股骨髓内定位孔封堵对膝关节置换后出血影响的Meta分析

Sealing of intramedullar femoral canal for blood loss after total knee arthroplasty: a meta-analysis

背景:全膝关节置换是治疗终末期膝骨关节炎的成熟技术,其围术期出血问题一直是临床研究热点,术中对股骨髓内定位孔是否进行封堵处理以及其对全膝关节置换出血的影响目前仍存在争议。目的:采用Meta分析方法对股骨髓内定位孔封堵技术减少膝关节置换后出血的临床效果进行评价。方法:检索Cochrane Library、Medline、Embase、PubMed、Web of science英文数据库以及CBM、维普、万方数据库、CNKI中文数据库,检索内容为膝关节置换术中是否进行股骨髓内定位孔封堵的临床对照试验。检索时间为建库至2018年7月。使用Revman 5.30进行Meta分析。结局指标包括:手术时间,24 h引流量,术中出血量,24、72 h血红蛋白减少量,输血率以及并发症。结果与结论:(1)共纳入10篇文献,11个对照试验,纳入患者1 190例,其中665例对股骨髓内定位孔进行自体骨或者骨水泥封堵,525例未对股骨髓内定位孔作封堵处理;(2)Meta分析结果:术中对股骨髓内定位孔进行封堵处理,有效减少了术中出血量(MD=-16.11,95%CI=[-23.51,-8.71],P <0.001),减少了24 h引流量(MD=-128.05,95%CI=[-212.06,-44.04],P <0.001),减少了24 h血红蛋白减少量(MD=-0.58,95%CI=[-1.08,0.08],P=0.02),降低输血率(OR=0.50,95%CI=[0.36,0.68],P <0.001)以及并发症(OR=0.44,95%CI=[0.21,0.91],P <0.05)。而在手术时间(P=0.2)及72 h血红蛋白减少量方面(P=0.9)差异无显著性意义;(3)结果提示,膝关节置换术中对股骨髓内定位孔进行封堵处理能有效控制显性出血,减少引流量,降低输血率及并发症,值得推广。

BACKGROUND:Total knee arthroplasty is a mature technique for end-stage knee osteoarthritis.The problem of postoperative blood loss has always been a hot issue in clinical discussion.Whether the intramedullar femoral canal is sealed during operation and its effect on blood loss in total knee arthroplasty remain controversial.OBJECTIVE:To evaluate the clinical effect of sealing of intramedullar femoral canal for reducing postoperative blood loss in total knee arthroplasty by meta-analysis.METHODS:English databases such as Cochrane Library,Medline,Embase,PubMed,and Web of science,and Chinese databases such as CBM,VIP,WanFang,and CNKI were retrieved for clinical controlled trials concerning whether the intramedullar femoral canal was sealed during total knee arthroplasty.The retrieval time was from database creation to July 2018.The outcome indexes included operation time,24-hour drainage,intraoperative blood loss,24-,and 72-hour hemoglobin reduction,blood transfusion rate,and complications.RESULTS AND CONCLUSION:(1)Ten articles were included,including 11 clinical controlled trials,involving 1 190 patients(665 cases underwent autologous bone or cement sealing in the intramedullar femoral canal,and 525 cases were not treated with occlusion in the intramedullar femoral canal).(2)The results of meta-analysis showed that sealing of intramedullar femoral canal in total knee arthroplasty reduced the amount of intraoperative blood loss(MD=-16.11,95%CI=(-23.51,-8.71),P<0.001),24-hour drainage(MD=-128.05,95%CI=(-212.06,-44.04),P<0.001),24-hour hemoglobin reduction(MD=-0.58,95%CI=(-1.08,0.08),P=0.02),blood transfusion rate(OR=0.50,95%CI=(0.36,0.68),P<0.001)and complications(OR=0.44,95%CI=(0.21,0.91),P<0.05).The operation time(P=0.2)and 72-hour hemoglobin reduction(P=0.9)did not differ significantly between groups.(3)These results indicate that based on the existing evidence,sealing of intramedullar femoral canal in total knee arthroplasty can effectively control visible blood loss,reduce drainage,reduce blood transfusion rate and complications,and it is worthy of promotion.