JBJS:双膝同期置换在院并发症发生率高

2014-07-24 佚名 丁香园

人工全膝关节置换术(TKA)是是一种疗效确切、成本效益良好的常见外科手术。随着人口老龄化和手术指征的扩大,预计未来二十年TKA的手术需求将会有明显增长。这些患者往往同时双侧膝关节受累,因此医生和患者需要决定应该采用同期双侧TKA还是分次手术。 同期双侧TKA的潜在优势主要在于缩短了住院日、更短的麻醉时间、更短的康复时间及更少的医疗费用,除此以外,同期双侧TKA在功能结果、放射学结果、疼痛

人工全膝关节置换术(TKA)是是一种疗效确切、成本效益良好的常见外科手术。随着人口老龄化和手术指征的扩大,预计未来二十年TKA的手术需求将会有明显增长。这些患者往往同时双侧膝关节受累,因此医生和患者需要决定应该采用同期双侧TKA还是分次手术。

同期双侧TKA的潜在优势主要在于缩短了住院日、更短的麻醉时间、更短的康复时间及更少的医疗费用,除此以外,同期双侧TKA在功能结果、放射学结果、疼痛缓解程度和患者满意度方面可以获得和分次手术相似的效果。尽管如此,这些优势与发病率、死亡率增加的可能性相比孰轻孰重,仍有一定争议。来自美国北卡的学者基于全美住院患者抽样调查(NIS)等三个大型医疗数据库的数据,对同期双侧和单侧全膝关节置换术(TKA)的在院并发症及相关因素进行了比较。

表1 研究对象的统计资料

表1.JPG

表2 双侧手术病例出现在院并发症的概率

表2.JPG

2004-2007年NIS数据中共有407,070例TKA,其中同期双侧TKA手术 24,574例,单侧TKA手术382,496例。根据国际疾病分类编码第九版(ICD-9-CM)分为无、轻度、中度、重度。协变量包括:合并症、人口学资料、费别和医院TKA手术量。采用多变量逻辑回归计算OR值和95%可信区间。

结果发现,在全部407,070例TKA病例中,女性259,851例(64%)、男性145,667例(36%)、另有1552名患者的性别信息遗失。40%患者的年龄在65岁以下,37%在65-74岁之间,23%在75岁以上。表1所示为单侧TKA组和同期双侧TKA组所有的相关变量。女性患者在两组中的比例均明显高于男性,分别为59%和64%。同期双侧TKA组中65岁以下病例的比例明显高于单侧TKA组,而75岁以上病例则呈现相反的趋势。

医保患者在两组病例中最为常见,分别为单侧TKA组59%和同期TKA组51%。两组患者的疾病负担和合并症情况相当。每组均有26%以上的患者具有3个以上的内科合并症。

24,574例同期双侧TKA中有6.85%出现轻度并发症,而单侧组为4.60%。同期双侧组出现中度的比例为1.52%,单侧组的这一比例为1.20%。在院死亡率:同期双侧组0.15%、单侧组0.07%。上述比例组间具有明显差异(p < 0.0001)。在未校正的情况下,同期双侧组出现轻度在院并发症或在院死亡的比例为单侧组的两倍以上(表2)。

多因素分析(表3)提示,同期双侧TKA的在院并发症要明显高于单侧TKA,其中轻度并发症 OR值1.51(95%区间, 1.42-1.62),中度并发症OR值 1.30 (95% 区间, 1.14 to 1.47),致死性(重度)并发症OR 2.51 (95%区间1.66-3.80)。内科合并症较多的患者更容易在住院期间出现并发症。非裔美国人、亚太岛民群体的轻度并发症发生率要高于白人,女性出现在院并发症的可能性要远低于男性。

手术时年龄小于65岁的患者出现轻度和致死性(重度)并发症的可能性远低于年龄75岁以上的患者。医院TKA手术量在850台以上时出现轻度和致死性(重度)并发症的可能性明显更低。

表3:多因素分析结果

表3.JPG

作者认为,该研究为目前最大样本的随访研究之一。虽然单侧TKA和同期双侧TKA的并发症发生率均较低,但同期双侧TKA包括死亡率在内的在院并发症仍要高于前者。患者的人口学资料、术前健康状况、费别及医院TKA手术量均为影响同期双侧TKA患者在院并发症的重要因素。

原始出处:

Odum SM1, Springer BD2.In-Hospital Complication Rates and Associated Factors After Simultaneous Bilateral Versus Unilateral Total Knee Arthroplasty.J Bone Joint Surg Am. 2014 Jul 2;96(13):1058-1065. [Epub ahead of print]


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    2015-06-25 zywlvao
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    2015-02-09 yxch48
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    2014-07-26 qingrejiedu

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