止血带对应用氨甲环酸的胫骨高位截骨术围手术期结果的影响

Effect of tourniquet on the perioperative results of high tibial osteotomy with tranexamic acid

背景:止血带可减少术中失血,但也可能对围手术期结果产生不良影响,氨甲环酸(TXA)能有效减少胫骨高位截骨术(HTO)围手术期出血量。因此,应用TXA的HTO是否需要应用止血带值得深入研究。目的:明确止血带在应用TXA的HTO中的必要性。方法:本研究为前瞻性、随机对照研究,2018年1月至2019年10月行HTO治疗70例内侧单间室膝关节轻中度关节炎(OA)患者,被随机分为两组,应用止血带组手术全程应用止血带,不应用止血带组不用止血带。皮肤切开前15 min、3 h后、6 h后分别给予静脉滴注15 mg/kg、10 mg/kg、10 mg/kg TXA。研究指标包括失血量、输血率、VAS疼痛评分、膝关节活动度、静脉血栓栓塞症(VTE)、切口并发症。结果:两组间总失血量、术后1 d及术后3 d的血红蛋白(Hb)下降量差异无统计学意义,两组均未输血,应用止血带组术后引流量为(337±142)ml,不应用止血带组为(169±99)ml,应用止血带组明显高于不应用止血带组,差异有统计学意义(P=0.026)。两组间膝关节术后1 d、3 d、5 d、30 d静息痛及术后3 d、5 d、30 d活动痛的差异无统计学意义,术后1 d应用止血带组活动痛VAS评分为(6.5±2.3)分,不应用止血带组为(5.6±1.8)分,差异有统计学意义(P=0.038)。术后1 d膝关节活动度,应用止血带组为65.5°±15.6°,不应用止血带组为77.2°±18.4°,差异有统计学意义(P<0.001);术后3 d膝关节活动度,应用止血带组为85.2°±14.0°,不应用止血带组为90.3°±15.8°,差异有统计学意义(P=0.012);术后5 d及术后30 d膝关节活动度组间差异无统计学意义。组间术后VTE及切口并发症的差异无统计学意义。结论:在应用TXA的HTO中,止血带对围手术期失血量、输血率、术后膝关节静息痛、VTE、切口并发症无明显影响,可能增加术后早期膝关节活动痛,降低膝关节活动度,因此止血带的应用可能并非必要。

Background: Tourniquet can reduce intraoperative blood loss, but it may also have adverse effects on several perioperative results. Tranexamic acid(TXA) can effectively reduce perioperative blood loss in high tibial osteotomy(HTO). Therefore, whether tourniquet is necessary in HTO with TXA is worthy of further study. Objective: To clarify the necessity of tourniquet application in HTO with TXA. Methods: This was a prospective, randomized, controlled study with 70 patients with mild or moderate osteoarthritis of inner compartment undergoing HTO who were randomly divided into two groups from January2018 to October 2019. Patients in the tourniquet group applied tourniquet during the whole operation, whereas patients in the non tourniquet group did not. 15 mg/kg, 10 mg/kg and 10 mg/kg TXA were given intravenously at the time of 15 minutes before skin incision, 3 and 6 hours later. Study outcomes included blood loss, blood transfusion, VAS score, knee range of motion(ROM), venous thromboembolism(VTE) and incision complications. Results: There was no significant differences between the two groups in total blood loss and hemoglobin reduction on the 1 st and 3 rd days after operation, and no transfusion happened in both groups. The postoperative blood drainage was(337±142) ml in the tourniquet group and(169±99) ml in the non tourniquet group, and the difference was statistically significant(P=0.026). There was no significant differences between the two groups in resting pain on the 1 st, 3 rd, 5 th and 30 th day and in active pain on the 3 rd, 5 th and 30 th day after operation. The VAS score of active pain was(6.5±2.3) in the tourniquet group and(5.6±1.8) in the non tourniquet group on the 1 st day after operation, and the difference was significant(P=0.038). ROM was 65.5°±15.6°in the tourniquet group and 77.2°±18.4° in the non tourniquet group on the 1 st day after operation(P<0.001);ROM was 85.2°±14.0° in the tourniquet group and 90.3°±15.8°in the non tourniquet group on the 3 rd day after the operation(P=0.012). There was no difference in ROM on 5 th and 30 th day,VTE and incision complications between the two groups. Conclusions: In HTO with TXA, tourniquet has no significant effect on total blood loss, transfusion, resting pain after operation, VTE and incision complications, and patients using tourniquet may have more activity pain and worse ROM in the early postoperative period. Tourniquet may not be necessary in HTO with TXA.