全膝关节置换中止血带的优化应用方案
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摘要
背景:气压止血带可减少术区出血,为手术提供清晰的视野,但由于其具有众多副损伤,国内外学者目前对止血带的应用方式存在较大争议。目的:探究优化止血带使用方案在全膝关节置换术中的临床疗效。方法:回顾分析2016年12月至2018年6月在鹤壁市人民医院行初次单侧全膝关节置换的96例骨关节炎患者的临床资料,按照止血带使用策略分2组。其中对照组56例在截骨前使用止血带,骨水泥固定后拆除;观察组40例为仅在骨水泥固定时使用止血带。记录2组患者的手术时长、止血带使用时长、术中失血量、术后出血量、并发症发生率,评估术后3 d目测类比评分、膝关节美国特种外科医院评分、膝关节活动度、患肢肿胀情况、股四头肌力恢复情况和手术满意度,并比较2组治疗差异。结果与结论:(1)2组患者手术时间和总失血量差异无显著性意义(P> 0.05),观察组止血带使用时间明显短于对照组,差异有显著性意义(P <0.05);观察组术中失血量高于对照组,术后出血量和隐形失血量低于对照组,差异有显著性意义(P <0.05);(2)观察组患者术后目测类比评分、膝关节活动度、美国特种外科医院评分、术后患肢肿胀率、直腿抬高至45°、术后满意度均优于对照组,差异有显著性意义(P<0.05);(3)2组患者术后并发症发生率差异无显著性意义(P> 0.05);(4)结果提示,优化使用止血带可降低术后疼痛、肿胀程度和术后引流量,促进肌力和关节功能恢复,提高患者满意度,对全膝关节置换总出血量无明显影响,但可增加术中出血量。
BACKGROUND: Pneumatic tourniquet can reduce bleeding in operation area and provide clear surgical visual field. However, because of its many collateral injuries, scholars at home and abroad have more controversies on the application of tourniquet.OBJECTIVE: To investigate the clinical efficacy of optimized use of tourniquet in total knee arthroplasty.METHODS: Clinical data of 96 patients with osteoarthritis who underwent primary unilateral total knee arthroplasty at the People's Hospital of Hebi from December 2016 to June 2018 were retrospectively analyzed. The patients were divided into two groups according to the strategy of tourniquet. The control group(n=56) was treated with tourniquet before osteotomy and removed after bone cement fixation. The observation group(n=40) used tourniquet only in bone cement fixation. The operation time, tourniquet usage time, intraoperative blood loss, postoperative blood loss, and incidence of complications were recorded. The Visual Analogue Scale score, Hospital for Special Surgery score, range of motion of the knee joint, swelling of the affected limb, quadriceps muscle strength recovery and surgical satisfaction at postoperative 3 days were evaluated and compared.RESULTS AND CONCLUSION:(1) There was no significant difference in the operation time and total blood loss between two groups(P >0.05). The tourniquet usage time in the observation group was significantly shorter than that in the control group(P < 0.05). The intraoperative blood loss in the observation group was higher than that in the control group, and the postoperative blood loss and hidden blood loss in the observation group were lower than those in the control group(P < 0.05).(2) The postoperative Visual Analogue Scale score, range of motion of the knee joint, Hospital for Special Surgery score, the swelling rate of the affected limbs, straight leg raise to 45°, and postoperative satisfaction in the observation group were significantly higher than those in the control group(P < 0. 05).(3) The incidence of postoperative complications in both groups showed no significant difference(P > 0.05).(4) In summary, the optimized use of tourniquet can reduce postoperative pain, swelling and drainage, promote the recovery of muscle strength and joint function, improve the satisfaction of patients, and has no significant effect on the total blood loss of total knee arthroplasty, but it can increase the intraoperative blood loss.
BACKGROUND: Pneumatic tourniquet can reduce bleeding in operation area and provide clear surgical visual field. However, because of its many collateral injuries, scholars at home and abroad have more controversies on the application of tourniquet.OBJECTIVE: To investigate the clinical efficacy of optimized use of tourniquet in total knee arthroplasty.METHODS: Clinical data of 96 patients with osteoarthritis who underwent primary unilateral total knee arthroplasty at the People's Hospital of Hebi from December 2016 to June 2018 were retrospectively analyzed. The patients were divided into two groups according to the strategy of tourniquet. The control group(n=56) was treated with tourniquet before osteotomy and removed after bone cement fixation. The observation group(n=40) used tourniquet only in bone cement fixation. The operation time, tourniquet usage time, intraoperative blood loss, postoperative blood loss, and incidence of complications were recorded. The Visual Analogue Scale score, Hospital for Special Surgery score, range of motion of the knee joint, swelling of the affected limb, quadriceps muscle strength recovery and surgical satisfaction at postoperative 3 days were evaluated and compared.RESULTS AND CONCLUSION:(1) There was no significant difference in the operation time and total blood loss between two groups(P >0.05). The tourniquet usage time in the observation group was significantly shorter than that in the control group(P < 0.05). The intraoperative blood loss in the observation group was higher than that in the control group, and the postoperative blood loss and hidden blood loss in the observation group were lower than those in the control group(P < 0.05).(2) The postoperative Visual Analogue Scale score, range of motion of the knee joint, Hospital for Special Surgery score, the swelling rate of the affected limbs, straight leg raise to 45°, and postoperative satisfaction in the observation group were significantly higher than those in the control group(P < 0. 05).(3) The incidence of postoperative complications in both groups showed no significant difference(P > 0.05).(4) In summary, the optimized use of tourniquet can reduce postoperative pain, swelling and drainage, promote the recovery of muscle strength and joint function, improve the satisfaction of patients, and has no significant effect on the total blood loss of total knee arthroplasty, but it can increase the intraoperative blood loss.
引文
[1]Smith TO,Hing CB.Is a tourniquet benef icial in total knee replacement surgery?A meta-analysis and systematic review.Knee.2010;17(2):141-147.
[2]Tai TW,Lin CJ,Jou IM,et al.Tourniquet use in totaI kn ee arthroplasty:a meta-analysis.Knee Surg Sports Traumatol Arthrosc.2011;19(7):1121-1130.
[3]马卫华,张树栋,王诗军,等.止血带的使用方式对膝关节置换术失血量和手术时间的影响[J].中华关节外科(电子版),2011,5(6):33-36.
[4]Kvederas G,Porvaneckas N,Andrijauskas A,et al.Arandomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2013;21(12):2790-2799.
[5]孙啸,王浩洋,康鹏德.TKA术中不同时机使用止血带对患者造成的损伤比较[J].四川大学学报(医学版),2016,47(1):135-137.
[6]Dennis DA,Kittelson AJ,Yang CC,et al.Does tourniquet use in tka affect recovery of lower extremity strength and function?a randomized trial.Clin Orthop Relat Res.2016;474(1):69-77.
[7]Jawhar A,Hermanns S,Ponelies N,et al.Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells:a randomized clinical trial.Knee Surg Sports Traumatol Arthrosc.2016;24(10):3313-3321.
[8]León-Mu?oz VJ,Lisón-Almagro AJ,Hernández-García CH,et al.Silicone ring tourniquet versus pneumatic cuff tourniquet in total knee arthroplasty surgery:A randomised comparative study.J Orthop.2018;15(2):545-548.
[9]Hasanain S,Apostu D,Alrefaee A,et al.Comparing the effect of tourniquet vs.tourniquet-less in simultaneous bilateral total knee replacements.J Arthroplasty.2018:S0883540318301426.
[10]Yang G,Huang W,Xie W.Patellar non-eversion in primary TKA reduces the complication rate.Knee Surg Sports Traumatol Arthrosc.2016;24(3):921-930.
[11]Si HB,Yang TM,Zeng Y,et al.No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty:a systematic review and meta-analysis.BMCMusculoskelet Disord.2016;17(1):183.
[12]Zhou K,Ling T,Wang H,et al.Influence of tourniquet use in primary total knee arthroplasty with drainage:a prospective randomised controlled trial.J Orthop Surg Res.2017;12(1):172.
[13]杜哲.TKA中止血带应对围手术期失血量及近期疗效的影响研究[D].济南:山东大学,2014.
[14]Tsunoda K,Sonohata M,Kugisaki H,et al.The effect of air tourniquet on interleukin-6 levels in total knee arthroplasty.Open Orthop J.2017;11(1):20-28.
[15]Matsui Y,Shintani K,Okajima Y,et al.The effect of tourniquets on patellofemoral joint congruity during total knee arthroplasty.J Orthop Sci.2016;21(5):630-634.
[16]Jiang FZ,Zhong HM,Hong YC,et al.Use of a tourniquet in total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.J Orthop Sci.2015;20(1):110-123.
[17]Mayer C,Franz A,Harmsen JF,et al.Soft-tissue damage during total knee arthroplasty.J Orthop.2017;14(3):347-353.
[18]Li Z,Liu D,Long G,et al.Association of tourniquet utilization with blood loss,rehabilitation,and complications in Chinese obese patients undergoing total knee arthroplasty.Medicine.2017;96(49):e9030.
[19]Lee O,Lee MC,Han HS.Efficacy and safety of a new elastic tourniquet cuff in total knee arthroplasty:a prospective randomized controlled study.Biomed Eng Online.2017;16(1):102.
[20]张炜,陈思锋,李宁,等.止血带对初次全膝关节表面置换作用的Meta分析[J].中华关节外科杂志(电子版),2014,8(2):215-221.
[21]张元凯,李德强,刘培来,等.气囊止血带的三种应用方法在TKA的影响分析[C]//中华骨科杂志论坛,2013.
[22]Ozkunt O,Sariyilmaz K,Gemalmaz HC,et al.The effect of tourniquet usage on cement penetration in total knee arthroplasty.Medicine.2018;97(4):e9668.
[23]Ryu KJ.CORR,Insights?:does tourniquet use in tka affect recovery of lower extremity strength and function?Arandomized trial.Clin Orthop Relat Res.2016;474(1):78-80.
[24]Tie K,Hu D,Qi Y,et al.Effects of tourniquet release on total knee arthroplasty.Orthopedics.2016;39(4):e642-e650.
[25]徐莉莉,林丽娜.TKA术中气囊止血带不同应用时机对出血量、皮肤并发症的影响[J].中国现代医生,2015,53(31):1-4.
[26]Barker T,Rogers VE,Brown KB,et al.Tourniquet use during total knee arthroplasty does not modulate the neutrophil-tolymphocyte ratio,pain,or activity.J Orthop Traumatol.2016;18(3):1-5.
[27]Numkanisorn S,Chareancholvanich K,Pornrattanamaneewong C.Intravenous tranexamic acid before and after tourniquet use can reduce blood loss and blood transfusion after total knee arthroplasty.J Med Assoc Thai.2016;99(11):1220-1225.
[28]Dreyer HC.Tourniquet use during knee replacement surgery may contribute to muscle atrophy in older adults.Exerc Sport Sci Rev.2016;44(2):61-70.
[29]Zhang P,Liang Y,He J,et al.Timing of tourniquet release in total knee arthroplasty:A meta-analysis.Orthop J China.2017;96(17):445-451.
[30]曹学伟,杨伟毅,梁比记,等.不同止血带使用方法对TKA围手术期失血量影响的临床研究[J].中华骨与关节外科杂志,2011,4(6):455-459.
[31]Chen S,Li JP,Peng H,et al.The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty.Int Orthop.2014;38(2):355-359.
[32]Ejaz A,Laursen AC,Kappel A,et al.Faster recovery without the use of a tourniquet in total knee arthroplasty.Acta Orthopaedica.2014;85(4):422-426.
[2]Tai TW,Lin CJ,Jou IM,et al.Tourniquet use in totaI kn ee arthroplasty:a meta-analysis.Knee Surg Sports Traumatol Arthrosc.2011;19(7):1121-1130.
[3]马卫华,张树栋,王诗军,等.止血带的使用方式对膝关节置换术失血量和手术时间的影响[J].中华关节外科(电子版),2011,5(6):33-36.
[4]Kvederas G,Porvaneckas N,Andrijauskas A,et al.Arandomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2013;21(12):2790-2799.
[5]孙啸,王浩洋,康鹏德.TKA术中不同时机使用止血带对患者造成的损伤比较[J].四川大学学报(医学版),2016,47(1):135-137.
[6]Dennis DA,Kittelson AJ,Yang CC,et al.Does tourniquet use in tka affect recovery of lower extremity strength and function?a randomized trial.Clin Orthop Relat Res.2016;474(1):69-77.
[7]Jawhar A,Hermanns S,Ponelies N,et al.Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells:a randomized clinical trial.Knee Surg Sports Traumatol Arthrosc.2016;24(10):3313-3321.
[8]León-Mu?oz VJ,Lisón-Almagro AJ,Hernández-García CH,et al.Silicone ring tourniquet versus pneumatic cuff tourniquet in total knee arthroplasty surgery:A randomised comparative study.J Orthop.2018;15(2):545-548.
[9]Hasanain S,Apostu D,Alrefaee A,et al.Comparing the effect of tourniquet vs.tourniquet-less in simultaneous bilateral total knee replacements.J Arthroplasty.2018:S0883540318301426.
[10]Yang G,Huang W,Xie W.Patellar non-eversion in primary TKA reduces the complication rate.Knee Surg Sports Traumatol Arthrosc.2016;24(3):921-930.
[11]Si HB,Yang TM,Zeng Y,et al.No clear benefit or drawback to the use of closed drainage after primary total knee arthroplasty:a systematic review and meta-analysis.BMCMusculoskelet Disord.2016;17(1):183.
[12]Zhou K,Ling T,Wang H,et al.Influence of tourniquet use in primary total knee arthroplasty with drainage:a prospective randomised controlled trial.J Orthop Surg Res.2017;12(1):172.
[13]杜哲.TKA中止血带应对围手术期失血量及近期疗效的影响研究[D].济南:山东大学,2014.
[14]Tsunoda K,Sonohata M,Kugisaki H,et al.The effect of air tourniquet on interleukin-6 levels in total knee arthroplasty.Open Orthop J.2017;11(1):20-28.
[15]Matsui Y,Shintani K,Okajima Y,et al.The effect of tourniquets on patellofemoral joint congruity during total knee arthroplasty.J Orthop Sci.2016;21(5):630-634.
[16]Jiang FZ,Zhong HM,Hong YC,et al.Use of a tourniquet in total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.J Orthop Sci.2015;20(1):110-123.
[17]Mayer C,Franz A,Harmsen JF,et al.Soft-tissue damage during total knee arthroplasty.J Orthop.2017;14(3):347-353.
[18]Li Z,Liu D,Long G,et al.Association of tourniquet utilization with blood loss,rehabilitation,and complications in Chinese obese patients undergoing total knee arthroplasty.Medicine.2017;96(49):e9030.
[19]Lee O,Lee MC,Han HS.Efficacy and safety of a new elastic tourniquet cuff in total knee arthroplasty:a prospective randomized controlled study.Biomed Eng Online.2017;16(1):102.
[20]张炜,陈思锋,李宁,等.止血带对初次全膝关节表面置换作用的Meta分析[J].中华关节外科杂志(电子版),2014,8(2):215-221.
[21]张元凯,李德强,刘培来,等.气囊止血带的三种应用方法在TKA的影响分析[C]//中华骨科杂志论坛,2013.
[22]Ozkunt O,Sariyilmaz K,Gemalmaz HC,et al.The effect of tourniquet usage on cement penetration in total knee arthroplasty.Medicine.2018;97(4):e9668.
[23]Ryu KJ.CORR,Insights?:does tourniquet use in tka affect recovery of lower extremity strength and function?Arandomized trial.Clin Orthop Relat Res.2016;474(1):78-80.
[24]Tie K,Hu D,Qi Y,et al.Effects of tourniquet release on total knee arthroplasty.Orthopedics.2016;39(4):e642-e650.
[25]徐莉莉,林丽娜.TKA术中气囊止血带不同应用时机对出血量、皮肤并发症的影响[J].中国现代医生,2015,53(31):1-4.
[26]Barker T,Rogers VE,Brown KB,et al.Tourniquet use during total knee arthroplasty does not modulate the neutrophil-tolymphocyte ratio,pain,or activity.J Orthop Traumatol.2016;18(3):1-5.
[27]Numkanisorn S,Chareancholvanich K,Pornrattanamaneewong C.Intravenous tranexamic acid before and after tourniquet use can reduce blood loss and blood transfusion after total knee arthroplasty.J Med Assoc Thai.2016;99(11):1220-1225.
[28]Dreyer HC.Tourniquet use during knee replacement surgery may contribute to muscle atrophy in older adults.Exerc Sport Sci Rev.2016;44(2):61-70.
[29]Zhang P,Liang Y,He J,et al.Timing of tourniquet release in total knee arthroplasty:A meta-analysis.Orthop J China.2017;96(17):445-451.
[30]曹学伟,杨伟毅,梁比记,等.不同止血带使用方法对TKA围手术期失血量影响的临床研究[J].中华骨与关节外科杂志,2011,4(6):455-459.
[31]Chen S,Li JP,Peng H,et al.The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty.Int Orthop.2014;38(2):355-359.
[32]Ejaz A,Laursen AC,Kappel A,et al.Faster recovery without the use of a tourniquet in total knee arthroplasty.Acta Orthopaedica.2014;85(4):422-426.