探討不穩定型轉子間骨折術後立即承重之急性後期照護計畫之成效

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Title:	探討不穩定型轉子間骨折術後立即承重之急性後期照護計畫之成效 Investigation of the Effects of an Early Mobilization Post Acute Care Program for Unstable Intertrochanteric Fracture
Authors:	李家媛;Jia-Yuan Li
Contributors:	物理治療學系復健科學碩士班
Keywords:	不穩定型轉子間骨折;術後立即承重;Unstable Intertrochanteric Fracture;Early Mobilization
Date:	2019-07-15
Issue Date:	2019-11-11
Publisher:	中國醫藥大學
Abstract:	背景：高齡轉子間骨折患者術後將面臨很大程度的失能結果。儘管有許多證據顯示術後早期(48小時內)承重能夠增加患者功能性活動以減少後續失能所導致的問題，但此流程仍未達到一個明顯的共識，因為有部分學者認為早期承重可能會增加手術失敗的風險。因此不穩定型轉子間骨折患者術後是否能即早進行承重訓練仍存在很多爭議。豐原醫院目前對於不穩定型轉子間骨折(AO/OTA 31A2,A3 )患者術後復健流程採用較保守方式，部分臨床醫師因擔憂會有機械性失敗及突出的問題主張在術後四週才能進行部分承重訓練(partial weight- bearing exercise)。另一方面，儘管Harris Hip Score(HHS)以及Barthel Index皆為臨床上常使用於髖關節的功能性量表，但是目前並無文獻探討這兩個量表是否適用於評估轉子間骨折患者術後功能性動作的恢復。然而，隨著未來轉子間骨折的發生率逐年增加，找出適合這類族群的評估表可以幫助臨床工作者在執行工作內容時有更好的醫療品質及效率。目的： 1) 探討不穩定型轉子間骨折患者術後進行提早承重訓練，對於功能性結果的影響。 2) 分析、比較兩種常見的功能性量表(HHS以及Barthel Index)是否適用於評估轉子間骨折患者術後功能性動作的恢復。假設： 1) 研究假設提早進行承重訓練族群比限制承重族群會有較好的功能性結果。 2) HHS比起Barthel Index較能夠精準表現出此類型骨折患者的能力。設計：本實驗使用量性(quantitative)的準實驗性(quasi- experimental)研究設計。方法：29位不穩定型轉子間骨折患者(65歲以上)被招募到此計畫案中並持續追蹤至術後六個月。患者在入院時即收集各項資料，包括年齡、性別以及骨折側。手術後這些患者被分配至早期承重組(Early Weight Bearing group)術後可立即接受承重訓練或控制組(Control group)術後四週才能進行部分承重。並且在每個時間點利用HHS、Barthel Index以及5- point Verbal Rating Scale(5- point VRS) 來評估患者的功能。結果：根據在所有時間點都有資料的患者進行統計分析(早期承重組:5人; 控制組:6人)，在介入前兩組之間無人口統計學上的差異。HHS的結果顯示早期承重組比起控制組在術後三個月的功能表現上明顯較好(p=0.05)。而在組內比較的部分，不論是控制組或早期承重組從Baseline到術後三個月功能都有顯著進步(p=0.043, p=0.028)。Barthel Index則因為有部分項目與下肢功能較無相關，因此將這些項目移除(進食、梳洗、排便控制以及排尿控制)，結果顯示早期承重組跟控制組比起來在術後三個月的功能明顯較好(p=0.017)。組內相比結果則僅有早期承重組從Baseline到術後三個月功能有顯著增加(p=0.027)。5- point VRS的結果則顯示僅有早期承重組從Baseline到術後三個月在疼痛方面獲得顯著改善(p=0.026)，控制組則沒有。結論：本研究結果顯示，雖然開刀後不論是否有進行早期承重訓練，因為手術本身具有一定療效因此兩組在手術後都有功能性進步。但是以術後半年內的成效來看進行早期承重訓練的這些轉子間骨折患者仍有比較好的功能性表現。而在量表比較的部分，HHS仍然是一個較Barthel Index精準的測量方式。 Background and Purpose: Geriatric patients with unstable intertrochanteric (ITC) fracture are at risk of high mortality and permanent disability even surgery. Although extensive evidence has suggested that mobilization should begin within 48 hours post operatively, such practice isn’t consistent clinically, due to some concerns of hardware failure associated with early weight bearing. This has led to an area of heated debate regarding the post- operative rehabilitation of unstable ITC fracture patients. Besides, it remains uncertain about which of the following hip functional scales (HHS and Barthel Index) are able to evaluate the functional abilities of the ITC fracture patients precisely. Since both functional scales weren’t originally design for the use of intertrochanteric fracture, according to previous researches there were some inappropriate items for these specific patients. The aim of this study was therefore to investigate the effects of early mobilization within 2- weeks post unstable ITC fracture surgery and determine which functional scale is more suitable in evaluating post-operative functional abilities in Feng- Yuan Hospital. Methods: 28 unstable ITC fracture (using AO/OTA classification system) patients (65 years or older) were enrolled and followed for 6 months. Patients were allocated to either the Early Weight Bearing group (experimental group) which involved immediate weight bearing interventions or Usual Care Program (control group) which allowed only partial weight bearing starting 4- week after surgery. The outcome measurements were the change in HHS, Barthel index and 5- point VRS . Results: 10 of the participants were included in the Early Weight Bearing group. Demographics were similar between groups. Statistical analyses were based on non-missing data. The HHS identified a better recovery of the Early Weight Bearing group at 3 months after the surgery (p=0.05), although both groups showed a significant improvement post- operatively at 3 months (p=0.043, p=0.028). However, the factor structure of Barthel Index depends upon the different types of patients. There are several items that may not be influenced by a hip fracture. Thus, we remove items of grooming, feeding, bowel and bladder control which was previously reported for the poor association of evaluating lower limb function. The subgroup analysis of modified Barthel Index result showed significantly difference between Early Weight Bearing group and Control group at 3 months after surgery (p=0.017), but only Early Weight Bearing group has reached statistically significant improvement from baseline to 3 months post-operatively (p=0.027) . As for the post- operative pain, only EWB group had significantly ameliorated from baseline to post- op 3 month. Conclusion: For unstable Intertrochanteric postoperative rehabilitation program, early weight bearing yielded observable improvements in both HHS and modified Barthel index compared to the control group and such protocol should be implemented clinically.
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