本文選題：全膝關節(jié)置換術 + 止血帶　； 參考：《山東大學》2017年碩士論文

【摘要】：目的探討有限使用止血帶對全膝關節(jié)置換術后早早期并發(fā)癥及膝關節(jié)早期康復的影響。材料和方法選取2015年9月～2016年5月在我院行初次單側(cè)TKA的120例患者,隨機將其分為A、B、C 3組,每組40例。試驗組A:手術開始前抬高患肢,驅(qū)血完畢后使用充氣止血帶,手術切口縫合紗布繃帶加壓包扎后再放松止血帶,即全程使用止血帶組;試驗組B:股骨截骨開始前患肢驅(qū)血使用充氣止血帶,安裝完人工假體后釋放止血帶并止血,即有限使用止血帶組;對照組C:整個手術過程均不使用止血帶,即不使用止血帶組。三組患者均記錄以下數(shù)據(jù):1.對手術的影響指標:平均手術時間(Operative time);2.與出血和栓塞有關的指標:術中失血量(Blood loss during operation),術后引流量(Drain volume),隱性失血量(Hidden blood loss),總失血量(Total blood loss)以及皮膚瘀斑、栓塞事件并發(fā)癥的發(fā)生例數(shù);3.與止血帶相關的早期并發(fā)癥:軟組織損傷(皮膚水泡、腫脹)、術后早期患膝靜息及活動時視覺模擬評分(Visual Analogue scale,VAS),4.早期康復指標:術后早期患膝關節(jié)活動度(Range of motion,ROM)及肌力。根據(jù)各組收集的數(shù)據(jù)結(jié)果,進行相互比較。結(jié)果1.對手術的影響指標,即平均手術時間:A、B、C三組手術時間(77.30±7.24min,77.33±7.OOmin,77.35±6.87min),差異無統(tǒng)計學意義(P1、P2、P3均0.05)。2.與出血和栓塞有關的指標:A組術中失血量(124.13± 15.89ml)少于B組(157.58±28.01ml),A、B 兩組術中失血量均少于 C 組(179.15±37.46ml),差異有統(tǒng)計學意義(P1、P2、P3均0.05);A、B、C三組術后引流量(337.25±240.78ml,308.25±220.50ml,305.88±232.51ml)、總失血量(810.28±242.14ml,780.95±209.00ml,737.43±232.51ml)無統(tǒng)計學意義(P 值均0.05);A 組隱性失血量(348.90±29.48ml)多于 B 組(315.13±22.96ml),A、B兩組隱性失血量多于C組(258.95±23.91ml),差異有統(tǒng)計學意義(P1、P2、P3均0.05);B、C兩組皮膚瘀斑發(fā)生例數(shù)(9例,4例)均少于A組(15例),B組皮膚瘀斑發(fā)生例數(shù)多于C組,A組患者皮膚瘀斑面積(46.75 ± 70.53cm2)大于 B、C 兩組(17.13±37.56cm2,8.28±27.49cm2),差異有統(tǒng)計學意義(P1、P2均0.05),B、C兩組皮膚瘀斑而積差異無統(tǒng)計學意義(P30.05);A、B、C三組患者均未發(fā)現(xiàn)癥狀性深靜脈血栓和肺動脈栓塞。3.與止血帶相關的早期并發(fā)癥:B、C兩組軟組織損傷(皮膚水泡、腫脹)發(fā)生例數(shù)(1例,0例)均少于A組(5例),B組軟組織損傷發(fā)生例數(shù)多于C組;靜息時VAS評分:A、B、C三組術后第1、7天,患膝VAS評分(A、B、C三組術后第1天的VAS評分分別為7.68±1.07,7.73±1.04,7.68± 1.05;A、B、C三組術后第7天的患膝VAS評分分別為2.03±0.86,1.98±0.83,1.85±0.86)無統(tǒng)計學差異(P值均0.05),第3天A、B兩組患膝VAS評分(6.10±0.78,5.93±1.00)大于 C 組(5.20±0.82),差異有統(tǒng)計學意義(P2、P3均0.05),A、B兩組患膝VAS評分無統(tǒng)計學差異(P10.05),第5天B、C兩組患膝 VAS 評分(3.95± 1.43,3.60±1.08)小于 A 組(4.55±1.04),差異有統(tǒng)計學意義(P1、P2均0.05),B、C兩組患膝VAS評分無統(tǒng)計學差異(P30.05);活動時VAS評分:A、B、C三組術后第1、7天,患膝VAS評分(A、B、C 三組術后第 1 天的 VAS 評分分別為 8.10±0.81,8.35±1.04,8.28±0.75;A、B、C三組術后第7天的患膝VAS評分分別為2.50±1.22,2.30±1.02,2.35± 1.05)無統(tǒng)計學差異(P值均0.05),第3天A、B兩組患膝VAS評分(6.85±0.83,6.53±1.09)大于 C 組(5.85±1.00),差異有統(tǒng)計學意義(P2、P3均0.05),A、B兩組患膝VAS評分無統(tǒng)計學差異(P10.05),第5天B、C兩組患膝 VAS 評分(4.55± 1.15,4.33±1.14)小于 A 組(5.18±0.78),差異有統(tǒng)計學意義(P1、P2均0.05),B、C兩組患膝VAS評分無統(tǒng)計學差異(P30.05)。4.早期康復的指標:術后早期膝關節(jié)活動度,術后第1天A組與B組以及B組與C組患膝關節(jié)活動度(A、B、C三組術后第1天的患膝關節(jié)活動度分別為20.70±6.22°,23.58±8.80°,26.73±9.09°)無統(tǒng)計學差異(P1,P3均0.05),A組患膝關節(jié)活動度小于C組(P20.05);術后第3天B、C兩組患膝關節(jié)活動度(50.08±7.55°,55.25±7.68°)大于 A 組(44.50±9.63°),C組患膝關節(jié)活動度大于B組,(P,、P2、P3均0.05),差異有統(tǒng)計學意義,術后第5天B、C兩組患膝關節(jié)活動度(76.93±4.38°,77.23±4.38°)大于A組(71.88±6.85°)(P1、P2均0.05),差異有統(tǒng)計學意義,B、C兩組患肢關節(jié)活動度差異無統(tǒng)計學意義(P30.05),術后第7天A、B、C三組患膝關節(jié)活動度分別為 95.63±6.49°,95.43±5.77°,95.80±5.00°)無統(tǒng)計學差異(P1、P2、P3均0.05);術后早期患肢肌力(以術后主動直腿抬高時間作為指標),B、C兩組直腿抬高時間(1.93±0.83天,1.88±0.85天)均短于A組直腿抬高時間(2.98±0.73天),差異有統(tǒng)計學意義(P1、P2均0.05),B、C兩組直腿抬高時間,差異無統(tǒng)計學意義(P30.05)。結(jié)論在TKA手術中,采取股骨截骨開始前患肢驅(qū)血使用充氣止血帶,安裝完人工關節(jié)假體后釋放止血帶并止血,在不影響解剖結(jié)構(gòu)的暴露和術中操作的前提下使用,在其放松后,便于發(fā)現(xiàn)出血點,并且縮短了使用時限,在一定程度上減少了相關的并發(fā)癥,所以,對于TKA術后早期康復具有積極意義,而全程不使用止血帶時,不會引起止血帶相關并發(fā)癥,患者在早期行膝關節(jié)功能鍛煉時存在優(yōu)勢,但是適用人群較為局限。對于合并高血壓病、冠心病及腦梗死等疾病的老年人群,術中血壓不能維持在較低水平,因而出血量會顯著增加,建議全程使用或有限使用止血帶;考慮到骨質(zhì)疏松較為嚴重的患者,在股骨及脛骨截骨時,截骨面滲血較多,有限使用止血帶可能更好;對于無基礎疾病的患者,可通過術中控制血壓減少出血,建議有限使用或全程不使用止血帶,并且可以減少早期并發(fā)癥。
[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.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R687.4

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