不放置引流管对中重度膝骨关节炎初次全膝关节置换术后快速康复的影响

Effects of drainage tube on rapid rehabilitation after primary total knee arthroplasty in patients with moderate-to-severe knee osteoarthritis

目的:观察不放置引流管对中重度膝骨关节炎初次全膝关节置换术后快速康复的影响。方法:采用随机数字表将符合要求的70例中重度膝骨关节炎患者随机分为引流管组和非引流管组,每组35例。2组患者均行全膝关节置换术且在安装骨水泥假体时使用止血带,引流管组在切口闭合前放置负压引流管并持续留置48h,非引流管组正常闭合切口而不放置负压引流管。记录并比较2组患者的手术时间、住院时间、理论失血总量、输血情况、膝关节主动屈曲90°所需时间、血红蛋白下降值、膝关节疼痛视觉模拟量表(visualanaloguescale,VAS)评分、膝关节周径增加率、膝关节屈曲度、美国膝关节协会评分(kneesocietyscore,KSS)及并发症发生情况。结果:①一般指标。2组患者手术时间、住院时间及理论失血总量比较,组间差异均无统计学意义[(87.11±7.16)min,(85.42±5.49)min,t=1.105,P=0.273;(7.74±2.20)d,(7.17±1.84)d,t=1.179,P=0.243;(1268.00±299.86)mL,(1170.00±182.62)mL,t=1.639,P=0.106];引流管组11例输血、非引流管组8例输血,2组患者输血率比较,差异无统计学意义(χ^2=0.650,P=0.420);引流管组膝关节主动屈曲90°所需时间长于非引流管组[(5.63±1.06)d,(4.91±1.15)d,t=2.206,P=0.009]。②血红蛋白下降值。时间因素与分组因素不存在交互效应(F=1.005,P=0.342);2组患者血红蛋白下降值总体比较,组间差异无统计学意义,即不存在分组效应(F=1.598,P=0.211);手术前后不同时间点之间血红蛋白下降值的差异有统计学意义,即存在时间效应(F=16255.255,P=0.000);2组患者血红蛋白下降值均呈先上升后平稳再下降趋势,且2组的变化趋势完全一致[(31.26±2.84)g·L^-1,(44.80±3.61)g·L^-1,(44.09±3.97)g·L^-1,(9.77±2.07)g·L^-1,F=10065.255,P=0.000;(30.00±3.09)g·L^-1,(43.86±3.93)g·L^-1,(43.14±3.85)g·L^-1,(9.14±1.94)g·L^-1,F=6776.683,P=0.000]。③膝关节疼痛VAS评分。时间因素与分组因素不存在交互效应(F=0.046,P=0.984);2组患者膝关节疼痛VAS评分总体比较,组间差异无统计学意义,即不存在分组效应(F=0.596,P=0.443);手术前后不同时间点之间膝关节疼痛VAS评分的差异有统计学意义,即存在时间效应(F=97.350,P=0.000);2组患者膝关节疼痛VAS评分均呈降低趋势,且2组的降低趋势完全一致[(3.71±0.80)分,(3.44±0.87)分,(2.53±0.85)分,(1.74±0.76)分,F=65.184,P=0.000;(3.58±0.74)分,(3.29±0.99)分,(2.45±1.10)分,(1.67±0.79)分,F=38.258,P=0.000]。④膝关节周径增加率。时间因素与分组因素不存在交互效应(F=1.321,P=0.269);2组患者膝关节周径增加率总体比较,组间差异有统计学意义,即存在分组效应(F=19.211,P=0.000);手术前后不同时间点之间膝关节周径增加率的差异有统计学意义,即存在时间效应(F=85.058,P=0.000);2组患者膝关节周径增加率随时间均呈先上升后降低趋势,但2组的变化趋势不完全一致[(4.97±0.86)%,(5.84±0.83)%,(5.11±0.77)%,(3.96±0.77)%,F=34.279,P=0.000;(5.72±0.93)%,(6.51±0.98)%,(5.67±0.89)%,(4.22±0.84)%,F=52.107,P=0.000];术后1d、3d和6d,引流管组膝关节周径增加率均小于非引流管组(t=-3.522,P=0.001;t=-3.053,P=0.003;t=-2.808,P=0.007);术后1个月,2组患者膝关节周径增加率比较,差异无统计学意义(t=-1.370,P=0.175)。⑤膝关节屈曲度。时间因素与分组因素存在交互效应(F=3.402,P=0.011);2组患者膝关节屈曲度总体比较,组间差异有统计学意义,即存在分组效应(F=6.676,P=0.012);手术前后不同时间点之间膝关节屈曲度的差异有统计学意义,即存在时间效应(F=1196.369,P=0.000);2组患者膝关节屈曲度随时间均呈先下降后上升趋势,且2组的变化趋势不完全一致(87.80°±4.92°,44.09°±5.52°,67.09°±4.18°,81.51°±6.24°,103.34°±6.18°,F=636.930,P=0.000;86.34°±5.32°,49.02°±5.56°,69.29°±5.07°,83.03°±5.37°,104.46°±5.17°,F=561.441,P=0.000);术后1d、6d、1个月和1年,2组患者膝关节屈曲度比较,差异均无统计学意义(t=1.190,P=0.238;t=-1.981,P=0.052;t=-1.089,P=0.280;t=-0.818,P=0.416);术后3d,引流管组膝关节屈曲度小于非引流管组(t=-3.734,P=0.000)。⑥KSS评分。术前和术后1年,2组患者KSS评分比较,差异均无统计学意义[(67.00±4.32)分,(66.23±4.77)分,t=0.710,P=0.480;(159.85±5.93)分,(160.57±6.81)分,t=-0.468,P=0.641];术后1年,2组患者KSS评分均较术前增加(t=-85.886,P=0.000;t=-81.456,P=0.000)。⑦安全性。引流管组2例发生无症状性肌间静脉血栓,1例发生切口相关并发症;非引流管组3例发生无症状性肌间静脉血栓,3例发生切口相关并发症。切口相关并发症经对症处理后,切口均完全愈合;无症状性肌间静脉血栓给予常规抗凝处理后,血栓消失。2组患者均无手术相关感染、肺栓塞等并发症发生。2组患者并发症发生率比较,差异无统计学意义(χ^2=0.510,P=0.475)。结论:在中重度膝骨关节炎初次全膝关节置换术后不放置引流管,能早期改善膝关节活动度,并发症少,虽然对早期预防血肿形成不利,但对膝关节疼痛缓解和膝关节功能恢复无明显影响,有利于术后快速康复的实施。

Objective:To observe the effects of drainage tube on rapid rehabilitation after primary total knee arthroplasty(TKA)in patients with moderate-to-severe knee osteoarthritis(KOA).Methods:Seventy patients with moderate-to-severe KOA were enrolled in the study and were randomly divided into drainage tube group and non-drainage tube group by using random digits table,35 cases in each group.The TKA were performed on all patients in the 2 groups,and a tourniquet was used when the bone cement prosthesis was installed.The negative-pressure drainage tube was placed before the incision was closed and was retained for 48 hours in patients of drainage tube group,while the incision was normally closed and no negative-pressure drainage tube was placed in patients of non-drainage tube group.The operative time,hospital stay,theoretical total blood loss,blood transfusion,the time spent in bending knee initiatively to a angle of 90 degrees,decreased values of hemoglobin(Hb)content,knee pain visual analogue scale(VAS)score,knee circumference increasing rate,knee flexion-extension range,American knee society score(KSS)and postoperative complications were recorded and compared between the 2 groups.Results:There was no statistical difference in operative time,hospital stay and theoretical total blood loss between the 2 groups(87.11+/-7.16 vs 85.42+/-5.49 min,t=1.105,P=0.273;7.74+/-2.20 vs 7.17+/-1.84 days,t=1.179,P=0.243;1 268.00+/-299.86 vs 1 170.00+/-182.62 mL,t=1.639,P=0.106).Blood transfusions were performed on 11 patients in drainage tube group and 8 patients in non-drainage tube group.There was no statistical difference in the blood transfusion rate between the 2 groups(χ^2=0.650,P=0.420).The time spent in bending knee initiatively to a angle of 90 degrees was longer in drainage tube group compared to non-drainage tube group(5.63+/-1.06 vs 4.91+/-1.15 days,t=2.206,P=0.009).There was no interaction between time factor and group factor in decreased values of Hb content(F=1.005,P=0.342).There was no statistical difference in decreased values of Hb content between the 2 groups in general,in other words,there was no group effect(F=1.598,P=0.211).There was statistical difference in decreased values of Hb content between different timepoints before and after the surgery,in other words,there was time effect(F=16 255.255,P=0.000).The decreased values of Hb content presented a time-dependent trend of increasing firstly and keeping subsequently and decreasing finally in both of the 2 groups,and the 2 groups were consistent with each other in the variation tendency of decreased values of Hb content(31.26+/-2.84,44.80+/-3.61,44.09+/-3.97,9.77+/-2.07 g/L,F=10 065.255,P=0.000;30.00+/-3.09,43.86+/-3.93,43.14+/-3.85,9.14+/-1.94 g/L,F=6 776.683,P=0.000).There was no interaction between time factor and group factor in knee pain VAS scores(F=0.046,P=0.984).There was no statistical difference in knee pain VAS scores between the 2 groups in general,in other words,there was no group effect(F=0.596,P=0.443).There was statistical difference in knee pain VAS scores between different timepoints before and after the surgery,in other words,there was time effect(F=97.350,P=0.000).The knee pain VAS scores presented a time-dependent decreasing trend in both of the 2 groups,and the 2 groups were consistent with each other in the decreasing trend of knee pain VAS scores(3.71+/-0.80,3.44+/-0.87,2.53+/-0.85,1.74+/-0.76 points,F=65.184,P=0.000;3.58+/-0.74,3.29+/-0.99,2.45+/-1.10,1.67+/-0.79 points,F=38.258,P=0.000).There was no interaction between time factor and group factor in knee circumference increasing rate(F=1.321,P=0.269).There was statistical difference in knee circumference increasing rate between the 2 groups in general,in other words,there was group effect(F=19.211,P=0.000).There was statistical difference in knee circumference increasing rate between different timepoints before and after the surgery,in other words,there was time effect(F=85.058,P=0.000).The knee circumference increasing rate presented a time-dependent trend of increasing firstly and decreasing subsequently in both of the 2 groups,and the 2 groups were inconsistent with each other in the knee circumference increasing rate(4.97+/-0.86,5.84+/-0.83,5.11+/-0.77,3.96+/-0.77%,F=34.279,P=0.000;5.72+/-0.93,6.51+/-0.98,5.67+/-0.89,4.22+/-0.84%,F=52.107,P=0.000).The knee circumference increasing rate was smaller in drainage tube group compared to non-drainage tube group at postoperative day 1,3 and 6(t=-3.522,P=0.001;t=-3.053,P=0.003;t=-2.808,P=0.007).There was no statistical difference in knee circumference increasing rate between the 2 groups at 1 month after the surgery(t=-1.370,P=0.175).There was interaction between time factor and group factor in knee flexion-extension range(F=3.402,P=0.011).There was statistical difference in knee flexion-extension range between the 2 groups in general,in other words,there was group effect(F=6.676,P=0.012).There was statistical difference in knee flexion-extension range between different timepoints before and after the surgery,in other words,there was time effect(F=1 196.369,P=0.000).The knee flexion-extension range presented a time-dependent trend of decreasing firstly and increasing subsequently in both of the 2 groups,and the 2 groups were inconsistent with each other in the knee flexion-extension range(87.80+/-4.92,44.09+/-5.52,67.09+/-4.18,81.51+/-6.24,103.34+/-6.18 degrees,F=636.930,P=0.000;86.34+/-5.32,49.02+/-5.56,69.29+/-5.07,83.03+/-5.37,104.46+/-5.17 degrees,F=561.441,P=0.000).There was no statistical difference in knee flexion-extension range between the 2 groups at 1 day,6 days,1 month and 1 year after the surgery(t=1.190,P=0.238;t=-1.981,P=0.052;t=-1.089,P=0.280;t=-0.818,P=0.416).The knee flexion-extension range was smaller in drainage tube group compared to non-drainage tube group at postoperative day 3(t=-3.734,P=0.000).There was no statistical difference in KSS scores between the 2 groups before the surgery and at 1 year after the surgery(67.00+/-4.32 vs 66.23+/-4.77 points,t=0.710,P=0.480;159.85+/-5.93 vs 160.57+/-6.81 points,t=-0.468,P=0.641).The KSS scores increased in both of the 2 groups at 1 year after the surgery compared to pre-surgery(t=-85.886,P=0.000;t=-81.456,P=0.000).The asymptomatic intermuscular venous thrombosis were found in 2 patients of drainage tube group and 3 patients of non-drainage tube group,and incision-related complications were found in 1 patient of drainage tube group and 3 patients of non-drainage tube group.The incision healed completely after the incision-related complications were treated with symptomatic supportive treatment,and the asymptomatic intermuscular venous thrombosis disappeared after conventional anticoagulation.No complications such as surgery-related infection and pulmonary embolism were found in the 2 groups.There was no statistical difference in complication incidences between the 2 groups(χ^2=0.510,P=0.475).Conclusion:Non-drainage can improve the range of motion of knee in the early period after primary TKA in patients with moderate-to-severe KOA,and it has less complications.Although it is detrimental to the early prevention of hematoma formation,it has no obvious effect on knee pain relief and knee function recovery,and it is conducive to the implementation of postoperative rapid rehabilitation.