The Effect of Surgical Approach on Outcomes Following Total Hip Arthroplasty Performed for Displaced Intracapsular Hip Fractures: An Analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.
- 作者列表："Matharu GS","Judge A","Deere K","Blom AW","Reed MR","Whitehouse MR
BACKGROUND:Studies have suggested that the anterolateral approach is preferable to the posterior approach when performing total hip arthroplasty (THA) for a displaced intracapsular hip fracture, because of a perceived reduced risk of reoperations and dislocations. However, this suggestion comes from small studies with short follow-up. We determined whether surgical approach in THAs performed for hip fracture affects revision-free hip survival, patient survival, and intraoperative complications. METHODS:We retrospectively analyzed all stemmed primary THAs for hip fracture that were recorded in the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man that were performed between 2003 and 2015. The 2 surgical approach groups, posterior and anterolateral, were matched for patient and surgical confounding factors using propensity scores, with outcomes compared using regression modeling (with regression model ratios of <1 representing a reduced risk of the specified outcome in the posterior group). Outcomes were 5-year hip survival free from revision (all-cause revision, revision for dislocation and/or subluxation, and revision for periprosthetic fracture), patient survival (30 days, 1 year, and 5 years postoperatively), and intraoperative complications. RESULTS:After matching, 14,536 THAs (7,268 per group) were studied. Five-year cumulative revision-free survival rates were similar (posterior group, 97.3%, and anterolateral group, 97.4%; subhazard ratio [SHR], 1.15 [95% confidence interval (CI), 0.93 to 1.42]). Five-year survival rates free from revision for dislocation (SHR, 1.28 [95% CI, 0.89 to 1.84]) and for periprosthetic fracture (SHR, 1.03 [95% CI, 0.68 to 1.56]) were also comparable between the 2 approach groups. Thirty-day patient survival was significantly higher following a posterior approach (99.5% compared with 98.8%; hazard ratio [HR], 0.44 [95% CI, 0.30 to 0.64]), which persisted at 1 year (HR, 0.73 [95% CI, 0.64 to 0.84]) and 5 years (HR, 0.87 [95% CI, 0.81 to 0.94]) postoperatively. The posterior approach was associated with a lower risk of intraoperative complications (odds ratio [OR], 0.59 [95% CI, 0.45 to 0.78]). CONCLUSIONS:In THA for hip fracture, the posterior approach was associated with a similar risk of revision and a lower risk of both patient mortality and intraoperative complications compared with the anterolateral approach. We propose that the posterior approach is as safe as the anterolateral approach when performing THA for hip fracture and that either approach may be used according to surgeon preference. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景: 研究表明，对于移位的髋关节囊内骨折行全髋关节置换术 (THA) 时，前外侧入路优于后侧入路，因为再手术和脱位的风险明显降低。然而，这一建议来自随访时间短的小型研究。我们确定了在髋部骨折中进行的手术入路是否影响无翻修髋关节存活、患者存活和术中并发症。 方法: 我们回顾性分析了 2003 年至 2015 年间在英格兰、威尔士、北爱尔兰和马恩岛的国家关节登记处记录的所有髋部骨折的带柄原发病例。后外侧和前外侧 2 个手术入路组使用倾向评分对患者和手术混杂因素进行匹配，与使用回归模型进行的结局比较 (回归模型比率 <1 表示后组中指定结局的风险降低)。结果为无翻修的 5 年髋关节生存率 (全因翻修、脱位和/或半脱位翻修和假体周围骨折翻修) 、患者生存率 (30 天、 1 年、和术后 5 年)，以及术中并发症。 结果: 匹配后，研究了 14,536 个THAs (每组 7,268 个)。五年累积无翻修生存率相似 (后部组，97.3%，前外侧组，97.4%; 亚风险比 [SHR]，1.15 [95% 置信区间 (CI)，0.93 至 1.42])。无翻修脱位 (SHR，1.28 [95% CI，0.89 至 1.84]) 和假体周围骨折 (SHR，1.03 [95% CI，0.68 至 1.56]) 的五年生存率 2 种方法组之间也具有可比性。后路手术后 30 天患者存活率显著升高 (99.5% 与 98.8% 相比; 风险比 [HR]，0.44 [95% CI，0.30 至 0.64])，持续 1 年 (HR，0.73 [95% CI，0.64 至 0.84]) 和 5 年 (HR，0.87 [95% CI，0.81 至 0.94]) 术后。后路手术与较低的术中并发症风险相关 (比值比 [OR]，0.59 [95% CI，0.45 ~ 0.78])。 结论: 在治疗髋部骨折的THA中，与前外侧入路相比，后侧入路的翻修风险相似，患者死亡率和术中并发症风险较低。我们建议，在进行髋关节骨折的THA时，后路与前外侧入路一样安全，根据外科医生的偏好，可以使用任何一种入路。 证据级别: 治疗III级。有关证据级别的完整描述，请参见作者说明。
METHODS:OBJECTIVE:Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality. METHODS:We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration). RESULTS:The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24). CONCLUSION:This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.
METHODS:OBJECTIVE:We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS:Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS:We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION:In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
METHODS:OBJECTIVE:Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS:Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS:Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION:These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.