全膝置换术中常规应用止血带，合理吗？
Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery
Aims: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.
Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.
Results: We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).
Conclusion: TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery.
重新考虑全膝关节置换术中常规应用止血带的合理性
译者：张蔷
目的：许多术者在全膝关节置换术中常规应用止血带。止血带是环绕下肢的束带装置，减少流向下肢的血液。应用的同时，我们需要考虑它的安全性，是否会给病人带来收益或者伤害。本篇文章的目的就是确定全膝关节置换术中应用止血带的收益或损害。
方法：我们搜索了MEDLINE、EMBASE和Cochrane数据库中截止2020年3月26日的数据。入组了所有比较全膝关节置换应用止血带和不应用止血带的随机对照试验（RCT）。评价指标包括：疼痛、功能、严重不良事件（SAEs）、失血、假体稳定性、手术时间和住院时长。
结果：我们入组了41项RCT试验共2819个病例。止血带组的SAEs明显多于非止血带组（53/901 vs 26/898, 止血带组 vs 非止血带组）（风险概率比1.73，95%置信区间1.10-2.73）。止血带组术后第一天的平均疼痛评分是非止血带组的1.25倍（95%置信区间0.32-2.19）。组间失血量并无显著性差异（平均差异8.61ml；95%置信区间-83.76-100.97）。止血带组的平均住院时长比非止血带组长0.34天（95%置信区间0.03-0.64），平均手术时间短3.7分钟（95%-5.53-1.87）。
结论：全膝关节置换应用止血带与严重不良事件增多、疼痛加重和住院时间延长相关。应用止血带的唯一优势是手术时间缩短。这一结果很难支持全膝关节置换术中常规应用止血带。
文献出处：Ahmed I, Chawla A, Underwood M, Price A, Metcalfe A, Hutchinson C, Warwick J, Seers K, Parsons H, Wall PDH. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. Bone Joint J. 2021 Mar 8:1-10. doi: 10.1302/0301-620X.103B.BJJ-2020-1926.R1. Epub ahead of print. PMID: 33683139.