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Ann Rheum Dis:激素替代疗法降低髋膝关节置换术后翻修率

2014-01-28 佚名 丁香园

随着人口老龄化的发展,下肢骨性关节炎的发生率在逐年增高,2010年在英国一共有153000例髋膝关节置换,其中90%的手术原因是因为骨性关节炎。对于严重的髋膝关节骨性关节炎,全髋和全膝关节置换是最有效的治疗方法,因为老年人口以及糖尿病患病率的增加,导致初次髋膝人工关节置换的数量也在逐渐增加。【原文下载】 英格兰和威尔士的一份关节年会报告指出初次置换术后3年内全髋关

随着人口老龄化的发展,下肢骨性关节炎的发生率在逐年增高,2010年在英国一共有153000例髋膝关节置换,其中90%的手术原因是因为骨性关节炎。对于严重的髋膝关节骨性关节炎,全髋和全膝关节置换是最有效的治疗方法,因为老年人口以及糖尿病患病率的增加,导致初次髋膝人工关节置换的数量也在逐渐增加。【原文下载】

英格兰和威尔士的一份关节年会报告指出初次置换术后3年内全髋关节置换THA的返修率是2.3%,TKA全膝关节置换的返修率是2.2%,而关节翻修术相对初次置换而言不仅费用昂贵而且临床效果不佳。在初次置换术后1年内手术失败的主要原因是由于骨溶解以及随之而来的假体松动,最终导致肢体功能障碍和手术失败,其发生比例在THA中占到75%TKA中占到40%。

采取药物治疗减少假体周围骨溶解避免假体松动可以减少关节置换手术的失败率。抗骨吸收药物的作用机制为对抗破骨细胞作用,已有研究表明双磷酸盐可有效改善关节置换术后的临床效果,提高植入物的生存时间。激素替代疗法(Hormone replacement therapy HRT)具有抗骨吸收的作用,在20世纪八九十年代被广泛使用,患者的长期随访时间通常超过5年,因此为研究此类药物对假体长期生存的影响的提供了可能。

为了解激素替代疗法能否减少下肢关节置换术后的返修率,英国的D Prieto-Alhambra进行了一项回顾性队列研究,其结果发表在2014年的Ann Rheum Dis上。

在医疗实践研究数据库(General Practice Research Database GPRD)中检索1986年至2006年进行初次TKA和THA置换的女性骨关节炎患者,排除标准为初次手术时年龄小于40岁的患者、既往存在髋部骨折的患者以及风湿性关节炎的患者。主要的研究内容是初次置换到假体失败的时间。根据患者情况限定随访期限为手术日期到下述事件发生日期,以最早出现的日期为准:翻修日期、或失访日期(死亡或搬出初次医疗保健区域)、THA/TKA术后10年、本次研究终止日期(2006年12月31日)。


 使用激素替代疗法组和非激素替代疗法组假体的Kaplan-Meier生存曲线

将翻修术前使用激素替代疗法治疗6个月的患者以及在初次置换术后使用激素替代疗法6个月的患者归为激素替代治疗组组患者。不能满足上述条件的患者以及在翻修术后才开始使用激素替代疗法的患者被归为非激素替代治疗组患者。

统计患者的以下数据进行分析研究:年龄、性别、体重指数、关节置换部位(髋/膝)、关节翻修的时间、是否诊断为骨性关节炎(是/否)、既往骨折情况(有/无)、钙剂及维生素D补充情况、双磷酸盐药物使用情况、选择性雌激素受体调节剂使用情况、口服糖皮质激素使用情况、初次关节置换前的吸烟和饮酒情况,全科医生剥夺评分、英国地区归属地、医疗并发疾病情况(哮喘,吸收不良综合征,炎性肠疾病,高血压,高脂血症,缺血性心脏疾病,中风,慢性阻塞性肺疾病,慢性肾功能衰竭,肺肿瘤,糖尿病),使用可能导致骨折风险的药物情况(质子泵抑制剂,抗心律失常药,抗惊厥药,抗抑郁药,抗帕金森病药物,他汀类,噻嗪类利尿药,抗焦虑药)。

为排除干扰因素,了解激素替代疗法的确切治疗有效性,作者采用倾向分数匹配法从进行关节置换的总人数中选取研究对象。倾向得分代表患者使用激素替代疗法的几率,通过多因素logistic回归模型·分析整个研究人群得出。使用cox回归模型对假体生存进行原因分析。

统计分析数据,作者发现使用激素替代治疗超过6个月的患者假体失败的风险明显降低,为2.61/1000人年,而非使用激素替代治疗的风险则高达4.25/1000人年,风险比HR为0.62。使用激素替代治疗超过1年的患者的失败风险也明显降低。将激素替代治疗组患者根据是初次置换前还是置换后使用激素替代治疗进行分组分析发现,置换术前使用激素替代疗法对延长假体生存时间没有明显意义,而术后使用激素替代疗法对增加假体生存时间的作用明显。患者使用激素替代疗法的依从性增高和治疗时间延长则可以进一步减少假体翻修率。

作者认为:在骨性关节炎关节置换患者中使用激素替代疗法可明显减少40%的髋膝关节假体失败,较高的依从性和较长时间的服用药物可进一步增加假体生存时间。

原文出处:

Prieto-Alhambra D, Javaid MK, Judge A, Maskell J, Cooper C, Arden NK; on behalf of the COASt Study Group.Hormone replacement therapy and mid-term implant survival following knee or hip arthroplasty for osteoarthritis: a population-based cohort study.Ann Rheum Dis. 2014 Jan 22. doi: 10.1136/annrheumdis-2013-204043. 【原文下载】

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    2014-05-22 yxch48
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