个体化止血带压力在初次全膝关节置换中的应用
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摘要
背景:全膝关节置换是关节外科的常规手术方式,止血带已广泛应用于全膝关节置换术中,但如何选择合适的下肢止血带压力尚无统一的认识。选择合适的个体化止血带压力是否有助于全膝关节置换患者的加速康复尚需进一步研究。目的:探讨个体化止血带压力在初次全膝关节置换中的临床疗效及并发症。方法:纳入100例初次接受单侧全膝关节置换的膝关节骨关节炎患者,随机分为2组,每组50例。全膝关节置换手术全程使用止血带,试验组在彩超监视下确定肢体动脉阻断压为止血带压力,对照组选择70kPa为止血带压力。2组患者对治疗方案均知情同意,且得到医院伦理委员会批准。记录2组患者术中失血量、术后引流量、隐性失血量、总失血量及深静脉血栓发生情况;比较2组患者术后第1,3,5天目测类比评分、膝关节活动度、下肢肿胀情况及术后1个月美国特种外科医院膝关节评分。结果与结论:(1)试验组术后第1,3天休息时及活动时目测类比评分、术后第5天活动时目测类比评分低于对照组(P <0.05),2组术后第5天休息时膝关节目测类比评分差异无显著性意义(P> 0.05);(2)试验组术后第1,3天下肢肿胀轻于对照组(P <0.05),2组术后第5天下肢肿胀差异无显著性意义(P> 0.05);(3)2组术后第1,3,5天膝关节主动活动度差异无显著性意义(P> 0.05);(4)2组术后1个月美国特种外科医院膝关节评分、术中失血量、术后引流量、隐性失血量及总失血量差异均无显著性意义(P> 0.05);(5)提示采用彩超辅助下个体化止血带压力有助于减轻初次全膝关节置换患者术后早期疼痛及下肢肿胀,加速患者康复。
BACKGROUND: Total knee arthroplasty is a routine surgical procedure for joint surgery. Tourniquet has been widely used in total knee arthroplasty. However, there is no unified understanding of how to select the appropriate tourniquet pressure, and whether the selection of appropriate individual tourniquet pressure is helpful to the enhanced rehabilitation of patients undergoing total knee arthroplasty needs further investigation.OBEJCTIVE: To investigate the clinical efficiency and complications of individualized tourniquet pressure in patients undergoing primary total knee arthroplasty.METHODS: One hundred patients with primary unilateral total knee arthroplasty were enrolled and randomly divided into trial and control groups, 50 in each group. The limb occlusion pressure was determined as tourniquet pressure by Doppler ultrasound in the trial group, while 70 kPa pressure was chosen as tourniquet pressure in the control group. All patients signed the informed consents and the study was approved by the ethics committee of the hospital. The intraoperative blood loss, postoperative drainage volume, hidden blood loss, total blood loss and the incidence of deep venous thrombosis were recorded. The Visual Analogue Scale score, range of motion of knee joint and lower extremity swelling at 1, 3 and 5 days after surgery, and the Hospital for Special Surgery score at 1 month after surgery were compared.RESULTS AND CONCLUSION:(1) The Visual Analogue Scale scores at rest and in activity at 1 and 3 days after surgery and in activity at 5 days after surgery in the trial group were significantly lower than those in the control group(P < 0.05). There was no significant difference in the Visual Analogue Scale scores at rest at 5 days after surgery between two groups(P > 0.05).(2) The lower extremity swelling at 1 and 3 days after surgery in the trial group was significantly lighter than that in the control group(P < 0.05), and there was no significant difference at 5 days after surgery between two groups(P > 0.05).(3) There was no significant difference in the range of motion of knee joint at 1, 3, and 5 days after surgery between two groups(P > 0.05).(4) There was no significant difference in the Hospital for Special Surgery score,intraoperative blood loss, postoperative drainage volume, hidden blood loss and total blood loss at 1 month after surgery between two groups(P > 0.05).(5) These results indicate that the individualized tourniquet pressure assisted by Doppler ultrasound contributes to relieving early pain and lower extremity swelling after primary total knee arthroplasty, and can accelerate the functional recovery.
BACKGROUND: Total knee arthroplasty is a routine surgical procedure for joint surgery. Tourniquet has been widely used in total knee arthroplasty. However, there is no unified understanding of how to select the appropriate tourniquet pressure, and whether the selection of appropriate individual tourniquet pressure is helpful to the enhanced rehabilitation of patients undergoing total knee arthroplasty needs further investigation.OBEJCTIVE: To investigate the clinical efficiency and complications of individualized tourniquet pressure in patients undergoing primary total knee arthroplasty.METHODS: One hundred patients with primary unilateral total knee arthroplasty were enrolled and randomly divided into trial and control groups, 50 in each group. The limb occlusion pressure was determined as tourniquet pressure by Doppler ultrasound in the trial group, while 70 kPa pressure was chosen as tourniquet pressure in the control group. All patients signed the informed consents and the study was approved by the ethics committee of the hospital. The intraoperative blood loss, postoperative drainage volume, hidden blood loss, total blood loss and the incidence of deep venous thrombosis were recorded. The Visual Analogue Scale score, range of motion of knee joint and lower extremity swelling at 1, 3 and 5 days after surgery, and the Hospital for Special Surgery score at 1 month after surgery were compared.RESULTS AND CONCLUSION:(1) The Visual Analogue Scale scores at rest and in activity at 1 and 3 days after surgery and in activity at 5 days after surgery in the trial group were significantly lower than those in the control group(P < 0.05). There was no significant difference in the Visual Analogue Scale scores at rest at 5 days after surgery between two groups(P > 0.05).(2) The lower extremity swelling at 1 and 3 days after surgery in the trial group was significantly lighter than that in the control group(P < 0.05), and there was no significant difference at 5 days after surgery between two groups(P > 0.05).(3) There was no significant difference in the range of motion of knee joint at 1, 3, and 5 days after surgery between two groups(P > 0.05).(4) There was no significant difference in the Hospital for Special Surgery score,intraoperative blood loss, postoperative drainage volume, hidden blood loss and total blood loss at 1 month after surgery between two groups(P > 0.05).(5) These results indicate that the individualized tourniquet pressure assisted by Doppler ultrasound contributes to relieving early pain and lower extremity swelling after primary total knee arthroplasty, and can accelerate the functional recovery.
引文
[1]Tai TW,Chang CW,Lai KA,et al.Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty:a randomized controlled trial.J Bone Joint Surg Am.2012;94(24):2209-2215.
[2]蔡道章,杨杨,张曾.高凝血状态患者人群全膝关节置换术中应用止血带的对照研究[J].中华关节外科杂志(电子版),2018,12(4):495-500.
[3]Abbas K,Raza H,Umer M,et al.Effect of early release of tourniquet in total knee arthroplasty.J Coll Physicians Surg Pak.2013;23(8):562-565.
[4]Kvederas G,Porvaneckas N,Andrijauskas A,et al.A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2013;21(12):2790-2799.
[5]Huang ZY,Pei FX,Ma J,et al.Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty:a prospective non-randomized clinical trial.Arch Orthop Trauma Surg.2014;134(4):561-570.
[6]Zhang W,Liu A,Hu D,et al.Effects of the timing of tourniquet release incemented total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.J Orthop Surg Res.2014;9(125):1-11.
[7]Na YG,Bamne AB,Won HH,et al.After early release of tourniquet in total knee arthroplasty,should it be reinflated or kept deflated?A randomized trial.Knee Surg Sports Traumatol Arthrosc.2015;25(9):2769-2777.
[8]Tie K,Hu D,Qi Y,et al.Effects of tourniquet release on total knee arthroplasty.Orthopedics.2016;39(4):642-650.
[9]Ishii Y,Matsuda Y.Effect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty.J Arthroplasty.2005;20(3):325-330.
[10]Ishii Y,Noguchi H,Matsuda Y,et al.A new tourniquet system that determines pressures in synchrony with systolic blood pressure in total knee arthroplasty.J Arthroplasty.2008;23(7):1050-1056.
[11]Tetro AM,Rudan JF.The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty.Can J Surg.2001;44(1):33-38.
[12]Smith TO,Hing CB.Is a tourniquet beneficial in total knee replacement surgery?A meta-analysis and systematic review.Knee.2010;17(2):141-147.
[13]谢小伟,岳辰,黄泽宇,等.全膝关节置换术应用与不应用止血带的随机对照研究[J].中国矫形外科杂志,2017,25(17):1572-1576.
[14]张琦,董纪元,龚科,等.应用止血带对人工全膝关节置换术的影响研究[J].中国修复重建外科杂志,2016,30(4):421-425.
[15]Zhang W,Li N,Chen S,et al.The effects of a tourniquet used in total knee arthroplasty:a meta-analysis.J Orthop Surge Res.2014;9(13):1-9.
[16]杜传超,邱海滨,张衡,等.关于全膝关节置换术中使用止血带利弊随机对照性研究的系统回顾及Meta分析[J].中国骨与关节损伤杂志,2017,32(8):800-803.
[17]Pfitzner T,von Roth P,Voerkelius N,et al.Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2016;24(1):96-101.
[18]Tejwani NC,Immerman I,Achan P,et al.Tourniquet cuff pressure:The gulf between science and practice.J Trauma.2006;61(6):1415-1418.
[19]Lee OS,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]薛晨曦,姚运峰,荆珏华.全膝关节置换术中使用止血带的效果与安全性分析[J].中国骨与关节损伤杂志,2018,33(6):626-628.
[21]Olivecrona C,Ponzer S,Hamberg P,et al.Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty.J Bone Joint Surg Am.2012;94(24):2216-2221.
[22]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.
[23]王刚,曹晓瑞,陈晓勇,等.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.
[24]李小磊,王琦,颜连启,等.全膝关节置换过程中止血带使用方法对患肢功能恢复的影响[J].中国组织工程研究,2014,18(53):8560-8564.
[25]Unver B,Karatosun V,Tuncali B.Effects of tourniquet pressure on rehabilitation outcomes in patients undergoing total knee arthroplasty.Orthop Nurs.2013;32(4):217-222.
[26]Zan PF,Yang Y,Fu D,et al.Releasing of tourniquet before wound closure or not in total knee arthroplasty:a meta-analysis of randomized controlled trials.J Arthroplasty.2015;30(1):31-37.
[27]de Souza Le?o MG,Neta GP,Coutinho LI,et al.Comparative analysis of pain in patients who underwent total knee replacement regarding the tourniquet pressure.Revista Brasileira de Ortopedia(English Edition).2016;51(6):672-679.
[28]Papalia R,Zampogna B,Franceschi F,et al.Tourniquet in knee surgery.Br Med Bull.2014;11(1):63-76.
[29]黄家谷,张克,田华,等.单侧初次全膝关节置换后隐性失血的因素分析[J].中国组织工程研究,2016,20(26):3823-3829.
[2]蔡道章,杨杨,张曾.高凝血状态患者人群全膝关节置换术中应用止血带的对照研究[J].中华关节外科杂志(电子版),2018,12(4):495-500.
[3]Abbas K,Raza H,Umer M,et al.Effect of early release of tourniquet in total knee arthroplasty.J Coll Physicians Surg Pak.2013;23(8):562-565.
[4]Kvederas G,Porvaneckas N,Andrijauskas A,et al.A randomized double-blind clinical trial of tourniquet application strategies for total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2013;21(12):2790-2799.
[5]Huang ZY,Pei FX,Ma J,et al.Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty:a prospective non-randomized clinical trial.Arch Orthop Trauma Surg.2014;134(4):561-570.
[6]Zhang W,Liu A,Hu D,et al.Effects of the timing of tourniquet release incemented total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials.J Orthop Surg Res.2014;9(125):1-11.
[7]Na YG,Bamne AB,Won HH,et al.After early release of tourniquet in total knee arthroplasty,should it be reinflated or kept deflated?A randomized trial.Knee Surg Sports Traumatol Arthrosc.2015;25(9):2769-2777.
[8]Tie K,Hu D,Qi Y,et al.Effects of tourniquet release on total knee arthroplasty.Orthopedics.2016;39(4):642-650.
[9]Ishii Y,Matsuda Y.Effect of tourniquet pressure on perioperative blood loss associated with cementless total knee arthroplasty.J Arthroplasty.2005;20(3):325-330.
[10]Ishii Y,Noguchi H,Matsuda Y,et al.A new tourniquet system that determines pressures in synchrony with systolic blood pressure in total knee arthroplasty.J Arthroplasty.2008;23(7):1050-1056.
[11]Tetro AM,Rudan JF.The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty.Can J Surg.2001;44(1):33-38.
[12]Smith TO,Hing CB.Is a tourniquet beneficial in total knee replacement surgery?A meta-analysis and systematic review.Knee.2010;17(2):141-147.
[13]谢小伟,岳辰,黄泽宇,等.全膝关节置换术应用与不应用止血带的随机对照研究[J].中国矫形外科杂志,2017,25(17):1572-1576.
[14]张琦,董纪元,龚科,等.应用止血带对人工全膝关节置换术的影响研究[J].中国修复重建外科杂志,2016,30(4):421-425.
[15]Zhang W,Li N,Chen S,et al.The effects of a tourniquet used in total knee arthroplasty:a meta-analysis.J Orthop Surge Res.2014;9(13):1-9.
[16]杜传超,邱海滨,张衡,等.关于全膝关节置换术中使用止血带利弊随机对照性研究的系统回顾及Meta分析[J].中国骨与关节损伤杂志,2017,32(8):800-803.
[17]Pfitzner T,von Roth P,Voerkelius N,et al.Influence of the tourniquet on tibial cement mantle thickness in primary total knee arthroplasty.Knee Surg Sports Traumatol Arthrosc.2016;24(1):96-101.
[18]Tejwani NC,Immerman I,Achan P,et al.Tourniquet cuff pressure:The gulf between science and practice.J Trauma.2006;61(6):1415-1418.
[19]Lee OS,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]薛晨曦,姚运峰,荆珏华.全膝关节置换术中使用止血带的效果与安全性分析[J].中国骨与关节损伤杂志,2018,33(6):626-628.
[21]Olivecrona C,Ponzer S,Hamberg P,et al.Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty.J Bone Joint Surg Am.2012;94(24):2216-2221.
[22]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.
[23]王刚,曹晓瑞,陈晓勇,等.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.
[24]李小磊,王琦,颜连启,等.全膝关节置换过程中止血带使用方法对患肢功能恢复的影响[J].中国组织工程研究,2014,18(53):8560-8564.
[25]Unver B,Karatosun V,Tuncali B.Effects of tourniquet pressure on rehabilitation outcomes in patients undergoing total knee arthroplasty.Orthop Nurs.2013;32(4):217-222.
[26]Zan PF,Yang Y,Fu D,et al.Releasing of tourniquet before wound closure or not in total knee arthroplasty:a meta-analysis of randomized controlled trials.J Arthroplasty.2015;30(1):31-37.
[27]de Souza Le?o MG,Neta GP,Coutinho LI,et al.Comparative analysis of pain in patients who underwent total knee replacement regarding the tourniquet pressure.Revista Brasileira de Ortopedia(English Edition).2016;51(6):672-679.
[28]Papalia R,Zampogna B,Franceschi F,et al.Tourniquet in knee surgery.Br Med Bull.2014;11(1):63-76.
[29]黄家谷,张克,田华,等.单侧初次全膝关节置换后隐性失血的因素分析[J].中国组织工程研究,2016,20(26):3823-3829.