Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
J Knee Surg. 2023 Sep;36(11):1132-1140. doi: 10.1055/s-0042-1749607. Epub 2022 Jul 11.
Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% ( 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% ( 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, 0.0001), 1 year (aOR = 2.66, 0.0001), and 2 years (aOR = 2.63, 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, 0.0001), with significant differences in survival to revision curves ( 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, = 0.0026 vs. aOR = 0.93, = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.
先前关于早期和晚期麻醉下手法松解术（MUA）的研究并未报告术后阿片类药物的使用情况或翻修情况，且主要集中在小型单机构回顾性队列研究上。PearlDiver 研究计划（www.pearldiverinc.com）使用了一个全面的保险数据库，该计划用于确定接受（1）晚期 MUA（>12 周）、（2）早期 MUA（≤12 周）或（3）仅 TKA 的初次全膝关节置换术（TKA）患者。为了开发仅接受 TKA 的患者对照队列，使用了 11 个通过卡方分析确定为显著的风险因素变量进行了 3:1 匹配。通过多元回归分析比较了并发症和阿片类药物的使用情况，控制了年龄、性别和 Charlson 合并症指数。通过 Cox 比例风险建模和 Kaplan-Meier 生存分析以及对数秩检验评估了 TKA 翻修的风险。在 2011 年至 2017 年期间，数据库中确定了 2062 例接受早期 MUA 的 TKA 患者、1112 例接受晚期 MUA 的 TKA 患者和一个对照队列的 8327 例仅接受 TKA 的患者。接受 MUA 的患者中，1 个月内登记使用阿片类药物的比例从 MUA 前的 54.6%下降到 1 个月后的 4.6%（ 0.0001），而晚期 MUA 后仅从 32.6%下降到 10.4%（ 0.0001）。晚期 MUA 与索引 MUA 后 6 个月（调整后的优势比[aOR] = 2.74， 0.0001）、1 年（aOR = 2.66， 0.0001）和 2 年（aOR = 2.63， 0.0001）时再次接受 MUA 的风险较高有关。风险建模和生存分析表明，与早期 MUA 相比，晚期 MUA 后 TKA 翻修的风险增加（调整后的危险比[aHR] = 3.50，95%置信区间[CI]：2.77-4.43， 0.0001），差异具有统计学意义（ 0.0001）。与早期 MUA 相比，晚期 MUA 在 1 年时与假体取出的风险显著增加相关（调整后的优势比[aOR] = 2.89， = 0.0026 与 aOR = 0.93， = 0.8563）。索引 TKA 后 12 周内的 MUA 可改善疼痛缓解，并显著减少阿片类药物的使用。此外，晚期 MUA 与延长阿片类药物的使用、增加翻修和假体取出的风险有关，支持在进展缓慢和僵硬的情况下进行筛查和早期干预。本研究的证据水平为 III 级。
