Total Diz Artroplastisi Uygulanan Hastalarda Turnike Kullanımının Alt Ekstremite Venöz Sistem Üzerine Etkisi

Amaç: Total diz artroplastisi (TDA) sonrasında meydana gelen alt ekstremite venöz sistem kaynaklı patolojileri incelemek ve cerrahisi sırasında uygulanan pnömatik turnikenin venöz damarların üzerine olan etkisini değerlendirmektir. Gereç ve Yöntemler: Primer diz osteoartriti nedeni ile turnike kullanılarak TDA uygulanan 42 (Grup 1) , turnike kullanılmadan TDA uygulanan 40 (Grup 2) olmak üzere toplam 82 hasta retrospektif olarak değerlendirilip çalışmaya alındı. İki grup arasında preoperatif vena sefana magna (VSM) çapı, klinik venöz yetmezlik derecesi ve intraoperatif operasyon süresi, turnike uygulama zamanı, uygulanan turnike basıncı, ortalama sistolik kan basıncı, uygulanan anestezi yöntemi parametreleri kıyaslandı. Bulgular: İki grup arasında venöz tromboembolik hastalık (VTEH) açısından fark bulunmadı. Grup 1’de postoperatif bacak ödemi anlamlı derecede yüksekti (p=0.02). Çok değişkenli regresyon analizine göre; turnike kullanılan hasta grubunda, turnike süresi >49.5 dk [odds değeri (OD) 2.48, 95% güven aralığı (GA) 0.48–0.91], turnike basıncı (mmHg) >275 mmHg [OD 1.98, 95% GA 0.23–0.84], preoperatif VSM reflü >1 sn [OD 1.23, 95% GA 0.32–0.93], ameliyat süresi >65 dk [OD 1.13, 95% GA 0.11–0.58] bacak ödemi gelişimi açısından bağımsız risk faktörü olarak belirlendi. Sonuç: TDA gibi alt ekstremiteyi ilgilendiren ortopedik girişimlerde turnike kullanımının hastaya göre bireyselleştirilmesinin; turnike süresi, turnike basıncı ve preoperatif venöz vasküler sistemin detaylı değerlendirilmesinin, postoperatif bacak ödemi ve diğer komplikasyonlardan kaçınma açısından önem arz ettiğini düşünmekteyiz.

Tourniquet Effect on the Lower Extremity Venous System in the Patients Undergoing Total Knee Arthoplasty

Aim: The aim of the study is to investigate the pathologies related with lower extremity venous system following total knee arthroplasty (TKA) and to evaluate the effect of tourniquet usage on the venous vascular system. Materials and Methods: The study cohort comprised 82 patients who underwent TKA due to primary knee osteoarthritis and was divided into the patients performed TKA with using tourniquet (Group 1, n=42 patients) and without using tourniquet (Group 2, n=40 patients). Two groups were compared in the respect of parameters inluding preoperative great saphenous vein (GSV) diameter, clinical venous insufficieny level, operation time, tourniquet application time, tourniquet pressure, mean systolic blood pressure and performed type of anesthesia. Results: No significant difference was determined between the groups in respect of venous thromboembolic disease (VTED. Postoperative leg swelling was found to be significantly higher in the group 1 (p=0.02). Tourniquet application time >49.5 min [odds ratio (OR) 2.48, 95% confidance interval (CI) 0.48–0.91], tourniquet pressure > 275 mmHg [OR 1.98, 95% CI 0.23–0.84], preoperative GSV reflux > 1 sec [OR 1.23, 95% CI 0.32–0.93], operation time > 65 min [OR 1.13, 95% CI 0.11–0.58] were identified as independent risk factors for leg swelling following TKA Conclusion: We think that it is very important to individualize the tourniquet application in the orthopedic interventions involving lower extremity such as TKA and to evaluate tourniquet time, tourniquet pressure and preoperative venous vascular system for avoiding postoperative leg swelling and other related complications.

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1. Guanche CA, Rorabeck CH, Kennedy JC. Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction. Arthroscopy 1995;11:620-622.
2. Hagan PF, Kaufman EE. Vascular complication of knee arthroplasty under tourniquet. A case report. Clin Orthop 1990; 257:159-161.
3. Shenton DW, Spitzer SA, Mulrennan BM. Tourniquet-induced rhabdomyolysis. A case report. J Bone Joint Surg Am 1990;72:1405-1406.
4. Klenerman L. Is a tourniquet really necessary for knee replacement? J Bone Joint Surg Br 1995;77:174-175.
5. Dai WL, Lin ZM, Shi ZJ, Wang J. Venous Thromboembolic Events after Total Knee Arthroplasty: Which Patients Are at a High Risk? [published online ahead of print, 2019 May 24]. J Knee Surg. 2019;10.1055/s-0039-1688962. doi:10.1055/s-0039-1688962
6. Murphy C, Winter D, Bouchier-Hayes D. Tourniquet injuries: Pathogenesis and modalities for attenuation. Acta Orthopaedica Belgica 2005;71(6):635.
7. Deitelzweig S. Preventing venous thromboembolic events after total hip arthroplasty: New developments in clinical practice. Hosp Pract 2012;40(02):79-87.
8. O’Reilly RF, Burgess IA, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. Med J Aust 2005;182(04):154-159
9. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell Jr CW. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2, Suppl):e278S–e325S
10. Zhang ZH, Shen B, Yang J, Zhou ZK, Kang PD, Pei FX. Risk factors for venous thromboembolismof total hip arthroplasty and total knee arthroplasty: A systematic review of evidences in ten years. BMC Musculoskelet Disord 2015;16(1):24.
11. Munk S, Jensen NJ, Andersen I, Kehlet H, Hansen TB. Effect of compression therapy on knee swelling and pain after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2013;21(2):388-392.
12. Pinsornsak P, Chumchuen S. Can a modified Robert Jones bandage after knee arthroplasty reduce blood loss? A prospective randomized controlled trial. Clin Orthop Relat Res 2013;471(5):1677-1681.
13. Matthews CN, Chen AF, Daryoush T, Rothman RH, Maltenfort MG, Hozack WJ. Does an elastic compression bandage provide any benefit after primary TKA? Clin Orthop Relat Res 2019;477(1):134-144.
14. Koçyiğit A, Atilla B. Venöz tromboembolizm risk faktörlerinin değerlendirilmesi. TOTBİD Dergisi 2019;18:473-481.
15. Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA, Landon GC, Jové M. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. J Bone Joint Surg Am 2001;83(3):336- 345.
16. Nielsen PT, Jorgensen LN, Albrecht-Beste, Leffers AM, Rasmussen LS. Lower thrombosis risk with epidural blockade in kneearthroplasty. Acta Orthop Scand 1990;61(1):29-31.
17. Lieberman JR, Huo MM, Hanway J, Salvati EA, Sculco TP, Sharrock NE. The prevalence of deep venous thrombosis after total hip arthroplasty with hypotensive epidural anesthesia. J Bone Joint Surg Am 1994;76(3):341-348.
18. Modig J, Malmberg P., Karlström G. Effect of epidural versus general anesthesia on calf blood flow. Acta Anaesthesiol Scand 1980;24(4):305-309.
19. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of a tourniquet used in total knee arthroplasty: A meta- analysis. J Orthop Surg Res 2014;9(1):13.
20. Cai DF, Fan QH, Zhong HH, Peng S, Song H. The effects of tourniquet use on blood loss in primary total knee arthroplasty for patients with osteoarthritis: A meta-analysis. J Orthop Surg Res 2019;14(1):348.
21. Clarke MT, Longstaff L, Edwards D, Rushton N. Tourniquet- induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 2001;83(1):40-44.
22. Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effeect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Relat Res 2000;371:169-177.
23. Fukuda A, Hasegawa M, Kato K, Shi D, Sudo A, Uchida A. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg 2007;127(8):671- 675.
24. Crenshaw A. Surgical Techniques and Approaches. DK Canale S, Jones L, editor. St 9th ed. Louis, Mosby;1998, pp. 129-142.