髋关节置换术后慢性疼痛危险因素及术前血清MMP-9、Galectin-3的预测价值

Risk factors for chronic pain after hip replacement and the predictive value of preoperative serum MMP-9 and Galectin-3

目的探讨髋关节骨折患者髋关节置换术后慢性疼痛(CPSP)发生情况及血清基质金属蛋白酶-9(MMP-9)、半乳糖凝集素-3(Galectin-3)的预测价值。方法前瞻性研究2021年3月—2023年3月于解放军联勤保障部队第903医院骨科行髋关节置换术的髋关节骨折患者116例,男性65例,女性51例;年龄18~80岁,平均59.1岁;道路交通伤68例,高处坠落伤19例,摔伤29例。术后连续随访4个月,根据是否发生CPSP分为CPSP组(27例)和非CPSP组(89例)。采用多因素Logistic逐步回归分析探讨髋关节骨折患者髋关节置换术后CPSP的影响因素;采用酶联免疫吸附法检测两组患者术前、术后4个月血清MMP-9、Galectin-3水平;采用受试者工作特征(ROC)曲线评估术前血清MMP-9、Galectin-3对髋关节骨折患者髋关节置换术后CPSP的预测价值。结果116例髋关节骨折患者髋关节置换术后共有27例发生CPSP,发生率为23.3%(95%CI:19.56%~27.49%)。CPSP组年龄≥60岁占比、糖尿病史占比、Garden分型为移位性骨折占比、术中出血量、手术时间、术前VAS≥3分占比、CRP、WBC、术后4个月VAS均多于非CPSP组(P<0.05)。多因素Logistic逐步回归分析显示,有糖尿病史(OR=2.321,95%CI:1.559~3.455)、手术时间≥2.8 h(OR=2.026,95%CI:1.418~2.894)、术前VAS≥3分(OR=2.787,95%CI:1.790~4.340)、术后CRP≥33.9 mg/L(OR=2.467,95%CI:1.628~3.738)是髋关节骨折患者髋关节置换术后CPSP的独立危险因素(P<0.05)。术前CPSP组血清MMP-9、Galectin-3水平高于非CPSP组(P<0.05);术后4个月非CPSP组血清MMP-9、Galectin-3水平较术前降低,术后4个月CPSP组血清MMP-9、Galectin-3水平较术前升高,且术后4个月CPSP组血清MMP-9、Galectin-3水平高于非CPSP组(P<0.05)。术前血清MMP-9、Galectin-3预测髋关节骨折患者髋关节置换术后CPSP的曲线下面积(AUC)分别为0.851(95%CI:0.800~0.902)、0.748(95%CI:0.697~0.799),两者联合预测的AUC为0.903(95%CI:0.852~0.954)。结论髋关节骨折患者髋关节置换术后CPSP与其糖尿病史、手术时间、术前VAS、术后CRP水平有关。血清MMP-9、Galectin-3对髋关节骨折患者髋关节置换术后CPSP具有一定的预测价值,可作为潜在的预测标记物。

Objective To explore the risk factors of developing chronic postsurgical pain(CPSP)after hip replacement in hip fracture patients and to investigate the predictive value of preoperative serum levels of matrix metalloproteinase-9(MMP-9)and Galectin-3(Galectin-3).Methods A total of 116 patients with hip fractures,including 65 males and 51 females who underwent hip replacement in the 903 Hospital of PLA Joint Logistic Support Force from Mar.2021 to Mar.2023,were prospectively selected.Patients aged 18-80 years,mean 59.1 years.The causes of injuries were road traffic accidents in 68 cases,falls from height in 19,and ground-level falls in 29.Patients were followed up for 4 months after surgery and according to whether CPSP occurred they were divided into CPSP group(n=27)and non-CPSP group(n=89).Multivariate Logistic stepwise regression analysis was adopted to investigate the risk factors of CPSP in hip fracture patients after hip replacement.Serum MMP-9 and Galectin-3 levels were detected by enzyme-linked immunosorbent assay before and 4 months after surgery.The predictive value of preoperative serum MMP-9 and Galectin-3 for CPSP after hip replacement was analyzed by receiver operating characteristic(ROC)curves.Results Among the 116 included patients,CPSP occurred in 27 cases,with the incidence being 23.3%(95%CI:19.56%-27.49%).Comparison between the CPSP and non-CPSP groups revealed significant differences in terms of proportions of patients(1)with an age≥60 years,(2)with diabetes,(3)with displaced fractures by Garden classification,and(4)with preoperative VAS score≥3,and intraoperatie blood loss,operation time,postoperative CRP or WBC level,and postoperative 4-month VAS(all P<0.05).Further multivariate Logistic stepwise regression analysis showed that history of diabetes(OR=2.321,95%CI:1.559-3.455),operation time≥2.8 h(OR=2.026,95%CI:1.418-2.894),preoperative VAS score≥3(OR=2.787,95%CI:1.790-4.340)and postoperative CRP level≥33.9 mg/L(OR=2.467,95%CI:1.628-3.738)were independent risk factors for CPSP in hip fracture patients after hip replacement(all P<0.05).The serum levels of MMP-9 and Galectin-3 in CPSP group were much higher than those in non-CPSP group before surgery(P<0.05),which were further increased in CPSP group but decreased in non-CPSP group at 4 months after surgery(P<0.05 compared with that before surgery and between two groups after surgery).The area under the curve of preoperative serum MMP-9 and Galectin-3 in predicting CPSP after hip replacement in patients with hip fractures were 0.851(95%CI:0.800-0.902)and 0.748(95%CI:0.697-0.799),respectively,and 0.903(95%CI:0.852-0.954)with a combined use.Conclusion The incidence of CPSP after hip replacement in patients with hip fractures is associated with diabetes history,operation time,preoperative VAS score and postoperative CRP levels;serum MMP-9 and Galectin-3 have certain predictive values in predicting CPSP,especially when used combinedly.