骨科手術風險在糖尿病、肥胖病患比較不成功


  March 9, 2008(舊金山) — 第1型糖尿病和肥胖,讓接受下肢關節內視鏡檢查法的病患有術間風險和術後限制,這些發現發表於美國骨科醫師學會(AAOS)第75屆年會中的兩篇報告。
  
  因為許多美國人有糖尿病且年紀超過60歲,估計2,000萬有糖尿病的美國人半數有關節炎,因此,許多有糖尿病的美國人需要髖或膝置換。
  
  一篇壁報報告糖尿病患骨科手術的併發症,作者是AAOS會員、杜克大學醫學中心成人復健主任 Michael P. Bolognesi醫師,他指出糖尿病患接受全髖關節置換(THA)或者全膝蓋置換(TKA)者增加了不良反應風險。
  
  Bolognesi醫師等人主導了對1988至2003年間全國住院樣本資料庫中的65,769名關節置換之糖尿病患的回溯研究,他比較了第1型糖尿病患(n = 8728)和第2型糖尿病患(n = 57,041),使用雙變項和多變項分析,檢視共同手術與全身併發症、死亡率、住院療程變化等;第1型糖尿病患狀況比第2型糖尿病患更糟,有較高的不良反應,如心肌梗塞和肺炎、較長住院天數、較高術後花費等風險(P < .001)。
  
  共同作者Milford H. Marchant Jr醫師向Medscape骨科學表示,骨科醫師必須在進行THA或者TKA手術之前,告訴第1型糖尿病患和第2型糖尿病患者他們有較高的併發症風險,特別是在最初或者後續住院期間,且根據本研究,第1型糖尿病患的風險更高。
  
  在一篇相關發表中,Marchant醫師表示,糖尿病患者接受最初的TKA者比接受最初THA者較不會發生心肌梗塞;主持人、也是本研究的共同作者、加州大學舊金山分校的Thomas Parker Vail醫師詢問何以如此,Marchant醫師表示,資料庫未顯示哪些病患事先篩選有心臟問題;另一名主持人,Grand Rapids的骨科醫師Gregory Golladay表示,有些病患或許有未被發現的心肌梗塞。
  
  Marchant醫師向Medscape骨科學表示,研究者在研究中未將肥胖也包括在共同變項內,因為身體質量指數(BMI)不是資料庫裡面的變項,或者資料庫裡面沒有可信賴的編碼。
  
  不過,AAOS會議中的另外一篇壁報,未檢視BMI對TKA的效果;紐約市特殊手術醫院的Geoffrey H. Westrich醫師,研究BMI對關節活動度(ROM)的效果,對特殊手術醫院的342名TKA病患進行一項回溯研究,病患的平均年紀為71歲。
  
  Westrich醫師發現ROM受到BMI和手術後時間的影響(在他的研究中最長達3年),他將病患依照BMI值分成5組,範圍從小於25.0到超過40.0kg/m2;3年的研究期間,在BMI超過25.0 kg/m2的4組中,術後ROM平均比BMI小於25.0 kg/m2 者少6-13度。
  
  年紀對 ROM 無顯著影響(P = .27),Westrich醫師在壁報中寫道,但是性別會 (P < .0001),女性的ROM 比男性少4.6度;女性也比男性更可能需要在麻醉下操作(MUA),女性和男性分別有18.5%和9.9%需要MUA;BMI也與需要MUA有關(P = .05)。
  
  一如Westrich醫師在壁報中表示的,肥胖病患必須被建議有關ROM的期望以及增加追蹤TKA;Westrich醫師向Medscape骨科學表示,Medicare健保也需要辨識肥胖對TKA結果的效果,肥胖病患在手術室耗費的時間更多,需要更多物理治療,更可能需要昂貴的MUA。
  
  Bolognesi醫師接受Orthosoft之研究或者機構支持、各種資金、股票選擇權、以及諮商顧問費用;接受Johnson & Johnson Company集團內的 DuPuy以及Zimmer的研究或者機構支持、各種資金、以及兩者的諮商顧問費用;接受AMEDICA的股票選擇權以及諮商顧問費用。Westrich醫師接受DJ Orthopaedics、Exactech公司和Stryker之研究或者機構支持以及諮商顧問費用,且他接受Sanofi-Aventis之研究或者機構支持。
  
  美國骨科醫師學會第75屆年會:摘要P069和P188。發表於2008年3月7日。
  

Orthopaedic Surgeries Riskier,

By Laurie Bouck
Medscape Medical News

Laurie Bouck

March 9, 2008 (San Francisco) — Both type 1 diabetes and obesity create perioperative risks and postoperative limitations in patients undergoing lower extremity arthroscopy. These findings were presented in 2 separate studies here at the American Academy of Orthopaedic Surgeons (AAOS) 75th Annual Meeting.

Because many Americans with diabetes are older than 60 years, half of the roughly 20 million Americans with diabetes have osteoarthritis. As a result, many Americans with diabetes require hip or knee replacements. In a poster on orthopaedic surgical complications in the diabetic patient, author Michael P. Bolognesi, MD, director of adult reconstruction at Duke University Medical Center, Durham, North Carolina, and an AAOS fellow, showed that patients with diabetes who have a total hip arthroplasty (THA) or total knee arthroplasty (TKA) have an increased risk of adverse events.

Dr. Bolognesi and colleagues conducted a retrospective study of 65,769 joint replacement patients with diabetes drawn from the Nationwide Inpatient Sample data from 1988 to 2003. He compared patients with type 1 diabetes (n = 8728) and patients with type 2 diabetes (n = 57,041), using bivariate and multivariate analyses, looking at "common surgical and systemic complications, mortality, and hospital course alterations." Patients with type 1 diabetes fared much worse than patients with type 2 diabetes, with a higher risk of adverse events such as myocardial infarction and pneumonia, longer hospital stays, and higher inflation-adjusted postsurgical costs (P < .001).

Coauthor Milford H. Marchant Jr, MD, told Medscape Orthopaedics that orthopaedic surgeons should tell patients with both type 1 and type 2 diabetes before undergoing THA or TKA "that they are at an increased risk for complications, particularly during the first, or index, hospitalization.... If they're a type 1 diabetic, based on this study, that risk is higher."

In a related presentation, Dr. Marchant said that patients with diabetes mellitus who undergo primary TKA are less likely to have a myocardial infarction than patients who undergo primary THA. Moderator Thomas Parker Vail, MD, from the University of California, San Francisco, who is also a coauthor on the study, asked why that was, and Dr. Marchant said that the database did not show which patients were prescreened for cardiac problems. Moderator Gregory Golladay, MD, an orthopaedic surgeon from Grand Rapids, Michigan, suggested that some patients might have a silent myocardial infarction.

Dr. Marchant told Medscape Orthopaedics that the researchers did not include obesity as a covariable in the study because body mass index (BMI) "is not a variable within the database...or if it is in the database it's not reliably coded."

Another poster at the AAOS meeting, however, did look at the effect of BMI on TKA. Geoffrey H. Westrich, MD, from the Hospital for Special Surgery in New York City, studied the effect of BMI on range of motion (ROM) and manipulation in a retrospective study of 342 TKA patients at the Hospital for Special Surgery. The average age of the patients was 71 years.

Dr. Westrich found that ROM was influenced by both BMI and length of time (up to 3 years in his study) since the surgery. He divided patients into 5 groups on the basis of their BMIs, ranging from less than 25.0 to more than 40.0 kg/m2. Throughout the 3 years that the groups were studied, postoperative ROM in the 4 groups with a BMI of more than 25.0 kg/m2 was on average 6 to 13 degrees lower than the postoperative ROM in the group with a BMI of less than 25.0 kg/m2.

Age did not influence ROM significantly (P = .27), Dr. Westrich wrote in the poster, but sex did (P < .0001), with women's ROM being 4.6 degrees less than men's. Women were also more likely to need manipulation under anesthesia (MUA) than men, with MUA provided for 18.5% of women and 9.9% of men. BMI was also related to the need for MUA (P = .05).

As Dr. Westrich stated in his poster, "Patients with obesity should be counseled as to realistic expectations regarding ROM and the increased need for manipulation following TKA." Dr. Westrich told Medscape Orthopaedics that Medicare also needs to recognize the effect of obesity on TKA outcome. Obese patients take more time in the operating room, need more physical therapy, and are more likely to need expensive MUA, Dr. Westrich said.

Dr. Bolognesi receives research or institutional support, miscellaneous funding, stock options, and is a consultant to or employee of Orthosoft; receives research or institutional support, miscellaneous funding, and is a consultant or employee to both DuPuy, a Johnson & Johnson Company, and Zimmer; and receives stock options and is a consultant or employee of AMEDICA.Dr. Westrich receives research or institutional support and is a consultant to or employee of DJ Orthopaedics, Exactech Inc, and Stryker, and he receives research or institutional support from Sanofi-Aventis.

American Academy of Orthopaedic Surgeons 75th Annual Meeting: Abstracts P069 and P188. Presented March 7, 2008.

    
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