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中华肩肘外科电子杂志 ›› 2023, Vol. 11 ›› Issue (01) : 63 -70. doi: 10.3877/cma.j.issn.2095-5790.2023.01.010

论著

氨甲环酸对肩关节镜手术疗效的Meta分析
吴宇顺1, 刘诗滦1, 卓鸿武1, 肖靖1, 潘玲1, 李坚1,()   
  1. 1. 350003 福州,福建中医药大学附属第二人民医院运动医学科
  • 收稿日期:2022-09-05 出版日期:2023-02-05
  • 通信作者: 李坚
  • 基金资助:
    福建省卫健委科技计划项目(2021CXA039)

Efficacy and safety of tranexamic acid for shoulder arthroscopic surgery: a Meta-analysis

Yushun Wu1, Shiluan Liu1, Hongwu Zhuo1, Jing Xiao1, Ling Pan1, Jian Li1,()   

  1. 1. Department of Sports Medicine, the Second People's Hospital Affiliated with the Fujian University of Traditional Chinese Medicine, Fuzhou 350003, China
  • Received:2022-09-05 Published:2023-02-05
  • Corresponding author: Jian Li
引用本文:

吴宇顺, 刘诗滦, 卓鸿武, 肖靖, 潘玲, 李坚. 氨甲环酸对肩关节镜手术疗效的Meta分析[J/OL]. 中华肩肘外科电子杂志, 2023, 11(01): 63-70.

Yushun Wu, Shiluan Liu, Hongwu Zhuo, Jing Xiao, Ling Pan, Jian Li. Efficacy and safety of tranexamic acid for shoulder arthroscopic surgery: a Meta-analysis[J/OL]. Chinese Journal of Shoulder and Elbow(Electronic Edition), 2023, 11(01): 63-70.

目的

对文献进行Meta分析,以探讨氨甲环酸(tranexamic acid,TXA)对肩关节镜手术的疗效。

方法

检索PubMed、Embase、Medline、Cochrane、Web of Science、中国知网、万方数据库,检索时限至2022年11月1日,包括随机对照试验、前瞻性研究、队列性研究,同时通过溯源检索补充相关文献,使用RevMan5.4统计软件进行Meta分析。

结果

纳入8项研究,共600例患者,其中接受TXA治疗的患者为300例、对照组300例。Meta分析结果显示:与对照组相比较,TXA组患者术中视野清晰度更佳(SMD = 0.38,95% CI:0.20,0.57,P<0.0001),手术时间更短(SMD=-9.83,95%CI:-12.89,-6.78,P<0.00001),灌注液体量更少(SMD=-2.10,95%CI:-3.41,-0.79,P=0.002),差异有统计学意义。而视觉模拟评分(SMD=-0.55,95%CI:-1.21,0.12,P=0.11)、肩关节周径(SMD=2.58,95%CI:-2.63,7.80,P=0.33)的比较,差异均无统计学意义。荟萃分析结果表明,在肩关节镜手术中使用TXA不会增加栓塞事件(深静脉血栓、肺栓塞)的发生率(RD = 0,95% CI:-0.02,0.02,P = 1)。

结论

在肩关节镜手术中使用TXA可以提高视觉清晰度,减少手术灌注液体量,缩短手术时间,没有栓塞事件的风险。但需要更多大样本的前瞻性随机对照研究来提高结果的论证强度。

Background

Perioperative hemorrhage during shoulder arthroscopy can lead to an unclear intraoperative field of view, prolonged operation time, associated postoperative shoulder swelling, bruising, and pain, and may increase the risk of infection. Therefore, minimizing perioperative bleeding during shoulder arthroscopy is crucial for reducing complications and speeding up postoperative recovery. Studies have reported that surgical trauma leads to increased fibrinolytic response, which accounts for 60% of the total perioperative blood loss in orthopedic surgery. In shoulder arthroscopic surgery bleeding in shoulder arthroscopic surgery can be reduced to a certain extent through delicate operation, anesthesia-controlled blood pressure reduction, and epinephrine perfusion. However, infiltration and bleeding of bones, muscles, and tissues are inevitable, so more surgeons further consider maintaining a balance between coagulation and fibrinolysis to reduce perioperative bleeding during shoulder arthroscopy. Tranexamic acid (TXA) is the most commonly used antifibrinolytic drug, which reversibly blocks the plasminogen's binding site, thereby preventing plasmin activation and reducing the degradation of plasmin to improve fibrin Clot stability. Many studies have shown that TXA can effectively minimize perioperative blood loss and blood transfusion rate in orthopedic surgery and does not increase the incidence of embolic events. In addition, studies have reported that TXA can regulate the immune system by blocking granules, thereby exerting anti-inflammatory effects. Therefore, in recent years, the clinical application of TXA in shoulder arthroscopic surgery has gradually increased. Liu et al. first reported the application of TXA in shoulder arthroscopic surgery. They found that intravenous injection of TXA can improve the clarity of field of view in shoulder arthroscopic surgery and reduce early postoperative pain and the number of analgesics without apparent side effects. Currently, there is a lack of clear consensus on using TXA in shoulder arthroscopic surgery. Objective A Meta-analysis of the literature was conducted to investigate the efficacy and safety of TXA for arthroscopic shoulder surgery.

Methods

We searched PubMed, Embase, Medline, Cochrane, Web of Science, CNKI, and WanFang databases until Nov 1, 2022, including randomized controlled trials and cohort studies, and supplemented relevant literature through traceability search. Meta-analysis was performed using RevMan5.4 statistical software.

Results

Six studies were included in this meta-analysis, involving 437 patients, of which 218 were treated with TXA. Meta-analysis showed that patients in the TXA group had better visual clarity in arthroscopic shoulder surgery compared with the control group (SMD=0.38, 95%CI: 0.20, 0.57, P<0.00001), with a statistically significant. There was no statistically significant difference in the comparison of VAS score (SMD=-0.55, 95%CI: -1.21, 0.12, P=0.11), operative time (SMD=-9.83, 95%CI: -12.89, -6.78, P<0.01), irrigation amount used in operation (SMD=-2.10, 95%CI: -3.41, 0.79, P=0.002), and shoulder circumference (SMD=2.58, 95%CI: -2.63, 7.80, P=0.33). In the incidence of the embolic events (deep vein thrombosis, pulmonary embolism), there was no difference between groups between the TXA and control groups (RD=0, 95% CI: -0.02, 0.02, P=1.00) .

Conclusion

TXA is safe and effective in arthroscopic shoulder surgery, significantly improves intraoperative visual clarity, and does not increase the incidence of embolic events.

图1 检索流程图
表1 纳入研究的基本特征
图2 随机对照试验的偏倚风险
表2 纳入研究的方案
研究 干预措施 给药途径 观察指标 栓塞事件
TXA组 对照组
Liu等[10] 术前10 min,1 000 mg TXA(20 ml生理盐水) 等量生理盐水静脉注射 静脉注射 视野清晰度、手术时间、VAS疼痛评分、肩关节周径
Ersin等[11] 麻醉诱导后,10 mg/kg TXA(100 ml生理盐水) 等量不含TXA的的生理盐水 静脉注射 视野清晰度、手术时间、灌注液体量 未提及
Bayram等[12] 浓度为0.42 g/L的TXA生理盐水灌注液 浓度为0.33 mg/L的EPN生理盐水灌注液 灌注液 视野清晰度、手术时间、灌注液体量、平均动脉压
Gao等[13] 术后50 mg/ml的TXA(生理盐水各10 ml) 术后,生理盐水各10 ml 关节腔及肩峰下注射 血红蛋白值、肩关节周径、皮下瘀血瘀斑
Takahashi等[14] 术前10 min,1 000 mg TXA(20 ml生理盐水) 术前10 min,20 ml生理盐水 静脉注射 视野清晰度、VAS疼痛评分、肩关节周径、围手术期失血量、手术时间 未提及
Mackenzie等[15] 麻醉诱导前,2 g TXA溶液(20 ml生理盐水) 麻醉诱导前,20 ml生理盐水 静脉注射 VAS疼痛评分、Constant评分、ASES评分、活动范围
Nicholson等[16] 浓度为83.33 mg/L的TXA生理盐水灌注液 不含TXA的生理盐水灌注液 静脉注射 视野清晰度、灌注泵压、压力升高次数、手术时间、灌注液体量 未提及
Bildik等[17] 浓度为83.3 mg/L的TXA生理盐水灌注液 生理盐水灌注液 灌注液 视野清晰度、VAS疼痛评分、手术时间
图3 TXA组与对照组视野清晰度的比较注:TXA为氨甲环酸
图4 TXA组与对照组VAS评分的比较注:TXA为氨甲环酸;VAS为视觉模拟评分
图5 TXA组与对照组手术时间的比较注:TXA为氨甲环酸
图6 TXA组与对照组灌注液体量的比较注:TXA为氨甲环酸
图7 TXA组与对照组肩关节周径的比较注:TXA为氨甲环酸
图8 TXA组与对照组栓塞事件发生率的比较注:TXA为氨甲环酸
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