关节置换日间手术模式构建及流程规范化探讨

A preliminary study on the construction and standardization of procedures for ambulatory joint arthroplasty surgery

目的探讨实施关节置换日间手术的安全性和有效性,并且总结关节置换日间手术模式的规范化流程。方法回顾性分析2023年4月至2024年1月于解放军总医院第四医学中心骨科医学部接受关节置换患者的病历资料,经门诊筛选评估后符合特定条件的59例患者纳人日间手术组,择期行单置换(unicompartmental knee arthroplasty,UKA)、全膝关节置换(total knee arthroplasty,TKA)或全关节置换(total hip arthroplasty,THA)的日间手术;严格选择同时期常规住院后施行的简单初次关节置换病例,根据性别和术式按1:1匹配进行对照研究(常规手术组)。临床疗效采用疼痛视觉模拟评分(visual analogue scale,VAS)、Harris评分、美国膝关节协会评分(the American Knee Society score,KSS)评估手术前后髋、膝关节功能。统计围手术期并发症、出院后并发症、术后90d内非计划再入院和再手术率。结果日间手术组年龄(62.0±6.5)岁(范围53~76岁),较常规手术组的(66.2±8.3)岁(范围46~81岁)年轻约4岁,差异有统计学意义(t=3.707,P=0.002);但体质指数、美国麻醉医师协会(the American Society of Anesthesiologists,ASA)分级的差异无统计学意义(P>0.05)。两组患者术后均有恶心呕吐、剧烈疼痛等发生,并发症发生率的差异无统计学意义(χ^(2)=0.083,P=0.752);日间手术组出现1例非计划急诊就医,但出院后并发症(剧烈疼痛)发生率的差异无统计学意义(3例和1例,P=0.473)。日间手术组因恶心呕吐、剧烈疼痛等围手术期并发症及患者依从性差,导致延迟出院率为9%。日间手术组患者术后2周内VAS评分较常规手术组低,差异有统计学意义(P<0.05);相较常规手术组,日间手术组术后1周时Harris评分明显改善(t=7.362,P=0.027),术后第1、7天和2周KSS膝评分改善明显(P<0.05)、KSS功能评分明显提高(P<0.05)。成本-效益分析显示去除假体费用后,单置换日间手术的住院费用为(1.95±0.42)万元,较常规手术的(2.25±0.41)万元节省约3000元,差异有统计学意义(t=3.699,P=0.001)。结论对特定患者进行关节置换日间手术安全且有效,术后短期并发症在可控范围内;日间手术模式能良好地控制疼痛并早期恢复关节功能;单置换日间手术能节省医疗费用、缩短住院时间以加快床位周转。

Objective To investigate the safety and effectiveness of ambulatory joint arthroplasty and to establish a standardized procedure for outpatient joint replacement surgery.Methods The clinical data from patients who underwent joint replacement surgery at the Orthopaedics Department of the General Hospital of PLA Fourth Medical Center between April 2023 and January 2024 were retrospectively analyzed.After screening and evaluation,fifty-nine patients who met specific criteria were enrolled for elective ambulatory surgery,including unicompartmental knee arthroplasty(UKA),total knee arthroplasty(TKA),and total hip arthroplasty(THA).For comparison,a 1:1 matched control group was created from patients who underwent primary joint arthroplasty with routine hospitalization during the same period,matched by gender and surgical procedure.Functional outcomes were assessed pre-and post-operatively using the visual analogue scale(VAS),Harris hip score(HHS),and American Knee Society score(KSS).Postoperative complications,post-discharge complications,unplanned 90-day readmissions,and reoperations were analyzed.Results The ambulatory surgery group had an average age of 62.0±6.5 years(range 53-76 years),which was significantly younger than the inpatient group at 66.2±8.3 years(range 46-81 years;t=3.707,P=0.002).No significant differences were observed in demographics such as body mass index(BMI)and American Society of Anesthesiologists(ASA)classification(P>0.05).The incidence of complications,including nausea,vomiting,and severe pain,was similar between groups,with no statistically significant difference(χ^(2)=0.083,P=0.752).One case of unplanned emergency treatment occurred in the day-surgery group,but post-discharge complication rates did not significantly differ between the groups(3 cases vs.1 case,P=0.473).The rate of delayed discharge in the ambulatory surgery group was 9%,primarily due to acute complications such as nausea,vomiting,severe pain,and poor patient compliance.VAS scores were lower in the ambulatory group compared to the conventional group within two weeks post-surgery,showing a statistically significant difference(P<0.05).At one week post-surgery,the Harris hip score of ambulatory patients was significantly improved compared to the inpatient group(t=7.362,P=0.027).The KSS knee score and KSS function score also showed significant improvement at two weeks post-surgery in the ambulatory group(P<0.05).Cost-benefit analysis indicated that the hospitalization cost for ambulatory UKA(19.5±0.42 k CNY),excluding prosthesis costs was approximately 3,000 CNY less than that for conventional surgery(22.5±0.41 k CNY),a statistically significant difference(t=3.699,P=0.001).Conclusion Ambulatory joint arthroplasty is a safe and effective option for selected patients,with manageable short-term postoperative complications.This outpatient surgery model promotes early recovery of joint function and provides effective pain management.Ambulatory UKA,in particular,offers enhanced cost-effectiveness,reduced length of stay,and faster bed turnover,making it a valuable approach for wider adoption.