Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database.
- 作者列表："Wilson JM","Farley KX","Bradbury TL","Guild GN
BACKGROUND:The incidence of revision THA continues to increase and there is a need to identify risk factors contributing to postoperative complications. Anesthesia type has been shown to be associated with complication rates in patients who undergo primary THA, but it is not clear whether the same is true among patients undergoing revision THA. QUESTIONS/PURPOSES:(1) After controlling for confounding variables, in the setting of a large-database analysis, is spinal anesthesia associated with a lower risk of death, readmission, reoperation, postoperative transfusion, thromboembolic events, surgical site infection (SSI), and re-intubation among patients undergoing revision THA? METHODS:The American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing aseptic, revision THA with either spinal or general anesthesia. Coarsened exact matching was used to match patients based on several baseline characteristics, including age, sex, body mass index, surgery type (Current Procedural Terminology code), and the modified Frailty Index score. Coarsened exact matching is a statistical method of exact matching that matches on chosen characteristics, in which continuous variables may be temporarily coarsened (such as, into discrete categorical variables) to facilitate matching. This method is an alternate to and requires less estimation than traditional propensity score matching. Then, using a model controlling for baseline patient characteristics and operative time, we performed multivariate logistic and linear regression analyses of matched cohorts to examine differences in mortality, readmission, reoperation, thromboembolic events, transfusion, SSI, and re-intubation. RESULTS:After statistical matching and controlling for baseline demographic variables, surgery type (one- or two-component revision), surgical time and modified Frailty Index we found that patients receiving general anesthesia had higher odds of mortality (OR 3.72 [95% CI 1.31 to 10.50]; p = 0.013), readmission (OR 1.49 [95% CI 1.24 to 1.80]; p < 0.001), reoperation (OR 1.40 [95% CI 1.13 to 1.73]; p = 0.002), thromboembolic events (OR 2.57 [95% CI 1.37 to 4.84]; p = 0.003), SSI (OR 1.32 [95% CI 1.01 to 1.72]; p = 0.046), postoperative transfusion (OR 1.57 [95%CI 1.39 to 1.78]; p < 0.001) and unplanned intubation or failure to wean off intubation (OR 5.95 [95% CI 1.43 to 24.72]; p = 0.014). CONCLUSIONS:In patients undergoing revision THA, spinal anesthesia is associated with a decreased risk of several complications. The current investigation suggests that, when practical (such as when long surgical times or changes to the surgical plan are not anticipated), spinal anesthesia should be considered for use during revision THA. LEVEL OF EVIDENCE:Level III, therapeutic study.
背景: 翻修THA的发生率持续增加，需要确定导致术后并发症的危险因素。麻醉类型已被证明与初次THA患者的并发症发生率相关，但不清楚翻修THA患者是否也是如此。 问题/目的 :( 1) 在控制混杂变量后，在大型数据库分析的背景下，脊髓麻醉是否与较低的死亡、再入院、再次手术、术后输血风险相关，翻修THA患者中的血栓栓塞事件、手术部位感染 (SSI) 和再次插管？ 方法: 查询美国外科医师学会-国家外科质量改进 (ACS-NSQIP) 数据库中接受脊柱或全身麻醉的无菌、翻修THA患者。基于几个基线特征，包括年龄、性别、体重指数、手术类型 (当前程序术语代码) 和修改的虚弱指数评分，使用粗化精确匹配对患者进行匹配。粗化精确匹配是一种精确匹配的统计方法，与所选择的特征相匹配，其中连续变量可能会暂时粗化 (例如，变成离散的分类变量)，以方便匹配。这种方法是一种替代和需要较少的估计比传统的倾向评分匹配。然后，使用控制基线患者特征和手术时间的模型，我们对匹配的队列进行多因素logistic和线性回归分析，以检查死亡率、再入院、再次手术、血栓栓塞事件、输血、SSI，再插管。 结果: 在统计匹配和控制基线人口统计学变量后，手术类型 (单组分或双组分翻修)，手术时间和改良虚弱指数我们发现接受全身麻醉的患者死亡率 (OR 3.72 [95% CI 1.31 ~ 10.50]; p = 0.013) 、再入院 (OR 1.49[95% CI 1.24 ~ 1.80]; p <0.001)，再次手术 (OR 1.40 [95% CI 1.13 ~ 1.73]; p = 0.002)，血栓栓塞事件 (OR 2.57 [95% CI 1.37 ~ 4.84]; p = 0.003) 、SSI (OR 1.32 [95% CI 1.01 ~ 1.72]; p = 0.046) 、术后输血(OR 1.57 [95% CI 1.39 ~ 1.78]; p < 0.001) 和计划外插管或中断插管失败 (or 5.95 [95% CI 1.43 ~ 24.72]; p = 0.014)。 结论: 在接受翻修THA的患者中，脊髓麻醉与几种并发症的风险降低相关。目前的调查表明，在实际情况下 (如手术时间较长或手术计划未预期改变时)，应考虑在翻修THA期间使用脊髓麻醉。 证据级别: III级，治疗性研究。
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.