PLOS MED:肥胖会导致膝关节置换术患者“二次手术”,但却降低死亡率!

2021-07-28 MedSci原创 MedSci原创

全膝关节置换术(TKR)是最常见的骨科手术之一,通常被认为是安全、经济、有效的,可以减少大多数患者的疼痛症状和功能限制。

全膝关节置换术(TKR)是最常见的骨科手术之一,通常被认为是安全、经济、有效的,可以减少大多数患者的疼痛症状和功能限制。在英国,几乎每10个人中就有1个人会在其一生中的某个时候接受TKR,在过去的4年中,英国每年大约有10万例TKR手术。

进行TKR的主要原因是关节疼痛和/或功能受限,并结合关节炎的影像学证据;尽管如此,对于表明需要手术的症状的严重程度并没有共识。对错误的病人进行TKRs可能会导致较差的结果,并导致早期翻修手术,这也给病人和医疗服务带来昂贵的费用。

以往描述的不良结果的具体风险因素包括年龄较大、合并症、虚弱、高体重指数(BMI)、心理因素以及患者对手术成功的期望值较低。随着人口的老龄化,预计接受TKR的人数会增加,在资金和能力方面给国家卫生服务系统(NHS)带来了越来越大的负担。

越来越多的证据表明,医务人员要么限制高BMI的病人接受TKR,要么鼓励在转诊手术前减轻体重。这可能是由于认为这些病人的并发症风险更高,同时假体的负荷增加会增加因松动或磨损而失败的风险,或者手术本身更加困难,导致围手术期问题的增加。

尽管有证据表明,总体而言,高BMI的患者在TKR的头6个月内发生术后并发症的绝对风险很低。近期,来自英国布里斯托大学的专家调查了BMI与翻修手术、死亡率和疼痛/功能之间的关系,结果发表在PLOS Medicine杂志上。

研究人员分析了2005-2016年英格兰、威尔士、北爱尔兰和马恩岛国家关节登记处(NJR)的493710例TKRs,以调查90天的死亡率和10年的死亡率。医院发作统计(HES)和患者报告结果措施(PROMs)数据库与NJR相连,以调查术后6个月牛津膝关节评分(OKS)的变化。

根据BMI初级TKR后11年内翻修的累积概率

在对年龄、性别、美国麻醉师协会(ASA)等级、手术指征、初级TKR年份和固定类型进行调整后,与BMI "正常 "的患者相比,高BMI患者更有可能在10年内接受翻修手术。其中,肥胖II级风险增加21%(HR=1.21,95%CI:1.10-1.32),肥胖III级则增加13%(HR=1.13,95%CI:1.02-1.26)。

所有BMI等级的修订估计值都在公认的10年基准值5%之内。超重和肥胖I级患者的死亡率却都低于BMI "正常 "的患者(HR=0.76,95% CI:0.65-0.90;HR=0.69,95% CI:0.58-0.82)。

BMI为22.5的患者在TKR后11年内翻修的危险性

此外,所有BMI类别在6个月后的OKS绝对值都有增加(范围为18-20点)。超重和肥胖患者的OKS相对改善低于 "正常 "BMI的患者,但差异低于最小可检测变化(MDC;4分)。文章的主要局限是外科医生选择BMI较高的合适患者进行手术的潜在选择偏倚效应。

综上,这个大型的全国性登记显示没有证据表明高BMI患者的结果更差。

 

参考文献:

Obesity and revision surgery, mortality, and patient-reported outcomes after primary knee replacement surgery in the National Joint Registry: A UK cohort study. https://doi.org/10.1371/journal.pmed.1003704

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    2021-07-28 土豆你个马铃薯

    意味着

    0

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本研究对全髋关节置换术和全髋关节置换术的大型连续队列进行了90天的随访,详细分析了术后胃肠道并发症导致住院时间或再入院时间增加的发生情况。

BMC Musculoskelet Disord:炎性血液参数作为原发性全髋关节或膝关节置换术后植入物相关感染的预后因素

假体相关感是全髋关节或膝关节成形术后的潜在并发症。炎症过程的初始阶段可以通过应用炎症血参数来测量。本文旨在评估IBP对骨科手术造成的创伤的反应,并评估IBP定量测量作为感染预后因素的临床应用。

BMC Musculoskelet Disord:基于ActivPAL的膝关节置换术对活动度的影响研究

膝关节置换(KR)手术旨在恢复活动水平,降低经历残疾的风险。对手术结果的评价主要采用主观工具或效度较低的客观工具。然而,手术对使用高效度客观加速度计的活动水平的影响仍存在疑问。