两种止血带使用方式对150例全膝关节置换术患者失血量和术后康复影响的前瞻性随机对照研究

Effect of two tourniquet application methods on blood loss and postoperative rehabilitation in 150 patients with total knee arthroplasty:a prospective randomized controlled study

背景:围手术期失血是全膝关节置换术(TKA)的一个主要问题,止血带的应用可以有效减少术中出血,但缺乏充足的科学依据证实手术患者能从止血带的使用中获益。目的:探讨术中全程使用止血带与安装假体至切口缝合包扎完毕间使用止血带对TKA患者围手术期失血量和功能恢复的影响。方法:前瞻性选取2018年8月至2019年10月接受初次单侧TKA的150例膝关节骨关节炎患者,术中全程使用止血带的75例为全程组,仅在安装假体至切口缝合包扎完毕使用止血带的75例为半程组。记录并比较两组患者的失血量、术后患肢周径增加率、术后VAS评分和HSS评分、ROM,术后血栓及切口并发症发生情况,并通过实验室检查测定手术前、后的IL-6,CRP以及肌酸激酶。结果:全程组术后显性失血量小于半程组,隐性失血大于假体组,差异有统计学意义(P<0.05);两组总失血量相当,差异无统计学意义(P>0.05);全程组术后大腿肿胀比和小腿肿胀比高于半程组,差异有统计学意义(P<0.05);全程组术后VAS评分高于半程组,差异有统计学意义(P<0.05);术后两组HSS评分均明显升高,半程组HSS评分高于全程组,差异有统计学意义(P<0.05);半程组术后5 d的ROM优于全程组,差异有统计学意义(P<0.05)。全程组术后15例出现不同程度的血栓(13例肌间静脉血栓及2例深静脉血栓形成),5例出现切口感染,半程组术后4例出现肌间静脉血栓,3例出现切口感染,差异有统计学意义(P<0.05)。半程组的术后血清IL-6、CRP、肌酸激酶水平均低于全程组,差异有统计学意义(P<0.05)。结论:全程使用止血带还是仅在安装假体至切口缝合包扎完毕使用止血带,尽管在显性失血量和隐形失血量存在差异,但总失血量方面并无差异,后者可以减轻术后疼痛肿胀的程度,降低术后血栓的发生率及炎症指标,术后膝关节功能也得到较快恢复。

Background:Perioperative blood loss is a main problem of total knee arthroplasty(TKA).Tourniquet is used to reduce blood loss during the operation,but whether the patients can obtain benefit from tourniquet application during whole course of the operation is still lack of evidences.Objective:To investigate the blood loss and functional recovery of patients with TKA using tourniquet during the whole course of operation or during the period from prosthesis installation to incision suture and bandage.Methods:A total of 150 patients with knee osteoarthritis undergoing the primary unilateral TKA from August 2018 to October 2019 were selected and divided into two groups as whole course group(n=75)using tourniquet during the whole course of the operation and half course group(n=75)using tourniquet from the installation of prosthesis to the end of incision suture and bandage.The volume of blood loss,the increasing rate of circumference of affected limb,VAS and HSS scores,knee ROM,and the incidence of thrombus and incision complications were recorded and compared between the two groups.Serum IL-6,CRP and creatine kinase were measured before and after operation.Results:The volume of dominant blood loss was lower,and the volume of invisible blood loss was higher in the whole course group than in the half course group(P<0.05).The total blood loss in the two groups was similar(P>0.05).The thigh swelling ratio,calf swelling ratio and VAS score after operation were significantly higher,and HSS score was significantly lower in the whole course group than in the half course group(P<0.05).ROM on 5 days after the operation in the half course group was better than that in whole course group(P<0.05).There were 15 patients of thrombosis(13 intermuscular venous thrombosis and 2 deep venous thrombosis)and 5 patients of incision infection in the whole course group,and 4 patients of intermuscular venous thrombosis and 3 patients of incision infection in the half course group,the difference was statistically significant(P<0.05).The levels of serum IL-6,CRP and creatine kinase were lower in the half course group than in the whole course group(P<0.05).Conclusions:Although there are differences in dominant blood loss and invisible blood loss between the two groups,there is no significant difference in the total blood loss.Tourniquet can reduce the degree of postoperative pain and swelling,decrease the incidence of postoperative thrombosis and inflammatory indexes,and improve the function of knee joint greatly when used during the period from prosthesis installation to the end of incision suture and bandage.