髋关节置换:90天死亡率在8年时减半


  【24drs.com】根据登载于9月28日Lancet期刊,于威尔斯和英格兰进行的一项超过400,000个案例的研究,配合采用四个临床管理策略下,与髋关节置换有关的90天死亡率减半。
  
  英国Bristol大学临床科学院肌肉骨骼研究小组副研究员Linda P. Hunt博士等人分析了英格兰和威尔斯的全国关节登记资料库,该资料库与全国死亡率资料库及医院统计资料库连结。
  
  2003年4月至2011年12月之间,共有409,096名病患因为骨关节炎而进行髋关节置换手术,研究者确认有1,743例属于术后90天内死亡。
  
  他们发现,90天死亡率从2003年的0.56%(72例死亡/12,621例骨关节炎)降低到2011年的0.29%(164例死亡/60,727例手术);校正年纪与性别后,研究期间内的相对风险减半,2011年对2003年的相对风险(HR)为0.49 (95%信心区间[CI],0.37 - 0.65;P < .001)。
  
  校正性别、年龄组与共病症之后,有多个临床因素与降低死亡率有关,包括后方手术术式(HR 0.82;95% CI,0.73 - 0.92;P = .001);使用heparin、并用或未并用阿斯匹灵进行化学性预防血栓形成(HR 0.79;95% CI,0.66 - 0.93;P = .005);机械性预防方式(HR,0.85;95% CI,0.74 - 0.99;P = .036);脊椎麻醉相较于全身麻醉(HR,0.85;95% CI,0.74 - 0.97;P = .019)。
  
  此外,研究者发现,对于身体质量指数26 -30 kg/m2者,假体的类型和死亡率无关,过重和死亡率降低有关(HR 0.76; 95% CI, 0.62 - 0.92; P = .006)。不过,作者们指出,近60%的身体质量指数资料漏失,计算时假设资料是随机漏失。
  
  作者们写道,如果证明存在因果关系,广泛采用四个简单的临床管理策略(后方手术方式、机械性与化学性预防、脊椎麻醉)可以进一步降低死亡率。
  
  健康不佳与死亡风险显著增加有关,校正性别、年龄组和共病症之后,中度或严重的肝病90天死亡率风险达将近10倍有关(HR,9.70;95% CI,5.94 - 15.84;P < .0005);癌症转移和死亡率增加7倍有关(HR,7.19;95% CI,5.51 - 9.38;P < .0005),心肌梗塞、郁血性心衰竭、糖尿病都与90天死亡率风险比增加2-3倍多有关。
  
  纽泽西若瑟区域医学中心、Seton Hall大学骨外科、马里兰巴尔的摩西奈医院关节保护与置换中心、Rubin骨科进阶研究中心的Kimona Issa医师,以及Rubin骨科进阶研究中心的Michael A. Mont医师在编辑评论中指出,虽然研究作者提议采用后方手术方式、机械性、化学性预防、以及脊椎麻醉,他们并未评估其它更广泛的生活质量测量方式,包括病患报告的结果,或可能引起严重发病的其它并发症。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7014&x_classno=0&x_chkdelpoint=Y
  

Hip Replacement: 90-Day Mortality Halved in 8 Years

By Jenni Laidman
Medscape Medical News

The 90-day mortality rate associated with hip replacement fell by half in conjunction with the adoption of 4 clinical management strategies, according to a study of more than 400,000 cases in Wales and England, published in the September 28 issue of the Lancet.

Linda P. Hunt, PhD, research associate, Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, United Kingdom, and colleagues analyzed data from the National Joint Registry for England and Wales, which was linked to a national mortality database and the Hospital Episode Statistics database.

Of 409,096 patients who underwent hip replacement for osteoarthritis between April 2003 and December 2011, the researchers identified 1743 deaths within 90 days of the surgery.

They found that 90-day mortality fell from 0.56% in 2003 (72 deaths/12,621 operations) to 0.29% in 2011 (164 deaths/60,727 surgeries). The relative risk halved during the study period after adjusting for age and sex, for a hazard ratio (HR) of 0.49 (95% confidence interval [CI], 0.37 - 0.65; P < .001) for 2011 relative to 2003.

Several clinical factors were associated with lower mortality after adjusting for sex, age group, and comorbidity. Those included a posterior surgical approach (HR 0.82; 95% CI, 0.73 - 0.92; P = .001); chemical thromboprophylaxis with heparin, with or without aspirin (HR 0.79; 95% CI, 0.66 - 0.93; P = .005); mechanical prophylaxis (HR, 0.85; 95% CI, 0.74 - 0.99; P = .036); and spinal vs general anesthetic (HR, 0.85; 95% CI, 0.74 - 0.97; P = .019).

In addition, the researchers found that the type of prosthesis showed no association with mortality and that being overweight was associated with reduced mortality (HR 0.76; 95% CI, 0.62 - 0.92; P = .006) for people with a body mass index of 26 to 30 kg/m2. However, the authors note, nearly 60% of body mass index data were missing, and the calculation assumes the data are missing at random.

"Widespread adoption of four simple clinical management strategies (posterior surgical approach, mechanical and chemical prophylaxis, and spinal anaesthesia) could, if causally related, reduce mortality further," the authors write.

Poor health was associated with a significantly increased risk for death, with moderate or severe liver disease associated with a nearly 10-fold greater risk for 90-day mortality adjusted for sex, age group, and comorbidity (HR, 9.70; 95% CI, 5.94 - 15.84; P < .0005). Metastatic cancer was associated with 7-fold increased mortality (HR, 7.19; 95% CI, 5.51 - 9.38; P < .0005), and myocardial infarction, congestive heart failure, and diabetes were all associated an increased hazard ratio for 90-day mortality between 2 and 3 times higher.

Kimona Issa, MD, from the Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Maryland, and the Department of Orthopaedic Surgery Seton Hall University, St. Joseph’s Regional Medical Center, Paterson, New Jersey, and Michael A. Mont, MD, from the Rubin Institute for Advanced Orthopedics, note in an accompanying comment that although the study authors propose the adoption of a posterior surgical approach, mechanical and chemical prophylaxis, and spinal anesthesia, they "were unable to evaluate other broader quality of life measures including patient-reported outcomes or other complications that might cause serious morbidity."

The authors and Dr. Issa have disclosed no relevant financial relationships. Dr. Mont receives royalties from Stryker and is a consultant for Janssen, Sage Products, Salient Surgical, Stryker, OCSI, and TissueGen, and receives institutional support from Stryker. He is also on the speakers bureau for Sage Products.

Lancet. 2013;382:1097-1076.

    
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