老年人工全髋关节置换术与全膝关节置换术后隐性失血的相关机制及输血策略

目的探讨人工全髋关节置换术(THA)、人工全膝关节置换术(TKA)后老年患者隐性失血的相关机制及输血策略。方法首诊、单侧髋(膝)关节置换老年患者182例,术后1 d内补液量低于2 000 ml;86例实施THA,96例实施TKA,依据术前体质量进行Gross方程计算围术期失血量,重点观察显性与隐性失血情况,探讨隐性失血机制,制定相应的输血策略。结果 (1)围术期实际失血总量,THA组(1 462.5±215.6)ml,TKA组(1 455.8±241.8)ml;(2)隐性失血量,THA组(482.3±42.7)ml,TKA组(732.5±152.3)ml;(3)隐性失血占实际失血总比,THA组占31.5%,THA组占51.2%,两组隐性失血情况差异有统计学意义(P<0.05);(4)TKA组采取引流血液回输处理患者25例隐性失血占实际失血总比47.6%,TKA组内未采取引流血液回输处理的71例隐性失血占实际失血总比58.3%,引流血液回输处理患者与未采取引流血液回输处理患者在实际的红细胞丢失量差异有统计学意义(P<0.05),二者间隐性失血量差异无统计学意义,证实引流血液回输处理对隐性失血影响较低;组间不同情况下血红蛋白(Hb)指标波动无统计学差异(P>0.05);(5)同组内肥胖病患与非肥胖病患隐性失血量并无明显差异(P>0.05)。结论 TKA患者在围术期隐性失血率较高于THA,因此在TKA或THA术中需及时对骨质残留物进行全面细致清除,密切监测患者Hb变化;制定相应的输血策略,保证充足的血液预存准备,确保患者血循环恢复,减少贫血风险。     

重组人促红细胞生成素联合蔗糖铁注射液治疗全髋关节置换术贫血的疗效

目的探讨重组人促红细胞生成素联合蔗糖铁注射液治疗全髋关节置换术贫血的疗效。方法行全髋关节置换术的75例贫血患者,随机将其分为观察组和对照组。观察组术前7 d开始给予促红细胞生成素及蔗糖铁注射液治疗,对照组使用等量的生理盐水。两组术中均应用氨甲环酸减少出血。观察两组术前及术后不同时间点血红蛋白、血细胞比容、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、C反应蛋白(CRP)的水平。记录两组拆线时间、卧床时间、输血情况、发热、过敏及下肢深静脉血栓形成等并发症发生情况。结果入院后两组血红蛋白水平和红细胞计数均有所升高,观察组升高更为明显(P0.05)。术后1 d、3 d两组患者血红蛋白水平和红细胞计数均有所下降,观察组在术后1 d及3 d时血红蛋白水平和红细胞计数均显著高于对照组(P0.05)。术后7 d时,两组血红蛋白水平和红细胞计数较术后1 d、3 d有所升高,但仍低于术前水平,且观察组血红蛋白水平和红细胞计数显著高于对照组(P0.05)。术后7 d时,观察组PT、APTT、FIB、CRP测量值明显小于对照组(P0.05)。观察组术后输血量及输血率明显低于对照组(P0.05)。观察组下床行走时间及切口愈合时间均显著短于对照组(P0.05)。观察组住院时间要长于对照组。两组未见过敏、发热、伤口感染与延迟愈合、下肢深静脉血栓形成等并发症。结论重组人促红细胞生成素联合蔗糖铁注射液治疗可安全有效地提高单侧全髋关节置换术贫血患者血红蛋白水平,促进术后快速康复。     

全膝关节置换术后关节线位置变化及其与膝关节临床功能的关系

目的观察全膝关节置换术(TKA)后关节线(JL)位置改变,探讨其与膝关节临床功能的关系。方法接受单侧TKA治疗的膝骨关节炎患者89例(89膝),手术均采用GENESISⅡ后稳定型假体。分别测量手术前后JL位置,计算JL位置改变程度;评估手术前后膝关节KSS评分、膝关节功能KSS评分、Feller髌骨评分,分析TKA后JL改变范围与临床功能评分的关系。结果术后随访假体生存率为100%(89/89),膝关节正位及侧位X线片均未显示影像学松动,膝关节KSS评分、功能评分、活动度及Feller髌骨评分均较术前增加(P均<0.01);手术前后JL改变≤4 mm患者术后膝关节KSS评分、功能评分、活动度及Feller髌骨评分均高于JL改变>4 mm患者(P<0.05或<0.01)。JL改变≤4 mm患者Feller髌骨评分与JL改变程度没有相关性(r=-0.162,P=0.205),JL改变>4 mm患者Feller髌骨评分与JL改变程度呈负相关(r=-0.724,P=0.000)。结论采用后稳定型膝关节假体的初次TKA患者术后JL改变>4 mm对于膝关节功能有影响,JL改变程度与伸膝装置功能呈负相关。     

老年骨关节炎患者全膝关节置换术后关节功能的影响因素

膝关节疼痛是骨关节炎治疗上颇为头疼的难题,保守治疗疗效往往不佳,如不进行手术,患者多患有不同程度的膝关节功能障碍,加重症状[1,2].全膝关节置换术(TKA)以及关节镜下清理术是目前减轻骨关节炎,改善关节功能较为可靠的两个治疗办法[3],本研究拟分析老年骨关节炎患者全膝关节置换术后关节功能的影响因素. 1资料与方法 1.1 一般资料 我院2001年1月至2012年12月骨关节炎需行TKA病例211例,其中男性97例、女性114例,年龄55 ～ 81岁,平均年龄(71.1±7.2)岁.其中131例患者体型较为肥胖,体重在70～116 kg,患者术前的膝关节活动度数以及HSS评分分别为(68±10.3)度、(46.8±6.2)分.手术植入的假体多为施乐辉公司的旋转半月板假体,其次为林克公司产品.另外选取同时期内210例行关节镜下清理术治疗骨关节炎的病例作为对照组,其中男性96例、女性114例,年龄53～ 84岁,平均年龄(71.7±7.1)岁.患者术前的膝关节活动度数以及HSS评分分别为(67±9.6)度、(47.1±7.5)分.两组年龄、性别、术前膝关节活动度数以及HSS评分差异无统计学意义(P＞0.05),具有可比性.     

减少人工全膝关节置换术围手术期失血措施的研究进展

随着我国人口老龄化,人工全膝关节置换术(total knee arthroplasty,TKA)手术量逐年增加。TKA术中的松质骨截骨和软组织松解会导致患者血液丢失,甚至造成术后贫血,给患者造成头晕等不适症状,且影响患者及患肢功能的快速康复,常需行同种异体输血治疗。而输血又存在传播疾病等风险,因此,减少TKA围手术期的失血就显得至关重要。目前,减少TKA围手术期失血的常用措施包括术前贫血的治疗、术中氨甲环酸的使用、术后引流管的使用等。     

鸡尾酒疗法对老年全膝关节置换术后镇痛的影响

目的探究鸡尾酒疗法对老年患者全膝关节置换术的镇痛效果及安全性。方法 2014年1月至2015年6月在该院行单侧全膝关节置换术的老年患者60例分为实验组和对照组各30例,男女比例1∶1。实验组患者膝关节置换完成缝合前在关节腔周围组织注射镇痛药物,对照组不进行相关处理。记录两组患者在术后4、8、12、24、48 h各时间点静止及运动视觉模拟疼痛评分(VAS),术后首次下床时间及静脉自控镇痛(PCIA)首次按压与术毕时间差,PCIA按压次数,患者镇痛满意度及不良反应发生情况。结果实验组患者术后8、12、24 h时间点静息及运动VAS疼痛评分显著低于对照组(P0.05);实验组患者PCIA首次自控追加药物时间显著晚于对照组,术后镇痛泵按压次数显著低于对照组,镇痛满意度显著高于对照组(P0.05)。结论关节周围注射镇痛药物与PCIA联合应用于老年患者全膝关节置换术后镇痛可显著降低患者术后静息和运动VAS疼痛评分,降低术后阿片类镇痛药物的用量,有利于患者术后早期功能康复训练和功能重建,是一种安全有效的治疗方法。     

下肢神经阻滞用于老年患者全膝关节置换术临床观察

目的 观察肢神经阻滞在老年患者全膝关节置换术中的应用效果,并与硬膜外阻滞进行比较.方法 择期行单侧全膝关节置换术的老年患者60例,ASA分级Ⅰ～Ⅲ级,随机分为观察组及对照组各30例,分别行神经刺激器引导下肢神经阻滞（腰丛—坐骨神经阻滞）及硬膜外阻滞.记录麻醉前（T0）、手术开始（T1）、剥离骨膜（T2）、手术结束（T3）等各时间点的心率（HR）、平均动脉压（MAP）及手术时间、上止血带时间.观察两组患者感觉和运动阻滞的起效时间、持续时间、阻滞效果以及术后24 h内恶心、呕吐、尿潴留等并发症发生情况.结果 观察组感觉和运动阻滞的起效时间短于对照组,观察组维持时间长于对照组（P均＜0.05）;麻醉起效后对照组患者在T1、T2、T3各时间点的HR快于术前T0（P均＜0.05）,MAP均低于术前（P均＜0.05）.对照组患者术后24h不良反应发生率高于观察组.结论 神经刺激器引导下肢神经阻滞对血流动力学影响小,镇痛完善且并发症少,可安全有效地用于老年全膝关节置换术.     

不同剂量氨甲环酸对全膝关节置换术后失血量的影响

目的 探讨不同剂量氨甲环酸对全膝关节置换术(TKA)围手术期失血量的影响.方法 选取2010年4月～2012年4月行单侧TKA的90例膝关节骨性关节炎和类风湿性关节炎患者,随机分为氨甲环酸10 mg/kg组、氨甲环酸15 mg/kg组、对照组三组各30例,分别将氨甲环酸分别按10、15 mg/kg的剂量(稀释于250 mL生理盐水后)静滴,3h后,以相同剂量再次给药;对照组予生理盐水250 mL静滴,3h后重复静滴1次.记录各组术后引流量、引流血液回输量、异体输血量、输血人数、输红细胞数,检测术前、术后6h、术后24 h、术后72 h血红蛋白量.结果 氨甲环酸10 mg/kg组、氨甲环酸15 mg/kg组术后引流血量均较对照组明显减少(P＜0.05、P＜0.01),术后6h的回输血量亦明显低于对照组(P ＜0.05、P＜0.01);氨甲环酸10 mg/kg组的术后异体输血量、输血人数较对照组和氨甲环酸15 mg/kg组明显减少(P均＜0.05);氨甲环酸15 mg/kg组有1例术后发生胸部疼痛,经螺旋CT检查发现有肺栓塞,但未危及生命,经抗血栓治疗后症状消失.结论 在TKA后早期使用氨甲环酸能明显降低患者术后失血量和异体输血量,剂量为10 mg/kg更为有效.     

全膝关节置换术康复治疗的研究进展

全膝关节置换术(TKA)是治疗膝关节炎的有效方法.但TKA术后患者常存在关节疼痛、肿胀、活动受限、肌力下降等问题.康复治疗在改善TKA术后并发症以及促进肢体功能恢复有良好作用.该文为TKA术后康复治疗的研究进展作一综述.     

老年全膝关节置换术患者术后康复训练依从性观察及其影响因素

目的 探讨老年全膝关节置换术(TKA)患者术后康复训练依从性及其影响因素分析。方法 回顾性分析2022年1月至2023年1月于武汉市第一医院行TKA的244例老年患者的临床资料,且在术后3个月评估所有患者康复训练依从性,并比较不同临床特征老年TKA患者康复训练依从性评分差异。通过多因素logistic回归分析影响老年TKA患者康复训练依从性的危险因素并构建风险预测模型。通过受试者工作特征(ROC)曲线分析风险预测模型预测老年TKA患者康复训练依从性的价值。选用SPSS 22.0统计软件对数据进行处理。根据数据类型,分别采用t、F检验进行组间比较。结果 244例老年TKA患者康复训练依从性评分中身体锻炼依从评分为(13.27±3.09)分、主动寻求锻炼依从评分为(6.88±2.04)分、锻炼监督依从评分为(6.12±1.81)分;康复训练依从性总分为15~32(23.27±6.94)分。女性、年龄≥80岁、合并疾病＞2种、初中文化程度、无配偶、独居、月收入＜500元、有慢性疼痛的老年TKA患者康复训练依从性总分显著低于男性、年龄＜80岁、合并疾病≤2种或无、高中及以上文化程度、有配偶、与配偶或子女同住或其他、月收入≥500元、无慢性疼痛的老年TKA患者,差异有统计学意义(P＜0.05)。经多因素logistic回归分析证实,女性(OR=3.544,95%CI 1.036～12.123)、年龄≥80岁(OR=1.052,95%CI 1.024～1.081)、合并疾病＞2种(OR=4.418,95%CI 1.274～15.321)、初中文化程度(OR=4.274,95%CI 1.542～11.846)、无配偶(OR=3.245,95%CI 1.244～8.465)、独居(OR=1.226,95%CI 1.105～1.360)、月收入＜500元(OR=2.429,95%CI 1.442～4.092)、有慢性疼痛(OR=2.015,95%CI 1.009～4.024)为影响老年TKA患者康复训练依从性的危险因素。经ROC分析证实,风险预测模型预测老年TKA患者康复训练依从性的曲线下面积为0.934,标准误为0.014,95%CI为0.907～0.961,最佳截断点为35.499,灵敏度为0.925,特异度为0.890。结论 老年TKA术后康复训练依从性受到较多因素的影响,同时经ROC分析证实风险预测模型对老年TKA患者康复训练依从性具有较好的预测价值,或可为后续康复训练工作的开展提供帮助。     

Effectiveness and safety of tranexamic acid administration during total knee arthroplasty

Background  The administration of tranexamic acid (TA) is associated with a decrease in the number of red blood cell (RBC) units transfused. However, concerns about its safety have hindered its broader use.
Study Design and Methods  We evaluated the effect of TA on RBC transfusion and thromboembolic complications in total knee arthroplasty. We retrospectively studied 414 patients, 215 immediately before introducing TA treatment (control group) and after, in 199 patients without history of thromboembolic diseases (TA group). In a subgroup of patients, a lower extremities contrast venography was performed.
Results  Fifty-four per cent of control group patients were transfused with RBC while only 17·6% of TA group patients received RBCs. In the TA that group, those transfused received less units (2·83 vs. 1·89), showed smaller mean calculated perioperative blood loss and haemoglobin values at discharge were higher compared to control group (10·1 vs. 9·3 g/dl). Thromboembolic complications were diagnosed in 2·8% of the patients in the control group and in 1·5% in the TA group. Asymptomatic distal deep venous thrombosis was found in 54 (14·8%) of TA group patients and 54 (30·1%) of control patients. TA administration reduced the expenditure for RBC transfusion plus the cost of TA from €148·94 to 33·87 per patient.
Conclusion  Routine administration of TA during total knee arthroplasty to patients without history of thromboembolic disease is associated with a 67% reduction in RBC transfusions and, in those transfused, with a reduction in the number of units administered. TA treatment was not associated with an increase in thromboembolic complications. Transfusion costs are significantly reduced.     

氟比洛芬联合罗哌卡因镇痛在老年全膝关节置换术患者中的应用研究

目的 观察氟比洛芬联合罗哌卡镇痛模式在老年膝关节置换术患者中的应用效果,为治疗该病症提供方法.方法 纳入2019年10月-2021年3月在汕头市中心医院行膝关节置换术的62例老年患者,按数字表法随机分为观察组(n=31)与对照组(n=31).对照组术后以舒芬太尼进行自控静脉镇痛,观察组以氟比洛芬联合罗哌卡因在术前、术中...     

Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation

Background

Blood loss during total joint arthroplasty strongly influences the time to recover after surgery and the quality of the recovery. Blood conservation strategies such as pre-operative autologous blood donation and post-operative cell salvage are intended to avoid allogeneic blood transfusions and their associated risks. Although widely investigated, the real effectiveness of these alternative transfusion practices remains controversial.

Materials and methods

The surgery reports of 600 patients undergoing total joint arthroplasty (312 hip and 288 knee replacements) were retrospectively reviewed to assess transfusion needs and related blood management at our institute. Evaluation parameters included post-operative blood loss, haemoglobin concentration measured at different time points, ASA score, and blood transfusion strategies.

Results

Autologous blood donation increased the odds of receiving a red blood cell transfusion. Reinfusion by a cell salvage system of post-operative shed blood was found to limit adverse effects in cases of severe post-operative blood loss. The peri-operative net decrease in haemoglobin concentration was higher in patients who had predeposited autologous blood than in those who had not.

Discussion

The strengths of this study are the high number of cases and the standardised procedures, all operations having been performed by a single orthopaedic surgeon and a single anaesthesiologist. Our data suggest that a pre-operative autologous donation programme may often be useless, if not harmful. Conversely, the use of a cell salvage system may be effective in reducing the impact of blood transfusion on a patient’s physiological status. Basal haemoglobin concentration emerged as a useful indicator of transfusion probability in total joint replacement procedures.     

Preoperative autologous blood donation in primary total knee arthroplasty: a single-centre experience on 214 consecutive patients

BACKGROUND AND OBJECTIVES: Although preoperative autologous blood donation (PABD) is a widespread practice in elective orthopedic surgery, it is controversial whether this procedure avoids allogeneic blood transfusions in patients undergoing total knee arthroplasty (TKA). PATIENTS AND METHODS: We performed a retrospective study on 214 consecutive patients undergoing PABD before elective primary TKA. RESULTS: Thirty-eight patients (17.8%) were transfused with autologous red blood cells (RBC), while four of them (10.5% of those requiring transfusions, 1.9% of all patients) also received allogeneic RBC. The transfused patients were, in most cases, female and had significantly lower basal and preoperative haemoglobin levels. CONCLUSIONS: Based on the results of this study, PABD is not necessary in most patients undergoing TKA, although older female patients with low basal haemoglobin levels could benefit from a predeposit programme and/or erythropoietin support in order to reduce the risk of exposure to allogeneic blood.     

Three-dimensional gait characteristics of patients after unilateral total knee arthroplasty

The purpose of this study is to evaluate the gait characteristics of bilateral limbs after unilateral total knee arthroplasty (TKA) using three-dimensional (3D) dynamic capture technology.Forty-two patients who underwent TKA were selected from the Orthopedic Medical Center of The Second Hospital of Jilin University from November 2018 to May 2019. We used a 3D dynamic capture system to measure the gait characteristics of patients at 3 months after TKA. The data, including relative position and direction of different body parts, the force between feet and ground, spatial and temporal relationship of the lower limb muscles, were measured. Besides, the surface electromyogram signal and the force plate analog signal were also collected. The walking ability, knee 3D kinematic, and kinetic characteristics were analyzed by the Cortex software.Spatial and temporal parameters, including stride frequency, double support phase, single support phase, step length, step time, step width, stride length, gait cycle, velocity, were no significant difference in bilateral lower extremities (P > .05). The reaction force of hip, knee, and ankle joint in the operation side were less than that of the healthy side, but the difference was not statistically significant (P > .05). However, when compared with the healthy side, the hip joint in operation side had a larger maximum extension angle (P < .001), the knee joint in operation side had a larger maximum valgus angle and valgus activity (P < .05), and had a smaller tibial maximum internal rotation angle (P < .05). Besides, the surface electromyogram signals of tibialis anterior muscles were reduced (P < .05).3D gait analysis, as an objective and quantitative evaluation method, is a safe, effective, and reliable method for evaluating postoperative knee function. The data of gait analysis prove that TKA is a vital treatment to improve the function of patients with knee arthritis. Besides, gait analysis also showed that there were various kinematic and biomechanical abnormalities in the knee after TKA, which may be the reason why the surgical knee could not immediately return to normal level.     

Allogeneic blood transfusion does not increase the risk of wound infection in total knee arthroplasty

Background and Objective Allogeneic blood transfusion has been reported to increase the risk of postoperative infection in arthroplasty though the results are inconclusive. Data from a previous clinical trial on antibiotic prophylaxis in knee arthroplasty were analysed to gain further insight into the relationship between wound infection and both blood transfusion and the storage time of transfused RBCs. Materials and Methods A total of 910 consecutive patients undergoing primary knee arthroplasty were prospectively followed for 12 months after surgery. The main outcome was wound infection, either superficial or deep‐tissue. Possible predictors for wound infection included the patient’s age and sex, preoperative physical status, time under leg ischaemia, postoperative fluid drainage, and the number and length of storage of transfused RBCs. Results Deep tissue infection was diagnosed in 28 (3%) patients, superficial infection in 25 (2·7%) and cellulitis in eight (0·8%) patients. Transfusion of at least one blood unit had been given to 22 (36%) of the 61 patients who later developed wound infection and 313 (36%) of those who did not (P > 0·05). Patients who developed wound infection had a significantly poorer physical status and longer time of leg ischaemia. There was no significant difference between both groups of patients in either the amount or the length of storage of transfused RBC units. Conclusion This study failed to find any association between the incidence of wound infection after knee arthroplasty and allogeneic transfusion.     

Autologous transfusion of drain contents in elective primary knee arthroplasty: its value and relevance

Background

Total knee arthroplasty is associated with significant post-operative blood loss often necessitating blood transfusions. Blood transfusions may be associated with transfusion reactions and may transmit human immunodeficiency virus, hepatitis C virus and hepatitis B virus, with devastating consequences. After total knee arthroplasty, transfusion of the contents of an autologous drain is becoming common practice. The aim of our study was to look at the effectiveness of these drains in elective primary total knee arthroplasty.

Materials and methods

A prospective study was conducted including 70 non-randomised patients. A normal suction drain was used in 35 patients (group A), whereas in the other 35 patients, a CellTrans^™ drain was used (group B). All the operations were performed by four surgeons using a tourniquet with a medial parapatellar approach. Pre- and post-operative haemoglobin concentrations were recorded in both groups. A Student’s t-test was applied to determine the statistical significance of the data collected.

Results

The average fall in post-operative haemoglobin was 3.66 g/dL (SD 1.46; range, 0.6–7.0) among patients in whom the simple drain was used (group A) and 2.29 g/dL (SD 0.92; range, 0.6–5.9) among those in whom the CellTrans^™ drain was used (group B) (p<0.0001). Twenty-five units of allogeneic blood were required in group A compared to four units in group B. The rate of transfusion was 5.7% (2 patients) in the group in which CellTrans™ drain was used and 25.7% (9 patients) in the group in which a simple suction drain was used.

Discussion

Total knee arthroplasty is associated with significant post-operative blood loss despite best operative technique. Autologous reinfusion of the contents of a CellTrans^™ drain significantly reduces the rate of post-operative blood transfusion. This study indicates that the use of an autologous drain could be recommended as routine practice in primary total knee arthroplasty.     

Efficacy and safety using autotransfusion system with postoperative shed blood following total knee arthroplasty in haemophilia

The purpose of this study was to evaluate the efficacy and safety of postoperative wound drain salvage and autotransfusion system in haemophilic patients undergoing elective total knee arthroplasty (TKA). No literature exists on reinfusing drained blood in patient with haemophilia undergoing TKA. Eighty‐eight knees of 66 patients received cemented TKA due to end‐stage haemophilic arthropathy (group I; with autotransfusion in 59 knees, group II; without autotransfusion in 29 knees). In group I, the postoperative shed blood was transfused within 6 h after surgery. The amount of blood drainage and reinfused blood, rate and amount of allogenic transfusion, postoperative change of haemoglobin level, prothrombin time (PT) and activated partial thromboplastin time were analysed. The mean postoperative blood drainage was 932 ± 479 mL in group I and 830 ± 492 mL in group II (P > 0.05). The mean volume of blood reinfused was 530 ± 265 mL in group I. Allogenic transfusion was needed in six knees (10.2%) of group I and eight knees (27.6%) of group II (P = 0.036). The mean volume of allogenic transfusion was 480 ± 49 mL in group I and 1041 ± 691 mL in group II (P > 0.05). Changes of all the laboratory results before and after TKA showed no statistically significant difference except PT was prolonged in group I (P = 0.008) at postoperative day 1. Moreover, there was no significant complication related to either reinfusion or allogenic transfusion in both groups . This study showed that reinfusion of drained blood is a simple, safe and efficacious method in patients with haemophilia undergoing TKA.