Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Orthopaedics, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Bone Joint J. 2021 Jun;103-B(6 Supple A):45-50. doi: 10.1302/0301-620X.103B6.BJJ-2020-2409.R1.
It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.
We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m, n = 512); obese (BMI 30 kg/m to 39.9 kg/m, n = 748); and morbidly obese (BMI > 40 kg/m, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes.
Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939).
With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: 2021;103-B(6 Supple A):45-50.
已经表明，与肥胖相关的术前危险因素的修正可以降低全膝关节置换术（TKA）后的并发症。然而，其最佳方法仍不清楚。本研究的目的是探讨我们机构设计的术前风险分层工具（RST）是否可以降低肥胖患者 TKA 后意外转入重症监护病房（ICU）和 90 天内急诊（ED）就诊、再入院和再次手术的发生率。
我们回顾性分析了 1614 例连续接受单侧初次 TKA 的患者。他们的平均年龄为 65.1 岁（17.9 至 87.7），平均 BMI 为 34.2kg/m²（标准差 7.7）。所有患者均接受 RST 的围手术期优化和监测，RST 是一种经过验证的计算工具，可提供术后 ICU 护理或增加护理支持的建议。患者分为三组：非肥胖组（BMI<30kg/m²，n=512）；肥胖组（BMI30kg/m²至 39.9kg/m²，n=748）；和病态肥胖组（BMI>40kg/m²，n=354）。使用逻辑回归分析评估了调整年龄、性别、吸烟和糖尿病因素后各组的结果。
与非肥胖患者相比，肥胖患者出院至康复机构的比例明显增加（分别为 38.7%（426/1102）和 26.0%（133/512）；p<0.001）。按 BMI 分层，与非肥胖患者（26.0%（133））相比，肥胖患者（34.2%（256），比值比（OR）1.6）和病态肥胖患者（48.0%（170），OR 3.1）出院至康复机构的比例仍然明显更高（p<0.001）。然而，意外转入 ICU 的比例没有显著差异（0.4%（2）非肥胖与 0.9%（7）肥胖（OR 2.5）与 1.7%（6）病态肥胖（OR 5.4）；p=0.054），急诊就诊（8.6%（44）与 10.3%（77）（OR 1.3）与 10.5%（37）（OR 1.2）；p=0.379），再入院（4.5%（23）与 4.0%（30）（OR 1.0）与 5.1%（18）（OR 1.4）；p=0.322）或再次手术（2.5%（13）与 3.3%（25）（OR 1.2）与 3.1%（11）（OR 0.9）；p=0.939）。
使用术前 RST，病态肥胖患者初次 TKA 后短期术后不良结局的发生率与非肥胖患者相似。这支持了这样一种观点，即病态肥胖患者可以在适当的围手术期优化和监测下安全地接受 TKA。
