限制性使用止血带结合氨甲环酸在初次全膝关节置换术中的临床效果分析

Analyse of Clinical Effect of Limited Tourniquet Usage with the Application of Tranexamic Acid During Primary Total Knee

目的:探究在初次全膝关节置换术(Total knee arthroplasty,TKA)中限制性使用止血带结合应用氨甲环酸的临床效果及应用价值。方法:选取2018年1月-2019年5月于我院就诊行初次全膝关节置换术的患者304例。采用随机数字表法将所有患者分为2组,观察组154例患者在准备安装假体进行创面冲洗前开始使用止血带至骨水泥凝固后释放,即限制性使用止血带,对照组150例患者采用切皮前开始使用止血带至假体安装完毕后释放,即全程使用止血带。2组患者围术期均采用抗纤溶序贯抗凝治疗;切皮前30分钟静脉滴注氨甲环酸(tranexamic acid,TXA)1g,术中关闭关节囊后使用注射器于关节腔内灌注TXA28(溶于生理盐水20ml),术后3小时再次静脉滴注TXAlg,术后6-8小时开始口服利伐沙班10mg,每天1次。比较⒉组患者手术时间,围术期失血量,术后血红蛋白水平,VAS评分,肢体肿胀率,膝关节活动度(Range of motion,ROM)及相关并发症发生率。结果:观察组的手术时间(79.53±7.65)分钟和术中出血量(78.12±17.32)ml,均大于对照组(77.48±8.82)分钟,(74.29±15.96)ml,隐性失血量观察组(497.40±69.76)ml,低于对照组(521.52±73.23)ml,差异有统计学意义(P<0.05),总失血量观察纽(575.53±69.1l5)ml,对照组(595.81±69.41)ml,差异无统计学意义(P>0.05)。术后1天,3天血红蛋白水平观察组(121.45土11.11)g/L,(114.70±12.30)g/L,优于对照组(118.34±13.91)g/L,(110.98±17.65)g/L(P<0.05),术后7天2组的血红蛋白水平比较,观察组(101.49±11.13)g/L,对照组(99.01±12.98)g/L,差异无统计学意义(P>0.05)。术后1天,3天在静息及活动时VAS评分观察组静息(3.11±0.96,2.43±1.11),活动(5.26±1.07,4.14±1.44),低于对照组静息(3.50±0.74,2.71±1.28),活动(5.67±1.41,4.68±1.43),差异有统计学意义(P<0.05),术后7天,14天2组VAS评分差异无统计学意义(P>0.05)。术后3天患肢肿胀率观察组(6.51±1.46)%,低于对照组(7.62±1.41)%,膝关节活动度观察组101.03°±12.21°,大于对照组93.70°±10.77°,差异均有统计学意义(P<0.05)。观察组89例出现皮肤瘀斑,对照组121例,差异有统计学意义(P<0.05)。观察组出现97例贫血,其中4例患者需输血纠正贫血,对照组有114例患者出现贫血,需输血纠正贫血的患者有7例,差异没有统计学意义(P>0.05)。所有对象均无血栓事件发生,差异无统计学意义(P>0.05)。结论:在初次全膝关节置换术中,限制性使用止血带结合术中控制性降压,不会增加总失血量,可以改善患者术后血红蛋白水平,减轻术后疼痛和肢体肿胀,增加膝关节活动度,有利于术后快速康复,并不会增加并发症发生风险。

Objective:To investigate the clinical effct and value of limited tourniquet usage during primary total knee arthropleasty withthe application of tranexamic acid.Method:From January 2018 to May 2019,a total of 304 patients admitted in our hospital to undergoprimary total knee arthroplasty were randomized to two groups:experimental group(n=154)and control group(n=150).In experimentalgroup,the tourniquet was used before flushing the wound and placing the cement type knee prosthesis,,released after bone cement solidif.cation,that is to say the tourniquet was limited to be used.In control group,air inflation before skin incision and released after the pros-thesis installing,that is to say the tourniquet was used in full-course.ln perioperative period,in accordance with expert consensus state-ment on anti-coagulation sequential anti-fibrinolysis,all patients received an intravenous dosage of 1g tranexamic acid before skin inci-sion,be infused with TXA 3g at joint capsule closure,and a second dosage of 1g 3 hours postoperatively、All patients took orally 10 mgRivaroxaban once daily 6-8 hours postoperatively.The main evaluation indicators included operation duration,perioperative blood loss,postoperative hemoglobin,VAS score,swelling rate,range of motion and incidence ot related complications.Result:Compared with con-trol group[(77.48±8.82)min,(74.29±15.96)ml],operation duration and intraoperative blood loss in experimental group[(79.53±7.65)min,(78.12±17.32)ml]increased,but the hidden blood loss decreased[experimental group(497.40±69.76)ml,control group(521.52±73.23)ml],with significant differences between the two groups(P<0.05),the differences in total blood loss[experimentalgroup(575.53±69.15)ml,control group(595.81±69.41)ml]between the two group were not statistically significant(P>0.05).Hemo-globin level on dayl and 3 postoperatively in experimental group[(121.45±11.11)g/L,(114.70±12.30)g/L]were superior to that incontrol group[(118.34±13.91)g/L,(110.98±17.65)g/L](P<0.05),the difference in hemoglobin level on day7 postoperatively between the two groupl[experimental group(101.49±11.13)g/L,control group(99.01±12.98)g/L]was not statistically significant(P>0.05).The VAS score in experimental groupl[rest(3.11±0.96,2.43±1.11),exercise(5.26±1.07,4.14±1.44)]was significantlylower than that in control group[rest(3.50±0.74,2.71±1.28),exercise(5.67±1.41,4.68±1.43)]at rest and on in exercise ondayl and 3 postoperatively.The VAS score in experimental group was still lower than that in control group at rest and on in exercise onday7,day14 postoperatively,but the difference between two groups had no statistical significance(P>0.05).Swellig rate on day3 postop-eratively in the experimental group(6.51±1.46)% was lower to that in control group(7.62±1.41)%,range of motion[experimental group(101.03±12.21)°]was superior to that in control group(93.70±10.77)°,with significant differences between the two groups(P<0.05).After operation total occurred in 89 cases of ecchymosis in experimental group and 12l cases in control group,with significantdifferences between the two groups(P<0.05).97 cases in experimental group occurred anemia,among which 4 patients needed bloodtransfusion to corrct anemia,114 cases in control group occurred anenia,among which 7 patients needed blood transfusion to correct ane-mia,the difference between two groups had no statistical significance(P>0.05).All subjects without thrombosis-related events oc-curred,the difference between two groups had no statistical significance(P>0.05).Conclusion:Patients treated with limited tourniquetusage during primary total knee arthroplasty in accordance with expert consensus statement on anti-coagulation sequential anti-fibrinoly-sis do not have the total blood loss increased,have higher hemoglobin level,less postoperative pain,less knee swelling,and better range ofmotion.It is contribute to the enhanced recovery after surgery,and will not increase the risk of complications.