术前优化不足：哪些可改变的风险因素最危险？
Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?
机构信息
Atrium Health - Department of Orthopaedics, Charlotte, NC; Atrium Health - Musculoskeletal Institute, Charlotte, NC.
OrthoCarolina - Hip & Knee Center, Charlotte, NC.
出版信息
J Arthroplasty. 2021 Jul;36(7):2452-2457. doi: 10.1016/j.arth.2021.02.061. Epub 2021 Feb 27.
BACKGROUND
Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA.
METHODS
The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m, had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups.
RESULTS
Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m, albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality.
CONCLUSION
Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization.
LEVEL OF EVIDENCE
Retrospective cohort study, level IV.
背景
全膝关节置换术（TKA）后的并发症对患者来说是毁灭性的，外科医生在替代支付模式下对此负有责任。优化可改变的危险因素已成为术前的主要手段。我们旨在评估在接受 TKA 的现代患者队列中，未能优化关键危险因素的后果。
方法
在美国外科医师学院国家手术质量改进计划数据库中搜索 2017-2018 年接受 TKA 的患者。如果患者的体重指数（BMI）<40kg/m、白蛋白>3.5g/dL、不吸烟且非糖尿病，则认为患者的风险因素得到了优化。然后，根据之前的 4 个风险因素对患者进行分组。分析并比较了各组之间的 30 天再入院率、感染率、总体并发症发生率和死亡率。
结果
总体而言，共有 84315 名患者纳入研究。共有 31.6%的患者未被认为是优化的。BMI>40kg/m、白蛋白<3.5、吸烟和胰岛素依赖型糖尿病均与术后感染、再入院、死亡率和总体并发症有关（P<0.05）。相比之下，未优化组的再入院率（5%比 3%）、感染率（2%比 1%）、总体并发症发生率（8%比 5%）和死亡率（0.35%比 0.1%）明显更高（均 P<0.001）。Logistic 回归显示，白蛋白<3.5g/dL 的患者感染的几率增加 3.7 倍，30 天死亡率增加 7.2 倍。
结论
尽管已知可改变的危险因素会显著影响术后结果，但外科医生仍继续对未优化的患者进行手术。在分析的可改变风险因素中，低白蛋白血症似乎是所有评估并发症的最强风险因素。术前应特别注意营养优化。
证据水平
回顾性队列研究，IV 级。
Zotero 插件