固定平台假体膝关节单髁置换术中止血带应用策略研究

doi:10.3877/cma.j.issn.1674-134X.2024.01.006

目的

研究固定平台假体膝关节单髁置换术中止血带的应用策略。

方法

选取2021年5月至2022年7月山东省文登整骨医院收治的并完成随访的131例(131膝)膝骨关节炎患者，纳入标准：单膝内侧间室骨关节炎，排除标准：存在膝关节韧带严重损伤、膝关节骨折史、膝关节多间室软骨磨损、类风湿性关节炎、感染性关节炎、伴有严重心脑肝肾异常、精神异常等。采用前瞻性随机对照研究，通过随机数字表法分为全程定压组(全程固定压力止血带)、全程个体化组(全程个体化压力止血带)、半程个体化组(半程个体化压力止血带)三组，所有患者均采用膝关节单髁固定平台假体行内侧间室膝关节单髁置换术，随访至术后2周，使用单因素/重复测量方差分析比较各组患者的总失血量、不同时期视觉模拟评分法(VAS)、美国特种外科医院膝关节评分(HSS)、肿胀程度，记录并使用卡方检验比较各组并发症情况。

结果

全程定压组44例，全程个体化组43例，半程个体化组44例，均成功完成治疗及随访。三组患者切口均Ⅰ期愈合，无假体周围骨折、感染、假体断裂等严重并发症。三组患者手术总失血量、并发症发生率差异无统计学意义(F＝0.123，χ²＝1.227，均为P>0.05)。术后第1天各组VAS评分均高于术前，全程个体化组与半程个体化组评分均低于全程定压组，差异有统计学意义(均为P<0.05)，但全程个体化组与半程个体化组相比，差异无统计学意义(P>0.05)；术后第3天的全程定压组VAS评分与术前评分对比差异无统计学意义，全程个体化组与半程个体化组评分较术前明显降低(均为P<0.05)，全程个体化组与半程个体化组比较差异无统计学意义；术后2周各组VAS评分均较术前明显降低，全程个体化组与半程个体化组比较差异无统计学意义(均为P>0.05)，全程个体化组与半程个体化组评分均低于全程定压组，差异有统计学意义(均为P<0.05)。术后第1天及术后第3天各组HSS评分较术前降低，术后2周HSS评分高于术前，差异有统计学意义(均为P<0.05)；术后1 d及术后3 d，全程个体化组与半程个体化组HSS评分均高于全程定压组(均为P<0.05)，但全程个体化组与半程个体化组相比，差异无统计学意义(均P>0.05)，术后2周各组HSS评分差异无统计学意义(均为P>0.05)。同组内，术后第3天肿胀率最高，术后2周肿胀率最低，差异有统计学意义(均为P<0.001)；同一时间点，全程个体化组与半程个体化组肿胀率均低于全程定压组，差异有统计学意义(均为P<0.001)，但全程个体化组与半程个体化组比较，差异无统计学意义(均为P>0.05)。

结论

固定平台假体膝关节单髁置换术中使用基于肢体闭塞压力(LOP)制定的个体化压力止血带在不增加并发症及失血量的基础上，能明显缓解术后早期的疼痛及肿胀程度，加快膝关节功能恢复。

关键词: 关节成形术，置换，膝, 止血带, 研究, 假体与植入物

Objective

To investigate the tourniquet application strategy in unicompartmental knee arthroplasty with fixed platform prosthesis.

Methods

A total of 131 patients (131 knee) with knee osteoarthritis who were admitted to Wendeng Osteopathic Hospital in Shandong Province from May 2021 to July 2022 and completed follow-up were selected, and the inclusion criteria: osteoarthritis of the medial compartment of single knee, exclusion criteria: severe injury to knee ligaments, history of knee fracture, wear and tear of multi-compartment cartilage of the knee joint, rheumatoid arthritis, infectious arthritis, severe heart, brain, liver and kidney abnormalities, mental abnormalities, etc. A prospective randomized controlled study was used to divide them into full process constant pressure group(constant pressure group, full course with fixed pressure), full process individualization group(full-individual group, full course with individualized pressure), and halfway individualization group (half-individual-group, half-course with individualized pressure) by random number table method. Visual analogue scale (VAS), Hospital of Special Surgery (HSS), degree of swelling, and complications in each group were recorded and compared with one-way or repeated measures ANOVA or chi square test.

Results

Forty-four patients were in the constant pressure group, 43 in the full-individual group and 44 in the half-individual-group, all the patients had completed treatment and follow-up successfully. All the incisions healed at stage I. There was no statistically significant difference in total blood loss or complication among the three groups (all P>0.05). On the first day after the operation, the VAS scores of all groups were higher than those in preoperative group, and the scores of the full-individual group and the half-individual-group were lower than those in the constant pressure group, the comparative differences were statistically significant (P<0.05), but there was no statistically significant difference between the full-individual group and the half-individual-group (P>0.05). On the third day after surgery, there was no significant difference in VAS scores between the constant pressure group and the preoperative group, the rest VAS scores on the third day and two weeks after surgery were significantly lower than those before surgery. The scores of the full-individual group and the half-individual-group were lower than those of the constant pressure group (P<0.05), and there was no statistically significant difference between the scores of the full-individual group and the half-individual-group (P>0.05). HSS scores of the groups at the first day and third day after operation were lower than those before surgery, but the scores of two weeks after surgery were higher than those before surgery (all P<0.05), and the scores of the full-individual group and the half-individual-group were higher than those in the constant pressure group (all P<0.05) at the first day and third day after operation, but there was no significant difference between the full-individual group and the half-individual-group (all P>0.05), there was no significant difference in the scores of all groups (all P>0.05) at two weeks after surgery. In each group, the swelling rate was the highest on the third day after surgery and the lowest at two weeks after surgery (all P<0.001). At the same time point, the swelling rates of the full-individual group and the half-individual-group were lower than those in the constant pressure group, and the difference was statistically significant (all P<0.001), but the difference between the full-individual group and the half-individual-group was not statistically significant (all P>0.05).

Conclusion

The use of personalized pressure tourniquet based on limb occlusion pressure (LOP) in unicompartmental knee arthroplasty with fixed platform prosthesis can significantly relieve the pain and swelling in the early postoperative period and accelerate the recovery of knee joint function without increasing complications and blood loss.

Key words: Arthroplasty, replacement, knee, Tourniquets, Research, Prostheses and implants

图1 多普勒彩超探测腘动脉血流随止血带压力增加时的变化。图A示多普勒彩超下止血带未加压时腘动脉血流信号通畅；图B示止血带逐渐加压后腘动脉血流信号逐渐减小；图C示止血带加压至LOP(肢体闭塞压力)，完全阻断腘动脉血流

Figure 1 Doppler ultrasound probed popliteal artery blood flow as the tourniquet pressure increased. A shows that the popliteal artery blood flow signal was unobstructed when the tourniquet was not pressurized under Doppler color ultrasound; B shows that the popliteal artery blood flow signal gradually decreased after the tourniquet is gradually compressed; C shows that tourniquet compressed to limb occlusion pressure (LOP), which completely blocked popliteal artery blood flow

图2 左膝关节固定平台假体UKA(单髁置换术)术前术后X线片。图A为术前负重正位X线片，图示左膝关节内侧间室骨关节炎，软骨磨损严重，膝内侧间隙狭窄；图B为固定平台假体UKA术后正位X线片，示假体位置好

Figure 2 Radiographs of left knee joint before and after UKA with fixed platform prosthesis. A is the anteroposterior radiograph at weight-bearing position before surgery, showing osteoarthritis of the medial compartment with severe cartilage wear and narrow medial knee space; B is the anteroposterior radiograph after UKA with a fixed platform prosthesis, showing the prosthesis in a good position

表1 入组患者基线资料

Table 1 Baseline data of enrolled patients

组别Groups	例数Number of cases	性别[例(%)]Gender		年龄[岁，(±s)]Age(year)	BMI[kg/m²，(±s)]	K-L分级[例(%)]K-L classification
组别Groups	例数Number of cases	男Male	女Female	年龄[岁，(±s)]Age(year)	BMI[kg/m²，(±s)]	Ⅲ级	Ⅳ级
全程定压组Constant pressure group	44	21(47.7)	23(52.3)	66.7±5.3	26.2±1.8	27(61.4)	17(38.6)
全程个体化组Full-individual group	43	22(51.2)	21(48.8)	66.6±4.9	26.56±1.9	30(69.8)	13(30.2)
半程个体化组Half-individual group	44	19(43.2)	25(56.8)	66.6±5.1	26.6±1.6	26(59.1)	18(40.9)
统计值Statistical value		χ²＝0.560		F ＝0.020	F＝0.134	χ²＝1.181
P值		>0.05		>0.05	>0.05	>0.05

表1 入组患者基线资料

Table 1 Baseline data of enrolled patients

组别Groups	例数Number of cases	性别[例(%)]Gender		年龄[岁，(±s)]Age(year)	BMI[kg/m²，(±s)]	K-L分级[例(%)]K-L classification
组别Groups	例数Number of cases	男Male	女Female	年龄[岁，(±s)]Age(year)	BMI[kg/m²，(±s)]	Ⅲ级	Ⅳ级
全程定压组Constant pressure group	44	21(47.7)	23(52.3)	66.7±5.3	26.2±1.8	27(61.4)	17(38.6)
全程个体化组Full-individual group	43	22(51.2)	21(48.8)	66.6±4.9	26.56±1.9	30(69.8)	13(30.2)
半程个体化组Half-individual group	44	19(43.2)	25(56.8)	66.6±5.1	26.6±1.6	26(59.1)	18(40.9)
统计值Statistical value		χ²＝0.560		F ＝0.020	F＝0.134	χ²＝1.181
P值		>0.05		>0.05	>0.05	>0.05

图3 止血带压力分布箱线图

Figure 3 Diagram of tourniquet pressure distribution

表2 三组术中情况及并发症比较

Table 2 Comparison of intra-operative information and of complication incidence among three groups

组别Groups	例数Number of cases	总出血量[ml，(±s)]Total blood loss	并发症发生率[例(%)]Incidence of complications	止血带压力[mmHg，(±s)]Tourniquet pressure	手术时间[min，(±s)]Surgical time
全程定压组Constant pressure group	44	320±55	1(2.3)	270±0	56±6
全程个体化组Full-individual group	43	320±44	0(0)	241±34	56±4
半程个体化组Half-individual group	44	314±59	1(2.3)	246±32	54±6
统计值Statistical value		F＝0.123	χ²＝1.227	F＝13.876	F＝1.469
P值		>0.05	>0.05	<0.001	>0.05

表2 三组术中情况及并发症比较

Table 2 Comparison of intra-operative information and of complication incidence among three groups

组别Groups	例数Number of cases	总出血量[ml，(±s)]Total blood loss	并发症发生率[例(%)]Incidence of complications	止血带压力[mmHg，(±s)]Tourniquet pressure	手术时间[min，(±s)]Surgical time
全程定压组Constant pressure group	44	320±55	1(2.3)	270±0	56±6
全程个体化组Full-individual group	43	320±44	0(0)	241±34	56±4
半程个体化组Half-individual group	44	314±59	1(2.3)	246±32	54±6
统计值Statistical value		F＝0.123	χ²＝1.227	F＝13.876	F＝1.469
P值		>0.05	>0.05	<0.001	>0.05

表3 三组手术前后各观察点VAS疼痛评分[分，(

±s)]

Table 3 VAS scores at different observation points before and after surgery in three groups

组别Groups	例数Number of cases	术前Before operation	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	5.4±0.8	7.6±0.7^a	5.5±0.7	2.7±0.7^a	351.495	<0.001
全程个体化组Full-individual group	43	5.5±0.8	7.2±0.7^ab	5.0±1.0^ab	2.3±0.6^ab	321.301	<0.001
半程个体化组Half-individual group	44	5.4±0.9	7.0±0.7^ab	5.0±1.0^ab	2.3±0.7^ab	435.401	<0.001
F值		0.339	8.018	4.593	4.820
P值		>0.05	0.001	0.012	0.010

表3 三组手术前后各观察点VAS疼痛评分[分，(

±s)]

Table 3 VAS scores at different observation points before and after surgery in three groups

组别Groups	例数Number of cases	术前Before operation	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	5.4±0.8	7.6±0.7^a	5.5±0.7	2.7±0.7^a	351.495	<0.001
全程个体化组Full-individual group	43	5.5±0.8	7.2±0.7^ab	5.0±1.0^ab	2.3±0.6^ab	321.301	<0.001
半程个体化组Half-individual group	44	5.4±0.9	7.0±0.7^ab	5.0±1.0^ab	2.3±0.7^ab	435.401	<0.001
F值		0.339	8.018	4.593	4.820
P值		>0.05	0.001	0.012	0.010

表4 三组手术前后各观察点膝关节HSS评分[分，(

±s)]

Table 4 HSS scores at various observation points before and after surgery of three groups

组别Groups	例数Number of cases	术前Before operation	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	58.3±4.7	35.8±2.4^a	50.5±2.4^a	80.2±2.9^a	1 801.787	<0.001
全程个体化组Full-individual group	43	58.0±4.1	41.8±2.2^ab	53.8±2.3^ab	80.3±2.8^a	1 323.000	<0.001
半程个体化组Half-individual group	44	58.1±3.8	41.9±2.1^ab	53.9±2.3^ab	80.5±2.9^a	1 631.489	<0.001
F值		0.040	106.286	31.309	0.100
P值		>0.05	<0.001	<0.001	>0.05

表4 三组手术前后各观察点膝关节HSS评分[分，(

±s)]

Table 4 HSS scores at various observation points before and after surgery of three groups

组别Groups	例数Number of cases	术前Before operation	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	58.3±4.7	35.8±2.4^a	50.5±2.4^a	80.2±2.9^a	1 801.787	<0.001
全程个体化组Full-individual group	43	58.0±4.1	41.8±2.2^ab	53.8±2.3^ab	80.3±2.8^a	1 323.000	<0.001
半程个体化组Half-individual group	44	58.1±3.8	41.9±2.1^ab	53.9±2.3^ab	80.5±2.9^a	1 631.489	<0.001
F值		0.040	106.286	31.309	0.100
P值		>0.05	<0.001	<0.001	>0.05

表5 三组术后各观察点肿胀率[%，(

±s)]

Table 5 Swelling rates at various observation time points of three groups

组别Groups	例数Number of cases	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	5.91±0.54	11.48±0.43	4.54±0.42	30.793	0.004
全程个体化组Full-individual group	43	5.11±0.41^a	9.78±0.29^a	3.31±0.44^a	18.621	0.015
半程个体化组Half-individual group	44	5.28±0.48^a	9.81±0.28^a	3.24±0.43^a	38.677	<0.001
F值		33.377	363.020	125.285
P值		<0.001	<0.001	<0.001

表5 三组术后各观察点肿胀率[%，(

±s)]

Table 5 Swelling rates at various observation time points of three groups

组别Groups	例数Number of cases	术后1 d One day after operation	术后3 d Three days after operation	术后2周Two weeks after operation	F值	P值
全程定压组Constant pressure group	44	5.91±0.54	11.48±0.43	4.54±0.42	30.793	0.004
全程个体化组Full-individual group	43	5.11±0.41^a	9.78±0.29^a	3.31±0.44^a	18.621	0.015
半程个体化组Half-individual group	44	5.28±0.48^a	9.81±0.28^a	3.24±0.43^a	38.677	<0.001
F值		33.377	363.020	125.285
P值		<0.001	<0.001	<0.001

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Research of tourniquet application strategy in unicompartmental knee arthroplasty with fixed platform prosthesis

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Research of tourniquet application strategy in unicompartmental knee arthroplasty with fixed platform prosthesis