改良生理学和手术严重度评分系统（POSSUM）预测髋部骨折手术并发症发生率及死亡率的价值
摘要
股骨颈骨折和转子间骨折在骨科临床中是两种常见骨科创伤。尤以老年人发生居多，且发生率随年龄的增长而增多。而老年人多在伤前即患有心、肝、肾等疾病，故并发症发生率及死亡率较一般骨折高。随生活水平提高和平均寿命的延长，上述两种疾病的发生率亦有增高趋势。针对类似上述两种骨折这样的以并发症发生率及死亡率较一般骨折高为特点的病种，我们急需一个可以准确估计术后死亡率及并发症发生率的评分系统来评价手术的结果
现在，许多骨科研究已经逐渐将注意力转移到术后结果的可变性上，尤其是对于像股骨颈骨折及股骨转子间骨折这类术后死亡率及并发症发生率较高的病例，此外关于病例复杂度与手术设备及医师对术后结果影响孰重孰轻一直是争论的焦点。最近一篇报道提醒人们仅仅考虑手术本身因素是不能得到正确结果的，因为患者自身因素也是非常重要的。在1996至1998年间Copeland等人应用与在前文的得到原始POSSUM评分一样的方法得到了适用于骨科系统的POSSUM评分系统，虽然二者中的一些因素及其衡量标准有所不同，但整体的评分模式十分近似。
改良POSSUM评分系统是根据骨科的特点，修改Copeland等提出的原始POSSUM评分系统评估量表中的部分指标：在手术严重度指标中以创口污染代替腹膜污染：将手术大小和手术类型按照骨科手术特点进行分级。评分标准见[表2][表3]。手术大小分级分为4级：小型手术手术包括筋膜切开术、腱鞘囊肿、腱切断或腱修补术、关节镜手术、腕管及神经松解术、金属植入物取出、骨折闭合复位等；中型手术包括切除小骨、小关节复位、截除单个或多个手指或足趾、用外固定器械闭合复位、小骨骨折的切开复位等：大型手术包括切除长骨、韧带改造加修补、大关节融合术、大关节的复位、前臂或小腿的截肢术、关节盘手术、长骨的切开复位等；超大型手术包括根治性
吉林大学硕士学位论文
肿瘤切除术、大范围脊柱重建、应用假体的大关节重建、肩或艘的离断术等。
应用改良的POSSUM评分系统对吉林大学第一医院骨科1995年1月
一2002年12月收治的295例股骨颈骨折及转子间骨折手术患者进行回顾性
分析，并按POSSUM评分系统的回归公式，比较术后30天内实际与预测的
术后死亡率及发症发病率人数，其中男139例，女156例。平均年龄63.70
岁。生理学评分(16.74士4.36)，手术严重度评分(12.31土2.32)。
结果:有并发症组97例，男50例，女47例。平均年龄66.59岁。平
均生理学评分(18.%士4.83)，平均手术严重度评分(13.47土2.01)。无并发
症组198例，男89例，女109例。平均年龄62.28岁。平均生理学评分(15.65
士3.66)，平均手术严重度评分(11.74士2.26)。两组间比较差别均有显著性
意义。按Copeland的回归公式预测并发症人数94例，实际并发症人数97例，
无显著性差别。有死亡组9例，男3例，女6例。平均年龄77名9岁。平均
生理学评分(25.56士3.78)，平均手术严重度评分(14.22士0.67)。无死亡组
286例，男136例，女巧0例。平均年龄63.25岁。平均生理学评分(16.46
士4.09)，平均手术严重度评分(12.25士2.33)。按POSSUM评分系统的回
归公式预测死亡人数19例，实际死亡人数9例。应用POSSUM评分系统的
回归公式计算总体患者的死亡率与实际情况不相符合，但在危险率较高组(预
测死亡率大于或等于10%)中POSSUM评分系统的回归公式计算每组患者的
死亡率与实际情况相符合。
结论:改良POSSUM评分系统可以准确预测骨科股骨颈骨折及转子间
骨折手术并发症发生率:但不能准确预测骨科股骨颈骨折及转子间骨折手术
死亡率，其预测值较实际值高，且误差源于低危险率组，但是在危险率较高
组(死亡率妻10%)中POSSUM评分系统的回归公式计算每组患者的死亡率与
实际情况相符合，因而POSSUM评分系统对股骨颈骨折及转子间骨折手术危
险率的预测有意义。
Hip fractures are common orthopaedic traumas and mostly occur in the old patients and the risk increases with age.The old patients often had maladies of the heart, liver and kidney before the trauma, therefore the mortality and the morbidity are higher than other fractures.Following improvement of the living standard and elongation of the mean longevity, the risk of two kinds of fractures have also the increasing trend, Aimed at the diseases like hip fracture which have higher risk than others, we need a scoring system which can exactly estimate operative mortality and morbidity to assess the results of the operation.
Nowadays, worldwide public and political interest has been turned on the assessment of quality of care and surgical outcome.especially on the hip fracture whose operative risk are higher in orthopaedic traumas.The focus of debates is the degree of influence on prognosis by the complexity of cases, operative equipment and the ability of doctor.A report recently warns that simply considering the factors of operation itself can't draw a reasonable conclusions in that factors of patients themselves are also very important.during the period between 1996 and 1998 Copeland et al applied the method similar to the original POSSUM scoring system acquiring in the former article, and get modified POSSUM scoring system suitable to the orthpaedic system, Although both of them are different in some factors and the measurement standard, Their whole scoring models are
approximate.
According to the orthopaedic characteristics, the original POSSUM scoring system is modified in some indeces: contamination replace peritoneal soiling in operative severity score; definitions of operative complexity are given as following: Minor: fasciotomy, ganglion/bursa, tenotomy/tendon repair, arthoscopic surgery, carpal tunnel/nerve release, removal of metal, closed reduction of fracture Intermediate:excision/osteotomy , small bone , minor joint replacement, amputation digit/digits, closed reduction with external fixation, open reduction of fracture of small bone. Majonosteotomy long bone, ligamentous reconstruction+prosthesis, arthrodesis large joint, major joint replacement, amputation limb, disc surgery, open reduction of fracture of long bone Major+:radical tumourectomy, major spinal reconstruction, revision prosthetic replacement, major joint hindquarter /forequarter amputation.
Methods :295 patients in the orthopaedics department of the first affiliated hospital of Jilin university were retrospectively analyzed with the mordified POSSUM surgical scoring system.The comparison between the observed and the predicted morbidity and the comparison between the observed and the predicted mortality were made With in 30 days after operation.
Result:In the complication group and noncomplication group, the mean age of the patients were 66.59 and 62.28, respectively. In the complication group , both the physiological scores and the operative severity scores of POSSUM scoring system were significantly higher
than the no complication group[ (18.96+4.83 ) vs (15.65+3.66) in pysiological score and ( 13.47+2.01 ) vs (11.74+2.26) in operative severity score], In the dead group and living group , the mean age of the patients were 77.89 and 63.25, respectively. In the dead group , both the physiological scores and the operative severity scores of POSSUM scoring system were significantly higher than the living group [ ( 25.56+3.78 ) vs ( 16.46+4.09 ) in pysiological score and ( 14.22+0.67 ) vs ( 12.25+2.33 ) in operative severity score ].Though POSSUM scoring system overpredict the overall risk of death , it produces a very close fit in the high risk band(10per cent or more).There was perfect agreement between the observed and the predicted morbidity as calculated by published predictor equation for morbidity.and agreement for mortality in the high risk band.
Conclusions :Modified POSSUM scoring msystem may be
appropriately used to predict the morbidity in patients of hip fracture.furthermore P
现在，许多骨科研究已经逐渐将注意力转移到术后结果的可变性上，尤其是对于像股骨颈骨折及股骨转子间骨折这类术后死亡率及并发症发生率较高的病例，此外关于病例复杂度与手术设备及医师对术后结果影响孰重孰轻一直是争论的焦点。最近一篇报道提醒人们仅仅考虑手术本身因素是不能得到正确结果的，因为患者自身因素也是非常重要的。在1996至1998年间Copeland等人应用与在前文的得到原始POSSUM评分一样的方法得到了适用于骨科系统的POSSUM评分系统，虽然二者中的一些因素及其衡量标准有所不同，但整体的评分模式十分近似。
改良POSSUM评分系统是根据骨科的特点，修改Copeland等提出的原始POSSUM评分系统评估量表中的部分指标：在手术严重度指标中以创口污染代替腹膜污染：将手术大小和手术类型按照骨科手术特点进行分级。评分标准见[表2][表3]。手术大小分级分为4级：小型手术手术包括筋膜切开术、腱鞘囊肿、腱切断或腱修补术、关节镜手术、腕管及神经松解术、金属植入物取出、骨折闭合复位等；中型手术包括切除小骨、小关节复位、截除单个或多个手指或足趾、用外固定器械闭合复位、小骨骨折的切开复位等：大型手术包括切除长骨、韧带改造加修补、大关节融合术、大关节的复位、前臂或小腿的截肢术、关节盘手术、长骨的切开复位等；超大型手术包括根治性
吉林大学硕士学位论文
肿瘤切除术、大范围脊柱重建、应用假体的大关节重建、肩或艘的离断术等。
应用改良的POSSUM评分系统对吉林大学第一医院骨科1995年1月
一2002年12月收治的295例股骨颈骨折及转子间骨折手术患者进行回顾性
分析，并按POSSUM评分系统的回归公式，比较术后30天内实际与预测的
术后死亡率及发症发病率人数，其中男139例，女156例。平均年龄63.70
岁。生理学评分(16.74士4.36)，手术严重度评分(12.31土2.32)。
结果:有并发症组97例，男50例，女47例。平均年龄66.59岁。平
均生理学评分(18.%士4.83)，平均手术严重度评分(13.47土2.01)。无并发
症组198例，男89例，女109例。平均年龄62.28岁。平均生理学评分(15.65
士3.66)，平均手术严重度评分(11.74士2.26)。两组间比较差别均有显著性
意义。按Copeland的回归公式预测并发症人数94例，实际并发症人数97例，
无显著性差别。有死亡组9例，男3例，女6例。平均年龄77名9岁。平均
生理学评分(25.56士3.78)，平均手术严重度评分(14.22士0.67)。无死亡组
286例，男136例，女巧0例。平均年龄63.25岁。平均生理学评分(16.46
士4.09)，平均手术严重度评分(12.25士2.33)。按POSSUM评分系统的回
归公式预测死亡人数19例，实际死亡人数9例。应用POSSUM评分系统的
回归公式计算总体患者的死亡率与实际情况不相符合，但在危险率较高组(预
测死亡率大于或等于10%)中POSSUM评分系统的回归公式计算每组患者的
死亡率与实际情况相符合。
结论:改良POSSUM评分系统可以准确预测骨科股骨颈骨折及转子间
骨折手术并发症发生率:但不能准确预测骨科股骨颈骨折及转子间骨折手术
死亡率，其预测值较实际值高，且误差源于低危险率组，但是在危险率较高
组(死亡率妻10%)中POSSUM评分系统的回归公式计算每组患者的死亡率与
实际情况相符合，因而POSSUM评分系统对股骨颈骨折及转子间骨折手术危
险率的预测有意义。
Hip fractures are common orthopaedic traumas and mostly occur in the old patients and the risk increases with age.The old patients often had maladies of the heart, liver and kidney before the trauma, therefore the mortality and the morbidity are higher than other fractures.Following improvement of the living standard and elongation of the mean longevity, the risk of two kinds of fractures have also the increasing trend, Aimed at the diseases like hip fracture which have higher risk than others, we need a scoring system which can exactly estimate operative mortality and morbidity to assess the results of the operation.
Nowadays, worldwide public and political interest has been turned on the assessment of quality of care and surgical outcome.especially on the hip fracture whose operative risk are higher in orthopaedic traumas.The focus of debates is the degree of influence on prognosis by the complexity of cases, operative equipment and the ability of doctor.A report recently warns that simply considering the factors of operation itself can't draw a reasonable conclusions in that factors of patients themselves are also very important.during the period between 1996 and 1998 Copeland et al applied the method similar to the original POSSUM scoring system acquiring in the former article, and get modified POSSUM scoring system suitable to the orthpaedic system, Although both of them are different in some factors and the measurement standard, Their whole scoring models are
approximate.
According to the orthopaedic characteristics, the original POSSUM scoring system is modified in some indeces: contamination replace peritoneal soiling in operative severity score; definitions of operative complexity are given as following: Minor: fasciotomy, ganglion/bursa, tenotomy/tendon repair, arthoscopic surgery, carpal tunnel/nerve release, removal of metal, closed reduction of fracture Intermediate:excision/osteotomy , small bone , minor joint replacement, amputation digit/digits, closed reduction with external fixation, open reduction of fracture of small bone. Majonosteotomy long bone, ligamentous reconstruction+prosthesis, arthrodesis large joint, major joint replacement, amputation limb, disc surgery, open reduction of fracture of long bone Major+:radical tumourectomy, major spinal reconstruction, revision prosthetic replacement, major joint hindquarter /forequarter amputation.
Methods :295 patients in the orthopaedics department of the first affiliated hospital of Jilin university were retrospectively analyzed with the mordified POSSUM surgical scoring system.The comparison between the observed and the predicted morbidity and the comparison between the observed and the predicted mortality were made With in 30 days after operation.
Result:In the complication group and noncomplication group, the mean age of the patients were 66.59 and 62.28, respectively. In the complication group , both the physiological scores and the operative severity scores of POSSUM scoring system were significantly higher
than the no complication group[ (18.96+4.83 ) vs (15.65+3.66) in pysiological score and ( 13.47+2.01 ) vs (11.74+2.26) in operative severity score], In the dead group and living group , the mean age of the patients were 77.89 and 63.25, respectively. In the dead group , both the physiological scores and the operative severity scores of POSSUM scoring system were significantly higher than the living group [ ( 25.56+3.78 ) vs ( 16.46+4.09 ) in pysiological score and ( 14.22+0.67 ) vs ( 12.25+2.33 ) in operative severity score ].Though POSSUM scoring system overpredict the overall risk of death , it produces a very close fit in the high risk band(10per cent or more).There was perfect agreement between the observed and the predicted morbidity as calculated by published predictor equation for morbidity.and agreement for mortality in the high risk band.
Conclusions :Modified POSSUM scoring msystem may be
appropriately used to predict the morbidity in patients of hip fracture.furthermore P
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52. Neary WD, Crow P, Foy C, Heather BP, Earshaw JJ.Selection of patients for repair of a ruptured aortic aneurysm.Br J Surg 2002; 89(Suppl 1):22(Abstract).
53. Sutton R, Bann S, Brooks M, Sarin S.The Surgical Risk Scale as an improved tool for risk-adjusted analysis in comparative surgical audit.Br J Surg 2002; 89:763-768.
54. Vascular Surgical Society of Great Britain and Ireland.National Vascular Database Report 2001.Dendrite Clinical Systems Ltd.UK.
55. Tekkis PP, Kessaris N, Kocher HM et al.Evaluation of POSSUM and P-POSSUM scoring system in patients undergoing colorectal surgery Br J Surg 2003 90(3):340-345.
56．梁存河，蒋朱明，唐伟松等．术后外周血内毒素水平与术后并发症及创伤程度的关系．中国临床营乔杂志[J] ．2001；9：230-232．
57．张群华，倪泉兴，张延龄等．应用APACHEⅡ和POSSUM评分指导胰腺癌患者外科治疗的临床分析．中华外科杂志[J] ．2001：39：266-268．
58．张云利，郭剑民，周立新等．影响胰十二指肠切除术疗效的因素分析．中华普通外科杂志[J] ．2002；17：423-424．
59．尹志，康何梓铭等．生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值．中华泌尿外科杂志[J] ．2002；23：43-45．
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52. Neary WD, Crow P, Foy C, Heather BP, Earshaw JJ.Selection of patients for repair of a ruptured aortic aneurysm.Br J Surg 2002; 89(Suppl 1):22(Abstract).
53. Sutton R, Bann S, Brooks M, Sarin S.The Surgical Risk Scale as an improved tool for risk-adjusted analysis in comparative surgical audit.Br J Surg 2002; 89:763-768.
54. Vascular Surgical Society of Great Britain and Ireland.National Vascular Database Report 2001.Dendrite Clinical Systems Ltd.UK.
55. Tekkis PP, Kessaris N, Kocher HM et al.Evaluation of POSSUM and P-POSSUM scoring system in patients undergoing colorectal surgery Br J Surg 2003 90(3):340-345.
56．梁存河，蒋朱明，唐伟松等．术后外周血内毒素水平与术后并发症及创伤程度的关系．中国临床营乔杂志[J] ．2001；9：230-232．
57．张群华，倪泉兴，张延龄等．应用APACHEⅡ和POSSUM评分指导胰腺癌患者外科治疗的临床分析．中华外科杂志[J] ．2001：39：266-268．
58．张云利，郭剑民，周立新等．影响胰十二指肠切除术疗效的因素分析．中华普通外科杂志[J] ．2002；17：423-424．
59．尹志，康何梓铭等．生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值．中华泌尿外科杂志[J] ．2002；23：43-45．