Holtzman Jeremy, Saleh Khal, Kane Robert
Clinical Outcomes Research Center, Division of Health Services Research and Policy, University of Minnesota, D-351 Mayo (Mailcode 197), 420 Delaware Street S.E., Minneapolis, MN 55455, USA.
J Bone Joint Surg Am. 2002 Nov;84(11):1942-8. doi: 10.2106/00004623-200211000-00006.
It is unknown whether there is an optimal time for surgery-that is, whether waiting until a patient has greater disability results in a worse outcome. We examined the effect of baseline status on the outcome of total hip arthroplasty to determine if such a relationship existed.
All Medicare patients undergoing total hip arthroplasty for osteoarthritis in twelve states were identified by the fiscal intermediary beginning in October 1994 and continuing for approximately eight months; 1640 eligible patients were identified. Consenting patients were surveyed within two months after the procedure and again at twelve months after the procedure, and their medical records were reviewed. The baseline survey, completed by 1120 patients, included items regarding the level of activity, the presence and severity of pain with walking, the need for assistance for walking, the distance that the patient could walk, and whether the patient could perform Instrumental Activities of Daily Living (IADLs). Data on comorbid diagnoses were collected from the medical records.
Patients with pain during walking at baseline were more likely to have pain at one year than those without pain at baseline (21% compared with 9%; p < 0.05). Patients who needed assistance with walking at baseline were more likely to need assistance at one year than those who did not need assistance at baseline (38% compared with 15%; p < 0.01). Similar results were seen with regard to the need for assistance with housework (39% compared with 18%; p < 0.01) and grocery shopping (37% compared with 14%; p < 0.01) and, to a lesser extent, for overall participation in moderate activity (17% compared with 10%; p < 0.01). These results persisted after controlling for comorbidities in a multiple regression equation. However, the worse a patient's preoperative status, the more he or she gained in all four measures (p < 0.01).
The findings of the present study suggest that the worse a patient's preoperative status, the more he or she may benefit from total hip arthroplasty. However, our findings also suggest that patients who have a worse preoperative status may not have as good an outcome as those who have a better preoperative status. Patients and physicians should consider these findings when discussing the timing of total hip arthroplasty.
目前尚不清楚是否存在手术的最佳时机，也就是说，等待患者残疾程度加重是否会导致更差的手术结果。我们研究了基线状态对全髋关节置换术结果的影响，以确定是否存在这样的关系。
从1994年10月开始，为期约八个月，由财务中介机构确定了十二个州所有因骨关节炎接受全髋关节置换术的医疗保险患者；共确定了1640例符合条件的患者。同意参与的患者在术后两个月内接受调查，并在术后十二个月再次接受调查，同时审查他们的病历。由1120名患者完成的基线调查包括有关活动水平、行走时疼痛的存在及严重程度、行走是否需要协助、患者能行走的距离以及患者是否能够进行日常生活工具性活动（IADL）等项目。从病历中收集共病诊断数据。
基线时行走时疼痛的患者在一年后比基线时无疼痛的患者更有可能仍有疼痛（分别为21%和9%；p<0.05）。基线时行走需要协助的患者在一年后比基线时不需要协助的患者更有可能仍需要协助（分别为38%和l5%；p<0.01）。在做家务（分别为39%和18%；p<0.01）和购物（分别为37%和14%；p<0.01）方面也观察到类似结果，在一定程度上，在总体参与适度活动方面（分别为17%和10%；p<0.01）也是如此。在多元回归方程中对共病进行控制后，这些结果仍然存在。然而，患者术前状态越差，在所有四项指标上获得的改善就越大（p<0.01）。
本研究结果表明，患者术前状态越差，从全髋关节置换术中获益可能就越大。然而，我们的研究结果还表明，术前状态较差的患者可能不会像术前状态较好的患者那样获得良好的手术结果。患者和医生在讨论全髋关节置换术的时机时应考虑这些研究结果。
