探討全人工髖/膝關節再置換手術病人健康相關生活品質之研究

研究背景及目的：根據世界衛生組織報告，到2025年，世界上將近有高達25％的人口會因為骨關節等問題，導致生活上的行動不便。近年來由於醫療技術進步，人口分佈逐漸高齡化，置換人工關節的病例日益增加。依據統計，2000年美國2.6億人口中實施全人工髖、膝關節置換術就達43萬例；台灣2,300萬人口中亦實施了1.5萬例，並且還在逐漸增加中，人工關節置換術已經成為骨科最常見的手術之一。因此，在醫療資源有限的前提下，長期追蹤評估Revision THR/TKR手術病人對手術的認知與術後療效之改善趨勢及其影響因素，是本研究的主要目的。研究方法：本研究採用前瞻性設計，收集2007年9月7日至2009年1月8日於高雄地區三家醫學中心接受全人工髖、膝關節再置換病患為研究樣本，分別為69位及33位。針對手術病患特性、手術相關因素等進行追蹤研究，使用SF-36、HHS及LKS量表評估病患術後健康相關生活品質之改善趨勢及幅度，進而探討其影響因子。並利用GEE模式針對重複測量資料做完整性分析。研究結果： Revision THR與Revision TKR，在SF-36的『身體功能』及『整體生理構面』術後六個月才有顯著改善情形發生(p<0.05)。而『身體疼痛』構面則是在術後三個月時就有顯著的改善情形發生。疾病別量表皆術前至術後三個月的改善情形明顯大於術後三個月至術後六個月的改善情形。在不同病人特性與手術相關因素上，研究發現女性、年長、平均住院天數較長、術後30天有再入院以及因Dislocation及Infection而再置換手術的病患會有較差的術後生活品質；然而因Mechanical Loosening而實施再置換手術以及主要診斷為類風濕性關節炎的病患皆有較好的術後健康相關生活品質。在不同病人認知滿意度上研究發現『是否曾被告知需要實施Revision？ (有§vs無)』、『期望這次手術的持續時間(比預期還少§vs與預期相同)』、『上次手術整體滿意度？』、『此次Revision的整體滿意度』以及『期望獲得的與實際接受到的解釋/衛教滿意度？』，皆為顯著的預測因子。不同術前健康狀況會顯著影響Revision THR/TKR病患健康相關生活品質，發現疾病別量表(HHS、Lysholm Knee Score)及整體性量表(SF-36)，其術前構面分數愈高，則術後構面分數顯著高於術前分數低的病患。結論：本研究發現疾病別量表在術前至術後三個月的改善情形明顯大於術後三個月至術後六個月的改善情形，且疾病別量表比整體性量表更能夠顯著測量出全人工髖/膝關節再置換病患的改善程度，且較具有敏感性。而『病患的期待』是Revision術後健康相關生活品質及整體滿意度重要預測因子，病患對Revision過度期待會影響術後的健康相關生活品質。各個構面的術前分數分別顯著影響術後量表的各個構面分數。整體而言，探討影響Revision THR/TKR病患健康相關生活品質，不僅需要考慮病人特性(性別、年齡)、臨床相關因素(手術原因、平均住院天數、術後30天是否再入院及主要診斷) 、病人認知滿意度，尚須要考慮術前健康功能狀況。因此，建議醫療提供者在術前及術後給予病患詳細衛教或解釋可促進病患自我照護，使病患更積極參與術後復健恢復療程。

關鍵字

全人工髖關節再置換；全人工膝關節再置換；認知；滿意度；健康相關生活品質

並列摘要

Background and Purpose： According to the World Health Organization report in 2025, it will reach as high as 25% populations having difficulty in moving. In recent years, due to medical technology progression and aging population, the joint replacements increased gradually. In 2000, there had 430,000 joint replacements in U.S., and, at the same time, 15000 cases were performed in Taiwan. Thus, the joint replacement has become one of a common surgery. On the other hand, based on limited medical resources, the purpose of this study is to evlacate long-term trends and its impacts of revision total hip/knee replacement (Revision THR/TKR). Methods： This is a prospective study, 69 Revision THRs and 33 Revision TKRs were performed from Septenber 2007 to January 2009 in three medical centers in Kaohsiung. Patients’ characteristic and related surgery factors were collected from chart review. The SF-36, Harris Hip Score and Lysholm Knee Scoring Scale were administrated by one research assistance pre-operatively, 3 months and 6 months post operatively. The generalized estimating equations (GEE) approach was employed in this study. Results： It showed a significant improvement in SF-36 ” Physical Function” and “PCS” after 6 months postoperatively(p<0.05). “Body Pain” 3 months post operation significantly improvement treand. The improment trend of the Harris Hip Score and Lysholm Knee Scoring Scale showed 3 months post operatively significantly better than 6 months post operatively. In the patients’s characteristic and related surgery factors, “women”, “aged”, “ longer length of stay ”, “ re-hospitalized in 30 days ”, and “ operation reason due to dislocation and infection ” had significantly poor HRQOL outcomes.On the other hand, ” operation reason due to Mechanical Loosening” and “rheumatoid arthritis diagnosis” showed significantly better HRQOL outcomes. In the patients’s perception and satisfaction, “Do you remember being told that this might happen during your original pre-op counseling？”, “Overall satisfaction with results of original(primary) surgery？”, “Compared to your expectation, your original total hip lasted？”, “Satisfaction with the explanation/education you received on what to expect following your revision surgery?”, “Overall statisfaction with the revision surgery?” were significant related with HRQOL outcomes. Higher preoperational functional subscale score has significant better health-related quality of life. Conclusions： First, in the Harris Hip Score and Lyshol Knee Score, the improvement trend was found in 3 months better than in 6 months post-operatively. Second, the study found that disease-specific questionnaires(HHS and LKS) were more responsive than generic questionnaire(SF-36). Thrid, “ the expectation of patients “awaiting revision THRs/TKRs is an important predictor of HRQoL and satisfaction factor. With patients undergoing revision procedures, it is more important for them to have realistic expectations regarding results to improve their level of satisfaction. The main predictor of outcome at 6 months post-operatively in all domains was the pre-intervention functional subscale score. Overall, patients should be informed that their postoperative HRQoL may depend not only on their patients characteristic (ex: sex and age), related surgery factors (ex: for revision reason, length of stay, re-hospitalized in 30 days and primary diagnosis), patients’ perception and satisfaction, but also on their preoperative functional status. Therefore, we suggested clinical staff gives patients realistic formal education and explains the reason that may be related to enhance self-efficacy, to promote patients more positive participates rehabilitation, and to restore the treatment course before and after surgery.