中国组织工程研究 ›› 2019, Vol. 23 ›› Issue (36): 5753-5759.doi: 10.3969/j.issn.2095-4344.1962

• 人工假体 artificial prosthesis • 上一篇    下一篇

后交叉韧带替代型骨水泥假体单侧膝关节置换:静脉注射与关节腔氨甲环酸并用可减少失血量及炎症反应

吴兴源1,张国如1,刘  傥2,周才盛1
  

  1. 1海南省第三人民医院骨关节外科,海南省三亚市  572000;2中南大学湘雅二医院关节外科,湖南省长沙市  410000
  • 出版日期:2019-12-28 发布日期:2019-12-28
  • 通讯作者: 张国如,硕士,主任医师,海南省第三人民医院骨关节外科,海南省三亚市 572000
  • 作者简介:吴兴源,男,1983年生,广东省广州市人,主治医师,主要从事骨科、关节外科、运动医学研究。

Intravenous and intraarticular tranexamic acid can reduce blood loss and inflammatory response during cemented posterior cruciate ligament-retaining unilateral total knee arthroplasty

Wu Xingyuan1, Zhang Guoru1, Liu Tang2, Zhou Caisheng1
  

  1. 1Department of Bone and Joint Surgery, the Third People’s Hospital of Hainan Province, Sanya 572000, Hainan Province, China; 2Department of Joint Surgery, the Second Xiangya Hospital of Central South University, Changsha 410000, Hunan Province, China
  • Online:2019-12-28 Published:2019-12-28
  • Contact: Zhang Guoru, Master, Chief physician, Department of Bone and Joint Surgery, the Third People’s Hospital of Hainan Province, Sanya 572000, Hainan Province, China
  • About author:Wu Xingyuan, Attending physician, Department of Bone and Joint Surgery, the Third People’s Hospital of Hainan Province, Sanya 572000, Hainan Province, China

摘要:

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文题释义:
膝关节置换围术期血液管理:该手术需要广泛松解软组织、截除关节面以及暴露髓腔,术后抗凝治疗、关节功能锻炼,往往伴随着大量失血,导致患者出现贫血。如果贫血状态得不到纠正会严重影响患者的预后,如增加感染风险、延缓术后康复、增加致残率和死亡率以及延长住院时间。因此在人工膝关节置换围手术期,做好血液管理显得尤为重要。
止血带:止血带的使用可以提供干燥清洁的手术区域,有助于改善术野、减少术中出血和缩短手术时间,但是止血带也可引起神经麻痹、肌肉萎缩、股四头肌无力等并发症,甚至止血带释放后局部纤溶系统的激活增加了术后出血量,如何减少全膝关节置换围手术期出血量和异体输血量是临床一直努力的方向。
 
摘要
背景:目前已有大量文献证实,全膝关节置换术中应用氨甲环酸可有效减少围术期出血,但哪种氨甲环酸使用方式最具优势尚无统一观点,而且给予氨甲环酸后血液中相关炎症因子的变化情况相关研究较少。
目的:探讨全膝关节置换术中不同氨甲环酸给药方法对围术期失血量及炎症反应的影响。
方法:选择2016年6月至2018年6月因膝关节骨性关节炎行初次单侧全膝关节置换的患者90例,利用信封抽签法随机分3组,每组30例,均进行后交叉韧带替代型骨水泥膝关节假体置换手术,A组术中静脉输注氨甲环酸止血,B组术中关节腔注射氨甲环酸止血,C组术中静脉输注与关节腔联合应用氨甲环酸止血。计算围术期患者总失血量及隐性失血量,并记录输血患者数和输血量;术前及术后1,3,7 d,检测纤维蛋白原水平、凝血酶原时间及活化部分凝血活酶时间;术前及术后1,3,7 d,测定炎性因子C-反应蛋白、白细胞介素6水平;术后1周检查是否有深静脉血栓形成,随访6个月观察下肢深静脉血栓及肺栓塞发生情况。研究方案经海南省第三人民医院伦理委员会批准。
结果与结论:①A、B组围术期总失血量高于C组(P < 0.05);3组隐性失血量及输血率比较差异无显著性意义(P > 0.05);②术前及术后1,3,7 d,3组间纤维蛋白原水平、凝血酶原时间及活化部分凝血活酶时间比较差异均无显著性意义(P > 0.05);③术后1,3 d,各组C-反应蛋白及白细胞介素6水平均高于术前(P < 0.05),3组间两指标比较差异无显著性意义(P > 0.05);术后7 d,各组C-反应蛋白及白细胞介素6水平基本下降至术前水平,3组间两指标比较差异无显著性意义(P > 0.05);④术后1周双下肢血管超声显示3组均无深静脉血栓形成;随访6个月,3组均未出现下肢深静脉血栓及肺栓塞病例;⑤结果表明与单独静脉注射及关节腔应用相比,二者联合应用氨甲环酸能明显降低全膝关节置换围术期的总出血量,并且不增加深静脉血栓形成的风险。不同氨甲环酸使用方式对炎症反应无明显影响。


ORCID: 0000-0001-5429-2481(吴兴源)

关键词: 全膝关节置换术, 氨甲环酸, 关节腔内注射, 静脉注射, 出血量, C-反应蛋白, 白细胞介素6, 深静脉血栓

Abstract:

BACKGROUND: A large number of literatures have confirmed that the use of tranexamic acid in total knee arthroplasty can effectively reduce perioperative bleeding, but there is no consensus on which tranexamic acid is most used. Little is reported on the changes of related inflammatory factors in blood after tranexamic acid is given.
OBJECTIVE: To investigate the effects of different tranexamic acid administration methods on perioperative blood loss and inflammatory response in total knee arthroplasty.
METHODS: Ninety patients who underwent unilateral total knee arthroplasty due to knee osteoarthritis from June 2016 to June 2018 were included in this study. They were randomly divided into three groups, 30 in each group using the envelope lottery method. All of them received cemented posterior cruciate ligament-retaining unilateral total knee arthroplasty. In group A, patients were treated by intravenous infusion of tranexamic acid. In group B, intraarticular injection of tranexamic acid was performed. In group C, both intravenous and intraarticular administration of tranexamic acid was used. Perioperative total blood loss and occult blood loss were calculated, and the number of patients receiving blood transfusion and the volume of blood transfused were recorded. Fibrinogen level, prothrombin time, activated partial thromboplastin time, and the levels of inflammatory factors C-reactive protein and interleukin-6 were measured before and 1, 3 and 7 days after surgery. Deep vein thrombosis was examined at 1 week after surgery. All patients were followed up for 6 months to determine the occurrence of deep vein thrombosis and pulmonary embolism. This study was approved by the Medical Ethics Committee of the Third People’s Hospital of Hainan Province, China.  
RESULTS AND CONCLUSION: (1) Total perioperative blood loss in groups A and B was significantly higher than that in group C (P < 0.05). There were no significant differences in occult blood loss and blood transfusion rate among the three groups (P > 0.05). (2) There were no significant differences in fibrinogen level, prothrombin time and activated partial thromboplastin time among three groups before surgery and at 1, 3 and 7 days after surgery (P > 0.05). (3) In each group, C-reactive protein and interleukin-6 levels at 1 and 3 days after surgery were significantly higher than those before surgery (P < 0.05), and there were no significant differences in C-reactive protein and interleukin-6 levels among three groups (P > 0.05). (4) At 7 days after surgery, the levels of C-reactive protein and interleukin-6 in each group decreased to the levels before surgery, and there were no significant differences among three groups (P > 0.05). Vascular ultrasound examination of the both lower limbs showed no deep vein thrombosis at 1 week after surgery. After 6 months of follow-up, there were no cases of deep venous thrombosis and pulmonary embolism in the lower limbs. (5) The results suggest that compared with simple intravenous or intraarticular administration of tranexamic acid, combined intravenous and intraarticular administration of tranexamic acid can greatly reduce total perioperative blood loss and does not increase the risk of developing deep vein thrombosis after total knee arthroplasty. Different administration methods of tranexamic acid have no obvious effects on inflammatory response.

Key words: total knee arthroplasty, tranexamic acid, intraarticular injection, intravenous injection, amount of blood loss, C-reactive protein, interleukin-6, deep vein thrombosis

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