全膝关节置换术中不同压力止血带与术后患肢疼痛肿胀的关系

The relationship between different tourniquet pressures in total knee arthroplasty and the pain and swelling of the affected limb after surgery

目的止血带在全膝关节置换术中的应用一直存在争议。文中探讨全膝关节置换术中不同止血带压力对于患肢术后疼痛肿胀的影响,并对损伤机制进行初步分析。方法选取2017年6月-12月于南京总医院行全膝关节置换术的患者96例,按照随机数字表法将患者分为240 mm Hg(低压力)组、270 mm Hg(中压力)组和300 mm Hg(高压力)组,对患者术前及术后1~2 d的疼痛及大腿周径进行测量;同时分别于术前及术后3、8、24 h抽取血标本检测过氧化物歧化酶1(SOD1)、前列腺素E2(PGE2)、肌红蛋白,并进行比较。结果术后第1天与第2天内,低压力组与中压力组患肢疼痛差异无统计学意义(P>0.05);低压力组、中压力组与高压力组之间比较,差异均有统计学意义(P<0.05),且低压力组更加明显(P<0.01)。术后第1天与第2天内,低压力组与中压力组患者大腿周径比较差异无统计学意义(P>0.05);低压力组、中压力组与高压力组比较,差异均有统计学意义(P<0.05)。相关分析结果显示,压力与疼痛(r=0.518,P<0.01)与肿胀(r=0.345,P<0.05)均呈正相关。术后3 h内,3组在SOD1和PGE2水平差异均有统计学意义(P<0.05);在术后8 h及24 h时,低压力组与中压力组在SOD1和PGE2水平上差异无统计学意义(P>0.05);仅高压力组分别与中压力组和低压力组之间差异有统计学意义(P<0.05)。而肌红蛋白在术后3 h时,低压力组与中压力组差异无统计学意义(P>0.05)。高压力组分别与中压力组、低压力组肌红蛋白水平差异有统计学意义(P<0.05)。在术后8 h及24 h,3组之间在肌红蛋白水平上差异均有统计学意义(P<0.05)。结论患肢术后疼痛、肿胀与术中止血带压力大小呈正相关,且肌肉坏死是损伤的主要机制。

Objective The use of tourniquets in total knee arthroplasty has been controversial. Many studies have focused only on the different time courses and neglected the effects of pressures. Currently,there is no study explaining the mechanism of tourniquet-induced injury. The aim of this study was to explore the effects of different tourniquet pressures on pain and swelling after total knee arthroplasty and to explore the mechanism of injury. Methods Ninety-six patients who underwent total knee arthroplasty at Nanjing General Hospital from June 2017 to December 2017 were randomly assigned to 240 mm Hg group（ low pressure）,270 mm Hg group（ medium pressure）,and 300 mm Hg group（ high pressure）. The patient＇s pain and thigh circumference were measured before and 1-2 days after surgery. Blood samples were taken before and 3,8,and 24 hours after surgery. Superoxide dismutase 1（ SOD1）,prostaglandin E2（ PGE2） and myoglobin were detected,analysed and compared. Results In the perspective of the pain and swelling of affected limb after surgery,the 300 mm Hg group（ 73.24±10.51） was significantly different from the 240 mm Hg group（ 58.18± 9.66） and the270 mm Hg group（ 63.06±10.06）. In the perspective of the SOD1 level in serum,the 300 mm Hg group（ 97.77±13.82） was significantly different from the 240 mm Hg group（ 63.72±15.02） and the 270 mm Hg group（ 70.58±5.85） at 3 h after surgery,and then the divergence was gradually decreased. In the perspective of the PGE2 level in serum,the 300 mm Hg group（ 478.05±35.80） was significantly different from the 240 mm Hg group（ 334.42±33.12） and the 270 mm Hg group（ 391.85±19.41） at 3 h after surgery,and the divergence was started to decrease after 8 h. In the perspective of the myoglobin level in serum,the 300 mm Hg group（ 30.43±9.79） was also significantly different from the 240 mm Hg group（ 17.58±1.93） and the 270 mm Hg group（ 22.28±4.21） at 8 h after operation,the divergence was started to decrease after 24 h. which began to decrease after 24 h. Correlation analysis showed that there was a significant correlation between pain（ correlation coefficient 0.518,P〈0.001）,swelling（ correlation coefficient 0.345,P〈0.05） and stress after surgery. Conclusion The pain and swelling of the affected limb is positively correlated with the pressure of the tourniquet during the operation. Muscle necrosis is the main mechanism of the injury. Oxidative stress occurs in the ischemic phase and inflammation occurs in the reperfusion phase.