Preliminary Application Of Evidence-based Medicine In Making Treatment-Decision Of Intertrochanteric Femoral Fracture

Objective To preliminary disscus the application and the significance of evidence-based medicine(EBM) principle and methods in the treatmentMethod According to the methods and steps of practizing EBM, the problems which need to be solved in clinic were put forward as follow : 1. operative treatment or conservative treatment; 2. evaluation of internal fixation methods; 3. the necessity of pre-operative traction; 4. medicines and methods of preventing deep vein thrombosis; 5. The significance of preventing infection after operations; 6. Functions of vitamin D and Calcium in preventing and curing hip fractures. Then, the best evidence is inquired in Cochrane review and the best evidence-based guideline made by New Zealand guidelines Group (NZGG). Finally, according to the three associated principles of evidence-based medicine (the best evidence, individual clinical expertise, patients'predicaments), the evidence is used to direct treatment decision-making.There were 35 patients with intertrochanteric femoral fractures. Their Evans types improved by Jensen-Michaelsen: Type IA 2, Type IB 4, Type IIA 8, Type IIB 12, Type III 9. 15 patients out of them with osteoporosis. All the cases were treated individually according to the EBM principle and were followed up after treatment. The patients'hip founction was evaluated with Merli D'Aubigne criterion improved by Kuderna. At the same time, the hip joint founction, the time of hospitalization, economy and the patients'satisfaction rates were observed and compared.Evidence-based results 1. Compared with sliding hip screws, external fixators and condylocephalic nails, especially Ender nails, were not appropriate for intertrochanteric femoral fractures any longer. 2. Compared with cephalocondylic nails, especially Gamma nails, DHS is obviously advanced in intertrochanteric femoral fractures. 3. There was insufficient evidence that could prove which was more suitable between replacement arthroplasty and internal fixation. But the limited evidence showed that replacement arthroplasty appropriated for unstable fractures. It could not be seen which was better between hemiarthroplasty and total hip replacement. 4. It was not necessary to use pre-operative traction. 5. Heparin and low molecular weight heparin could be used to prevent deep vein thrombosis following surgery for hip fractures. 6. Prophylaxis with ceftriaxone is a cost-effective intervention. 7. Vitamin D and calcium can marginally reduce the risk of hip fractures and they should be taken every day.Clinical Results Directed by EBM, the 35 cases received different treatments on the basis of their individual disease in three groups. In the DHS group, among 24 cases, there were no cases of broken internal fixators and fracture nonunion; no cases of death; lung infection in two cases; heart disease in one case; worn-off femoral neck by screw in one case. The average time of hospitalization was 22 days. During this period, the rate of coxa vara was 4.1%; the average cost was RMB 17,000; the rate of the patients'satisfaction was 98%; The excellent and good rate was 91.6%. Arthroplasty in five cases; no complications caused by staying in bed; no dislocation of hip, no prosthesis loosing,no peri-prosthesis fracture;the average time of hospitalization was 14 days. During this period, no case of coxa vara; the average cost was RMB 35,000; the rate of the patients'satisfaction was 100%; The excellent and good rate was 100%. Six cases in traction group,; one case dead of kidney failure; disagreement with operation in one case, which died after two months; the average time of hospitalization was 82 days. During this period, the rate of coxa vara was 50%; the average cost was RMB 23,000; the patients'satisfaction rate was 98%; The excellent and good rate was 33.3%.Conclusion Appling the EBM principle and method to make the surgical decision of intertrochanteric femoral fractures can not only avoid the current trend of making clinical decision by clinical experience , ignoring patients'humanity psychology in traditional medical model, but also can perform individuation treatment for different patients to realize their most benefit. In addition, waste of medical resources can be avoided; economic load of patients and their relatives can be lightened; all this can do benefit to improving doctor-patient relationships.