同期双侧全膝关节置换中止血带的使用策略

Strategy of using a tourniquet in simultaneous bilateral total knee arthroplasty

背景:止血带在双侧膝关节置换中通常被全程使用或双侧部分时间使用,但极少有人尝试一侧不使用,对侧部分时间使用。目的:探讨在同期双侧全膝关节置换术中可行有效的止血带使用策略。方法:纳入2013年1至12月解放军医学院骨科收治的双膝重度骨关节炎患者80例(160膝),施行初次同期双膝置换,按先左后右顺序施行,按照止血带使用策略将分为两组,每组40例。试验组左膝不用止血带,右膝部分时间使用止血带;对照组双侧均全程使用止血带。记录两组患者术中及置换后失血量,置换后3 d大腿肿胀率及疼痛目测类比评分,置换后3周及1年后膝关节功能美国膝关节协会评分。结果与结论:两组患者围手术期总失血量差异无显著性意义(P>0.05),但是试验组患者置换后失血量少于对照组(P<0.05)。试验组患者置换后3 d疼痛目测类比评分明显低于对照组(P<0.05),试验组患者置换后3 d左侧疼痛目测类比评分低于右侧(P<0.05);试验组患者置换后3 d双侧大腿肿胀率明显低于对照组(P<0.05),试验组左侧置换后3 d大腿肿胀率低于右侧(P<0.05);早期美国膝关节协会评分试验组高于对照组,远期评分两组差异无显著性意义(P>0.05)。提示同期双侧全膝关节置换中采用先置换侧不使用止血带后置换侧部分时间使用止血带的策略,可在不增加围手术期总失血量的情况下减轻置换后疼痛及肿胀,促进膝关节早期功能恢复。

BACKGROUND： The tourniquet is usually fully used or bilaterally used in partial time during bilateral total knee arthroplasty. However, very few people try to use it on one side and on the other side in partial time. OBJECTIVE： To investigate the effective strategy of using a tourniquet in simultaneous bilateral total knee arthroplasty. METHODS： 80 patients（160 knees） with severe osteoarthritis who underwent simultaneous bilateral total knee arthroplasty in the Department of Orthopedics, Chinese PLA Medical School from January to December 2013 were divided into two groups according to the different tourniquet strategies. In test group（n=40）, left knees did not receive tourniquet, and right knees received tourniquet in partial time. In control group（n=40）, all knees received tourniquet in the whole time. The perioperative and postoperative blood loss, 3-day postoperative thigh swelling rate and pain visual analog scale, 3-week and 1-year postoperative Knee Society Score were recorded in both groups. RESULTS AND CONCLUSION： There were no statistically significant differences between two groups in perioperative total blood loss（P〉0.05）. However, postoperative blood loss in test group was less than that in control group（P〈0.05）. The visual analog scale scores were significantly lower in the test group than in the control group at 3 days after surgery（P〈0.05）. Visual analog scale scores on the left side were lower than on the right side in the test group at 3 days post surgery（P〈0.05）. Bilateral thigh swelling rate was significantly lower in the test group than in the control group at 3 days after surgery（P〈0.05）. The thigh swelling rate was lower on the left side than on the right side in the test group at 3 days after surgery（P〈0.05）. Knee Society Score was higher in the test group than in the control group in the early stage, and no significant difference in long-term Knee Society Score was detected（P〈0.05）. These findings verify that taking the strategy that the first knee without tourniquet and the second knee with part time tourniquet technique in simultaneous bilateral total knee arthroplasty will alleviate pain and swelling after operation and promote early functional rehabilitation without increasing the perioperative total blood loss.