关节镜灌洗清创术与切开灌洗清创术治疗肩化脓性关节炎的翻修手术风险较低。
Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis.
机构信息
From the Department of Orthopaedic Surgery (Upfill-Brown, Shi, Hart, Shah, Brodke, Hsiue, Lee, and Stavrakis), David Geffen School of Medicine at UCLA, Santa Monica, CA, the David Geffen School of Medicine at UCLA (Carter and Maturana), Los Angeles, CA, and the Cedars-Sinai Kerlan-Jobe Institute (Photopoulos), Los Angeles, CA.
出版信息
J Am Acad Orthop Surg. 2022 Dec 1;30(23):e1504-e1514. doi: 10.5435/JAAOS-D-22-00428. Epub 2022 Sep 7.
BACKGROUND
In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches.
METHODS
The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression.
RESULTS
A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17).
CONCLUSION
Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D.
LEVEL OF EVIDENCE
III.
背景
在治疗原发性肩脓毒性关节炎时，关节镜与开放式冲洗清创术的最佳治疗方式存在争议。我们旨在比较这两种方法的无翻修生存率（RFS）、并发症和资源利用情况。
方法
从 2016 年至 2019 年，我们通过国际疾病分类第 10 次修订版的诊断和程序代码，在国家再入院数据库中查询了患者信息。计算了索引住院期间或随后再次入院的患者进行翻修冲洗和清创术（I&D）的天数。使用多变量回归分析医疗保健利用情况。使用 Kaplan-Meier 分析和 Cox 比例风险回归进行生存分析。
结果
共确定了 4113 例接受 I&D 的原发性肩脓毒性关节炎患者，其中 2775 例为关节镜（67.5%），1338 例为开放式（32.5%）。中位随访时间为 170 天（四分位距 79-265）。共有 341 例患者（8.3%）在中位时间 9 天内行翻修 I&D。多变量分析显示，关节镜 I&D 可降低 4154 美元的医院费用（P<0.001）和 0.78 天的住院时间（P=0.030）。关节镜 I&D 与减少输血（比值比 0.69，P=0.001）和伤口并发症（比值比 0.30，P<0.001）有关。关节镜 I&D 的 10、30、90 和 180 天 RFS 分别为 96.4%、94.9%、93.3%和 92.6%，而开放式 I&D 的 RFS 分别为 94.1%、92.6%、90.4%和 89.0%（P=0.00043）。多变量 Cox 模型分析显示，关节镜 I&D 与生存改善相关（风险比 0.67，P=0.00035）。分层分析显示，关节镜 I&D 与 65 岁或以上患者的 RFS 改善相关（P<0.001），但在 65 岁以下患者中 RFS 相似（P=0.17）。
结论
与开放式 I&D 相比，关节镜 I&D 后翻修 I&D 的风险明显降低，尽管保护益处仅限于 65 岁或以上的患者。关节镜手术还与降低成本、住院时间和并发症有关。尽管外科医生必须考虑特定的患者因素，但我们的结果表明，关节镜 I&D 优于开放式 I&D。
证据水平
III 级。
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