持续优化技术在膝关节表面置换术失血损害控制中的作用

目的评价持续优化技术对行初次单侧人工膝关节表面置换术(TKA)围术期失血损害控制的临床疗效。方法回顾性分析2016年1月-2019年7月陆军军医大学第二附属医院骨科符合纳入排除标准的177例单侧初次TKA患者,根据不同假体类型分为两组试验,每组根据采用不同手术技术及围术期管理方式分为3组,具体如下:试验1均采用后交叉韧带替代型假体(posterior stabilization,PS)及手术技术,其中对照组1使用传统鸡尾酒(肾上腺素5mg、罗哌卡因300mg、复方倍他米松7mg、吗啡10mg,使用生理盐水配制至50mL),试验组1.1采用改良鸡尾酒(氨甲环酸1g、罗哌卡因300mg、复方倍他米松7mg、吗啡10mg,使用生理盐水配制至100mL),试验组1.2采用氨甲环酸序贯疗法。试验2均采用后交叉韧带保留型假体(posterior retaining,CR)及手术技术,其中对照组2为常规CR手术技术,试验组2.1为计算机导航辅助的CR手术技术,试验组2.2为经股内侧肌下入路微创CR手术技术。分别记录各组患者的术前术后血红细胞压积(HCT)、血红蛋白(HB)、术后引流量及输血率,计算围术期失血量。结果试验1:对照组1、试验组1.1、试验组1.2的术前术后HCT、HB、术后引流量均值分别为,HCT术前:37.3%、39.3%、39.8%;HB术前:121.2 g/L、128.4 g/L、129.6 g/L;HCT术后:28.3%、31.4%、32.0%;HB术后:90.8 g/L、100.9g/L、102.1g/L;术后引流量:205.6mL、99.5mL、62.5mL。改良"鸡尾酒"组较传统"鸡尾酒"组出血量平均下降198.6mL(GROSS方程)、153.6mL(HB-balance方程);氨甲环酸序贯疗法组较传统"鸡尾酒"组出血量平均下降203.9mL(GROSS方程)、141.9mL(HB-balance方程),以上差异均有统计学意义(P<0.05)。试验2:对照组2、试验组2.1、试验组2.2的术前术后HCT、HB、术后引流量均值分别为,HCT术前:39.8%、36.6%、39.8%;HB术前:129.8 g/L、119.3 g/L、127.5g/L;HCT术后:33.2%、30.1%、34.6%;HB术后:107.0 g/L、97.0 g/L、109.3g/L;术后引流量:58.8mL、63.5mL、48.6mL。计算机导航辅助CR手术技术组较常规CR手术技术组出血量平均上升61.6mL(GROSS方程),41.3 mL(HB-balance方程),差异无统计学意义(P>0.05);试验组2.2相比对照组2出血量平均下降159.8 mL(GROSS方程)、116.0 mL(HB-balance方程),差异有统计学意义(P<0.05)。结论改良"鸡尾酒"配方、氨甲环酸序贯治疗、经股内侧肌下入路微创手术技术,对于降低初次TKA的围术期失血量作用显著,而计算机导航辅助截骨TKA未见显著差异。

The role of continuous optimization program in damage control of perioperative blood loss during primary total knee arthroplasty

Objective To evaluate the clinical effect of continuous optimization technique on perioperative blood loss and damage control of primary unilateral knee arthroplasty. Methods A retrospective analysis was conducted on 177 unilateral primary TKA cases that met the inclusion and exclusion criteria in our joint center from Jan. 2016 to Jul. 2019. According to the use of different types of prosthesis,the test was divided into two groups,and each group was divided into three groups according to the use of different surgical techniques and perioperative management as follows.In trail 1,the posterior cruciate ligament replacement prosthesis(PS) and surgical techniques were used. The control group 1 was given traditional cocktail(epinephrine 5 mg,ropivacaine 300 mg,compound betamethasone 7 mg,morphine 10 mg,and prepared to 50 mL with normal saline). Trail group 1.1 was treated with a modified cocktail(1 g tranexamic acid,300 mg ropivacaine,7 mg compound betamethasone and 10 mg morphine,prepared to 100 mL with normal saline),while trail group 1.2 was treated with tranexamic acid sequential therapy. In trail 2,posterior cruciate ligament retained prosthesis posterior retaining(CR)] and surgical technique were used,including routine CR surgical technique in control group 2,computer navigation-assisted CR surgical technique in trail group 2.1,and minimally invasive CR surgical technique in trail group 2.2 through subfemoral medial approach. The preoperative and postoperative hematocrit(HCT),hemoglobin(HB),postoperative drainage and transfusion rate of each group were recorded,and the perioperative blood loss was calculated. Results Trail 1:the mean value of preoperative and postoperative HCT,HB of control group 1,trail group 1.1 and trail group 1.2 were as follows,HCT preoperative:37.3%,39.3%,39.8%;HB preoperative:121.2 g/L,128.4 g/L,129.6 g/L;HCT postoperative:28.3%,31.4%,32.0%;HB postoperative:90.8 g/L,100.9 g/L,102.1 g/L;postoperative drainage:205.6 mL,99.5 mL and 62.5 mL. Compared with the traditional "cocktail" group,the blood loss in the improved "cocktail" group decreased by 198.6 mL(GROSS) and 153.6 mL(HB-balance) on average.Compared with the traditional "cocktail" group,the blood loss in the tranexamic acid continuous therapy group decreased by 203.9 mL(GROSS) and 141.9 mL(HB-balance) on average,with statistically significant differences(P<0.05). Trail 2:the mean value of preoperative and postoperative HCT,HB of control group 2,trail group 2.1 and trail group 2.2 were as follows,HCT preoperative:39.8%,36.6%,39.8%;HB preoperative:129.8 g/L,119.3 g/L,127.5 g/L;HCT postoperative:33.2%,30.1%,34.6%;HB postoperative:107.0 g/L,97.0 g/L,109.3 g/L;postoperative drainage:58.8 mL,63.5 mL,48.6 mL. Compared with the conventional CR surgery group,the blood loss in the computer navigation assisted CR surgery group increased by 61.6 mL(GROSS) and 41.3 mL(HB-balance) on average(P>0.05).The average amount of bleeding in the trial group 2.2 was 159.8 mL(GROSS) and 116.0 mL(HB-balance), lower than those in the control group 2(P<0.05). Conclusion Local use of improved "cocktail" recipes,sequential administration of tranexamic acid,and minimal invasive surgery via mini-midvastus approach,exhibited excellent and significant effects on reducing perioperative blood loss in unilateral primary TKA,while no significant difference was observed in the computer-assisted TKA.