全膝关节置换术中有限使用止血带的临床效果观察

发布时间：2018-06-05 02:00

本文选题：全膝关节置换术 + 止血带　；参考：《山东大学》2017年硕士论文

【摘要】：目的探讨有限使用止血带对全膝关节置换术后早早期并发症及膝关节早期康复的影响。材料和方法选取2015年9月～2016年5月在我院行初次单侧TKA的120例患者,随机将其分为A、B、C 3组,每组40例。试验组A:手术开始前抬高患肢,驱血完毕后使用充气止血带,手术切口缝合纱布绷带加压包扎后再放松止血带,即全程使用止血带组;试验组B:股骨截骨开始前患肢驱血使用充气止血带,安装完人工假体后释放止血带并止血,即有限使用止血带组;对照组C:整个手术过程均不使用止血带,即不使用止血带组。三组患者均记录以下数据:1.对手术的影响指标:平均手术时间(Operative time);2.与出血和栓塞有关的指标:术中失血量(Blood loss during operation),术后引流量(Drain volume),隐性失血量(Hidden blood loss),总失血量(Total blood loss)以及皮肤瘀斑、栓塞事件并发症的发生例数;3.与止血带相关的早期并发症:软组织损伤(皮肤水泡、肿胀)、术后早期患膝静息及活动时视觉模拟评分(Visual Analogue scale,VAS),4.早期康复指标:术后早期患膝关节活动度(Range of motion,ROM)及肌力。根据各组收集的数据结果,进行相互比较。结果1.对手术的影响指标,即平均手术时间:A、B、C三组手术时间(77.30±7.24min,77.33±7.OOmin,77.35±6.87min),差异无统计学意义(P1、P2、P3均0.05)。2.与出血和栓塞有关的指标:A组术中失血量(124.13± 15.89ml)少于B组(157.58±28.01ml),A、B 两组术中失血量均少于 C 组(179.15±37.46ml),差异有统计学意义(P1、P2、P3均0.05);A、B、C三组术后引流量(337.25±240.78ml,308.25±220.50ml,305.88±232.51ml)、总失血量(810.28±242.14ml,780.95±209.00ml,737.43±232.51ml)无统计学意义(P 值均0.05);A 组隐性失血量(348.90±29.48ml)多于 B 组(315.13±22.96ml),A、B两组隐性失血量多于C组(258.95±23.91ml),差异有统计学意义(P1、P2、P3均0.05);B、C两组皮肤瘀斑发生例数(9例,4例)均少于A组(15例),B组皮肤瘀斑发生例数多于C组,A组患者皮肤瘀斑面积(46.75 ± 70.53cm2)大于 B、C 两组(17.13±37.56cm2,8.28±27.49cm2),差异有统计学意义(P1、P2均0.05),B、C两组皮肤瘀斑而积差异无统计学意义(P30.05);A、B、C三组患者均未发现症状性深静脉血栓和肺动脉栓塞。3.与止血带相关的早期并发症:B、C两组软组织损伤(皮肤水泡、肿胀)发生例数(1例,0例)均少于A组(5例),B组软组织损伤发生例数多于C组;静息时VAS评分:A、B、C三组术后第1、7天,患膝VAS评分(A、B、C三组术后第1天的VAS评分分别为7.68±1.07,7.73±1.04,7.68± 1.05;A、B、C三组术后第7天的患膝VAS评分分别为2.03±0.86,1.98±0.83,1.85±0.86)无统计学差异(P值均0.05),第3天A、B两组患膝VAS评分(6.10±0.78,5.93±1.00)大于 C 组(5.20±0.82),差异有统计学意义(P2、P3均0.05),A、B两组患膝VAS评分无统计学差异(P10.05),第5天B、C两组患膝 VAS 评分(3.95± 1.43,3.60±1.08)小于 A 组(4.55±1.04),差异有统计学意义(P1、P2均0.05),B、C两组患膝VAS评分无统计学差异(P30.05);活动时VAS评分:A、B、C三组术后第1、7天,患膝VAS评分(A、B、C 三组术后第 1 天的 VAS 评分分别为 8.10±0.81,8.35±1.04,8.28±0.75;A、B、C三组术后第7天的患膝VAS评分分别为2.50±1.22,2.30±1.02,2.35± 1.05)无统计学差异(P值均0.05),第3天A、B两组患膝VAS评分(6.85±0.83,6.53±1.09)大于 C 组(5.85±1.00),差异有统计学意义(P2、P3均0.05),A、B两组患膝VAS评分无统计学差异(P10.05),第5天B、C两组患膝 VAS 评分(4.55± 1.15,4.33±1.14)小于 A 组(5.18±0.78),差异有统计学意义(P1、P2均0.05),B、C两组患膝VAS评分无统计学差异(P30.05)。4.早期康复的指标:术后早期膝关节活动度,术后第1天A组与B组以及B组与C组患膝关节活动度(A、B、C三组术后第1天的患膝关节活动度分别为20.70±6.22°,23.58±8.80°,26.73±9.09°)无统计学差异(P1,P3均0.05),A组患膝关节活动度小于C组(P20.05);术后第3天B、C两组患膝关节活动度(50.08±7.55°,55.25±7.68°)大于 A 组(44.50±9.63°),C组患膝关节活动度大于B组,(P,、P2、P3均0.05),差异有统计学意义,术后第5天B、C两组患膝关节活动度(76.93±4.38°,77.23±4.38°)大于A组(71.88±6.85°)(P1、P2均0.05),差异有统计学意义,B、C两组患肢关节活动度差异无统计学意义(P30.05),术后第7天A、B、C三组患膝关节活动度分别为 95.63±6.49°,95.43±5.77°,95.80±5.00°)无统计学差异(P1、P2、P3均0.05);术后早期患肢肌力(以术后主动直腿抬高时间作为指标),B、C两组直腿抬高时间(1.93±0.83天,1.88±0.85天)均短于A组直腿抬高时间(2.98±0.73天),差异有统计学意义(P1、P2均0.05),B、C两组直腿抬高时间,差异无统计学意义(P30.05)。结论在TKA手术中,采取股骨截骨开始前患肢驱血使用充气止血带,安装完人工关节假体后释放止血带并止血,在不影响解剖结构的暴露和术中操作的前提下使用,在其放松后,便于发现出血点,并且缩短了使用时限,在一定程度上减少了相关的并发症,所以,对于TKA术后早期康复具有积极意义,而全程不使用止血带时,不会引起止血带相关并发症,患者在早期行膝关节功能锻炼时存在优势,但是适用人群较为局限。对于合并高血压病、冠心病及脑梗死等疾病的老年人群,术中血压不能维持在较低水平,因而出血量会显著增加,建议全程使用或有限使用止血带;考虑到骨质疏松较为严重的患者,在股骨及胫骨截骨时,截骨面渗血较多,有限使用止血带可能更好;对于无基础疾病的患者,可通过术中控制血压减少出血,建议有限使用或全程不使用止血带,并且可以减少早期并发症。
[Abstract]:Objective to investigate the effect of limited use of tourniquet on early early complications and early rehabilitation of knee joint after total knee arthroplasty. Materials and methods were selected from September 2015 to May 2016 in 120 cases of primary unilateral TKA in our hospital. They were randomly divided into groups of A, B, C, group 3, 40 cases in each group. With the inflatable tourniquet, the surgical incision sutured the gauze bandage and then relaxed the tourniquet, that is, the whole use tourniquet group. In the experimental group B: femur osteotomy before the osteotomy, the blood filled tourniquet was used, the tourniquet was released and hemostasis was released after the prosthesis was installed, and the control group C: was not used for the whole operation. Blood bands, that is, no tourniquet group. Three groups of patients recorded the following data: 1. the index of the operation: average operation time (Operative time); 2. indexes related to bleeding and embolism: intraoperative blood loss (Blood loss during operation), postoperative flow rate (Drain volume), recessive blood loss (Hidden blood loss), total loss of blood (Total) Loss) and the number of cases of complications of skin ecchymosis and Embolism Events; 3. early complications associated with tourniquet: soft tissue injury (skin blister, swelling), visual analogue score (Visual Analogue scale, VAS) at early postoperative knee resting and activity (VAS), and early rehabilitation index of 4.: early postoperative knee joint activity (Range of motion, ROM) Muscle strength. Results according to the data collected in each group, the results of the results were compared with each other. Results 1. operation time, mean operation time: A, B, C three groups of operation time (77.30 + 7.24min, 77.33 + 7.OOmin, 77.35 + 6.87min), the difference was not statistically significant (P1, P2, P3 0.05).2. with bleeding and embolism related indicators: A group of blood loss (124.13 + 15.89ml) Less than the group B (157.58 + 28.01ml), A, B two were less than the C group (179.15 + 37.46ml), and the difference was statistically significant (P1, P2, P3 0.05), A, B, and three groups of C (337.25 +, 308.25, 305.88 +), and the total loss of blood (810.28 +, 780.95 +, 737.43 +) was not statistically significant 0.05): the recessive blood loss in group A (348.90 + 29.48ml) was more than that of group B (315.13 + 22.96ml), and the recessive blood loss in group A and B two was more than that of group C (258.95 + 23.91ml), and the difference was statistically significant (P1, P2, P3 0.05), and two groups of skin ecchymosis cases (9 cases, 4 cases) were less than those in 15 cases (15 cases), and the skin ecchymosis area of the group was more than that of the group, and the skin ecchymosis area of the group was more than that of the group. (46.75 + 70.53cm2) greater than B, C two group (17.13 + 37.56cm2,8.28 + 27.49cm2), the difference was statistically significant (P1, P2 all 0.05), B, C two groups of skin ecchymosis and no statistically significant difference (P30.05); A, B, three groups of patients had not found the early complications associated with symptomatic deep venous thrombosis and pulmonary embolism: two groups of soft tissues The number of cases (1 cases, 0 cases) of injury (1 cases, 0 cases) was less than that of group A (5 cases), and the number of soft tissue injuries in group B was more than that in group C, and the rest VAS scores in group A, B, C, 1,7 days after the operation (A, B, first days after operation in C three) were 7.68 and seventh days after the operation of three groups. There was no statistical difference between 2.03 + 0.86,1.98 + 0.83,1.85 + 0.86) (P value 0.05), third days A, and two group of B (6.10 + 0.78,5.93 + 1) higher than C group (5.20 + 0.82), the difference was statistically significant (P2, P3, 0.05), A, B two had no statistical difference between the knee and fifth days. Less than A group (4.55 + 1.04), the difference was statistically significant (P1, P2 0.05), B, C two had no statistically significant difference in knee VAS score (P30.05), and VAS score in group A, B, C three after operation, and first days after operation 8.10 + first + 0.75. The scores were 2.50 + 1.22,2.30 + 1.02,2.35 + 1.05), there were no statistical differences (P value 0.05), third days A, B two group of knee VAS scores (6.85 + 0.83,6.53 + 1.09) greater than C group (5.85 + 1), the difference was statistically significant (P2, P3, 0.05), A, fifth days, fifth, two sets of knees 3 + 1.14) was less than group A (5.18 + 0.78), the difference was statistically significant (P1, P2 0.05), B, C two group had no statistical difference (P30.05) the index of early.4. rehabilitation: early knee joint activity after operation, first days after operation, A group and B group, B group and C group. 2 There was no statistical difference between 0.70 + 6.22 degrees, 23.58 + 8.80 degrees, 26.73 + 9.09 degrees (P1, P3 0.05), and the activity of knee joint in group A was less than that of group C (P20.05), and B in the third days after operation, and in group C two (50.08 + 7.55 degrees, 55.25 + 7.68 degrees) greater than that in A group (P), and there was a statistically significant difference between the C group and B group. The knee joint activity (76.93 + 4.38 degrees, 77.23 + 4.38 degrees) in group C fifth days after the operation was greater than that in group A (71.88 + 6.85 degrees) (P1, P2 0.05). The difference was statistically significant, B, C two group had no statistical significance (P30.05) in the limb joint activity (P30.05) on the seventh days after the operation. There was no statistical difference (P1, P2, P3 0.05); early postoperative limb muscle strength (as an indicator of active straight leg elevation after operation), B, C two groups of straight leg elevating time (1.93 + 0.83 days, 1.88 + 0.85 days) were shorter than the A group straight leg elevation time (2.98 + 0.73 days), and there was no statistical significance (P1, P2 0.05), B, C two with no statistically significant difference. Conclusion (P30.05). Conclusion in the operation of TKA, the inflatable tourniquet was used before the osteotomy of the femur, and the tourniquet was released and hemostasis was released after the artificial joint prosthesis was installed, without affecting the exposure and operation of the anatomical structure. After it was relaxed, the bleeding point was easily found and the time limit was shortened to a certain extent. The associated complications are reduced, so it is of positive significance for early rehabilitation after TKA, and no tourniquet related complications are caused when the tourniquet is not used throughout the course. The patients have advantages in the early stage of knee joint function exercise, but the application of the population is limited. During the year, blood pressure can not be maintained at a lower level, so the amount of bleeding will increase significantly, and it is suggested that the whole use or limited use of tourniquet should be used. Considering that the patients with osteoporosis are more severe, the osteotomy of the osteotomy is more effective when the osteotomy of the femur and tibia, and the limited use of the tourniquet can be achieved; for patients with no basic disease, the operation can be achieved through the operation. Control blood pressure, reduce bleeding, suggest limited use or no tourniquet, and reduce early complications.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.4

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