Evidence-Based Treatment for an Elderly Patient with Intertrochanteric Fractures_Chinese Journal of Evidence-Based Medicine

Authors：

DENG Zhouming ,  CAI Lin

Department of Orthopedics, Zhongnan Hospital, Wuhan University, Wuhan 430071, China;

Corresponding author：

CAI Lin, Email: guke3224@yahoo.com.cn

Keywords：

Elderly patient; Intertrochanteric fracture; Evidence-based treatment

DOI：

10.7507/1672-2531.20100533

Video：

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

Citation： DENG Zhouming,CAI Lin. Evidence-Based Treatment for an Elderly Patient with Intertrochanteric Fractures. Chinese Journal of Evidence-Based Medicine, 2010, 10(8): 1004-1008. doi: 10.7507/1672-2531.20100533 Copy

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2.	杨学宁, 吴一龙. 临床证据水平分级和推荐级别. 循证医学, 2003, 3(2): 111-113.
3.	米登海, 姜雷, 杨克虎, 等. 一例广泛期小细胞肺癌的循证治疗. 中国循证医学杂志, 2009, 9(4): 4884-4488.
4.	Scottish intercollegiate guideline network management of hip fracture in older people. scottish intercollegiate guideline network 2009 (cited 2009 dec 29 ). Available from :URL : http://www.sign. ac.uk/pdf/sign111.pdf.
5.	Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev, 2008(3): CD000337.
6.	Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2008, (3): CD000093.
7.	Ding XF, Pei GX, Lin J, et al. [Postoperative implant-related complications after treatment of intertrochanteric fracture by gamma nail or by sliding hip screw: a meta-analysis]. Zhonghua Yi Xue Za Zhi, 2008, 88(33): 2364-2368.
8.	刘嵬, 雪原, 赵宏, 等. 我国高龄不稳定型转子问骨折经人工关节置换术与内固定术治疗的Meta分析. 天津医科大学学报, 2009, 15(1): 70-73.
9.	Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2006, (2): CD000086.
10.	Parker MJ, Handoll HH. Extramedullary fixation implants for extracapsular hip fractures. Cochrane Database Syst Rev, 2002, (2): CD000339.
11.	Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies. Injury, 1999, 30(3): 157-163.
12.	Parker MJ, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev, 2007, (3): CD001825.
13.	Clifton R, Haleem S, McKee A, et al. Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials. Int Orthop, 2008, 32(6): 723-727.
14.	Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth, 2008, 55(3): 146-154.
15.	Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am, 2008, 90(7): 1436-1442.
16.	Southwell-Keely JP, Russo RR, March L, et al. Antibiotic prophylaxis in hip fracture surgery: a meta analysis. Clin Orthop Relat Res, 2004, (419): 179-184.
17.	Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev, 2001, (1): CD000244. .
18.	中华医学会. 中国骨科大手术静脉血栓栓塞症预防指南. 中华骨科杂志, 2009, 29(6): 602-604.
19.	Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med, 2007, 146(3): 204-210.
20.	Segal JB SM, Hofmann LV, Thornton K, et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med, 2007, 146(3): 211-222.
21.	Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev, 2006, (4): CD001880.
22.	Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg, 2006, 76(7): 607-611.

1. Guyatt GH, Rennie D, Editors. The Evidence-Based Medicine Working Group.Users’Guides to the Medical literature:A Mannual for Evidence-Based Clinical Practice. Chicago. AMA Press 2002.
2. 杨学宁, 吴一龙. 临床证据水平分级和推荐级别. 循证医学, 2003, 3(2): 111-113.
3. 米登海, 姜雷, 杨克虎, 等. 一例广泛期小细胞肺癌的循证治疗. 中国循证医学杂志, 2009, 9(4): 4884-4488.
4. Scottish intercollegiate guideline network management of hip fracture in older people. scottish intercollegiate guideline network 2009 (cited 2009 dec 29 ). Available from :URL : http://www.sign. ac.uk/pdf/sign111.pdf.
5. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev, 2008(3): CD000337.
6. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2008, (3): CD000093.
7. Ding XF, Pei GX, Lin J, et al. [Postoperative implant-related complications after treatment of intertrochanteric fracture by gamma nail or by sliding hip screw: a meta-analysis]. Zhonghua Yi Xue Za Zhi, 2008, 88(33): 2364-2368.
8. 刘嵬, 雪原, 赵宏, 等. 我国高龄不稳定型转子问骨折经人工关节置换术与内固定术治疗的Meta分析. 天津医科大学学报, 2009, 15(1): 70-73.
9. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2006, (2): CD000086.
10. Parker MJ, Handoll HH. Extramedullary fixation implants for extracapsular hip fractures. Cochrane Database Syst Rev, 2002, (2): CD000339.
11. Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies. Injury, 1999, 30(3): 157-163.
12. Parker MJ, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev, 2007, (3): CD001825.
13. Clifton R, Haleem S, McKee A, et al. Closed suction surgical wound drainage after hip fracture surgery: a systematic review and meta-analysis of randomised controlled trials. Int Orthop, 2008, 32(6): 723-727.
14. Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth, 2008, 55(3): 146-154.
15. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am, 2008, 90(7): 1436-1442.
16. Southwell-Keely JP, Russo RR, March L, et al. Antibiotic prophylaxis in hip fracture surgery: a meta analysis. Clin Orthop Relat Res, 2004, (419): 179-184.
17. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev, 2001, (1): CD000244. .
18. 中华医学会. 中国骨科大手术静脉血栓栓塞症预防指南. 中华骨科杂志, 2009, 29(6): 602-604.
19. Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med, 2007, 146(3): 204-210.
20. Segal JB SM, Hofmann LV, Thornton K, et al. Management of venous thromboembolism: a systematic review for a practice guideline. Ann Intern Med, 2007, 146(3): 211-222.
21. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev, 2006, (4): CD001880.
22. Oldmeadow LB, Edwards ER, Kimmel LA, et al. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg, 2006, 76(7): 607-611.

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