Rheumatology：器质性和精神性合并症是全膝关节置换术后疼痛的危险因素

全膝关节置换术（TKA）已是一种普遍的骨科关节手术。前期一些研究发现，首次TKA手术后患者的疼痛和功能障碍与患者的器质性合并症有相关性。然而，具体哪些合并症与术后疼痛相关仍不明确。针对这一问题，来自美国明尼苏达州罗彻斯特梅奥临床医学院矫形外科系的Jasvinder A. Singh等人进行了一项研究。研究结果发表于2013年5月的《风湿病学》（Rheumatology）杂志上。研究发现，器质性和精神性合并症预示全膝关节置换术后较差的疼痛结局。

研究者采用全身关节登记数据库的数据，验证了器质性疾病（心脏病，周围血管疾病，肾脏病，慢性阻塞性肺疾病，糖尿病，及CTD）和精神性疾病（焦虑和抑郁）作为合并症，是否与首次或TKA翻修手术后患者的中重度疼痛有关。对所有合并症、年龄、性别、BMI、潜在诊断、美国麻醉(ASA)分级通过多变量调整的逻辑回归模型同时进行调整，对首次和TKA翻修手术的患者分别分析患者距离医疗中心的距离以及植入的内固定物（仅对首次TKA手术患者而言）的不同。

在首次TKA手术组中，术后2年可回访的患者为7139例，术后5年可回访的患者为4234例（应答率分别为65%和57%）。在TKA翻修手术组中，术后2年可回访的患者为1533例，术后5年可回访的患者为881例（应答率分别为57%和48%）。首次TKA手术组中，术后2年的数据显示，焦虑作为合并症增加了1.4倍中重度膝关节疼痛的风险（95%CI 1.0,2.0）；术后5年的数据显示，心脏病（OR 1.7；95%CI 1.1,2.6）、抑郁状态（OR 1.7；95%CI 1.1,2.5）及焦虑状态（OR 1.9；95%CI 1.2,3.1）与中重度疼痛相关。在TKA翻修手术的患者中，CTD（OR 0.5；95%CI 0.2,0.9）及抑郁状态（OR 1.8；95%CI 1.1,3.1）与中重度疼痛明显相关。

本研究证明，器质性和精神性合并症是首次及TKA翻修手术后患者的中重度疼痛的危险因素。对于即将接受首次或TKA翻修手术的患者，该研究结果可用于预测其术后疼痛的改善情况。

与置换术相关的拓展阅读：

• JBJS （Am）综述：颈椎椎间盘置换术
• Ann Throac Surg：一种新的瓣保留主动脉根部置换术
• AAOS2013：肥胖对膝关节置换术后直接医疗费用的影响
• AAOS 2013：≤55岁全髋关节置换术（THA）患者翻修失败率更高
• AAOS 2013：全髋关节置换术（THA）前路与后路手术疗效相似
• 微创人工全髋关节置换术与传统置换术临床疗效的Meta分析
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Medical and psychological comorbidity predicts poor pain outcomes after total knee arthroplasty.
Objective
To study comorbidity correlates of moderate to severe pain after total knee arthroplasty (TKA).
Methods
We analysed prospectively collected Total Joint Registry data to examine whether medical (heart disease, peripheral vascular disease, renal disease, chronic obstructive pulmonary disease, diabetes and CTD) and psychological (anxiety and depression) comorbidity is associated with moderate to severe pain after primary or revision TKA. Multivariable-adjusted logistic regression simultaneously adjusted for all comorbidities, age, sex, BMI, underlying diagnosis, American Society of Anesthesiologist (ASA) class, distance from medical centre and implant fixation (only for primary TKA) was used to analyse primary and revision TKA separately.
Results
The primary TKA cohort consisted of 7139 and 4234 TKAs (response rates 65% and 57%) and the revision TKA cohort consisted of 1533 and 881 TKAs at 2 and 5 years (response rates 57% and 48%), respectively. In the primary TKA cohort, anxiety was associated with 1.4 higher odds (95% CI 1.0, 2.0) of moderate to severe index knee pain at 2 years; at 5 years, heart disease (OR 1.7; 95% CI 1.1, 2.6), depression (OR 1.7; 95% CI 1.1, 2.5) and anxiety (OR 1.9; 95% CI 1.2, 3.1) were significantly associated with moderate to severe pain. For revision TKA, CTD (OR 0.5; 95% CI 0.2, 0.9) and depression (OR 1.8; 95% CI 1.1, 3.1) were significantly associated with moderate to severe pain.
Conclusion
This study identified medical and psychological comorbidity risk factors for moderate to severe pain after primary and revision TKA. This information can be used to provide realistic outcome expectations for patients before undergoing primary or revision TKA.