通大学学报（医学版）, 2024, 44(7): 891-898.

WANG Beichen, YANG Yaoqi, BAO Qiyuan, WEN Junxiang, ZHANG Weibin, WAN Rong. Effect of early postoperative administration of zoledronic acid on the prognosis of osteoporotic femoral intertrochanteric fracture in patients with advanced ages[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(7): 891-898.

图/表 4

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Characteristic	Before PSM (n=174)			After PSM (n=90)
Characteristic	ZA group (n=26)	Control group (n=148)	P value	ZA group (n=25)	Control group (n=65)	P value
Age/year	83.5 (80.8, 87.2)	87.0 (84.0, 90.0)	0.002	84.0 (81.0, 87.0)	85.0 (82.0, 87.5)	0.418
Gender/n(%)			0.438			0.952
Male	18 (69.2)	113 (76.4)		18 (72.0)	49 (75.4)
Female	8 (30.8)	35 (23.6)		7 (28.0)	16 (24.6)
BMI/(kg·m^-2)	21.9 (18.9, 24.0)	21.3 (18.7, 23.4)	0.893	21.8 (18.9, 23.9)	20.8 (18.3, 23.4)	0.975
Fracture classification/n(%)			0.299			1.000
Stable fracture	19 (73.1)	124 (83.8)		19 (76.0)	50 (76.9)
Unstable fracture	7 (26.9)	24 (16.2)		6 (24.0)	15 (23.1)
Multiple fractures/n(%)			0.785			0.973
Yes	5 (19.2)	22 (14.9)		5 (20.0)	11 (16.9)
No	21 (80.8)	126 (85.1)		20 (80.0)	54 (83.1)
Surgical reduction/n(%)			0.103			0.101
Good	15 (57.7)	60 (40.5)		14 (56.0)	24 (36.9)
Acceptable	11 (42.3)	88 (59.5)		11 (44.0)	41 (63.1)
Bone density/n(%)			0.071			0.285
Osteoporosis	18 (69.2)	127 (85.8)		18 (72.0)	55 (84.6)
Osteopenia	8 (30.8)	21 (14.2)		7 (28.0)	10 (15.4)
Diabetes/n(%)			0.315			0.178
Yes	8 (30.8)	61 (41.2)		8 (32.0)	31 (47.7)
No	18 (69.2)	87 (58.8)		17 (68.0)	34 (52.3)
Cardio-cerebral vascular events/n(%)			0.671			0.371
Yes	12 (46.2)	75 (50.7)		12 (48.0)	38 (58.5)
No	14 (53.8)	73 (49.3)		13 (52.0)	27 (41.5)
LLDVT/n(%)			0.891			0.543
Yes	6 (23.1)	36 (24.3)		5 (20.0)	17 (26.2)
No	20 (76.9)	112 (75.7)		20 (80.0)	48 (73.8)
Hb/(g·L^-1)	111.5 (97.5, 120.8)	103.5 (89.0, 117.8)	0.100	112.0 (96.0, 121.5)	108.0 (87.0, 121.0)	0.322
Alb/(g·L^-1)	34.5 (32.8, 37.3)	34.0 (31.0, 36.0)	0.071	35.0 (33.0, 37.5)	35.0 (32.0, 36.5)	0.198

Characteristic	Before PSM (n=174)			After PSM (n=90)
Characteristic	ZA group (n=26)	Control group (n=148)	P value	ZA group (n=25)	Control group (n=65)	P value
Age/year	83.5 (80.8, 87.2)	87.0 (84.0, 90.0)	0.002	84.0 (81.0, 87.0)	85.0 (82.0, 87.5)	0.418
Gender/n(%)			0.438			0.952
Male	18 (69.2)	113 (76.4)		18 (72.0)	49 (75.4)
Female	8 (30.8)	35 (23.6)		7 (28.0)	16 (24.6)
BMI/(kg·m^-2)	21.9 (18.9, 24.0)	21.3 (18.7, 23.4)	0.893	21.8 (18.9, 23.9)	20.8 (18.3, 23.4)	0.975
Fracture classification/n(%)			0.299			1.000
Stable fracture	19 (73.1)	124 (83.8)		19 (76.0)	50 (76.9)
Unstable fracture	7 (26.9)	24 (16.2)		6 (24.0)	15 (23.1)
Multiple fractures/n(%)			0.785			0.973
Yes	5 (19.2)	22 (14.9)		5 (20.0)	11 (16.9)
No	21 (80.8)	126 (85.1)		20 (80.0)	54 (83.1)
Surgical reduction/n(%)			0.103			0.101
Good	15 (57.7)	60 (40.5)		14 (56.0)	24 (36.9)
Acceptable	11 (42.3)	88 (59.5)		11 (44.0)	41 (63.1)
Bone density/n(%)			0.071			0.285
Osteoporosis	18 (69.2)	127 (85.8)		18 (72.0)	55 (84.6)
Osteopenia	8 (30.8)	21 (14.2)		7 (28.0)	10 (15.4)
Diabetes/n(%)			0.315			0.178
Yes	8 (30.8)	61 (41.2)		8 (32.0)	31 (47.7)
No	18 (69.2)	87 (58.8)		17 (68.0)	34 (52.3)
Cardio-cerebral vascular events/n(%)			0.671			0.371
Yes	12 (46.2)	75 (50.7)		12 (48.0)	38 (58.5)
No	14 (53.8)	73 (49.3)		13 (52.0)	27 (41.5)
LLDVT/n(%)			0.891			0.543
Yes	6 (23.1)	36 (24.3)		5 (20.0)	17 (26.2)
No	20 (76.9)	112 (75.7)		20 (80.0)	48 (73.8)
Hb/(g·L^-1)	111.5 (97.5, 120.8)	103.5 (89.0, 117.8)	0.100	112.0 (96.0, 121.5)	108.0 (87.0, 121.0)	0.322
Alb/(g·L^-1)	34.5 (32.8, 37.3)	34.0 (31.0, 36.0)	0.071	35.0 (33.0, 37.5)	35.0 (32.0, 36.5)	0.198

Follow-up index	Before PSM (n=174)			After PSM (n=90)
Follow-up index	ZA group (n=26)	Control group (n=148)	P value	ZA group (n=25)	Control group (n=65)	P value
Healed 6 weeks after surgery/n(%)			0.000			0.030
Yes	4 (15.4)	1 (0.7)		4 (16.0)	1 (1.5)
No	22 (84.6)	147 (99.3)		21 (84.0)	64 (98.5)
Healed 12 weeks after surgery/n(%)			0.022			0.019
Yes	25 (96.2)	113 (76.4)		24 (96.0)	48 (73.8)
No	1 (3.8)	35 (23.6)		1 (4.0)	17 (26.2)
Household ambulatory ability 6 weeks after surgery/n(%)			0.015			0.074
Yes	21 (80.8)	82 (55.4)		20 (80.0)	39 (60.0)
No	5 (19.2)	66 (44.6)		5 (20.0)	26 (40.0)
Harris score 12 weeks after surgery/point	86.0 (82.0, 91.0)	81.0 (75.3, 88.0)	0.001	86.0 (82.0, 91.0)	82.0 (77.0, 88.0)	0.019

Follow-up index	Before PSM (n=174)			After PSM (n=90)
Follow-up index	ZA group (n=26)	Control group (n=148)	P value	ZA group (n=25)	Control group (n=65)	P value
Healed 6 weeks after surgery/n(%)			0.000			0.030
Yes	4 (15.4)	1 (0.7)		4 (16.0)	1 (1.5)
No	22 (84.6)	147 (99.3)		21 (84.0)	64 (98.5)
Healed 12 weeks after surgery/n(%)			0.022			0.019
Yes	25 (96.2)	113 (76.4)		24 (96.0)	48 (73.8)
No	1 (3.8)	35 (23.6)		1 (4.0)	17 (26.2)
Household ambulatory ability 6 weeks after surgery/n(%)			0.015			0.074
Yes	21 (80.8)	82 (55.4)		20 (80.0)	39 (60.0)
No	5 (19.2)	66 (44.6)		5 (20.0)	26 (40.0)
Harris score 12 weeks after surgery/point	86.0 (82.0, 91.0)	81.0 (75.3, 88.0)	0.001	86.0 (82.0, 91.0)	82.0 (77.0, 88.0)	0.019

Factor	OR	95%CI	P value
Gender (male vs female)	1.46	0.59‒3.63	0.412
Age	0.96	0.88‒1.04	0.310
BMI	1.02	0.94‒1.12	0.584
Fracture classification (unstable vs stable)	0.09	0.04‒0.21	0.000
Multiple fractures (yes vs no)	1.60	0.52‒4.96	0.420
Surgical reduction (good vs acceptable)	19.09	4.41‒82.60	0.000
Bone density (osteoporosis vs osteopenia)	1.00	0.37‒2.68	1.000
Diabetes (yes vs no)	0.90	0.43‒1.90	0.900
Cardio-cerebral vascular events (yes vs no)	1.00	0.48‒2.08	1.000
LLDVT (yes vs no)	1.14	0.48‒2.75	0.763
Hb	1.02	1.00‒1.04	0.049
Alb	1.13	1.04‒1.24	0.004
Use of zoledronic acid (yes vs no)	7.74	1.01‒59.22	0.049