Get Started. It's Free
or sign up with your email address
大腿骨転子部骨折歩行能力 by Mind Map: 大腿骨転子部骨折歩行能力

1. Intro

1.1. 股関節骨折の発生率は高齢化社会の中で増加しつづけています。

1.1.1. The number of hip fractures is expected to increase approximately 2.3 times between 2018 and 2050, with 260,000 fractures expected to occur annually. The direct costs of hip fractures will increase from US$9.5 billion in 2018 to US$15 billion in 2050, an increase of about 1.6 times. The incidence of hip fracture has continued to increase among the ageing population.1,2 1. Johnell O, Kanis J. Epidemiology of osteoporotic fractures. 2. Sambrook P, Cooper C. Osteoporosis. Lancet 2006;367:2010-8. We show that the number of hip fracture will increase from 1,124,060 in 2018 to 2,563,488 in 2050, a 2.28-fold increase. This increase is mainly due to the changes on the population demographics, especially in China and India, which have the largest population size. The direct cost of hip fracture will increase from 9.5 billion United State dollar (USD) in 2018 to 15 billion USD in 2050, resulting a 1.59-fold increase. A 2%-3% decrease in incidence rate of hip fracture annually is required to keep the total number of hip fracture constant over time.

1.1.2. 1. Johnell O, Kanis J. Epidemiology of osteoporotic fractures.

1.1.3. 2. Sambrook P, Cooper C. Osteoporosis. Lancet 2006;367:2010-8.

1.1.4. (Cheung et al., 2018)

1.2. <骨粗鬆症性股関節骨折は死亡率上昇・機能低下・コスト上昇につなながる。社会的重要性>

1.2.1. Osteoporotic hip fracture is a significant health problem due to increased mortality, morbidity, and functional impact in these patients (only 30–40% of these patients recover their previous functional status) [1, 2,] as the economic cost for the National Health System. O’Neill TW, Roy DK. How many people develop fractures with what outcome? Best Pract Res Clin Rheumatol. 2005;19:879–8955. Cree M, Soskolne CL, Belseck E, Hornig J, McElhaney JE, Brant R, SuarezAlmazor M. Mortality and institutionalization following hip fracture. J Am Geriatr Soc. 2000;48:283–8.

1.2.2. The enormous costs of patient care due to the loss of walking ability after a fracture can be more burdensome than the mortality issue. Therefore, minimizing the loss of functional ability after hip fracture is a significant health economic challenge.[5] 5.PMID: 21918484 J Orthop Trauma. 2012 Naoshi Fukui

1.3. ファンクショナルアウトカムについて調べた研究がたくさんある

1.3.1. Several studies have attempted to identify determinants of functional outcome after hip fracture in the elderly.

1.4. 機能的予測因子として、年齢、性別、骨折前の居住地、退院時の機能状態などいくつかの因子が術後機能的転帰の予測因子として、明らかになっている。

1.4.1. Several predictors of functional outcome have been detected, including age, gender, prefracture residence, and functional status at hospital discharge. Despite these limitations, several predictors of functional outcome have been delineated, including age, gender, prefracture residence, and functional status at hospital discharge. Interestingly, a number of studies found no relationship between the type of implant and functional recovery at one year. 2,6,9,12,29,38 The following factors before or at the time of fracture have been associated with a decline in ADL at 6 months, 1 year, or 2 years after surgery: age5-8 ; ADL5,8-10 ; living in an institution at the time of injury6,8 ; the ability to shop for self or the degree of independent walking7,11 ; type of fracture7 ; concomitant diseases12,13 ; and cognitive impairment. 5,13 Predictors after fracture include a shorter hospital stay, 12 poor functional status,6,11 poor mental status, 7,10 poor physical health, 7 need for a caregiver at discharge, 14 emotional support at 1 month after discharge, 15 impaired cognitive functioning, 16 and fear of falling16 assessed 6 weeks after surgery. factors before or at the time of fracture ADL低下に関連する受傷時因子 Predictors after fracture

1.5. <股関節骨折患者の多様性>

1.5.1. These fractures usually occur in elderly people who are the heterogenous group. Many of them already have some comorbidities and loss of physical functioning, including loss of mobility and self­care. 3. Ioannidis G, Jantzi M, Bucek J, Adachi JD, Giangregorio L, Hirdes J, Pickard L, Papaioannou A (2017) Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study. BMJ Open 7(9):e016477 4. Maharlouei N, Khodayari M, Forouzan F, Rezaianzadeh A, Lankarani KB (2014) The incidence rate of hip fracture in Shiraz, Iran during 2008–2010. Arch Osteoporos 9(1):165 In general, most evaluated populations were heterogenous with respect to prefracture health status, living situation, and mental health.

1.6. 術前の歩行能力がアウトカムに与える影響

1.6.1. The prefracture ability of mobility could significantly affect the outcome. PMID: 21918484 J Orthop Trauma. 2012 Naoshi Fukui

1.7. 頸部骨折と転子部骨折の間にも患者特性に違いがある

1.7.1. tomoo

1.8. しかし、多くの研究では、転子部骨折と頸部骨折が同時に検討されている。

1.8.1. However, in most of these references, both intracapsular and extracapsular fractures have been analyzed together. Moreover, nearly all reports were based on combined analyses of both intracapsular (femoral neck) and extracapsular (intertrochanteric) fractures.12,14,21,22,28,29,38,41,42

1.9. 3.Clinical and functional outcomes of internal fixation with intertrochanteric antegrade nail in older patients with proximal extracapsular femoral fractures

1.10. 本研究の目的は、対象を大腿骨転子部骨折に対し髄内釘で手術を行った患者に絞り、機能的転帰の決定因子を探ることであった。 本論文では、患者の術後3ヶ月時の機能的転帰を予測する統計モデルを開発した。 私たちの知る限りでは、私たちの予測モデルは、髄内釘で手術を行った大腿骨転子部骨折患者に対する初めてのものである。 大腿骨転子部骨折に対する髄内釘手術は世界的に標準的な日常臨床で広く使用されている治療法である。

1.10.1. The objective of our prospective study was to explore the determinants of functional outcome in patients operated on with intramedullary nails for extracapsular femoral fractures. In this paper, we developed a statistical model to predict the functional outcome of patients at 3 months postoperatively. To the best of our knowledge, our predictive model is the first of its kind for patients with femoral metaphyseal fractures operated on with intramedullary nails. Intramedullary nail surgery for femoral extracapsular fractures is a widely used treatment method in standard daily practice worldwide.1.2.3. The objective of our prospective study was to document functional outcome one year after intracapsular hip fracture, and to explore determinants of functional outcome, including surgical treatment type. In this paper, we developed statistical models to predict functional outcome at one year in women with an intracapsular hip fracture. To our knowledge, our predictive models are the first to include total hip arthroplasty, internal fixation and hemiarthroplasty, currently three widely used treatment options in standard day-to-day clinical practice, worldwide.5,17,23,25,26,27,31,33,39 1.Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies 2.Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis

2. abstract

2.1. Design: A retrospective observational cohort study. Setting: From hospital to home Patients:● patients with trochanteric fractures after surgery with intramedullary nailing. Main Outcome Measures: Recovery of ambulatory ability 3months after surgery Interventions: No particular intervention was employed in this study. Results: Conclusions:

3. Discussion

4. Acknowledgements

4.1. 土方先生

4.1.1. We thank Dr. Yasukazu Hijikata for providing the detailed information on the statistical analysis.

5. Title

6. Key Words

6.1. trochanteric fracture, mobility

6.2. intramedullary nailing

6.3. ambulatory ability

6.4. activity of daily living

7. ボトムラインメッセージ

7.1. Thema:髄内釘手術を行った転子部骨折患者の術後3ヶ月歩行能力に対する決定木モデルを作る。

7.2. Message:大腿骨転子部骨折髄内釘手術患者の歩行能力改善には退院時のBI改善が重要である。 Doctors should pay attention to Barthel index in the early postoperative period following intramedullary nailing for trochanteric fractures to regain the walking ability.

7.3. 急性期病院で入院中の間に、得られたデータを基に、転院して積極的にリハビリを受けるのか、積極的リハビリプロトコールに入れる必要はない患者なのかが判断できればいいな。

8. Result

8.1. validation of reproducibility(再現性の担保)

8.2. Table1.

8.2.1. Table 1. Characteristics of study population (n=358)

8.3. Table3.

8.3.1. Table 3. Predictors for declines in ambulatory ability in the independent ambulator group at 3 and 6 months after surgery

8.4. BI単独モデルと、決定木モデルの違い

8.4.1. BI単独より決定木の方がAUCは低い。

8.4.2. 実際の臨床現場でテスト結果から診断を考えるにあたって最も重要な指数はPPVとNPVである。 決定木モデルのほうがすぐれている。

8.4.3. SensitivityがBIより決定木でよい 感度が高い:陰性の結果は疾患が存在する確率が低いことを意味する 陰性であれば、歩ける確率が低いことを意味する

8.4.4. specificityがBI単独がすぐれる。 特異度が高い:陽性の結果は疾患が存在する確率が高い 特異度が低い:陽性の結果がでても、疾患が存在する確率は低い 陽性でも、実際には歩行獲得できない可能性が一定数ある。

8.4.5. NPVは決定木がBIより優れている NPV:陰性の結果が得られた場合、実際に疾患を有しない確率 検査で陰性であれば、3ヶ月でも歩けない可能性が高い。

9. 参考文献・論文

9.1. スコアリング抄読会論文

9.2. 決定木メイン論文

9.2.1. A Clinical Prediction Rule for Declines in Activities of Daily Living at 6 Months after Surgery for Hip Fracture Repair

9.3. デザイン乾論文

9.3.1. Early postoperative Barthel index score and long‑term walking ability in patients with trochanteric fractures walking independently before injury: a retrospective cohort study

10. 参考資料 by 乃利男先生

10.1. 結果から投稿までの道のり 2020/2/14 片岡裕貴

11. ★研究デザイン

11.1. PECO

11.1.1. P:大腿骨転子部骨折AO分類31、髄内釘治療、術前歩行可能(車いす以外) E:術前患者因子:術前合併症(category)、術前歩行レベル(category)、栄養スコア(continous)、筋量(continous)  術中術者因子:整復良し悪し(binary)、 nail長(continous) C: なし O: 術後3M時点での術前と同程度の歩行レベル再獲得有無(binary)

11.2. 目的

11.2.1. 術前と同程度の歩行レベル再獲得に影響する患者因子、術者因子の解明できれば、急性期病院退院時における、患者さんの術後歩行予後の予想に役立つ。

11.2.2. 大腿骨転子部骨折患者における髄内釘手術の整復位・nailの長さと、術後歩行能力の検証

11.3. 今回の研究の強み

11.3.1. 術後の歩行能力に術者が修正可能な因子である、整復位・使用nailの長さを考慮した点。:先行研究がほぼない。 *術後成績のアウトカムを、再手術・破綻率ではなく歩行能力としたこと*

11.4. 対象

11.4.1. 期間 2008年1月から2020年3月.

11.4.2. Inclusion 髄内釘で治療した連続した大腿骨転子部骨折症例 60歳以上 骨折型:AO/OTA AO31すべて F/U期間:術後3か月以上(90日)(術後成績の関係をみるので)

11.4.3. Exclusion 術前歩行能力が車椅子以下 開放骨折、病的骨折、多発骨折(除外数は最終的にpatient flowとして記載するのでその症例数は必要)

11.5. 術前因子検討項目

11.5.1. 患者因子 年齢 高齢者で悪い 性別 女性が悪い:Female more likely poor outcomes 男性が悪い:<受傷前household ambulators>における12ヶ月じ歩行能力、女性の方が良い 身長 文献なし 体重(BMI) 痩せすぎも太り過ぎも悪い

11.5.2. 受傷前居住場所( Residence before injury ) Predictors for ambulatory ability and the change in ADL after hip fracture in patients with different levels of mobility before injury: a 1-year prospective cohort study - PubMed

11.5.3. 術前歩行機能(独歩,杖,歩行器,車いす) 受傷前ADL Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review - PubMed 術前walking aid使用はbasic activetyのdependencyに関与 OR2.0(術後3ヶ月) Prognostic factors for self-rated function and perceived health in patient living at home three months after a hip fracture - PubMed 受傷前歩行機能自立が急性期リハ病院退院時のFIMに影響 Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture - PubMed 病院退院時の杖歩行できていれば、術後6ヶ月、12ヶ月時歩行能力goodに影響。 受傷前入浴自立・受傷前community ambulators は歩行能力に影響。 受傷前household ambulator かどうかは歩行能力に影響しない Predictors for ambulatory ability and the change in ADL after hip fracture in patients with different levels of mobility before injury: a 1-year prospective cohort study - PubMed 受傷前mobility score>7 Mobility after intertrochanteric hip fracture fixation with either a sliding hip screw or a cephalomedullary nail: Sub group analysis of a randomised trial of 1000 patients - PubMed

11.5.4. 採血(Alb、Hb) Alb ・リハ病院退院時FIMに(リハ病院)入院時のAlbが影響 <受傷前household ambulators>における12ヶ月じ歩行能力、受傷時ALB>3.6が良い Hb 入院時Hb高いほうが歩行能力再獲得に良い。受傷前community ambulatorsにおいて術後6ヶ月・1年: weak evidence level but strongest ・anaemia on admission 入院時の貧血の有無は recovery of ambulatory abilityに関係無し。(術後3/6/12ヶ月)

11.5.5. 術前合併症 ASA-PS(ASA physical status) ASA≧3で歩行能力( New Mobility Score (NMS) )良い ASA-PSとは CCI(Charlson Risk Index) CCIに含まれる疾患 パーキンソン病 We assigned Parkinson's disease an inconclusive evidence level. 認知症 Predictors for ambulatory ability and the change in ADL after hip fracture in patients with different levels of mobility before injury: a 1-year prospective cohort study - PubMed 智雄今回研究では:既往歴、カルテ記載があるか持参薬に認知症内服薬があれば認知症有りと診断 3ヶ月時点のADL,IADLに悪影響 退院時FIMに認知症(MMSE)が急性期リハ病院退院時のFIMに影響 受傷前community ambulatorsにおいて認知症は歩行能力低下。 cognition:weak evidence level but strongest 片麻痺(対麻痺も含む。脳血管障害に起因していなくても可) Predictors for ambulatory ability and the change in ADL after hip fracture in patients with different levels of mobility before injury: a 1-year prospective cohort study - PubMed

11.5.6. 術前画像評価 転子部骨折型 CTI (Cortical Thickness Index) 腸腰筋面積

12. 歩行能力関連判定基準等

12.1. ASA-PS(ASA physical status)

12.1.1. ASAリスクファクター別術前診断とは、米国麻酔学会(ASA)による、患者の健康状態に応じた麻酔のリスク分類で、以下のように分類されるもの。 Class I:正常健康患者 Class II:軽度の全身性疾患,軽度の糖尿病,高血圧,慢性気管支炎など,高齢者(70歳以上).新生児,肥満者も含む Class III:中~高度の全身性疾患を有し,日常の活動が制限されている患者 Class IV:生命を脅かす程の全身性疾患を有し,日常の活動が不能である患者 Class V:手術の施行,非施行にかかわらず,24時間以上は延命できそうにない瀕死の患者,救急にはEを数字の後におく

12.2. CCI(Charlson comorbidity index)

12.2.1. 高齢者は併存疾患が多いので、疾患単独の予測式ではなく、複数の併存疾患がある場合の総合した予後予測式が必要だよね?ということから出来たindex

12.2.2. CCIに含まれる疾患 1点 心筋梗塞 うっ血性心不全 末梢血管疾患 脳血管疾患 認知症 慢性肺疾患 膠原病 消化性潰瘍 軽度肝疾患 糖尿病 2点 片麻痺 中等度−高度腎機能障害 糖尿病 固形がん 白血病 リンパ腫 3点 中等度―高度肝機能障害 (門脈圧亢進を伴う肝硬変) 6点 転移性固形癌 AIDS (Aquired immunodeficiency syndrome)

12.2.3. 判定基準 Low:0 Medium:1~2 High:3~4 Very high:≧5


12.4. BI(Barthel Index)バーセルインデックス

13. メ