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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2018, Vol. 12 ›› Issue (01) : 77 -86. doi: 10.3877/cma.j.issn.1674-134X.2018.01.014

所属专题： 文献；

荟萃研究

收肌管阻滞与股神经阻滞在全膝关节置换术后镇痛疗效的Meta分析
李灿锋1, 曾羿1, 沈彬1,†(), 裴福兴1, 杨静1, 周宗科1, 康鹏德1   
  1. 1. 610041　成都，四川大学华西医院骨科
  • 收稿日期:2016-10-16 出版日期:2018-02-01
  • 通信作者: 沈彬
  • 基金资助:
    卫生行业科研专项项目(201302007); 四川省科技厅科技支撑计划(2014SZ0023-2)

Effects of adductor canal block and femoral nerve block for postoperative analgesis after total knee arthroplasty

Canfeng Li1, Yi Zeng1, Bin Shen1,†(), Fuxing Pei1, Jing Yamg1, Zongke Zhou1, Pengde Kang1   

  1. 1. Department of orthopedics, West China Hospital of Sichuan University, Chengdu 610041, China
  • Received:2016-10-16 Published:2018-02-01
  • Corresponding author: Bin Shen
  • About author:
    Corresponding author: Shen Bin, Email:
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引用本文：

李灿锋, 曾羿, 沈彬, 裴福兴, 杨静, 周宗科, 康鹏德. 收肌管阻滞与股神经阻滞在全膝关节置换术后镇痛疗效的Meta分析[J/OL]. 中华关节外科杂志(电子版), 2018, 12(01): 77-86.

Canfeng Li, Yi Zeng, Bin Shen, Fuxing Pei, Jing Yamg, Zongke Zhou, Pengde Kang. Effects of adductor canal block and femoral nerve block for postoperative analgesis after total knee arthroplasty[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2018, 12(01): 77-86.

目的

系统评价收肌管阻滞(ACB)与股神经阻滞(FNB)在全膝关节置换(TKA)术后镇痛及早期康复中临床疗效差异，为临床提供参考。

方法

检索Cochrane图书馆、PubMed、EMbase、CNKI、维普资讯数据库及万方数据库等中英文数据库，检索截止日期为2016年8月。由两名评价员独立筛查文献、提取资料和方法学质量评估，采用Rev Man 5.2.0软件进行Meta分析，并绘制漏斗图评定有无发表偏倚。

结果

一共纳入12篇临床随机对照试验文献(9篇英文文献，3篇中文文献)，共分析772膝，其中ACB组382膝，FNB组390膝。Meta分析结果显示：ACB组与FNB组患者视觉模拟(VAS)疼痛评分分别在术后2～4 h、6～8 h、24 h及48 h的静息评分[WMD＝0.20，95%CI(－0.33，0.72)；WMD＝0.24，95%CI(－0.12，0.60)；WMD＝0.31，95%CI(－0.07，0.69)；WMD＝0.03，95%CI(－0.29，0.35)]和运动评分[WMD＝0.10，95%CI(－0.41，0.62)；WMD＝0.64，95%CI(0.15，1.12)；WMD＝0.17，95%CI(－0.37，0.70)；WMD＝0.03，95%CI(－0.57，0.62)]差异均无统计学意义；ACB组患者的肌力在术后4～8 h、24 h及48 h[WMD＝0.45，95%CI(0.25，0.64)；WMD＝0.38，95%CI(0.14，0.61)；WMD＝0.41，95%CI(0.18，0.63)]均显著优于FNB组；与FNB组比较，ACB组患者在术后24 h、48 h及72 h的膝关节活动度[WMD＝5.01，95%CI(0.78，0.92)；WMD＝8.74，95%CI(3.54，13.93)；WMD＝6.65，95%CI(1.97，11.33)]、站立行走试验所需时间[WMD＝－55.98，95%CI(－109.60，－2.35)]及术后平均住院时间[WMD＝－0.049，95%CI(－0.96，－0.03)]等方面有优势，而在术后补救性阿片类药物用量及术后恶心呕吐发生率等方面差异均无统计学意义。

结论

收肌管阻滞与股神经阻滞在TKA术后镇痛疗效相当，同时收肌管阻滞对股四头肌肌力影响更小，从而有利于患者术后早期活动及功能康复。上述结果尚需更多高质量、大样本及多中心随机对照试验来进一步验证。

关键词: 关节成形术，置换，膝, 股神经, 镇痛, 康复
Objective

To compare adductor canal block (ACB) with femoral nerve block (FNB) for postoperative analgesic effect and early rehabilitation after total knee arthroplasty (TKA).

Methods

The Cochrane Library, PudMed, EMBASE, CNKI, VIP and Wan Fang were searched to identify randomized controlled trials (RCTs) articles comparing the ACB with the FNB in TKA up to August 2016. Study selection and assessment, data collection and analysis were undertaken by two authors independently. The meta-analysis was performed using Review Manager 5.2.0, and publication bias was evaluated through a funnel plot.

Results

Twelve studies were included, involving nine English studies and three Chinese studies There was a total of 772 cases comparing ACB (n=382) with FNB (n=390). Meta-analysis suggested that the resting VAS scores[WMD=0.20, 95%CI(-0.33, 0.72); WMD=0.24, 95%CI(-0.12, 0.60); WMD=0.31, 95%CI(-0.07, 0.69); WMD=0.03, 95%CI(-0.29, 0.35)] and motion VSA scores[WMD=0.10, 95%CI(-0.41, 0.62); WMD=0.64, 95%CI(0.15, 1.12); WMD=0.17, 95%CI(-0.37, 0.70); WMD=0.03, 95%CI(-0.57, 0.62)]were similar to the ACB group and FNB group at 2-4 h, 6-8 h, 24 h and 48 h. The quadriceps strength in the ACB group was better than that in the FNB group at 4 to 8 h, 24 h and 48 h[WMD=0.45, 95%CI(0.25, 0.64); WMD=0.38, 95%CI(0.14, 0.61); WMD=0.41, 95%CI(0.18, 0.63)]. The range of motion in the ACB group was also better than that in the FNB group at 24 h, 48 h and 72 h[WMD=5.01, 95%CI(0.78, 0.92); WMD=8.74, 95%CI(3.54, 13.93); WMD=6.65, 95%CI(1.97, 11.33)]. Besides, ACB group had advantages in time-up-go test[WMD=-55.98, 95%CI(-109.60, -2.35)] and length of hospital stay[WMD=-0.049, 95%CI(-0.96, -0.03)]. There was no difference in opioid consumption and side effect of nausea and vomiting.

Conclusion

When comparing with FNB, the ACB shows similar postoperative analgesia effects and has advantages in quadriceps strength recovery and promoting early postoperative rehabilitation, but more high-quality RCTs are required for further investigation.

Key words: Arthroplasty, replacement, knee, Femoral nerve, Analgesia, Rehabilitation
表1 纳入研究的一般资料
纳入研究 TKA例数 评价年龄(岁) 性别(M/F,例) BMI(kg/cm2) ASA分级 随访时间
ACB组/FNB组 ACB组/FNB组 ACB组/FNB组 ACB组/FNB组
J? ger [25] 23/27 70±8/66±9 5/18　 14/13 26.8/21.8 不清楚 24 h
Kim [20] 46/47 68.0±9.4/67.6±11.0 22/24　18/29 29.9±6.4/30.3±5.8 Ⅰ～Ⅲ 48 h
Zhangl [21] 30/30 63.7±5.8/61.9±6.7 6/24　 8/22 25.2/24.1 Ⅰ～Ⅲ 48 h
Shah [9] 48/50 68.3±7.6/65.9±7.2 13/35　14/36 29.5±5.5/30.5±5.3 Ⅰ～Ⅲ 48 h
Machi [11] 39/41 67±8/66±7 16/23　14/27 30±5/29±5 不清楚 72 h
Grevstad [12] 25/25 65(46－85)/64(42－84) 7/18　 8/17 27.7/28.4 Ⅰ～Ⅲ 不清楚
Wiesmann [8] 21/21 72(59－75)/66(62－74) 9/12　 9/12 29(25－33)/32(27－35) Ⅰ～Ⅲ 72 h
Elkassabany[19] 31/31 63±8/65±8 9/22　 12/19 31±5/32±6 Ⅰ～Ⅲ 72 h
Memtsoudis [27] 60/58 64.4±7.4/64.4±7.4 26/33　26/33 28.4±4.4/28.4±4.4 Ⅰ～Ⅱ 48 h
谭振[24] 40/40 64.8±7.7/62.7±6.7 13/27　12/28 26.1±3/25±3 Ⅰ～Ⅲ 14 d
张云慧[28] 30/30 不清楚 不清楚 不清楚 Ⅱ～Ⅲ 48 h
刘玥[29] 10/19 61.0±9.8/63.0±7.4 2/17　 4/15 27.0±3.4/25.0±4.6 Ⅱ～Ⅲ 72 h
表2 纳入研究的质量评价
纳入研究 随机方法 分配隐藏 盲法 失访与退出 选择性报告 其他偏倚
J?ger [25] 是 是 是 是 是 是
Kim [20] 是 是 是 是 是 是
Zhangl [21] 是 不清楚 不清楚 是 是 是
Shah [9] 是 不清楚 是 是 是 是
Machi [11] 是 是 是 是 是 是
Grevstad [12] 是 不清楚 是 是 是 是
Wiesmann [8] 是 是 是 是 是 是
Elkassabany[19] 是 是 是 是 是 是
Memtsoudis [27] 是 是 是 是 是 是
谭振[24] 是 不清楚 是 是 是 是
张云慧[28] 是 不清楚 不清楚 是 是 是
刘玥[29] 是 不清楚 不清楚 是 是 是
图1 静息VAS(视觉模拟)评分森林图
图2 运动VAS(视觉模拟)评分森林图
图3 股四头肌肌力森林图
图4 术后ROM(活动范围)森林图
图5 站立行走时间
图6 术后平均住院时间森林图
图7 术后阿片类药物用量森林图
图8 术后恶心呕吐发生率森林图
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