背景:在有症状的终末期踝关节骨关节炎中,对于保守治疗失败的患者,全踝关节置换和踝关节固定术是两种主要的手术选择。公布的修订率往往有偏差,难以比较。在这项研究中,根据大型数据集确定两种手术干预的计划外再手术率和翻修率,并确定了计划外再操作的风险因素。
方法:对德国最大的医疗保险公司在2001年至2012年间的全德国健康数据进行回顾性分析,并确定了2001年和2002年进行的指数手术在10年内的计划外再手术率。将2001/2002年进行的指数手术在5年内的计划外再手术率与2006/2007年进行的指数手术进行了比较。采用多因素logistic回归分析非计划再手术的危险因素。
结果:踝关节固定术后,19%(95%置信区间[CI],741例患者中有16-22%)需要在十年内进行计划外的再次手术。全踝关节置换后,172例患者的非计划再手术率为38%[95%CI,29-48%].对于稍后进行的初始手术,1,168例踝关节固定术患者的5年内计划外再手术率为21%[95%CI,19-24%],561例踝关节置换患者的计划外再手术率为23%[95%CI,19-28%]。初始队列中踝关节固定术后非计划再次手术的重要危险因素为年龄<50岁(比值比[OR]=4.65[95%CI1.10;19.56])和骨质疏松(OR=3.72[95%CI,1.06;13.11]);全踝关节置换术后,他们是骨质疏松症(OR=2.96[95%CI,1.65;5.31]),患者临床复杂性水平(PCCL)3级(OR=2.19[95%CI,1.19;4.03]),PCCL4级(OR=2.51[95%CI,1.22;5.17])和糖尿病(OR=2.48[95%CI,1.33;4.66])。Kaplan-Meier分析包括1,525名踝关节固定术患者和644名全踝关节置换患者,显示两种手术的平均非计划再手术时间约为17年。
结论:在后期队列中,两种手术的类似翻修率和计划外再手术率可能归因于外科医生的学习曲线以及植入物设计的进步。对计费健康保险数据的分析支持了踝关节置换手术的总数量的增加。
BACKGROUND: In symptomatic end-stage osteoarthritis of the ankle joint, total ankle replacement and ankle arthrodesis are the two primary surgical options for patients for whom conservative treatment fails. Published revision rates are often biased and difficult to compare. In this study, unplanned reoperation rates and revision rates were determined for both surgical interventions based on a large dataset, and risk factors for unplanned reoperations were identified.
METHODS: German-wide health data of the largest German health-care insurance carrier between 2001 and 2012 were retrospectively analyzed, and unplanned reoperation rates within 10 years were determined for index surgeries conducted in 2001 and 2002. Unplanned reoperation rates within 5 years for index surgeries conducted in 2001/2002 were compared to index surgeries conducted in 2006/2007. Multivariate logistic regression was used to identify risk factors for unplanned reoperations.
RESULTS: After ankle arthrodesis, 19% (95% confidence interval [CI], 16-22%) of 741 patients needed to undergo an unplanned reoperation within ten years. After total ankle replacement, the unplanned reoperation rate was 38% [95% CI, 29-48%] among 172 patients. For initial surgeries conducted at a later date, unplanned reoperation rates within five years were 21% [95% CI, 19-24%] for 1,168 ankle arthrodesis patients and 23% [95% CI, 19-28%] for 561 total ankle replacement patients. Significant risk factors for unplanned reoperations after ankle arthrodesis in the initial cohort were age < 50 years (odds ratio [OR] = 4.65 [95% CI 1.10;19.56]) and osteoporosis (OR = 3.72 [95% CI, 1.06;13.11]); after total ankle replacement, they were osteoporosis (OR = 2.96 [95% CI, 1.65;5.31]), Patient Clinical Complexity Level (PCCL) grade 3 (OR = 2.19 [95% CI, 1.19;4.03]), PCCL grade 4 (OR = 2.51 [95% CI, 1.22;5.17]) and diabetes mellitus (OR = 2.48 [95% CI, 1.33;4.66]). Kaplan-Meier analyses including 1,525 ankle arthrodesis patients and 644 total ankle replacement patients revealed an average unplanned reoperation-free time of approximately 17 years for both procedures.
CONCLUSIONS: Similar revision rates and unplanned reoperation rates for both procedures in the later-date cohort can likely be attributed to a learning curve for surgeons as well as advances in implant design. This analysis of billing health insurance data supports an increase in total ankle replacement surgeries.