止血带是肢体手术常用的工具，能满足术野清晰，最大限度减少创面出血，利于精细操作，缩短手术时间。然而使用中引起的并发症也时有报道，膝关节置换术中使用止血带与否以及如何使用仍然存在较大争论。在线发表于《Eur J Orthop Surg Traumatol》杂志的一篇研究显示，全膝关节置换术中减少使用止血带时间可能并不会加快愈合，。

由于近年来骨关节炎的发病率不断增涨并且严重影响人的生活质量，因此世界卫生组织（WHO）将其认定为需要优先治疗的疾病。由于医院的经费有限，不得不限定置换的数量及尽量减少病人的住院时间。目前有人认为增加止血带的使用时间会导致疼痛和活动减少而使得康复时间延迟。因此本研究旨在明确止血带使用时间对全膝置换术后快速康复是否影响。

研究人员选择了从2015年7月到2017年10月在皇家自由医院行全膝关节置换术的123名患者。所有的患者均按照快速康复外科临床路径的标准化要求完成手术操作，使用相同的假体，采用相同的止痛药和功能锻炼方法。比较止血带使用时长与术后住院时间和24小时内总的阿片类止痛药的用量之间的关系。

图 止血带使用时间对全膝置换术后快速康复的影响

结果显示，总的止血带使用时间的中位数是74分钟。与以往相比，同期内使用时长从108分钟减少到现在的60分钟(p=0.000)。病人的住院时间的中位数是5天，与以往比较没有降低(p=0.667)。增加止血带的使用时长不会延长住院时间，实际上反而会减少住院时间(p=0.03199)。延长止血带使用时长与增加使用阿片类止痛药无关(p=0.78591)。也没有发现增加止血带使用时长会增加如深静脉血栓和感染等并发症的发生率。

作者认为目前没有证据显示在全膝关节置换手术中减少使用止血带时间会加快愈合，如减少住院时间或减少阿片类药物的使用量，并希望这个研究可以充实国家关节登记系统（NJR）的患者疗效报告数据(PROMs)。

原始文献

Much ado aboutnothing:

the effect of tourniquet time on an accelerated rehabilitationprogramme following total knee replacement (TKR)

BACKGROUND:

TheWHO includes osteoarthritis as a disease of priority, owing to its significantimpact on quality of life, and globally increasing prevalence. Hospital budgetsare under pressure to ration knee replacements and shorten inpatient stays.Prolonged tourniquet application has been hypothesised to extend recoverythrough pain and reduced mobility.

PATIENTS ANDMETHODS:

A total of 123 elective total knee replacements meeting inclusioncriteria took place from July 2015 to October 2017 at the Royal Free Hospital.Cases were standardised by method of TKR, implant, physiotherapy and analgesicregime according to the trust Enhanced Recovery after Surgery pathway.Tourniquet time was compared to length-of-stay post-operatively and total opioidanalgesia requirement over 24 h.

RESULTS:

Mediantourniquet time overall was 74 min and was decreased year-on-year from 108 to60 min (p = 0.000). Inpatient median length-of-stay was 5 days and did notdecrease (p = 0.667). Increased tourniquet time was not associated with longerlength-of-stay but in fact shorter (p = 0.03199), likely due to thisconfounding temporal trend. Increased tourniquet time was not associated withincreased opioid requirement (p = 0.78591). No association was found betweentourniquet time and other complications including DVT and infection.

CONCLUSIONS:

Ourstudy finds no evidence that reductions in tourniquet time in TKR improverecovery including length-of-stay or opioid requirement. This clinical data isexpected to augment PROMs collected by the National Joint Registry.

文献出处：

WynellMayow W, Saeed MZ. Much ado about nothing: the effect oftourniquet time on an accelerated rehabilitation programme following total kneereplacement (TKR). Eur J Orthop Surg Traumatol. 2018 Mar 14.