- 作者列表："Malcolm TL","Knezevic NN","Zouki CC","Tharian AR
BACKGROUND:Pulmonary complications after total joint arthroplasty (TJA) are uncommon but have significant cost impact. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are 2 of the 5 top procedures requiring inpatient stay within the United States. Subsequent pulmonary complications therefore may impose substantial cost burden for US health care. The purpose of this study was to describe the incidence, risk factors, and clinical implications of pulmonary complications (ie, pneumonia, respiratory failure, pulmonary embolism [PE], and aspiration) after TJA in the United States. METHODS:The National Inpatient Sample (NIS) was queried for all patients undergoing primary, elective THA and TKA between years 2004 and 2014. Pulmonary complications were defined as the occurrence of pneumonia, respiratory failure, PE, or aspiration after TJA. Demographic and clinical characteristics, inpatient cost, length of stay (LOS), and mortality were compared between patients with and without documented perioperative pulmonary complications. Given the stratified nature of the NIS database, estimates of incidence throughout the United States were made with application of trend weights to observed database frequencies. Analyses of estimated annual complication rates were made using χ tests. RESULTS:Between 2004 and 2014, an estimated 2,679,351 patients underwent elective primary THA. A total of 5,527,205 patients were estimated to have undergone elective primary TKA. THA 1.42% (95% CI, 1.37%-1.47%) and 1.71% (95% CI, 1.66%-1.76%) of TKA procedures were complicated by pneumonia, respiratory failure, PE, or aspiration. During this time, the incidence of perioperative pulmonary complications decreased from 1.57% (95% CI, 1.41%-1.73%) to 1.01% (95% CI, 0.92%-1.10%) after THA (P < .0001) and from 2.03% (95% CI, 1.88%-2.18%) to 1.33% (95% CI, 1.25%-1.42%) after TKA (P < .0001). The adjusted odds ratio (aOR) of experiencing a pulmonary complication was highest among patients with history of significant weight loss (aOR = 4.77; 99.9% CI, 3.97-5.73), fluid/electrolyte disorders (aOR = 3.33; 99.9% CI, 3.11-3.56), congestive heart failure (CHF; aOR = 3.32; 99.9% CI, 3.07-3.58), preexisting paralytic condition (aOR = 2.03; 99.9% CI, 1.57-2.61), and human immunodeficiency virus infection (aOR = 2.00; 99.9% CI, 1.06-3.78). Perioperative pulmonary complications were associated with increased LOS (THA = 3.03 days; 99.9% CI, 2.76-3.31; TKA = +2.72 days; 99.9% CI, 2.58-2.86), increased hospital costs (THA = +9163 US dollars; 99.9% CI, 8054-10,272; TKA = +7257 US dollars; 99.9% CI, 6650-7865), and increased mortality (THA: aOR = 121; 99.9% CI, 78-187; TKA: aOR = 150; 95% CI, 97-233). CONCLUSIONS:Despite a decline in overall incidence, perioperative pulmonary complications represent a significant potential source of perioperative morbidity and mortality. The current study highlights potential risk factors for pulmonary complications. Recognition of these factors may help to better stratify patients and mitigate risk of potential complications. This is particularly true of respiratory failure as it is associated with the high increases in resource utilization and mortality in this group.
背景: 全关节置换 (TJA) 术后肺部并发症并不常见，但有显著的成本影响。全髋关节置换术 (THA) 和全膝关节置换术 (TKA) 是美国需要住院的 5 个顶级手术中的 2 个。因此，随后的肺部并发症可能会给美国医疗保健带来巨大的成本负担。本研究的目的是描述肺部并发症 (如肺炎、呼吸衰竭、肺栓塞 [PE] 和误吸) 的发生率、危险因素和临床意义在美国TJA之后。 方法: 对 2004 年至 2014 年间接受初次、择期THA和TKA的所有患者进行全国住院样本 (NIS) 查询。肺部并发症定义为TJA后发生肺炎、呼吸衰竭、PE或误吸。比较有和无记录的围手术期肺部并发症患者的人口统计学和临床特征、住院费用、住院时间 (LOS) 和死亡率。鉴于NIS数据库的分层性质，对整个美国的发病率进行了估计，对观察到的数据库频率应用趋势权重。使用 χ 检验对估计的年度并发症发生率进行分析。 结果: 在 2004-2014 之间，估计有 2,679,351 例患者接受了选择性初次THA。估计共有 5,527,205 例患者接受了选择性原发性TKA。THA 1.42% (95% CI，1.37%-1.47%) 和 1.71% (95% CI，1.66%-1.76%) 的TKA手术并发肺炎、呼吸衰竭、PE或误吸。在此期间，围手术期肺部并发症发生率从THA后的 1.57% (95% CI，1.41%-1.73%) 降至 1.01% (95% CI，0.92%-1.10%) (P < .0001) TKA术后从 2.03% (95% CI，1.88%-2.18%) 到 1.33% (95% CI，1.25%-1.42%) (P <.0001)。在有显著体重减轻史的患者中，经历肺部并发症的调整比值比 (aOR) 最高 (aOR = 4.77; 99.9% CI，3.97-5.73)，液体/电解质紊乱 (aOR = 3.33; 99.9% CI，3.11-3.56)，充血性心力衰竭 (CHF; aOR = 3.32; 99.9% CI，3.07-3.58)，预先存在的麻痹状况 (aOR = 2.03; 99.9% CI，1.57-2.61)，与人体免疫机能丧失病毒感染 (aOR = 2.00; 99.9% CI，1.06-3.78).围手术期肺部并发症与LOS增加相关 (THA = 3.03 天; 99.9% CI，2.76-3.31; TKA = + 2.72 天; 99.9% CI，2.58-2.86)，增加的住院费用 (THA = + 9163 美元; 99.9% CI，8054-10,272; TKA = + 7257 美元; 99.9% CI，6650-7865)，死亡率增加(THA: aOR = 121; 99.9% CI，78-187; TKA: aOR = 150; 95% CI，97-233)。 结论: 尽管总体发病率有所下降，围手术期肺部并发症仍然是围手术期发病率和死亡率的重要潜在来源。目前的研究强调了肺部并发症的潜在危险因素。识别这些因素可能有助于更好地对患者进行分层，减轻潜在并发症的风险。呼吸衰竭尤其如此，因为它与该组资源利用率和死亡率的高增加相关。
METHODS:BACKGROUND:Postoperative cognitive dysfunction (POCD) is a common complication after orthopedic surgery, which is not conducive to the prognosis of the elderly. AIMS:We performed this study to investigate the effects of oxycodone applied for patient-controlled intravenous analgesia (PCIA) on postoperative cognitive function in elderly patients after total hip arthroplasty (THA). METHODS:Ninety-nine participants were enrolled and allocated into two groups: oxycodone group (group O) and sufentanil group (group S). The primary outcome was the incidence of POCD, diagnosed according to the changes in the Mini-mental status examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes included the plasma levels of S-100B protein and neuron-specific enolase (NSE), the amount of postoperative analgesic consumption and the incidence of adverse reactions. RESULTS:The incidence of POCD was significantly lower in patients receiving oxycodone up to the 3rd postoperative day (POD, 1st POD 27.3% vs. 51.1%, P = 0.021; 3rd POD 20.5% vs. 40.0%, P = 0.045), as compared to patients receiving sufentanil. The MMSE and MoCA scores of both groups decreased to varying degrees. However, compared with group S, the MMSE scores at 1st POD, 3rd POD, 5th POD and 7st POD in group O were higher than that in group S, while MoCA scores at 1st POD, 3rd POD and 5th POD in group O were higher. Compared with group S, the plasma levels of S-100B protein in group O at 4 h, 8 h, 12 h post-surgery were lower. While the plasma levels of NSE in group O at 4 h, 8 h, 12 h, 24 h post-surgery were lower. Number of PCIA boluses and consumption of analgesic drug during the first two POD were similar between two groups. However, postoperative incidence of nausea, vomiting and pruritus was significantly lower in patients receiving oxycodone. CONCLUSION:Oxycodone applied for PCIA in elderly patients after THA could reduce the incidence of POCD, improve postoperative cognitive function and decrease the adverse reactions.
METHODS:BACKGROUND:Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS:We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS:In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS:Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE:Level III-retrospective comparative study with a systematic review.
METHODS:INTRODUCTION:As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS:Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS:Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION:Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.