人工全膝关节置换加速康复中优化止血带的使用策略

Usage strategy of optimized tourniquet in enhanced recovery after total knee arthroplasty

背景:在全膝关节置换手术中使用止血带,可减少术中出血、保持术野清晰、增加假体的稳定性,但也会引发缺血再灌注损伤、止血带局部麻痹、肿胀、疼痛等不良反应,因此术中如何优化止血带使用策略,达到止血带应用获益最大化成为现当下研究的热点。目的:对比分析不同止血带使用策略对人工全膝关节置换术后加速康复的影响。方法:选择2017 年7 月至2018 年5 月南京中医药大学附属医院收治的86 例骨关节炎患者,均进行初次全膝关节置换,根据术中止血带使用策略不同,分为2 组:全程组(n=43)从切皮至假体安装完成后全程使用止血带,优化组(n=43)仅于假体安装时使用止血带。记录2 组手术时间、止血带使用时间、失血量;术后1,3,5,7 d,测量患者膝关节周围肿胀程度;出院前,进行膝关节功能HSS 评分、目测类比评分、抑郁和焦虑评分及社会客观和主观支持评分。试验已获得江苏省中医院伦理审批。结果与结论:①两组手术时间比较差异无显著性意义(P > 0.05),全程组止血带使用时间长于优化组(P <0.05);②两组总失血量比较无差异,但全程组术中出血量少于优化组(P < 0.05),术后引流量与隐性失血量多于优化组(P < 0.05);③优化组术后第3,5 天的膝关节肿胀率低于全程组(P < 0.05);④优化组HSS 评分、社会客观和主观支持评分高于全程组(P < 0.05),目测类比评分、抑郁和焦虑评分低于全程组(P < 0.05);⑤两组术后并发症发生率比较差异无显著性意义(P > 0.05);⑥结果表明,优化止血带使用策略能够减少全膝关节置换手术中的隐性失血量,减轻术后炎症反应及疼痛,降低术后关节肿胀程度并有效控制患者负面情绪。

BACKGROUND: Tourniquets used in total knee arthroplasty can reduce intraoperative bleeding, maintain clear surgical field, and increase the stability of the prosthesis, but can cause adverse reactions such as ischemia/reperfusion injury, local paralysis of the tourniquet, swelling, and pain. Therefore, how to optimize the usage strategy during surgery to maximize the benefit of tourniquet application has become a hotspot. OBJECTIVE: To compare and analyze the effects of different tourniquet usage strategies on enhanced recovery after total knee arthroplasty. METHODS: Eighty-six patients with osteoarthritis who underwent primary total knee arthroplasty at Affiliated Hospital of Nanjing University of Chinese Medicine from July 2017 to May 2018 were randomly divided into two groups. Whole process group used tourniquet in the whole process from cut to prosthesis implantation (n=43) and optimized group used tourniquet only when the prosthesis was implanted (n=43). The operation time, tourniquet usage time, and blood loss were recorded. The swelling degree of knee joint at postoperative 1, 3, 5, and 7 days was measured. The Hospital for Special Surgery score, Visual Analog Scale score, Hamilton Anxiety and Depression Scale, and social objective and subjective support score were detected before discharge. RESULTS AND CONCLUSION:(1) There was no significant difference in the operation time between two groups (P > 0.05). The tourniquet usage time in the whole process group was significantly longer than that in the optimized group (P < 0.05).(2) There was insignificant difference in the total blood loss between two groups. The intraoperative blood loss in the whole process group was significantly less than that in the optimized group (P < 0.05), and the postoperative drainage volume and hidden blood loss were more than those in the optimized group (P < 0.05).(3) The swelling degree of knee joint at postoperative 3 and 5 days in the optimized group was significantly lower than that in the whole process group (P < 0.05).(4) The Hospital for Special Surgery score, and social objective and subjective support score in the optimized group were significantly higher than those in the whole process group, and the Visual Analog Scale score, and Hamilton Anxiety and Depression Scale were significantly lower than those in the whole process group (P < 0.05).(5) There was no significant difference in the incidence of complications between two groups (P > 0.05).(6) Our results manifest that optimization of tourniquet usage can reduce hidden blood loss, alleviate postoperative pain, inflammation reaction and swelling degree, and effectively control patients, negative emotions.