全膝关节置换翻修术的临床疗效及影响因素分析

A Study of the clinical effect and related factors on revision total knee arthroplasty

目的通过对芬兰关节置换登记系统的资料分析,探讨全膝关节翻修术的治疗结果,并以再次翻修为终点评估翻修假体生存的预测指标。方法1990年至2002年芬兰国家关节置换登记系统共录入全膝关节翻修术2637例,以再次翻修为统计止点,对上述完整材料进行各种统计学分析,主要包括单因素分析中的Kaplan-Meier生存分析,Log-Rank检验,Cox回归分析及模型诊断。结果全膝关节翻修术后假体2年生存率为95%(1874膝)(95%置信区间,94%～96%),5年为89%(944膝)(95%置信区间,88%～90%),10年为79%(141膝)(95%置信区间,78%～81%)。多变量回归分析表明,假体生存最显著的预测指标是患者的年龄及初次全膝关节置换术后的使用时间(即初次与翻修手术间隔的时间)。预测生存率的其他重要指标有第1次翻修的年份及翻修原因。结论预测全膝关节翻修术后假体生存率较好的因素有:患者年龄在70岁以上、初次关节置换术后5年或以上施行翻修以及无髌骨半脱位。同时,随着年龄的增长、疾病的加重(骨关节炎和类风湿关节炎)及其治疗(初次全膝关节置换术),均可以减少关节活动量,加上医师不主张对老年患者施行手术,使得老年患者的再翻修率有所降低。

Objective To present the results of revision total knee replacements and describe predictors of survival of those replacements, with repeat revision as the end point. Methods The nationwide Finnish Arthroplasty Registry included 2637 revision total knee arthroplasties from 1990 through 2002. Survivorship of the revision total knee arthroplasties was analyzed, with repeat revision as the endpoint. The survivorship analyses comprised Kaplan-Meier Survival Analysis and Log-Rank Tests followed by calcula- tions of univariate and multivariate statistics and model diagnostics as appropriate. Results The survival rate of revision total knee arthroplasties was 95% （95% confidence interval, 94% to96% ） at two years, 89% （95% confidence interval, 88% to90% ） at five years, and 79% （95% confidence interval, 78% to 81% ） at ten years. Multivariate regression analysis showed the most significant predictors of prosthetic survival were the age of the patient and the life in service of the primary total knee replacement （that is, the time between the primary total knee replacement and the revision）. Survivorship was also significantly predicted by the year of the first revision total knee arthroplasty and the reason for the revision. Conclusions An age greater than seventy years, revision five years or more after the primary arthroplasty, and absence of patellar sublnxation are positive indicators of survival of a revision total knee replacement. We believe that normal aging as well as the deconditioning effect of disease （osteoarthritis and rheumatoid arthritis） and its treatment （primary total knee replacement） may lead to a reduced activity level, which, tozether with a presumed reluctance to operate on elderly patients, protects against repeat revisions.