切换至 "中华医学电子期刊资源库"
高级检索
中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2020, Vol. 14 ›› Issue (04) : 486 -490. doi: 10.3877/cma.j.issn.1674-134X.2020.04.016

所属专题： 总编推荐； 文献；

综述

全膝关节置换术后镇痛应用外周神经阻滞的进展
王波1, 董补怀1,†()   
  1. 1. 710000　西安交通大学附属红会医院
  • 收稿日期:2019-02-22 出版日期:2020-08-01
  • 通信作者: 董补怀

Progress of peripheral nerve block in analgesic management after total knee arthroplasty

Bo Wang1, Buhua Dong1,†()   

  1. 1. Department of Osteonecrosis & Joint Reconstruction Surgery, HongHui Hospital, Xi’an Jiaotong University, Xi’an 710000, China
  • Received:2019-02-22 Published:2020-08-01
  • Corresponding author: Buhua Dong
  • About author:
    Corresponding author: Dong Buhuai, Email:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

王波, 董补怀. 全膝关节置换术后镇痛应用外周神经阻滞的进展[J]. 中华关节外科杂志(电子版), 2020, 14(04): 486-490.

Bo Wang, Buhua Dong. Progress of peripheral nerve block in analgesic management after total knee arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2020, 14(04): 486-490.

全膝关节置换术(TKA)是膝关节终末期骨关节炎或类风湿性关节炎的最有效治疗方法，而术后疼痛是影响功能重建的重要因素，多模式镇痛可以给TKA患者术后提供"舒适"的康复环境。其中，外周神经阻滞是多模式镇痛的重要组成，常用的外周神经阻滞方式包括股神经阻滞、闭孔神经阻滞、坐骨神经阻滞、内收肌管阻滞、关节周围局部浸润麻醉等，这些方法具有效果确切、操作相对简单、副作用较少的优势。本综述主要检索近5年关于外周神经阻滞在TKA术后镇痛管理中的应用的国内外文献，通过比较不同阻滞方式的镇痛效果、对术后功能重建的促进作用及其副作用等，试图探索患者获益最大也最安全的术后外周神经阻滞的方法最后发现，外周神经阻滞对TKA患者术后功能康复具有良好的促进作用，并且可以明显减少镇痛药物，此外，股神经阻滞是外周神经阻滞的金标准，内收肌管阻滞是理想的替代方法。

关键词: 关节成形术, 置换, 膝, 神经阻滞, 疼痛管理

Total knee arthroplasty (TKA) is the most effective treatment for end-stage osteoarthritis or rheumatoid arthritis of the knee. Postoperative pain is an important factor affecting functional reconstruction, and multimodal analgesia can provide a "comfortable" rehabilitation environment for TKA patients. Peripheral nerve block is an important component of multimodal analgesia, which includes femoral nerve block, adductor canal block, sciatic nerve block, obturator nerve block, local Infiltration anesthesia, and so on. The advantages of these methods are effect, relative simple procedure and less side effects. This review mainly retrieved literatures about the application of peripheral nerve block in the management of postoperative analgesia after TKA in recent five years, and tried to find out the most beneficial and safest method of peripheral nerve block after operation by comparing the analgesic effect, the promotion of functional reconstruction after operation and side effects of different blockade modes. This review found that the peripheral nerve block may play an increasing prominent role in the postoperative pain management of TKA patients, which can promote the postoperative functional rehabilitation and significantly reduce the occurrence of side effects of analgesics. In addition, femoral nerve block is the gold standard of peripheral nerve block, and adductor canal block is an ideal alternative method.

Key words: Arthroplasty, replacement, knee, Nerve block, Pain management
表1 外周神经阻滞在关节置换术后镇痛中的适应证及优缺点
种类 适应证 优点 缺点
FNB 膝、髋关节置换术 镇痛效果确切 股四头肌麻痹
SNB 降低阿片类药物用量 坐骨神经麻痹
ACB 膝关节置换术 缩短住院日 作用局限于膝关节
LIA 效果确切操作简便 内侧局部肿胀
[1]
Becker R. Total knee arthroplasty 2010[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(7): 851-852.
[2]
Ma LP, Qi YM, Zhao DX. Comparison of local infiltration analgesia and sciatic nerve block for pain control after total knee arthroplasty: a systematic review and meta-analysis[J/OL]. J Orthop Surg Res, 2017, 12(1): 85. doi: 10.1186/s13018-017-0586-z.
[3]
Ban WR, Zhang EA, Lv LF, et al. Effects of periarticular injection on analgesic effects and NSAID use in total knee arthroplasty and total hip arthroplasty[J]. Clinics (Sao Paulo), 2017, 72(12): 729-736.
[4]
Saraev AV, Kornilov NN, Kulyaba TA. Efficiency of the multimodal approach to analgesia in total knee arthroplasty[J]. Khirurgiia (Mosk), 2018, 11(6): 83-90.
[5]
Mcdonald LT, Corbiere NC, Delisle JA, et al. Pain management after total joint arthroplasty[J]. AORN J, 2016, 103(6): 605-616.
[6]
Velcic BS, Rakovac I, Papez Kinkela D, et al. Postoperative regional analgesia is effective in preserving perforin-expressing lymphocytes in patients after total knee replacement[J]. Med Sci Monit, 2018, 24(7): 5320-5328.
[7]
臧学慧，孙辉，高立华，等．股神经阻滞镇痛对全膝关节置换术后早期功能的影响[J/CD]．中华关节外科杂志(电子版)，2016，10(2):26-29.
[8]
Wang D, Yang Y, Li Q, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty: a meta-analysis of randomized controlled trials[J/OL]. Sci Rep, 2017, 7(4): 721. doi: 10.1038/srep40721.
[9]
Tanikawa H, Harato K, Ogawa R, et al. Local infiltration of analgesia and sciatic nerve block provide similar pain relief after total knee arthroplasty[J/OL]. J Orthop Surg Res, 2017, 12(1): 109. doi: 10.1186/s13018-017-0616-x.
[10]
Bergeron SG, Kardash KJ, Huk OL, et al. Functional outcome of femoral versus obturator nerve block after total knee arthroplasty[J]. Clin Orthop Relat Res, 2009, 467(6): 1458-1462.
[11]
Seangleulur A, Vanasbodeekul P, Prapaitrakool S, et al. The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: a systematic review and meta-analysis[J]. Eur J Anaesthesiol, 2016, 33(11): 816-831.
[12]
De Jonge T, Gorgenyi S, Szabo G, et al. Local infiltration analgesia in total joint replacement[J]. Orv Hetil, 2017, 158(9): 352-357.
[13]
Li DH, Tan Z, Kang PD, et al. Effects of multi-site infiltration analgesia on pain management and early rehabilitation compared with femoral nerve or adductor canal block for patients undergoing total knee arthroplasty: a prospective randomized controlled trial[J]. Int Orthop, 2017, 41(1): 75-83.
[14]
Terkawi AS, Mavridis D, Sessler DI, et al. Pain management modalities after total knee arthroplasty[J]. Anesthesiology, 2017, 126(5): 923-937.
[15]
Gaffney CJ, Pelt CE, Gililland JM, et al. Perioperative pain management in hip and knee arthroplasty[J]. Orthop Clin North Am, 2017, 48(4): 407-419.
[16]
Al-Zahrani T, Doais KS, Aljassir F, et al. Randomized clinical trial of continuous femoral nerve block combined with sciatic nerve block versus epidural analgesia for unilateral total knee arthroplasty[J]. J Arthroplasty, 2015, 30(1): 149-154.
[17]
Albrecht E, Morfey D, Chan V, et al. Single-injection or continuous femoral nerve block for total knee arthroplasty？[J]. Clin Orthop Relat Res, 2014, 472(5): 1384-1393.
[18]
Alijanipour P, Tan TL, Matthews CN, et al. Periarticular injection of liposomal bupivacaine offers no benefit over standard bupivacaine in total knee arthroplasty: a prospective, randomized, controlled trial[J]. J Arthroplasty, 2017, 32(2): 628-634.
[19]
Kuang MJ, Du YR, Ma JX, et al. The efficacy of liposomal bupivacaine using periarticular injection in total knee arthroplasty: a systematic review and meta-analysis[J]. J Arthroplasty, 2017, 32(4): 1395-1402.
[20]
Bagsby DT, Ireland PH, Meneghini RM. Liposomal bupivacaine versus traditional periarticular injection for pain control after total knee arthroplasty[J]. J Arthroplasty, 2014, 29(8): 1687-1690.
[21]
Albrecht E, Guyen O, Jacot-Guillarmod A, et al. The analgesic efficacy of local infiltration analgesia vs femoral nerve block after total knee arthroplasty: a systematic review and meta-analysis[J]. Br J Anaesth, 2016, 116(5): 597-609.
[22]
Saranteas T, Anagnostis G, Paraskeuopoulos T. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerveblock[J]. Reg Anesth Pain Med, 2011, 36(4):399-402.
[23]
Perret M, Fletcher P, Firth L, et al. Comparison of patient outcomes in periarticular and intraarticular local anaesthetic infiltration techniques in total knee arthroplasty[J/OL]. J Orthop Surg Res, 2015, 10(5): 119. doi: 10.1186/s13018-015-0249-x.
[24]
Fan L, Yu X, Zan PF, et al. Comparison of local infiltration analgesia with femoral nerve block for total knee arthroplasty: a prospective, randomized clinical trial[J]. J Arthroplasty, 2016, 31(6): 1361-1365.
[25]
Macrinici GI, Murphy C, Christman L, et al. Prospective, Double-Blind, randomized study to evaluate Single-Injection adductor canal nerve block versus femoral nerve block: postoperative functional outcomes after total knee arthroplasty[J]. Reg Anesth Pain Med, 2016, 42(1): 10-16.
[26]
Biswas A, Perlas A, Ghosh M, et al. Relative contributions of adductor canal block and intrathecal morphine to analgesia and functional recovery after total knee arthroplasty: a randomized controlled trial[J]. Reg Anesth Pain Med, 2018, 43(2): 154-160.
[27]
Wiesmann T, Piechowiak K, Duderstadt SA, et al. Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment: a randomised and blinded clinical trial[J]. Arch Orthop Trauma Surg, 2016, 136(3): 397-406.
[28]
Ross JA, Greenwood AC, Sasser IP. Periarticular injections in knee and hip arthroplasty: where and what to inject[J]. J Arthroplasty, 2017, 32(9): S77-S80.
[29]
Ashraf A, Raut VV, Canty SJ, et al. Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block[J]. Knee, 2013, 20(5): 324-327.
[30]
Sardana V, Burzynski JM, Scuderi GR. Adductor canal block or local infiltrate analgesia for pain control after total knee arthroplasty? A systematic review and meta-analysis of randomized controlled trials[J]. J Arthroplasty, 2019, 34(1): 183-189.
[31]
Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, et al. Anterior vs posterior periarticular multimodal drug injections: a randomized, controlled trial in simultaneous bilateral total knee arthroplasty[J]. J Arthroplasty, 2017, 32(7): 2100-2104.
[32]
Reinhardt KR, Duggal S, Umunna BP, et al. Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial[J]. Clin Orthop Relat Res, 2014, 472(5): 1400-1408.
[33]
Beausang DH, Pozek J-, Chen AF, et al. A randomized controlled trial comparing adductor canal catheter and intraarticular catheter after primary total knee arthroplasty[J]. J Arthroplasty, 2016, 31(9 Suppl): 298-301.
[34]
Zhou M, Ding H, Ke J. Adductor canal block in combination with posterior capsular infiltration on the pain control after TKA[J]. Ir J Med Sci, 2018, 187(2): 465-471.
[35]
Li J, Deng XL, Jiang T. Combined femoral and sciatic nerve block versus femoral and local infiltration anesthesia for pain control after total knee arthroplasty: a meta-analysis of randomized controlled trials[J/OL]. J Orthop Surg Res, 2016, 11(1): 158. doi: 10.1186/s13018-016-0495-6.
[36]
Hinarejos P, Capurro B, Santiveri X, et al. Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(10): 3299-3305.
[37]
Manickam B, Perlas A, Duggan E, et al. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal[J]. Reg Anesth Pain Med, 2009, 34(6): 578-580.
[38]
Benedikt B, Dracklé J, Kristof K, et al. Paths of femoral nerve catheters placed using ultrasound-guided in plane vs out of plane techniques[J/OL]. Medicine, 2018, 97(43): e12958. doi: 10.1097/MD.0000000000012958.
[39]
Büttner B, Mansur A, Kalmbach M, et al. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial[J/OL]. PLoS One, 2018, 13(7): e0199776. doi：10.1371/journal.pone.0199776.
[40]
刘睿轩，刘宁，姜脉涛，等．收肌管阻滞技术在初次全膝置换术后早期镇痛中的应用研究[J/CD]．中华关节外科杂志(电子版)，2018，12(2):192-196.
[1] 金鑫, 谢卯, 刘芸, 杨操, 杨述华, 许伟华. 个性化股骨导向器辅助初次全髋关节置换的随机对照研究[J]. 中华关节外科杂志(电子版), 2023, 17(06): 780-787.
[2] 邓华梅, 袁札根, 曾德荣, 潘珊珊, 张葆青, 欧爱华, 曹学伟. 全膝关节置换术中气压止血带应用效果与影响因素分析[J]. 中华关节外科杂志(电子版), 2023, 17(06): 788-794.
[3] 张思平, 刘伟, 马鹏程. 全膝关节置换术后下肢轻度内翻对线对疗效的影响[J]. 中华关节外科杂志(电子版), 2023, 17(06): 808-817.
[4] 李培杰, 乔永杰, 张浩强, 曾健康, 谭飞, 李嘉欢, 王静, 周胜虎. 细菌培养阴性的假体周围感染诊治的最新进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 827-833.
[5] 林文, 王雨萱, 许嘉悦, 王矜群, 王睿娜, 何董源, 樊沛. 人工关节置换登记系统的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 834-841.
[6] 闫文, 谢兴文, 顾玉彪, 雷宁波, 马成, 于文霞, 高亚雄, 张磊. 微小RNA与全膝关节置换术后深静脉血栓的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 842-846.
[7] 黄子荣, 罗渝鑫, 杨文瀚, 陈小虎, 谢环宇, 朱伟民. 前交叉韧带重建对膝关节稳定性影响的研究进展[J]. 中华关节外科杂志(电子版), 2023, 17(06): 847-854.
[8] 陈山林, 魏绮珮, 刘畅. 腕关节假体：路在何方？[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 469-475.
[9] 吴香敏, 吴鹏. 超声引导下收肌管阻滞联合腘动脉与膝关节后囊间隙阻滞在老年患者全膝关节置换术中的应用效果[J]. 中华损伤与修复杂志(电子版), 2023, 18(06): 516-522.
[10] 王敏, 蒋家斌, 李茂新. 预警宣教联合个性化疼痛管理对腹股沟疝手术患者的影响[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 764-767.
[11] 中华医学会骨科分会关节学组. 中国髋、膝关节置换日间手术围手术期管理专家共识[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 321-332.
[12] 邱红生, 林树体, 梁朝莹, 劳世高, 何荷. 模拟现实步态训练对膝关节前交叉韧带损伤的功能恢复及对跌倒恐惧的影响[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 343-350.
[13] 付庆鹏, 邓晓强, 高伟, 姜福民, 范永峰, 吴海贺, 齐岩松, 包呼日查, 徐永胜. 新型股骨测量定位器在全膝关节置换术中的临床应用[J]. 中华临床医师杂志(电子版), 2023, 17(9): 980-987.
[14] 李岩松, 李涛, 张元鸣飞, 李志鹏, 周谋望. 头戴式虚拟现实设备辅助全膝关节置换术后康复的初步研究[J]. 中华临床医师杂志(电子版), 2023, 17(06): 676-681.
[15] 戴俊, 李硕, 曹影, 汪守峰, 宋红毛, 蔡菁菁, 邵敏, 陈莉, 程雷, 怀德. 鼻内镜下改良高选择性翼管神经低温等离子消融术对中重度变应性鼻炎的效果研究[J]. 中华临床医师杂志(电子版), 2023, 17(06): 689-693.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号