A meta-analysis of pneumatic tourniquet used in total knee arthroplasty

doi:10.3969/j.issn.2095-4344.0155

Abstract

Abstract:

BACKGROUND: Pneumatic tourniquet can reduce the amount of bleeding during operation, but simultaneously, pneumatic tourniquet will bring perioperative adverse reactions. It is still controversial whether to use a pneumatic tourniquet during total knee arthroplasty.

OBJECTIVE: To evaluate the effect and safety of pneumatic tourniquet in total knee arthroplasty.

METHODS: We searched PUBMED, EMBASE, the Cochrane Library, CNKI, Wanfang before July 2017 for randomized controlled trials regarding the effect of pneumatic tourniquet in total knee arthroplasty. Data were extracted and analyzed by using Revman 5.3 software.

RESULTS AND CONCLUSION: Totally 18 studies were included. Meta-analysis suggested that the use of pneumatic tourniquet could reduce the total amount of blood loss in the total knee arthroplasty, shorten operation time, but could increase postoperative pain and thrombosis incidence (P < 0.05). There was no statistically significant difference in HSS score and range of motion of the knee at 7 days after operation (P > 0.05). These results confirm that the use of a pneumatic tourniquet in total knee arthroplasty can reduce the total blood loss, shorten the operation time, but have no effect on knee function 7 days after total knee arthroplasty, but will increase postoperative pain and thrombosis incidence.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tissue Engineering, Knee Joint, Pulmonary Embolism

CLC Number:

R318

Gu Pei-lun, Dong Jin-bo, Wang Wei-shan, Chen Lei, Yu Hong-tao, Li Yue-jun, Gao Peng, Wang Kai . A meta-analysis of pneumatic tourniquet used in total knee arthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2018, 22(15): 2446-2452.

Figures/Tables 3

2.1 文献检索结果初步检索共获得617篇文献，去除重复文献124篇，将剩余的493篇文献阅读题目及摘要，去除不相关文献，初筛出86篇随机对照试验，通过阅读全文，共22篇文献被纳入，其中2篇文献由于质量评价高偏倚风险被排除，2篇文献因无法获得原始数据被排除，最终纳入文献18篇[1-18]，共1 234例患者，其中止血带组为623例，非止血带组为611例(图3)。所有文献均有纳入及排出标准，所有纳入文献均可查及人口学特征。9篇研究报道了随机分组具体情况[3，5，7，13-14，16-18]，7篇文献报道了分配隐藏情况[2，4，9，11-13，16]，3篇文献具体说明盲法实施情况[5，12-13]。 2.2 纳入文献人口学特征共有18篇文献被纳入[1-18]，共有1 234例患者被纳入分析，止血带组为623例，非止血带组为611例，每篇文献的患者例数从10例到84例不等。所有研究地点均有描述，9项研究地点在中国(大陆8项及台湾1 项)[3，5，9-10，13-14，16-18]，2项研究在英国[1，6]，其他研究各所在地为：伊朗、丹麦、法国、瑞典、日本及意大利[2，4，7-8，11-12，15]。有16项研究报道了止血带压力[1-13，16-18]，为240-300 mm Hg (1 mm Hg=0.133 kPa)。所有研究均报道了麻醉方式，3项研究为全身麻醉[9，13-14]，其他均为脊髓麻醉及神经阻滞麻醉。10项研究报道了引流管使用情况，其中8项常规放置引流20-48 h，2项研究未放置引流装置[6，18]。1项研究为双膝关节置换，为自身对照，仅仅纳入观察指标为：手术时间，膝关节活动度及HSS评分，失血量及目测类比评分不被纳入分析。 2.3 Meta分析结果 2.3.1 总出血量总出血量为术中及术后出血量之和。共有12项研究报道了总出血量的均值和标准差[1-12]。12项研究中存在异质性(P < 0.000 1，I²=75%)，故分析采用随机效应模型，使用WMD值进行效应量合并分析，得出结果表明失血量差异有显著性意义(WMD=-80.60，95%CI：-140.02至-21.19) (图4)。 2.3.2 手术时间共有11篇研究[2-7，10-11，13-15]，736例病例被纳入分析，均报道了手术时间均值及标准差。各项研究结果存在异质性(P=0.000 7，I²=67%)，采用随机效应模型分析，应用WMD值进行效应量合并分析，结果表明：两组病例中结果差异存在显著性意义(WMD=-2.17，95%CI：-4.12-0.22)(图5)。 2.3.3 HSS评分膝关节HSS评分为：美国特种外科医院对膝关节评分系统，有4项研究报道术后7 d患肢膝关节HSS评分[1，11，13，16]，各项研究结果存在异质性(P=0.04，I²=63%)，采用随机效应模型分析，应用WMD值进行效应量合并分析，结果表明两组患者膝关节HSS评分差异无显著性意义(WMD=-2.71，95%CI：-5.77-0.34)(图6)。 2.3.4 膝关节活动度膝关节活动度正常范围为-5°-135°。有7项研究阐述了术后7 d膝关节活动范围[1，5，10，11，13，17，18]，各项研究结果存在异质性(P=0.001，I²=78%)，采用随机效应模型分析，应用WMD值进行效应量合并分析，结果表明两组患者中术后7 d患肢膝关节活动度无显著性意义(WMD=-3.56，95%CI：-8.16-1.04)(图7)。 "

References

[1] Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study. J Bone Joint Surg Br. 1995;77(2):250-253.

[2] Yavarikia A, Amjad GG, Davoudpour K. The influence of tourniquet use and timing of its release on blood loss in total knee arthroplasty. Pak J Biol Sci. 2010;13(5):249-252.

[3] Tetro AM, Rudan JF. The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg. 2001;44(1):33.

[4] Vandenbussche E, Duranthon LD, Couturier M, et al. The effect of tourniquet use in total knee arthroplasty. Int Orthop. 2002;26(5):306-309 .

[5] Håkan L, Per A, Lars G. Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion. Acta Orthop. 2012;83(5):499.

[6] Mori N, Kimura S, Onodera T, et al. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: a prospective, randomized study. Knee. 2016;23(5):887.

[7] Aglietti P, Baldini A, Vena LM, et al. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res. 2000;(371): 169.

[8] Tai TW, Chang CW, Lai KA, et al. Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2012;94(24):2209-2215.

[9] Zhang FJ, Xiao Y, Liu YB, et al. Clinical effects of applying a tourniquet in total knee arthroplasty on blood loss. Chin Med J (Engl). 2010;123(21): 3030-3033.

[10] Li B, Wen Y, Wu H, et al. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop. 2009;33(5):1263-1268.

[11] 王刚,曹晓瑞,陈晓勇,等.膝关节置换中止血带的使用对术后加速康复的影响[J].中华骨与关节外科杂志,2017,10(1):27-32.

[12] 张阳,钱齐荣,吴海山,等.止血带对全膝关节置换术后深静脉血栓形成的影响[J].中华骨科杂志,2009,29(10):910-914.

[13] Zhang Q, Dong J, Gong K, et al. Effects of tourniquet use on perioperative outcome in total knee arthroplasty. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2016;30(4):421.

[14] Kumar N, Yadav C, Singh S, et al. Evaluation of pain in bilateral total knee replacement with and without tourniquet: a prospective randomized control trial. J Clin Orthop Trauma. 2015;6(2):85.

[15] Ejaz A, Laursen AC, Kappel A, et al. Faster recovery without the use of a tourniquet in total knee arthroplasty. Acta Orthop. 2014;85(4):422-426 .

[16] 沈忠伟,童培建,邵营钢,等.止血带对全膝关节置换术后肿胀及功能影响的临床研究[J].浙江临床医学,2010,12(3):261-262.

[17] 鲍航行,王金法,蔡运火,等.全膝关节置换术后止血带性缺血再灌注损伤的临床研究[J].中华创伤骨科杂志,2011,13(3):242-246 .

[18] 杨健齐,魏鲁青,张健平,等.全膝关节置换中止血带应用对假体骨水泥厚度影响的对照研究[J].重庆医学,2017,46(6):782-785 .

[19] 潘凡武,毕树雄.气压止血带在四肢骨科手术中应用研究进展[J].国际骨科学杂志,2011,32(1):33-36 .

[20] Huda R, Solanki D R, Mathru M. Inflammatory and redox responses to ischaemia/reperfusion in human skeletal muscle. Clin Sci. 2004;107(5): 497-503.

[21] Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee. 2009;17(2): 141-147.

[22] Thorey F, Stukenborgcolsman C, Windhagen H, et al. The effect of tourniquet release timing on perioperative blood loss in simultaneous bilateral TKA. 2010.

[23] Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty?Correct blood loss management should take hidden loss into account. Knee.2005;7(3):151-155.

[24] Chen S, Li J P, Peng H, et al. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop. 2014;38(2):355-359 .

[25] Johnson DP. Infection after knee arthroplasty. Clinical studies of skin hypoxia and wound healing. Acta Orthop Scand Suppl. 2009;252(1):1-48 .

[26] 周媛.人工全膝关节置换术后感染相关危险因素分析[D].乌鲁木齐:新疆医科大学,2014.

[27] Shimizu M, Kubota R, Nasu M, et al. The influence of tourniquet during total knee arthroplasty on perioperative blood loss and postoperative complications. Masui. 2016;65(2):131-135 .

[28] Katsumata S, Nagashima M, Kato K, et al. Changes in coagulation-fibrinolysis marker and neutrophil elastase following the use of tourniquet during total knee arthroplasty and the influence of neutrophil elastase on thromboembolism. Acta Anaesthesiol Scand. 2005;49(4): 510-516.

[29] Kato N, Nakanishi K, Yoshino S, et al. Abnormal echogenic findings detected by transesophageal echocardiography and cardiorespiratory impairment during total knee arthroplasty with tourniquet. Anesthesiology. 2002;97(97):1123-1128.