【作者】 张磊；

【导师】 闫新峰；

【作者基本信息】 山东大学 ， 外科学（骨科）（专业学位）， 2020， 硕士

【摘要】 目的:通过对比同期与分期双侧膝、髋关节置换术在术后功能效果、术后并发症、手术风险、费用、术后恢复速度等方面的差异,明确两种手术方式利弊,探讨两种手术方式的性价比差异,以期为临床工作中同期或分期手术方式的选择提供借鉴及参考。方法:收集2014年01月01日至2018年12月31日于山东省千佛山医院骨科实施双侧全膝关节置换术(bilateral total knee arthroplasty,BTKA)和双侧全髋关节置换术(bilateral total hip arthroplasty,BTHA)的患者的临床资料。按照患者手术是在单次麻醉下行同期双侧关节置换,还是在分次麻醉下先行一侧关节置换,待患者恢复一段时间,再行另一侧关节置换的分期双侧关节置换,将患者分为同期手术组与分期手术组。经筛选,其中同期BTKA组,共50例;分期BTKA组,共42例;同期BTHA,共46例;分期BTHA组,共30例。选用合适的观察指标(膝关节WOMAC评分、膝关节ROM、髋关节Harris评分、下蹲情况、FJS-12评分、术后并发症、手术时长、住院时长、输血量、实验室检查、花费情况、术后恢复到日常生活基本不受影响所需时间),分别比较同期组与分期组在术后功能效果、术后并发症、风险性、经济效益、时间效益等方面的差异,统计后进行分析评价。结果:对于BTKA患者:1、同期组术后功能效果优于分期组,表现为:(1)同期组术后膝关节 ROM(116.30°±11.420°)优于分期组(101.67°±9.151°);(2)同期组术后WOMAC评分(6.56±2.366分)优于分期组(12.95±2.389);(3)同期组术后FJS-12评分(82.29±4.635)优于分期组(65.77±3.854);2、同期组与分期组术后并发症方面无显著差异;3、不同角度对比,两种手术方式的手术风险大小不同;4、同期组扣除假体费用外的总住院费用(23042.85士3282.09元)远低于分期组(35142.27±5373.14元);5、同期组术后恢复到正常生活基本不受影响所花费的时间(3.990±1.391月)短于分期组(7.810土3.563 月)。对于BTHA患者:1、同期组术后功能效果优于分期组,表现为:(1)同期组比分期组术后具有更好的下蹲情况;(2)同期组术后HARRIS评分(96.43±2.228分)优于分期组(91.53±3.267分);(3)同期组术后FJS-12评分(86.957±2.614分)优于分期组(72.014±9.440分);2、同期组与分期组术后并发症方面无明显差异;3、不同角度对比,两种手术方式的手术风险大小不同;4、同期组扣除假体费用外的总住院费用(22552.07±2843.45元)远低于分期组(32635.40±6648.90元);5、同期组术后恢复到正常生活基本不受影响所花费的时间(3.880±1.924月)短于分期组(7.133±4.303月)。结论:对于有BTKA或BTHA手术指征的患者,在术前充分评估,且病情允许的情况下,同期BTKA、BTHA 比分期BTKA、BTHA具有更好的手术效果,且具有手术花费更低、术后恢复到正常生活基本不受影响所花费的时间更短、不增加术后并发症发生率等优点,因此同期双侧手术“性价比”更高,更推荐同期双侧手术。但同期双侧手术患者在某些方面的手术风险高于分期双侧手术患者,因此,对于高龄、术前合并基础病多、身体一般状况差、术前血色素低、病情严重而预期手术时间长的患者,选择同期手术时须慎重,术前须做好严格的术前评估及准备。更多还原

【Abstract】 Objective:By comparing the differences between simultaneous and staged bilateral total knee and total hip arthroplasty in terms of postoperative functional effect,postoperative complications,surgical risk,cost,postoperative recovery speed,in order to clarify the advantages and disadvantages of the two surgical methods.And to explore the cost-effective difference between the two surgical methods,in order to provide reference for the selection of simultaneous or staged surgical methods in clinical work.Methods:The clinical data of patients who underwent bilateral total knee arthroplasty(BTKA)and bilateral total hip arthroplasty(BTHA)in the Department of Orthopaedics of Qianfoshan Hospital of Shandong Province from January 1,2014 to December 31,2018 were collected.According to whether the patients underwent simultaneous bilateral joint replacement under single anesthesia,or underwent staged bilateral joint replacement(one side joint replacement was performed first,and then the other side joint replacement was performed after the patient recovered for a period of time)under twice anesthesia,the patients were divided into simultaneous operation group and staged operation group.After filtering,there were 50 cases in the simultaneous BTKA group,42 cases in the staged BTKA group,46 cases in the simultaneous BTHA group,and 30 cases in the staged BTHA group.Appropriate observation indexes(Knee WOMAC score,knee ROM,hip Harris score,squatting,FJS-12 score,postoperative complications,length of operation,length of hospital stay,blood transfusion,laboratory examination,cost,time required to recover to daily life basically unaffected after operation)were selected to compare the differences in postoperative functional effect,postoperative complications,risk,economic benefit and time benefit between the simultaneous group and the staged group,and then make a statistical analysis.Results:For BTKA patients:1.The postoperative functional effect of the simultaneous group was better than that of the staged group,which was as follows:(1)the postoperative knee joint ROM of the simultaneous group(116.30°±11.420°)was better than that of the staged group(101.67°±9.151°);(2)the postoperative WOMAC score of the simultaneous group(6.56±2.366)was better than that of the staged group(12.95±2.389);(3)The postoperative FJS-12 score of the simultaneous group(82.29±4.635)was better than that of the staged group(65.77±3.854).2.There was no significant difference in postoperative complications between the simultaneous group and the staged group.3.When compared from different aspects,the surgical risks of the two surgical methods are different.4.The total hospitalization expenses excluding the cost of prosthesis in the simultaneous group(23042.85±3282.09 yuan)was much lower than that in the staged group(35142.27±5373.14 yuan).5.The time required to recover to daily life basically unaffected after operation in the simultaneous group(3.990±1.391 months)was shorter than that in the staged group(7.810±3.563 months).For BTHA patients:1.The postoperative functional effect of the simultaneous group was better than that of the staged group,which was as follows:(1)the postoperative squatting condition of the simultaneous group was better than that of the staged group,(2)the postoperative HARRIS score of the simultaneous group(96.43±2.228)was better than that of the staged group(91.53±3.267);(3),and the postoperative FJS-12 score of the simultaneous group(86.957±2.614)was better than that of the staged group(72.014±9.440).2.There was no significant difference in postoperative complications between the simultaneous group and the staged group.3.When compared from different aspects,the surgical risks of the two surgical methods are different.4.The total hospitalization expenses excluding the cost of prosthesis in the simultaneous group(22552.07±2843.45 yuan)was much lower than that in the staged group(32635.40±6648.90 yuan).5.The time required to recover to daily life basically unaffected after operation in the simultaneous group(3.880±1.924 months)was shorter than that in the staged group(7.133±4.303 months).Conclusion:For patients with surgery indications of BTKA or BTHA,simultaneous BTKA and BTHA have better surgical effects than staged BTKA and BTHA if they are fully evaluated before the operation and the condition permits.Simultaneous bilateral group also have the advantages of lower cost of operation,shorter time required to recover to daily life basically unaffected after operation,and no increase in the incidence of postoperative complications.Therefore,the"cost-effective" ratio of simultaneous bilateral group is higher,and simultaneous bilateral group is more recommended.However,in some aspects,the surgical risk of patients undergoing simultaneous bilateral surgery is higher than that of patients with staged bilateral surgery.Therefore,for the elderly,for the patients with many preoperative complications,for patients with poor physical condition,for the patients with low preoperative hemoglobin,for patients with serious condition and long expected operation time,the simultaneous operation should be chosen carefully and strict preoperative evaluation and preparation should be made before operation.更多还原