背景：髖部骨折是高齡者常見的疾病，骨折後患者具高死亡率，是已開發國家在骨質疏鬆症相關負擔的主要原因，本研究主要探討之股骨頸骨折約佔髖部骨折的45%，主要治療方式為置換雙極式半人工髖關節，本研究欲探討股骨頸骨折病患選用健保給付之金屬雙極式半人工髖關節或自付差額之陶瓷雙極式半人工髖關節術後臨床結果及存活狀況。
目的：探討使用健保給付之金屬半人工髖關節患者（以下簡稱健保組）及民眾自付差額之陶瓷半人工髖關節患者（以下簡稱自付差額組）的健康科技評估，使醫療服務提供者和骨折病患瞭解不同材質髖關節的療效。
方法：本研究使用「衛生福利部衛生福利資料科學中心」2009-2019年之全民健保資料庫，以2010-2018年的資料篩選首次發生股骨頸骨折患者，將研究族群追蹤至2019年，計算使用不同材質的半人工髖關節的術後臨床指標。
本研究的主要樣本分為自付差額組和健保組，以兩組1:2比例配對年齡±1歲、相同性別、診斷年及共病（糖尿病、急性心肌梗塞、中風、慢性阻塞性肺病、末期腎臟病、肝硬化）選取配對後病人，並以使用股骨柄之病人（次族群樣本）為敏感度分析樣本。統計方法使用Kaplan–Meier 法分析術後存活、Cox proportional hazards model 計算死亡的風險比、R軟體的iSQoL2 package外推計算平均餘命及平均餘命損失，並使用sub-distribution hazard model，以死亡為競爭風險，控制性別、年齡、醫院權屬別、醫院所在地、醫院層級、是否使用骨水泥及投保金額類別，計算兩組病人使用不同材質的再置換手術、再手術及術後併發症的風險比。
結果：配對前樣本：健保組為47158人，自付差額組為2637人；配對後樣本：健保組為5118人，自付差額組為2559人；次族群樣本：健保組為4583人，自付差額組為2072人。配對後樣本大多為女性(69.7%)，平均年齡73.4歲，健保組以低收入戶、榮民、地區人口及職業工會等非薪資所得投保者所佔的比例高於自付差額組的佔比，兩組就醫之醫療院所分布最多位於北北基、法人醫院、區域醫院。
術後臨床結果－兩組的再置換手術風險未達顯著，自付差額組的再手術風險（術後一年、五年、十年），術後併發症之壓瘡（術後一年）、肺炎（術後三個月及一年）、全因併發症（術後三個月及一年）和住院天數，皆顯著低於健保組。年齡分層分析結果顯示，65-84歲的自付差額組在再手術風險(術後一年、十年)顯著低於健保組；50-84歲的自付差額組在死亡風險(術後一年、五年、十年)顯著低於健保組；所有年齡層的自付差額組在的全因併發症風險（術後三個月）顯著低於健保組；65-85歲以上的自付差額組在的全因併發症風險（術後一年）顯著低於健保組。
存活及平均餘命－自付差額組相較於健保組經Kaplan–Meier 法檢定發現術後存活顯著較好(P<0.01)，自付差額組的死亡風險及術後累積死亡率顯著低於健保組，將兩組存活外推終身進行估算的結果顯示，自付差額組之平均餘命較健保組多1.74年，但兩組並無顯著差異(P=0.14)，自付差額組之平均餘命損失較健保組少1.72年，亦未達顯著差異(P=0.15)。
結論：股骨頸骨折患者使用自付差額之陶瓷雙極式半人工髖關節與健保給付之金屬雙極式半人工髖關節相比，兩組的再置換手術風險、平均餘命和平均餘命損失未達顯著差異，但再手術風險、壓瘡風險、肺炎風險、全因術後併發症風險、住院天數和死亡風險，自付差額之陶瓷半人工髖關節顯著低於健保給付之金屬半人工髖關節。
關鍵字：股骨頸骨折、雙極式半人工髖關節、再手術、存活、全民健康保險

SUMMARY
Introduction: This study aimed to investigate the clinical outcomes and survival for femoral neck fracture (FNF) patients with hip hemiarthroplasty using ceramic versus metal heads.
Methods: The study sample contained patients with an index FNF admission and hip hemiarthroplasty identified from the National Health Insurance claims data (2009-2019) available from the Health and Welfare Data Science Center. To compare these two groups using different heads, a 1:2 matching of the ceramic versus metal group was performed according to age, gender, index year, and six major comorbidities. Sub-distribution hazard and Cox proportional hazards models were used to estimate the hazard ratios of revision, reoperation, post-operative complications and death for the two groups of patients using different materials. Lifetime survival extrapolation were performed to estimate life expectancy (LE) and loss-of- life expectancy (loss-of-LE).
Results: 2559 ceramic head users and 5118 metal head users were included after matching; 69.7% of the samples were female, and the mean age was 73.4 years. Compared to the metal users, the ceramic users had lower hazard ratios in reoperation (postoperative one year, five years, ten years), pressure ulcers (postoperative one year) , pneumonia (postoperative three months and one year), all-cause complications (postoperative three months and one year), and mortality (postoperative one year and ten years)
Conclusion: Compared to metal group, there was no significant difference in revision, LE, loss-of-LE between the two groups. The ceramic group had significantly lower hazards in reoperation, pressure ulcer, pneumonia, all-cause complications, length of stay, and death.
Key words: Femoral neck fracture, bipolar hemiarthroplasty, reoperation, survival, National Health Insurance

Bhandari, M., Einhorn, T. A., Guyatt, G., Schemitsch, E. H., Zura, R. D., Sprague, S., . . . Devereaux, P. J. (2019). Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med, 381(23), 2199-2208. doi:10.1056/NEJMoa1906190
Bhandari, M., & Swiontkowski, M. (2017). Management of acute hip fracture. N Engl J Med, 377(21), 2053-2062. doi:10.1056/NEJMcp1611090
Biçen, Ç., Akdemir, M., Türken, M. A., Çekok, K., Ekin, A., & Turan, A. C. (2021). Analysis of risk factors affecting mortality in elderly patients operated on for hip fractures: a retrospective comparative study. Acta Orthop Traumatol Turc, 55(6), 493-499. doi:10.5152/j.aott.2021.21004
London Implant Retrieval Centre (2020). Hip implants explained. Retrieved from: http://www.lirc.co.uk/hips
Chan, D. C., Lee, Y. S., Wu, Y. J., Tsou, H. H., Chen, C. T., Hwang, J. S., . . . Yang, R. S. (2013). A 12-year ecological study of hip fracture rates among older Taiwanese adults. Calcif Tissue Int, 93(5), 397-404. doi:10.1007/s00223-013-9759-x
Chang, C. Y., Tang, C. H., Chen, K. C., Huang, K. C., & Huang, K. C. (2016). The mortality and direct medical costs of osteoporotic fractures among postmenopausal women in Taiwan. Osteoporos Int, 27(2), 665-676. doi:10.1007/s00198-015-3238-3
Chen, F. P., Huang, T. S., Fu, T. S., Sun, C. C., Chao, A. S., & Tsai, T. L. (2018). Secular trends in incidence of osteoporosis in Taiwan: a nationwide population-based study. Biomed J, 41(5), 314-320. doi:10.1016/j.bj.2018.08.001
Çiloglu, O., & Karaali, E. (2021). The role of stem modularity in the failure of internal fixation in geriatric patients with distally fixed hemiarthroplasty. Orthopedics, 44(1), e119-e124. doi:10.3928/01477447-20201007-02
Colas, S., Collin, C., Piriou, P., & Zureik, M. (2015). Association between total hip replacement characteristics and 3-Year prosthetic survivorship: a population-based study. JAMA Surg, 150(10), 979-988. doi:10.1001/jamasurg.2015.1325
Donaldson, A. J., Thomson, H. E., Harper, N. J., & Kenny, N. W. (2009). Bone cement implantation syndrome. Br J Anaesth, 102(1), 12-22. doi:10.1093/bja/aen328
Farey, J. E., Cuthbert, A. R., Adie, S., & Harris, I. A. (2021). Revision risk after unipolar or bipolar hemiarthroplasty for femoral neck fractures: an instrumental variable analysis of 62,875 procedures from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am, 103(3), 195-204. doi:10.2106/jbjs.20.00486
Farey, J. E., Cuthbert, A. R., Adie, S., & Harris, I. A. (2022). Bipolar hemiarthroplasty does not result in a higher risk of revision compared with total hip arthroplasty for displaced femoral neck fractures: an instrumental variable analysis of 36,118 procedures from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am, 104(10), 919-927. doi:10.2106/jbjs.21.00972
Fine, J. P., & Gray, R. J. (1999). A proportional hazards model for the subdistribution of a competing risk. Journal of the American Statistical Association, 94(446), 496-509. doi:10.2307/2670170
Gosling, O. B., Ferreri, T. G., Khoshbin, A., Whitehouse, M. R., & Atrey, A. (2020). A systematic review and meta-analysis of survivorship and wear rates of metal and ceramic heads articulating with polyethylene liners in total hip arthroplasty. Hip Int, 30(6), 761-774. doi:10.1177/1120700019866428
Grammatopoulos, G., Wilson, H. A., Kendrick, B. J., Pulford, E. C., Lippett, J., Deakin, M., . . . Kambouroglou, G. (2015). Hemiarthroplasty using cemented or uncemented stems of proven design: a comparative study. Bone Joint J, 97-b(1), 94-99. doi:10.1302/0301-620x.97b1.34138
Griffiths, R., White, S. M., Moppett, I. K., Parker, M. J., Chesser, T. J., Costa, M. L., . . . Timperley, A. J. (2015). Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society. Anaesthesia, 70(5), 623-626. doi:10.1111/anae.13036
Hsu, I. L., Chang, C. M., Yang, D. C., Chang, Y. H., Li, C. C., Hu, S. C., & Li, C. Y. (2018). Socioeconomic inequality in one-year mortality of elderly people with hip fracture in Taiwan. Int J Environ Res Public Health, 15(2). doi:10.3390/ijerph15020352
Hwang, J. S., & Wang, J. D. (1999). Monte Carlo estimation of extrapolation of quality-adjusted survival for follow-up studies. Stat Med, 18(13), 1627-1640. doi:10.1002/(sici)1097-0258(19990715)18:13<1627::aid-sim159>3.0.co;2-d
Jia, Z., Ding, F., Wu, Y., Li, W., Li, H., Wang, D., . . . Ruan, D. (2015). Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res, 10, 8. doi:10.1186/s13018-015-0165-0
Johnell, O., & Kanis, J. A. (2006). An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int, 17(12), 1726-1733. doi:10.1007/s00198-006-0172-4
Kim, H., Cheng, S. H., Yamana, H., Lee, S., Yoon, N. H., Lin, Y. C., . . . Yasunaga, H. (2021). Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data. BMC Health Serv Res, 21(1), 694. doi:10.1186/s12913-021-06621-y
Kong, X. (2020). Meta-analysis of the effect of cemented and uncemented hemiarthroplasty on displaced femoral neck fracture in the elderly. Exp Ther Med, 20(3), 2173-2183. doi:10.3892/etm.2020.8921
Kurtz, S. M., Lau, E., Baykal, D., & Springer, B. D. (2017). Outcomes of ceramic bearings after primary total hip arthroplasty in the Medicare population. J Arthroplasty, 32(3), 743-749. doi:10.1016/j.arth.2016.08.038
López-López, J. A., Humphriss, R. L., Beswick, A. D., Thom, H. H. Z., Hunt, L. P., Burston, A., . . . Marques, E. M. R. (2017). Choice of implant combinations in total hip replacement: systematic review and network meta-analysis. Bmj, 359, j4651. doi:10.1136/bmj.j4651
Lêng, C. H., Chou, M. H., Lin, S. H., Yang, Y. K., & Wang, J. D. (2016). Estimation of life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for schizophrenia in Taiwan. Schizophr Res, 171(1-3), 97-102. doi:10.1016/j.schres.2016.01.033
LeBlanc, E. S., Hillier, T. A., Pedula, K. L., Rizzo, J. H., Cawthon, P. M., Fink, H. A., . . . Browner, W. S. (2011). Hip fracture and increased short-term but not long-term mortality in healthy older women. Arch Intern Med, 171(20), 1831-1837. doi:10.1001/archinternmed.2011.447
Lee, S. H., Chen, I. J., Li, Y. H., Fan Chiang, C. Y., Chang, C. H., & Hsieh, P. H. (2016). Incidence of second hip fractures and associated mortality in Taiwan: a nationwide population-based study of 95,484 patients during 2006-2010. Acta Orthop Traumatol Turc, 50(4), 437-442. doi:10.1016/j.aott.2016.06.008
Leonardsson, O., Kärrholm, J., Åkesson, K., Garellick, G., & Rogmark, C. (2012). Higher risk of reoperation for bipolar and uncemented hemiarthroplasty. Acta Orthop, 83(5), 459-466. doi:10.3109/17453674.2012.727076
Lin, C. N., Lee, K. T., Chang, S. M., & Wang, J. D. (2022). Cost-effectiveness evaluation of mammography screening program in Taiwan: adjusting different distributions of age and calendar year for real world data. J Formos Med Assoc, 121(3), 633-642. doi:10.1016/j.jfma.2021.06.013
Lin, J. C., & Liang, W. M. (2015). Outcomes after fixation for undisplaced femoral neck fracture compared to hemiarthroplasty for displaced femoral neck fracture among the elderly. BMC Musculoskelet Disord, 16, 199. doi:10.1186/s12891-015-0671-6
Mathur, A., Fassihi, S. C., Ramamurti, P., & Doerre, T. (2020). Deep vein thrombosis after cement intravasation during hip hemiarthroplasty. Arthroplast Today, 6(2), 283-287. doi:10.1016/j.artd.2020.03.007
Medin, E., Goude, F., Melberg, H. O., Tediosi, F., Belicza, E., & Peltola, M. (2015). European regional differences in all-cause mortality and length of stay for patients with hip fracture. Health Econ, 24 Suppl 2, 53-64. doi:10.1002/hec.3278
Murphy, D. K., Randell, T., Brennan, K. L., Probe, R. A., & Brennan, M. L. (2013). Treatment and displacement affect the reoperation rate for femoral neck fracture. Clin Orthop Relat Res, 471(8), 2691-2702. doi:10.1007/s11999-013-3020-9
Ng, D. Z., & Lee, K. B. (2015). Unipolar versus bipolar hemiarthroplasty for displaced femoral neck fractures in the elderly: Is there a difference? Ann Acad Med Singap, 44(6), 197-201.
Nurmi, I., Narinen, A., Lüthje, P., & Tanninen, S. (2004). Functional outcome and survival after hip fracture in elderly: a prospective study of 106 consecutive patients. Journal of Orthopaedics andTraumatology, 5(1), 7-14. doi:10.1007/s10195-004-0033-x
Okike, K., Chan, P. H., Prentice, H. A., Paxton, E. W., & Burri, R. A. (2020). Association between uncemented vs cemented hemiarthroplasty and revision surgery among patients with hip fracture. Jama, 323(11), 1077-1084. doi:10.1001/jama.2020.1067
Ong, K. L., Richards, J. A., Lau, E. C., & Malkani, A. L. (2020). Corrosion concerns? Trends in metal-on-polyethylene total hip arthroplasty revision rates and comparisons against ceramic-on-polyethylene up to 10 years of follow-up. J Arthroplasty, 35(10), 2919-2925. doi:10.1016/j.arth.2020.05.007
Parker, M. (2021). Total hip arthroplasty versus hemiarthroplasty for intracapsular hip fractures. Bone Joint J, 103-b(1), 3-4. doi:10.1302/0301-620x.103b1.Bjj-2020-1438.R1
Pitto, R. P., Garland, M., & Sedel, L. (2015). Are ceramic-on-ceramic bearings in total hip arthroplasty associated with reduced revision risk for late dislocation? Clin Orthop Relat Res, 473(12), 3790-3795. doi:10.1007/s11999-015-4395-6
Sabnis, B., & Brenkel, I. J. (2011). Unipolar versus bipolar uncemented hemiarthroplasty for elderly patients with displaced intracapsular femoral neck fractures. J Orthop Surg (Hong Kong), 19(1), 8-12. doi:10.1177/230949901101900103
Sims, A. L., Parsons, N., Achten, J., Griffin, X. L., Costa, M. L., & Reed, M. R. (2018). A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip: the WHiTE 3: HEMI Trial. Bone Joint J, 100-b(3), 352-360. doi:10.1302/0301-620x.100b3.Bjj-2017-0872.R2
Tsai, C. H., Muo, C. H., Hung, C. H., Lin, T. L., Wang, T. I., Fong, Y. C., & Hsu, H. C. (2016). Disorder-related risk factors for revision total hip arthroplasty after hip hemiarthroplasty in displaced femoral neck fracture patients: a nationwide population-based cohort study. J Orthop Surg Res, 11(1), 66. doi:10.1186/s13018-016-0400-3
Tsai, M. C., Ng, Y. Y., Chen, W. M., Tsai, S. W., & Wu, S. C. (2019). the effects of cement fixation on survival in elderly patients with hip hemiarthroplasty: a nationwide cohort study. BMC Musculoskelet Disord, 20(1), 628. doi:10.1186/s12891-019-3013-2
Veldman, H. D., Heyligers, I. C., Grimm, B., & Boymans, T. (2017). Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck:
a systematic review and meta-analysis of current generation hip stems.Bone & Joint Journal, 99B(4), 421-431. doi:10.1302/0301-620x.99b4.Bjj-2016-0758.R1
Wang, C. B., Lin, C. F., Liang, W. M., Cheng, C. F., Chang, Y. J., Wu, H. C., . . . Leu, T. H. (2013). Excess mortality after hip fracture among the elderly in Taiwan: a nationwide population-based cohort study. Bone, 56(1), 147-153. doi:10.1016/j.bone.2013.05.015
Wu, T. Y., Hu, H. Y., Lin, S. Y., Chie, W. C., Yang, R. S., & Liaw, C. K. (2017). Trends in hip fracture rates in Taiwan: a nationwide study from 1996 to 2010. Osteoporos Int, 28(2), 653-665. doi:10.1007/s00198-016-3783-4
Yeung, C. Y., Tsai, S. W., Wu, P. K., Chen, C. F., Chang, M. C., & Chen, W. M. (2020). Low rates of all-cause revision in displaced subcapital femoral neck fractures treated with hip hemiarthroplasty - a retrospective review of 4516 patients from a single institute. BMC Musculoskelet Disord, 21(1), 700. doi:10.1186/s12891-020-03725-0
Yoshioka, T., Okimoto, N., Fuse, Y., Kawasaki, M., Mori, T., Sakai, A., & Majima, T. (2018). In-vivo postoperative motion analysis of metal and ceramic bipolar hip hemiarthroplasty. J Orthop Sci, 23(2), 371-376. doi:10.1016/j.jos.2017.11.015
Yurdakul, E., Karaaslan, F., Korkmaz, M., Duygulu, F., & Baktir, A. (2015). Is cemented bipolar hemiarthroplasty a safe treatment for femoral neck fracture in elderly patients? Clinical Interventions in Aging, 10, 1063-1067. doi:10.2147/cia.S85039
中央健康保險署。(2022)。醫材比價網。取自：https://www.nhi.gov.tw/QueryN_New/SpecialMaterial/SpecialMaterial
衛生福利部中央健康保險署。(2017)。從健保給付人工髖關節，提醒老年人預防跌倒! 取自：https://www.nhi.gov.tw/Content_List.aspx?n=C6DF8F8EEA2F3F55&topn=5FE8C9FEAE863B46
衛生福利部中央健康保險署。 (2020)。全新「自費醫材比價網」，資訊更公開，查詢更便利。 取自：https://www.mohw.gov.tw/cp-4631-54371-1.html
衛生福利部統計處。(2011)。衛生福利資料科學中心。 取自：https://dep.mohw.gov.tw/DOS/cp-5119-59201-113.html
賴麗容、劉瑞瑤。(2012)。中老年人髖部骨折簡介。家庭醫學與基層醫療, 27(10), 364-369. doi:10.6965/fmpmc.201210.0364