髖關節置換:90天死亡率在8年時減半


  【24drs.com】根據登載於9月28日Lancet期刊,於威爾斯和英格蘭進行的一項超過400,000個案例的研究,配合採用四個臨床管理策略下,與髖關節置換有關的90天死亡率減半。
  
  英國Bristol大學臨床科學院肌肉骨骼研究小組副研究員Linda P. Hunt博士等人分析了英格蘭和威爾斯的全國關節登記資料庫,該資料庫與全國死亡率資料庫及醫院統計資料庫連結。
  
  2003年4月至2011年12月之間,共有409,096名病患因為骨關節炎而進行髖關節置換手術,研究者確認有1,743例屬於術後90天內死亡。
  
  他們發現,90天死亡率從2003年的0.56%(72例死亡/12,621例骨關節炎)降低到2011年的0.29%(164例死亡/60,727例手術);校正年紀與性別後,研究期間內的相對風險減半,2011年對2003年的相對風險(HR)為0.49 (95%信心區間[CI],0.37 - 0.65;P < .001)。
  
  校正性別、年齡組與共病症之後,有多個臨床因素與降低死亡率有關,包括後方手術術式(HR 0.82;95% CI,0.73 - 0.92;P = .001);使用heparin、併用或未併用阿斯匹靈進行化學性預防血栓形成(HR 0.79;95% CI,0.66 - 0.93;P = .005);機械性預防方式(HR,0.85;95% CI,0.74 - 0.99;P = .036);脊椎麻醉相較於全身麻醉(HR,0.85;95% CI,0.74 - 0.97;P = .019)。
  
  此外,研究者發現,對於身體質量指數26 -30 kg/m2者,假體的類型和死亡率無關,過重和死亡率降低有關(HR 0.76; 95% CI, 0.62 - 0.92; P = .006)。不過,作者們指出,近60%的身體質量指數資料漏失,計算時假設資料是隨機漏失。
  
  作者們寫道,如果證明存在因果關係,廣泛採用四個簡單的臨床管理策略(後方手術方式、機械性與化學性預防、脊椎麻醉)可以進一步降低死亡率。
  
  健康不佳與死亡風險顯著增加有關,校正性別、年齡組和共病症之後,中度或嚴重的肝病90天死亡率風險達將近10倍有關(HR,9.70;95% CI,5.94 - 15.84;P < .0005);癌症轉移和死亡率增加7倍有關(HR,7.19;95% CI,5.51 - 9.38;P < .0005),心肌梗塞、鬱血性心衰竭、糖尿病都與90天死亡率風險比增加2-3倍多有關。
  
  紐澤西若瑟區域醫學中心、Seton Hall大學骨外科、馬里蘭巴爾的摩西奈醫院關節保護與置換中心、Rubin骨科進階研究中心的Kimona Issa醫師,以及Rubin骨科進階研究中心的Michael A. Mont醫師在編輯評論中指出,雖然研究作者提議採用後方手術方式、機械性、化學性預防、以及脊椎麻醉,他們並未評估其他更廣泛的生活品質測量方式,包括病患報告的結果,或可能引起嚴重發病的其他併發症。
  
  資料來源: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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