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인공슬관절전치환술시압박대의압력에따른대퇴부동통과실혈량에대한영향 서울의료원정형외과, 1 수정형외과 서재성ㆍ민학진ㆍ윤의성ㆍ김진수ㆍ조기현ㆍ김용훈 1 ㆍ박철희 The Effects of Tourniquet Pressure on the Postoperative Thigh Pain and Blood Loss in Total Knee Arthroplasty Jae Seong Seo, M.D., Hak Jin Min, M.D., Ui Seoung Yoon, M.D., Jin Soo Kim, M.D., Ki Hyun Jo, M.D., Yong Hoon Kim, M.D. 1 and Cheol Hee Baak, M.D. Department of Orthopedic Surgery, Seoul Medical Center, 1 Su Orthopedic Clinic, Seoul, Korea Purpose: We wanted to analyze the effects of tourniquet pressure on the postoperative thigh pain and blood loss of patients who undergo total knee arthroplasty. Materials and Methods: This prospective randomized study focused on one-hundred sixty-one unilateral total knee arthroplasties that were done with using a tourniquet. The tourniquet pressures were 300 mmhg in group I (seventy-four cases) and 100 mmhg higher than the systolic blood pressure in group II (eighty-seven cases). We analyzed the postoperative thigh pain with using a visual analog scale (VAS), and we assessed the hemoglobin levels and the hematocrits. Results: The incidence of postoperative thigh pain in group II was statistically lower than that of group I. The intensity of the postoperative thigh pain of group II was lower than that of group I at both 6 hours and 72 hours after surgery. There were no statistical differences in blood loss between the two groups. Conclusion: Using a tourniquet pressure of 100 mmhg above the systolic blood pressure during total knee arthroplasty can reduce the postoperative thigh pain. When comparing the above technique with a TKA using 300 mmhg of tourniquet pressure, there was no statistically significant difference of the postoperative blood loss. Key Words: Knee, Thigh pain, Blood loss, Total knee arthroplasty, Pneumatic tourniquet 서 인공슬관절전치환술시에압박대의사용은출혈이없는깨끗한수술시야의확보로해부학적접근을용이하게 론 통신저자 : 민학진 135-740, 서울시강남구삼성동 171-1 서울의료원정형외과 TEL: 02-3430-0675, FAX: 02-539-1262 E-mail: spinemin@dreamwiz.com 하고수술시간을단축시키는장점이있어널리사용되고있다 1,7,9). 그러나높은압박대의압력과장시간의사용은여러가지합병증을발생시킬수있어압박대의사용은논란의대상이되고있다 1,7,8,10,20). 압박대의사용으로야기될수있는부작용및합병증을최소화하려는임상및실험실연구들이진행되어왔고 2,4,15,20,22), 이는주로압박대의압력및사용시간의변화에따른부작용및합병증발생과의연관관계비교를통하여이루어졌다. 117

118 문헌에따르면현재인공슬관절전치환술시에압박대의압력은 300 350 mmhg 3,11,15) 로사용되고있다. 이에저자들은 300 mmhg 의압력으로압박대를사용한군과수축기혈압보다 100 mmhg 높은압력을사용한군에서수술후대퇴부동통및출혈량의차이를전향적으로연구해보고자하였다. Table 1. Clinical Features of the Two Groups (Mean± SD*) Parameter 대상및방법 2003 년 7월부터 2005 년 2월까지본원에서인공슬관절전치환술을시행받은 161 예를무작위표본추출하여전향적방법으로연구를시행하였다. 남자 9명, 여자 152 명으로모두일측성으로시행되었으며우측 90예, 좌측 71예였다. 술전진단은 157 예에서골관절염, 4예에서류마티스관절염이었다. 과거력상출혈성질환이나감염, 말초혈관질환을앓았던환자는제외하였다. 압박대의압력을 300 mmhg 로사용한군 (I군) 은 74예였으며, 수축기혈압보다 100 mmhg 높은압력으로사용한군 (II군 ) 은 87예였다. I군의평균나이는 66.9 세 (50 82 세 ), 남자 2예, 여자 72예였고, 제II군의평균나이는 66.5 세 (50 77 세 ), 남자 7예, 여자 80예였다 (Table 1). 모든환자에게척추마취하에수술을시행하였으며, 인공관절치환물로는 Maxim R (Biomet Inc., Warsaw, Indiana, USA) 을전예에서사용하였다. 수술측의대퇴부에 Group I Group II (n=74) (n=87) p-value Sex (Male:Female) 2:72 7:80 0.45 Age (Year) 66.9±7.3 66.5±7.4 0.40 Preoperative 12.2±1.7 13.2±1.4 0.38 hemoglobin (g/dl) Preoperative 36.9±4.8 40.0±4.3 0.26 hematocrit (%) Tourniquet time 40.6±5.8 40.7±15.3 0.36 (minute) Hemovac drainage 640±88 655±92 0.16 (cc) *SD: Standard deviation, Group I: tourniquet pressure= 300 mmhg, Group II: tourniquet pressure=systolic blood pressure+100 mmhg 솜을이용하여 padding 을한후압박대 (Zimmer A.T.S R 2000, Dover, Ohio, USA) 를감았다. I군의압박대의압력은 300 mmhg, II군에서는수술장에서절개직전의수축기혈압을기준으로수축기혈압보다 100 mmhg 높은압력을사용하였다. 수술수기는전예에서내측슬개접근법 (median parapatella approach) 으로한명의시술자에의해시행되었으며시멘트를사용하여인공삽입물을고정하였다. 창상봉합을하기전미리압박대를풀어현저한출혈혈관의지혈을시행하였고배액관을삽입후창상봉합을하였다. 술후통증조절은정맥주사에 Fentanyl주 (Fentanyl citrate) 를이용한 PCA (patient contolled analgesia) 로하였고술후 48시간동안시행하였다. 술후 48시간째수술부위소독시배액관을제거하였으며, CPM (Cnotinuous passive motion) 및체중부하를시행하였다. 술후통증은술후 2시간, 6시간, 12시간, 24시간, 48 시간, 72시간에서발생빈도 (%) 와통증의강도를 VAS (visual analogue scale) 을이용하여평가하였다. 실혈량은술후 2일과 7일혈색소수치와적혈구용적률을비교하였다. 자료의통계처리는 SPSS (SPSS for window Release 11.0) 를사용하였으며비모수, Mann-Whitney 방법으로검증하였다. 결과두군모두에서출혈이없는깨끗한수술시야의확보가가능하였으며, 수술도중특별한문제점은발생하지않았다. 압박대의사용시간은압박대의압력을 300 mmhg 설정한 I군에서는 40.6±5.8 분이었고, 수축기혈압보다 100 mmhg 높게압박대의압력을설정한 II군에서는평균 220 mmhg (200 240 mmhg) 압력으로 40.7±7.3 분으로두군간의통계적차이는없었다 (p>0.05)(table 1). 두군에서의압박대사용시간과동통의발생빈도및동통의강도는통계적으로연관성이없었다 (p>0.05). 대퇴부동통의발생빈도는술후 12시간까지두군간의차이는보이지않았고술후 24 시간부터 77.4% (I군 ), 50.1% (II 군 ) 차이를보이기시작하였으나통계적의의는없었으며 (p>0.05), 술후 72시간에 58.1% (I군), 38.1% (II군) 로통계적으로의미있는차이를보였다 (p<0.05) (Fig. 1). 통증의강도는술후 6시간에서 VAS 2.7 (I군), 1.9 (II

서재성외 : 압박대의압력에따른대퇴부동통과실혈량에대한영향 119 군 ) 으로통계적으로차이가있었으며 (p<0.05), 술후 72 시간에서도 1.5 (I군), 0.8 (II군) 로나타나두군간에차이가있는것으로나타났다 (p<0.05)(table 2, Fig. 2). Fig. 1. The incidence of postoperative thigh pain of Group II was statistically lower than that of Group I. 술후 48시간까지헤모백배액량은 I군 640±88 cc, II 군 655±92 cc로헤모백으로배액된출혈량의차이는통계적으로유의하지않았다 (p>0.05). I군과 II군의술전혈색소수치는각각 12.3±1.7 g/dl, 12.2±1.4 g/dl였으며, 적혈구용적률은 36.9±4.8%, 38.2±4.3% 였다. 술후혈색소수치의변화는 I군이술후 2일째 9.7±1.5 g/dl, 7일째 9.6±1.3 g/dl였고, II군이술후 2일째 9.5±1.3 g/dl, 7일째 9.6±1.2 g/dl였다. 술후 2일째혈색소수치가 8.0 g/dl 이하인경우가두군에서각각 6예, 3예가있었으며이들에대하여는수혈을시행하였고통계에서제외하였다. 적혈구용적률의변화는 I군이술후 2일째 29.4±4.1%, 7일째 29.3±4.4% 였고, II군은술후 2일째 28.7±3.9%, 7일째 29.2±4.2% 였다. 두군간의술후혈색소수치및적혈구용적률은통계적으로의미있는차이가없었다 (p>0.05)(table 3). 고찰 인공슬관절전치환술에서압박대의사용으로압박대의대퇴부에대한직접적인압박과그로인한허혈에의해대퇴부구획증후군 18), 신경마비 8), 술후대퇴사두근의위 Table 2. The Intensity of Tourniquet Pain after Total Knee Arthroplasty 2 6 12 24 48 72 hour hour hour hour hour hour Fig. 2. The intensity of postoperative thigh pain of Group II was lower than that of Group I at 6 hours & 72 hours after Total knee arthroplasty. Group I* 0.8 2.7 2.5 2.2 1.8 1.5 Group II 0.5 1.9 2.4 1.7 1.5 0.8 p-value 0.15 0.04 0.34 0.11 0.27 0.02 *Group I: tourniquet pressure=300 mmhg, Group II: tourniquet pressure=systolic blood pressure+100 mmhg Table 3. The Change of Hemoglobin and Hematocrit after Total Knee Arthroplsty Preop.* POD 2th POD 7th Preop. POD 2nd POD 7th Hg (g/dl) Hg (g/dl) Hg (g/dl) Hct (%) Hct (%) Hct (%) Group I 12.3±1.7 9.7±1.5 9.6±1.3 36.9±4.8 29.4±4.1 29.3±4.4 Group II 12.2±1.4 9.5±1.3 9.6±1.2 38.2±4.3 28.7±3.9 29.2±4.2 P-value 0.38 0.34 0.38 0.26 0.34 0.29 *Preop: preoperative, Hg: Hemoglobin, POD: Post operation day, Hct: Hematocrit, Group I: tourniquet pressure=300 mmhg, Group II: tourniquet pressure=systolic blood pressure+100 mmhg

120 축 7,8,10,17), 근육의기능적및미세적인변화 14) 등의부작용을초래한다. 이러한부작용은수술후강직, 이상감각, 동통등의발생과관련이있으며여러임상및실험실연구에서압박대의압력과압박시간에비례하여신경및근육에손상이발생하는것으로보고되었다 4,7,9,19,21). Gersoff 등 9) 은압박대의과다한압력은신경손상및근육손상을일으키지만특히압박대아래의근육을손상시킴으로서기능저하및동통을발생시킨다고하였다. Tountas 와 Bergman 21) 은이러한근육손상은신경손상이 2주후거의회복되는것에반해 2주후에도완전한회복이되지않는다고하였다. Bruner 4) 는압박대의사용시간이 60분에가까워질수록압박대에의한합병증발생이증가하고 20 30 분간사용했을경우에는합병증의발생을볼수없다고하였으며 Sherman 등 19) 은 40 60 분을초과할때합병증발생이발생할수있는고위험군이라하였다. 본연구에서는압박대사용시간이 40.6±5.8 분 (I군 ), 40.7±7.3 분 (II 군 ) 으로대퇴부동통이외에합병증은발생하지않았으며, 통증의발생빈도및통증의강도와의통계적인연관성이없는것으로확인되었다. 술후출혈에대한압박대의영향에관하여서는 Burkart 등 5) 과 Page 등 16) 은압박대의조기감압후의세밀한지혈이술후출혈량을감소시킨다고보고하였으나 Brian 등 4) 은수술중압박대를조기감압하여지혈을한군과하지않은군간의비교연구에서술후출혈량, 수혈횟수에차이가없다고하여조기감압및지혈의효과는논쟁의대상이되고있다. 본연구에서는모든수술에서조기감압후출혈혈관의지혈을통하여실혈량측정에영향을미칠수있는요건을최대한배제시켰다. Ishii 와 Matzuda 12) 는무시멘트인공슬관절전치환술에서압박대의압력이 350 mmhg 인군과수축기혈압보다 100 mmhg 높은군간의술후출혈량의비교연구에서두군에차이가없었다고보고하였다. Cho 등 6) 도인공슬관절전치환술시압박대의사용은수술중출혈량을줄여수술시야를확보할수있으나압박대를사용하지않은군과의연구에서수술시간, 헤모백배액량, 수혈량및입원기간에는차이가없었다고하였다. 본연구에서도 300 mmhg 인군과수축기혈압보다 100 mmhg 높은군간에술후수술시간, 헤모백배액량, 혈색소수치, 적혈구용적률에차이가없는것으로나타났다. 압박대에의한술후대퇴부통증및출혈등의합병증 을최소화하기위해통상적인 300 350 mmhg 대신적절한압박대의압력을찾기위한여러연구가있었다. Worland 등 22) 은수축기혈압보다 100 mmhg 높은압력으로실험하였고 Barwell 등 2) 은수축기혈압의두배의압력으로, Jarolem 등 13) 은족부맥박이멈추는압력보다 50 mmhg 높은압력등으로연구하였다. 이들은실험에서적용한압박대의압력이대조군 (350 mmhg) 에비하여수술중지혈효과에통계학적으로유의한차이가없었다고보고하였다. Worland 등 22) 은인공슬관절전치환술을양측슬관절에동시에시행한환자에서양측의압박대압력을달리하여동통의정도를비교한연구에서수술직후의대퇴부동통은압박대의압력과밀접한관계가있으며수축기혈압보다 100 mmhg 높은압력 ( 평균 230 mmhg ( 범위, 212 260 mmhg)) 을사용함으로써수술후압박대로인한동통을감소시키고출혈없는수술시야를확보할수있었으며, 동통의감소는회복을촉진시키며환자의만족도를높여재활치료를앞당길수있고재원일수를단축시킬수있다고하였다. 또한특별한혈관질환이없는대퇴부둘레가 46 76 cm인환자의경우깨끗한수술시야확보및동통감소, 빠른회복등을위하여수축기혈압보다 100 mmhg 높은압력의압박대의사용을제안하였다. 본연구에서저자들은수축기혈압보다 100 mmhg 높은압력으로압박대를사용한경우에수술시야및수술시간, 술후출혈량등에는차이가없으나술후 6시간과 72 시간에서통계적으로의의있게대퇴부동통의강도가작았음을알수있었다. 결론슬관절전치환술시 300 mmhg 보다낮은압박대압력 ( 수축기혈압+100 mmhg) 을사용함으로써실혈량의차이없이술후압박대에의한대퇴부동통을경감시키는결과를얻을수있었으며, 인공슬관절전치환술시압박대사용에서의압박대의압력을정하는기준으로사용해볼수있을것으로생각한다. REFERENCES 1. Arciero RA, Scoville CR, Hayada RA, Snyder RJ:

서재성외 : 압박대의압력에따른대퇴부동통과실혈량에대한영향 121 The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study. Am J Sports Med, 24: 758-764, 1996. 2. Barwell J, Anderson G, Hassan A, Rawlings I: The effects of early tourniquet releasing during total knee arthroplasty: a prospective randomized double-blind study. J Bone Joint Surg Br, 79: 265-268, 1997. 3. Bould M, Freeman BJ, Pullyblank A, Newman JH: Blood loss in sequential bilateral total knee arthroplasty. J Athroplasty, 13: 77-79, 1998. 4. Bruner JM: Safety factors in the use of the pneumatic tourniquet for hemostasis in surgery of the hand. J Bone Joint Surg Am, 33: 221-224, 1951. 5. Burkart BC, Bourne RB, Roro-beck CH, Kirk PG, Nott J: The efficacy of tourniquet release in blood conservation after total knee arthroplasty. Clin Orthop Relat Res, 299: 147-152, 1994. 6. Cho SH, Ha YC, Chun CW: The role of tourniquet in total knee arthroplasty. J Korean Knee Soc, 16: 33-37, 2004. 7. Daniel DM, Lumkong G, Stone ML, Pedowitz RA: Effects of tourniquet use in anterior cruciate ligament reconstruction. Arthroscopy, 11: 307-311, 1995. 8. Dobner JJ, Nitz AJ: Postmenisectomy tourniquet palsy and functional sequelae. Am J Sports Med, 10: 211-214, 1982. 9. Gersoff WK, Ruwe P, Jokl P, Panjabi M: The effects of tourniquet pressure on muscle function. AM J Sports Med, 17: 123-127, 1989. 10. Graf B, Jensen K, Orwin J, Duck H, Hagen P, Keene J: The effect of tourniquet use on postoperative strength recovery after arthroscopic menisectomy. Orthopedics, 19: 497-500, 1996. 11. Hiippala ST, Strid LJ, Wennerstrand MI, et al: Tranexamic acid radically decreases blood loss and transfusions associated with total knee arthroplasty. Anesth Analg, 84: 839-844, 1997. 12. Ishii Y, Matzuda Y: Effect of tourniquet pressure on peripoerative blood loss associated with cementlness total knee arthroplasty: a prospective, randomized study. J Arthroplasty, 20: 325-330, 2005. 13. Jarolem KL, Scott DF, Jaffe WL, Stein KS, Jaffe FF, Atik T: A Comparison of blood loss and transfusion requirements in total knee arthroplasty with and without arterial tourniquet. Am J Orthop, 24: 906-909, 1995. 14. Lotke PA, Echer ML, Alavic A, Berkowitz H: Indications for the treatment of deep venous thrombosis following total knee replacement. J Bone Joint Surg Am, 66: 202-208, 1984. 15. Mylod AG Jr, France MP, Muser DE, Parsons JR: Perioperative blood loss associated with total knee arthroplasty. A comparison of procedures performed with and without cementing. J Bone Joint Surg Am, 72: 1010-1012, 1990. 16. Page MH, Shepherd BD, Harrison JM: Reduction of blood loss in knee arthroplasty. Aust N Z J Surg, 54: 141-144, 1984. 17. Saunders KC, Louis DL, Weingarden SI, Waylonis GW: Effect of tourniquet time on postoperative quadriceps function. Clin Orthop Relat Res, 143: 194-199, 1979. 18. Seybold EA, Busconi BD: Anterior thigh compartment syndrome following prolonged tourniquet application and lateral positioning. Am J Orthop, 25: 493-496, 1996. 19. Sherman OH, Fox JM, Snyder SJ, et al: Arthroscopy-"no-problem surgery." An analysis of complications in two thousand six hundred and forty cases. J Bone Joint Surg Am, 68: 256-265, 1986. 20. Silver R, de la Garza J, Rang M, Koreska J: Limb swelling after release of a tourniquet. Clin Orthop Relat Res, 206: 86-89, 1986. 21. Tountas CP, Bergman RA: Tourniquet ischemia: ultrastructural and histochemical observations of ischemic human muscle and of monkey muscle and nerve. J Hand Surg Am, 2: 31-37, 1977. 22. Worland RL, Arrendondo J, Angeles F, Lopez- Jimenez F, Jessup DE: Thigh pain folowing tourniquet application in simultaneous bilateral total knee replacement arthroplasty. J Arthroplasty, 12: 848-852, 1997.

122 = 국문초록 = 목적 : 인공슬관절전치환술에서압박대의압력에따른수술후대퇴부동통및실혈량의변화를비교해보고자하였다. 대상및방법 : 2003 년 7 월부터 2005 년 2 월까지본원에서인공슬관절전치환술을시행한 161 명의환자를대상으로전향적연구를시행하였다. 압박대의압력을 300 mmhg 로사용한군 (I 군 ) 과수축기혈압보다 100 mmhg 높은압력을사용한군 (II 군 ) 으로나누어술후의대퇴부동통의발생빈도, 동통의강도및실혈량을측정하여비교분석하였다. 결과 : 술후대퇴부통증의빈도는술후 12 시간째 I 군 (72.5%), II 군 (70.7%), 24 시간째 I 군 (77.4%), II 군 (50.1%), 72 시간째 I 군 (58.1%), II 군 (34.7%) 으로 II 군에서통계적으로유의하게낮게측정되었으며, 통증의강도도술후 6 시간 (p=0.04) 과 72 시간 (p=0.02) 에서 II 군에서통계적으로유의하게낮게나타났다. I 군과 II 군에서수술후실혈량에는통계적으로유의한차이가없었다. 결론 : 인공슬관절전치환술시수축기혈압보다 100 mmhg 높은압력의압박대를사용함으로써술후지혈대에의한대퇴부동통을감소시킬수있었으며, 300 mmhg 의압력을사용하였을때와비교시술후실혈량에영향을미치지않았음을확인하였다. 색인단어 : 슬관절, 대퇴부동통, 실혈량, 인공슬관절전치환술, 압박대