Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Orthopaedic Surgery, Stanford Medicine, Redwood City, California.
J Bone Joint Surg Am. 2021 Mar 3;103(5):424-431. doi: 10.2106/JBJS.20.00969.
There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA.
A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017.
Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample.
The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
翻修全关节置换术后（TJA）存在发生围手术期并发症的重大风险。外科医生和患者之间复杂的共同决策将受益于一种高保真工具，以识别 TJA 翻修后死亡风险的患者。因此，我们开发了 CARDE-B 评分。CARDE-B 是充血性心力衰竭、白蛋白或营养不良（<3.5mg/dL）、透析肾功能衰竭、日常生活依赖、老年（>65 岁）和体重指数<25kg/m2 的缩写。我们开发并验证了 CARDE-B 评分，以确定 TJA 翻修后 30 天内死亡的风险。
共分析了来自国家手术质量改进计划（NSQIP）数据库的 13118 例 TJA 翻修（40%髋关节和 60%膝关节）。基于逻辑回归模型，创建了一个简单的 1 分评分系统 CARDE-B，用于预测 TJA 翻修后 30 天的死亡率。CARDE-B 评分系统为缩写中的每个标准分配 1 分：充血性心力衰竭、白蛋白（<3.5mg/dL）、透析肾功能衰竭、日常生活依赖、老年（>65 岁）和体重指数<25kg/m2。CARDE-B 评分系统与 2 种常用评分方法进行了比较：美国麻醉医师协会（ASA）身体状况分类和 5 项改良虚弱指数（mFI-5）。曲线下面积（AUC）用于评估每个模型的准确性。Hosmer-Lemeshow 检验用于评估拟合优度。最后，使用 2017 年接受 TJA 翻修的 19153 例患者的全国住院患者样本（NIS）对 CARDE-B 评分进行外部验证。
88 例（0.7%）患者在 TJA 翻修后 30 天内未存活。NSQIP 中使用的推导和内部验证样本中，逻辑回归模型的 AUC 分别为 0.88。TJA 翻修后 30 天死亡率的预测概率从 CARDE-B 评分 0 分的<0.01%逐步增加到 CARDE-B 评分 5 分的 39%。CARDE-B 评分预测 TJA 翻修后 30 天死亡率的 AUC 为 0.85。这比 ASA 身体状况分类（AUC，0.77）和 mFI-5（AUC，0.67）更准确（p<0.001）。CARDE-B 评分在 NIS 外部验证集中的 AUC 为 0.75。拟合优度的 Hosmer-Lemeshow p 值为 0.34，表明外部验证样本的拟合度良好。
CARDE-B 评分是一种简单的系统，可预测 TJA 翻修后 30 天内的死亡风险，为外科医生和患者提供了一种有价值且经过验证的风险分层工具。
预后 III 级。请参阅《作者须知》，以获取完整的证据水平描述。
