全膝关节置换过程中限制时间使用和不使用止血带的相关问题
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摘要
背景:关于全膝关节置换中止血带使用与否的术后效果对比已有报道,但鲜有文献明确提出限制性使用止血带和不使用止血带术后效果的差异。目的:观察全膝关节置换中限制性使用和不使用止血带对患者术后加速康复的影响。方法:随机选取2017年7月至2018年12月在成都中医药大学附属医院接受全膝关节置换治疗的患者90例,将患者随机分为3组:(1)限制使用止血带组:截骨完成后,仅于假体安装时应用止血带治疗,于膝关节假体成功放置且骨水泥硬化时结束;(2)后半程使用止血带组:截骨完成后,安装假体时开始使用止血带,直到切口缝合加压包扎;(3)不使用止血带组:全程不使用止血带,每组各30例。各组患者皆采用同样的围术期处理及加速康复训练,比较3组患者术后静脉血血红蛋白水平、C-反应蛋白水平、目测类比及HSS评分变化。结果与结论:(1)与限制性使用组和不使用止血带组比较,后半程使用止血带组术后1,3 d的膝关节疼痛目测类比评分和静脉血C-反应蛋白水平及术后1d血红蛋白水平升高(P<0.05),术后3,7d膝关节HSS评分降低(P<0.05);(2)术后限制使用止血带组和不使用止血带组的目测类比评分、HSS评分、C-反应蛋白及血红蛋白水平无显著差异;(3)结果证实,限制性使用止血带与不使用止血带对全膝关节置换后早期康复效果无明显差异,全膝关节置换后半程使用止血带会加重术后早期疼痛。
BACKGROUND: A comparison of the postoperative effects of the use of tourniquet has been reported, but few literatures have clearly indicated differences in the effects of restrictive use of tourniquets and no use of tourniquets.OBJECTIVE: To investigate the effects of restrictive use and non-use of tourniquet in patients undergoing preliminary total knee arthroplasty within enhanced recovery after surgery mode.METHODS: Totally 90 patients who underwent total knee arthroplasty in Affiliated Hospital of Chengdu University of Traditional Chinese Medicine from July 2017 to December 2018 were enrolled. The patients were randomly divided into three groups(n=30 per group) according to the method of the tourniquet during the operation. In the restrictive use group, after the osteotomy was completed, only the tourniquet treatment was applied when th e prosthesis was installed, and the knee joint prosthesis was successfully placed and the cement was hardened. In the second half use group, after the osteotomy was completed, the tourniquet was used when the prosthesis was installed until the incision was sutured and pressur e-wrapped. In the non-use group, no inflated tourniquet was used during operation. The same perioperative management and rehabilitation training were used in all patients of each group. Hemoglobin, C-reactive protein, visual analogue scale scores and HSS score were observed and compared between groups.RESULTS AND CONCLUSION:(1) Compared with the restrictive use group and the non-use group, the knee visual analogue scale scores and C-reactive protein level at 1 and 3 days after operation and the hemoglobin level at 1 day after operation both increased in th e second half use group(P < 0.05); however, the knee HSS scores at 3 and 7 days decreased(P < 0.05).(2) There were no significant differences in visual analogue scale score, HSS score, C-reactive protein, and hemoglobin levels between the restrictive use group and the non-use group after surgery.(3) There was no significant difference in the early postoperative rehabilitation between the restrictive use and non-use tourniquet,but the use of tourniquets in the second half would aggravate early postoperative pain.
BACKGROUND: A comparison of the postoperative effects of the use of tourniquet has been reported, but few literatures have clearly indicated differences in the effects of restrictive use of tourniquets and no use of tourniquets.OBJECTIVE: To investigate the effects of restrictive use and non-use of tourniquet in patients undergoing preliminary total knee arthroplasty within enhanced recovery after surgery mode.METHODS: Totally 90 patients who underwent total knee arthroplasty in Affiliated Hospital of Chengdu University of Traditional Chinese Medicine from July 2017 to December 2018 were enrolled. The patients were randomly divided into three groups(n=30 per group) according to the method of the tourniquet during the operation. In the restrictive use group, after the osteotomy was completed, only the tourniquet treatment was applied when th e prosthesis was installed, and the knee joint prosthesis was successfully placed and the cement was hardened. In the second half use group, after the osteotomy was completed, the tourniquet was used when the prosthesis was installed until the incision was sutured and pressur e-wrapped. In the non-use group, no inflated tourniquet was used during operation. The same perioperative management and rehabilitation training were used in all patients of each group. Hemoglobin, C-reactive protein, visual analogue scale scores and HSS score were observed and compared between groups.RESULTS AND CONCLUSION:(1) Compared with the restrictive use group and the non-use group, the knee visual analogue scale scores and C-reactive protein level at 1 and 3 days after operation and the hemoglobin level at 1 day after operation both increased in th e second half use group(P < 0.05); however, the knee HSS scores at 3 and 7 days decreased(P < 0.05).(2) There were no significant differences in visual analogue scale score, HSS score, C-reactive protein, and hemoglobin levels between the restrictive use group and the non-use group after surgery.(3) There was no significant difference in the early postoperative rehabilitation between the restrictive use and non-use tourniquet,but the use of tourniquets in the second half would aggravate early postoperative pain.
引文
[1]Tiwari MK,Vaishya R,Agarwal AK.Tourniquet during total knee arthroplasty:a review.Apollo Med.2017;14(1):8-11.
[2]Mutlu S,Guler O,Mutlu H.Tourniquet use during total knee arthroplasty does not offer significant benefit:a retrospective cohort study.Int J Surg.2015;18:123-127.
[3]Olivecrona C,Lapidus LJ,Benson L.Tourniquet time affects postoperative complications after knee arthroplasty.Int Orthop.2013;37(5):827-832.
[4]Li B,Wen Y,Wu H.The effect of tourniquet use on hidden blood loss in total knee arthroplasty.Int Orthop.2009;33(5):1263-1268.
[5]杨建平,蒋涛,吕正祥.止血带优化对全膝关节置换术快速康复的影响[J].中国矫形外科杂志,2018,26(1):33-37.
[6]Rasmussen LE,Holm HA,Kristensen PW.Tourniquet time in total knee arthroplasty.Knee.2018;25(2):306-313.
[7]中华医学会骨科学分会关节外科学组.骨关节炎诊疗指南(2018年版)[J].中华骨科杂志,2018,38(12):705-715.
[8]赵学千,贾育松,孙旗,等.关节镜清理联合术后针刺与鸡尾酒疗法治疗膝骨关节炎[J].中华关节外科杂志(电子版),2018,12(5):681-686.
[9]Touzopoulos P,Ververidis A,Mpogiatzis C.The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty.Eur J Orthop Surg Traum,2019.DOI:10.1007/s00590-019-02369-8.
[10]裴福兴.加速康复外科是现代骨外科发展的趋势[J].中国骨与关节杂志,2017,6(12):881-882.
[11]王宏庆,刘祖耀,李珂,等.加速康复外科理念指导下单髁关节置换术后疼痛的相关因素分析[J].临床合理用药杂志,2017,10(29):134-135.
[12]谢小伟,岳辰,康鹏德,等.加速康复模式下初次全膝关节置换术后急性疼痛的相关因素分析[J].中华骨与关节外科杂志,2016,9(6):489-492.
[13]Drysch M,Wallner C,Schmidt SV.An optimized low-pressure tourniquet murine hind limb ischemia reperfusion model:Inducing acute ischemia reperfusion injury in C57BL/6 wild type mice.PLoS One.2019;14(1):e210961.
[14]Yu F,Jin J,Zhijian S.The limited use of a tourniquet during total knee arthroplasty:a randomized controlled trial.Knee.2014;21(6):1263-1268.
[15]Yavarikia A,Amjad GG,Davoudpour K.The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty.Pak J Biol Sci.2010;13(5):249.
[16]Farhang B,Lesiak AC,Ianno DJ.Venous pressure during intravenous regional anesthesia:implications for setting tourniquet pressure.J Anaesthesiol Clin Pharmacol.2018;34(4):507-512.
[17]Alcelik I,Pollock RD,Sukeik MA.Comparison of outcomes with and without a tourniquet in total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.JArthroplasty.2012;27(3):331-340.
[18]Hernandez AJ,Almeida AMD,Fávaro E.The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty.Clinics.2012;67(9):1053-1057.
[19]王刚,曹晓瑞,陈晓勇.膝关节置换术中止血带的使用对术后加速康复的影响[J].中华骨与关节外科杂志,2017,10(1):27-32.
[20]Wang K,Ni S,Li Z.The effects of tourniquet use in total knee arthroplasty:a randomized,controlled trial.Knee Surg Sports Trauma Arthroscopy.2016;25(9):1-9.
[21]Harsten A,Bandholm T,Kehlet H.Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty;a randomized controlled trial.Knee.2015;22(2):126-130.
[22]Yan C,Chan P,Fu C.Effect of tourniquet use on blood loss and post-operative function in total knee arthroplasty.Osteoarthritis Cartilage.2016;24(1):S518.
[23]Koehler SM,Fields A,Noori N.Safety of tourniquet use in total knee arthroplasty in patients with radiographic evidence of vascular calcifications.Am J Orthop.2015;44(9):E308-E316.
[24]刘佩佩,高巍,周小红,等.帕瑞昔布钠联合地佐辛超前镇痛对下肢骨折手术术后镇痛和应激反应的影响[J].重庆医学,2019,48(3):489-491.
[25]李敏清,张广清.术前功能锻炼对全膝关节置换患者术后康复效果影响的Meta分析[J].中国老年学杂志,2018,38(15):3676-3679.
[26]Mayer C,Franz A,Harmsen JF.Soft-tissue damage during total knee arthroplasty:Focus on tourniquet-induced metabolic and ionic muscle impairment.J Orthop.2017;14(3):347-353.
[27]李伟,夏仁云.止血带疼痛机制[J].中国矫形外科杂志,2000,7(1):60-62.
[28]姜路,赵延涛,姜侃,等.老年肥胖患者TKA术前CRP与术后膝关节功能恢复的相关性分析[J].中国骨与关节损伤杂志,2019,34(1):21-24.
[29]赵洪顺,阿尖措,高顺红,等.全髋关节置换局部应用氨甲环酸术中术后失血及白细胞介素6和C-反应蛋白的变化[J].中国组织工程研究,2019,23(4):493-498.
[30]张立,苏伟,赵劲民.股骨近端锁定加压钢板治疗老年股骨转子间骨折围手术期出血的危险因素[J].南方医科大学学报,2015,35(12):1797-1801.
[2]Mutlu S,Guler O,Mutlu H.Tourniquet use during total knee arthroplasty does not offer significant benefit:a retrospective cohort study.Int J Surg.2015;18:123-127.
[3]Olivecrona C,Lapidus LJ,Benson L.Tourniquet time affects postoperative complications after knee arthroplasty.Int Orthop.2013;37(5):827-832.
[4]Li B,Wen Y,Wu H.The effect of tourniquet use on hidden blood loss in total knee arthroplasty.Int Orthop.2009;33(5):1263-1268.
[5]杨建平,蒋涛,吕正祥.止血带优化对全膝关节置换术快速康复的影响[J].中国矫形外科杂志,2018,26(1):33-37.
[6]Rasmussen LE,Holm HA,Kristensen PW.Tourniquet time in total knee arthroplasty.Knee.2018;25(2):306-313.
[7]中华医学会骨科学分会关节外科学组.骨关节炎诊疗指南(2018年版)[J].中华骨科杂志,2018,38(12):705-715.
[8]赵学千,贾育松,孙旗,等.关节镜清理联合术后针刺与鸡尾酒疗法治疗膝骨关节炎[J].中华关节外科杂志(电子版),2018,12(5):681-686.
[9]Touzopoulos P,Ververidis A,Mpogiatzis C.The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty.Eur J Orthop Surg Traum,2019.DOI:10.1007/s00590-019-02369-8.
[10]裴福兴.加速康复外科是现代骨外科发展的趋势[J].中国骨与关节杂志,2017,6(12):881-882.
[11]王宏庆,刘祖耀,李珂,等.加速康复外科理念指导下单髁关节置换术后疼痛的相关因素分析[J].临床合理用药杂志,2017,10(29):134-135.
[12]谢小伟,岳辰,康鹏德,等.加速康复模式下初次全膝关节置换术后急性疼痛的相关因素分析[J].中华骨与关节外科杂志,2016,9(6):489-492.
[13]Drysch M,Wallner C,Schmidt SV.An optimized low-pressure tourniquet murine hind limb ischemia reperfusion model:Inducing acute ischemia reperfusion injury in C57BL/6 wild type mice.PLoS One.2019;14(1):e210961.
[14]Yu F,Jin J,Zhijian S.The limited use of a tourniquet during total knee arthroplasty:a randomized controlled trial.Knee.2014;21(6):1263-1268.
[15]Yavarikia A,Amjad GG,Davoudpour K.The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty.Pak J Biol Sci.2010;13(5):249.
[16]Farhang B,Lesiak AC,Ianno DJ.Venous pressure during intravenous regional anesthesia:implications for setting tourniquet pressure.J Anaesthesiol Clin Pharmacol.2018;34(4):507-512.
[17]Alcelik I,Pollock RD,Sukeik MA.Comparison of outcomes with and without a tourniquet in total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.JArthroplasty.2012;27(3):331-340.
[18]Hernandez AJ,Almeida AMD,Fávaro E.The influence of tourniquet use and operative time on the incidence of deep vein thrombosis in total knee arthroplasty.Clinics.2012;67(9):1053-1057.
[19]王刚,曹晓瑞,陈晓勇.膝关节置换术中止血带的使用对术后加速康复的影响[J].中华骨与关节外科杂志,2017,10(1):27-32.
[20]Wang K,Ni S,Li Z.The effects of tourniquet use in total knee arthroplasty:a randomized,controlled trial.Knee Surg Sports Trauma Arthroscopy.2016;25(9):1-9.
[21]Harsten A,Bandholm T,Kehlet H.Tourniquet versus no tourniquet on knee-extension strength early after fast-track total knee arthroplasty;a randomized controlled trial.Knee.2015;22(2):126-130.
[22]Yan C,Chan P,Fu C.Effect of tourniquet use on blood loss and post-operative function in total knee arthroplasty.Osteoarthritis Cartilage.2016;24(1):S518.
[23]Koehler SM,Fields A,Noori N.Safety of tourniquet use in total knee arthroplasty in patients with radiographic evidence of vascular calcifications.Am J Orthop.2015;44(9):E308-E316.
[24]刘佩佩,高巍,周小红,等.帕瑞昔布钠联合地佐辛超前镇痛对下肢骨折手术术后镇痛和应激反应的影响[J].重庆医学,2019,48(3):489-491.
[25]李敏清,张广清.术前功能锻炼对全膝关节置换患者术后康复效果影响的Meta分析[J].中国老年学杂志,2018,38(15):3676-3679.
[26]Mayer C,Franz A,Harmsen JF.Soft-tissue damage during total knee arthroplasty:Focus on tourniquet-induced metabolic and ionic muscle impairment.J Orthop.2017;14(3):347-353.
[27]李伟,夏仁云.止血带疼痛机制[J].中国矫形外科杂志,2000,7(1):60-62.
[28]姜路,赵延涛,姜侃,等.老年肥胖患者TKA术前CRP与术后膝关节功能恢复的相关性分析[J].中国骨与关节损伤杂志,2019,34(1):21-24.
[29]赵洪顺,阿尖措,高顺红,等.全髋关节置换局部应用氨甲环酸术中术后失血及白细胞介素6和C-反应蛋白的变化[J].中国组织工程研究,2019,23(4):493-498.
[30]张立,苏伟,赵劲民.股骨近端锁定加压钢板治疗老年股骨转子间骨折围手术期出血的危险因素[J].南方医科大学学报,2015,35(12):1797-1801.