切换至 "中华医学电子期刊资源库"

中华关节外科杂志(电子版) ›› 2020, Vol. 14 ›› Issue (05) : 540 -545. doi: 10.3877/cma.j.issn.1674-134X.2020.05.004

所属专题: 文献

临床论著

加速康复外科在全膝关节置换术中的随机对照研究
董佩龙1, 唐晓波1, 王健1, 李志云1, 谢淑君1,()   
  1. 1. 224700 盐城,南通大学附属建湖医院
  • 收稿日期:2020-02-05 出版日期:2020-10-01
  • 通信作者: 谢淑君
  • 基金资助:
    2018年度江苏省第五期"333工程"科研项目资助计划(BRA2018250); 盐城市医学科技发展计划资助项目(YK2017080)

Clinical study of enhanced recovery after surgery in total knee arthroplasty

Peilong Dong1, Xiaobo Tang1, Jian Wang1, Zhiyun Li1, Shujun Xie1,()   

  1. 1. Department of Orthopedics, Affiliated Jianhu Hospital of Nantong University, Yancheng 224700, China
  • Received:2020-02-05 Published:2020-10-01
  • Corresponding author: Shujun Xie
  • About author:
    Corresponding author: Xie Shujun, Email:
引用本文:

董佩龙, 唐晓波, 王健, 李志云, 谢淑君. 加速康复外科在全膝关节置换术中的随机对照研究[J/OL]. 中华关节外科杂志(电子版), 2020, 14(05): 540-545.

Peilong Dong, Xiaobo Tang, Jian Wang, Zhiyun Li, Shujun Xie. Clinical study of enhanced recovery after surgery in total knee arthroplasty[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2020, 14(05): 540-545.

目的

通过临床随机对照研究,探讨加速康复外科(ERAS)在初次单侧人工全膝关节置换术中的应用效果。

方法

2016年1月至2018年1月,将南通大学附属建湖医院骨科88例拟定行人工全膝关节置换术患者纳入研究。纳入符合膝关节骨关节炎诊断标准,初次行全膝关节置换的患者;排除不符合诊断及纳入标准者。经随机余数法分组,其中44例采用ERAS围手术期方案(实验组),44例采用传统围手术期方案(对照组)。对其进行临床评价,包括术后24 h血红蛋白及输血比例、住院时间(LOS)、术后并发症、术后24 h、1个月、6个月、12个月疼痛视觉模拟(VAS)评分、膝关节纽约特种外科医院(HSS)评分及膝关节活动度(ROM)。两组LOS、血红蛋白比较采用成组设计资料t检验,组内手术前后血红蛋白比较采用配对设计资料t检验,VAS评分、HSS评分、膝关节ROM的比较采用重复测量资料的方差分析,计数资料采用卡方检验或Fisher确切概率法。

结果

实验组术后24 h血红蛋白明显高于对照组,实验组输血比例、术后并发症发生率明显低于对照组,实验组LOS明显短于对照组。两组VAS评分、HSS评分、膝关节ROM的重复测量方差分析差异有统计学意义(VAS评分F=9.87,P<0.001;HSS评分F=10.98,P<0.001;ROM F=9.94,P<0.001),均为实验组优于对照组。分组上,术后24 h、1个月实验组和对照组的VAS评分的差异有统计学意义(t=7.1392、3.9855,均为P<0.05),术后24 h、1个月及6个月实验组和对照组的HSS评分和膝关节ROM的差异有统计学意义(HSS评分t=6.6350、5.7948、3.5763,均为P<0.05;ROM t=7.8032、3.9390、4.7654,均为P<0.05),术后6个月及12个月实验组和对照组的VAS评分的差异不具有统计学意义(t=0.5688、0.5180,均为P>0.05),术后12个月实验组和对照组的HSS评分和膝关节ROM的差异不具有统计学意义(HSS评分t=0.7687,P>0.05;ROM t=0.9523,P>0.05)。时间上,实验组和对照组从手术前到术后12个月VAS评分呈降低趋势,实验组和对照组从手术前到术后12个月HSS评分和膝关节ROM呈升高趋势。

结论

ERAS理念干预下,患者初次单侧人工全膝关节置换术后失血少、住院时间短、并发症发生率低、术后短期疼痛轻,康复快,利于膝关节功能的早期恢复。

Objective

To investigate the effect of enhanced recovery after surgery (ERAS) in primary unilateral total knee arthroplasty (TKA).

Methods

From January 2016 to January 2018, 88 patients who underwent primary unilateral TKA from the orthopedic department of affiliated Jianhu Hospital of Nantong University were divided into two groups by random number method: ERAS group(experimental group, n=44)and routine group (control group, n=44). Inclusion criteria: the patients meet the diagnostic criteria for knee arthritis, and undergoing total knee replacement for the first time. Those who did not meet the diagnosis and inclusion criteria were excluded. Follow-up assessment included postoperative hemoglobin at 24 h after operation, blood transfusion ratio, length of stay (LOS), postoperative complications, visual analogue scale(VAS), the Hospital for Special Surgery (HSS) score and knee range of motion (ROM) at 24 h, one month, six months and 12 months after the operation. Group design data t test was used to compare LOS and hemoglobin between the two groups. Paired design data t test was used to compare hemoglobin before and after operation in the two groups. Analysis of variance of repeated measurement data was used to compare VAS score, HSS score and ROM of knee joint. Chi-square test or Fisher exact probability method was used for counting data.

Results

The postoperative hemoglobin after 24 h in the experimental group was significantly higher than that in the control group. The blood transfusion ratio and the incidence of complications in the experimental group were significantly lower than those in the control group. The LOS in the experimental group was significantly shorter than that in the control group. The total difference of VAS score, HSS score, knee ROM between the two groups were statistically significant(VAS score F=9.87, HSS score F=10.98, ROM F=9.94, all P<0.001) which showed that the experimental group were better than the control group. In terms of grouping, the difference of VAS score between the experimental group and the control group was statistically significant at 24 h, and one month postoperatively(t=7.1392, 3.9855, both P<0.05). The difference of HSS score and ROM of knee joint between the experimental group and the control group was statistically significant at 24h, one month, and six months postoperatively(HSS score t=6.6350, 5.7948, 3.5763, all P<0.05; ROM t=7.8032, 3.9390, 4.7654, all P<0.05). The difference of VAS score between the experimental group and the control group was not statistically significant at six and 12 months postoperatively(t=0.5688, 0.5180, both P>0.05). The HSS score and ROM of knee joint between the experimental group and the control group was not statistically significant at 12 months postoperatively(HSS t=0.7687, ROM t=0.9523, both P>0.05). In terms of time, the VAS score of the experimental group and the control group decreased from pre-operation to 12 months after operation, and the HSS score and ROM of the knee joint of the experimental group and the control group increased from pre-operation to 12 months after operation.

Conclusion

The application of ERAS in primary unilateral TKA can reduce blood loss and the incidence of complications, shorten hospital stay, cause less short-term pain after operation, and achieve faster recovery, which is beneficial to the early recovery of knee joint function.

表1 两组患者术前临床资料比较
表2 两组患者手术后24 h血红蛋白、输血比例和住院时间比较
表3 两组患者手术前后VAS评分、HSS评分和ROM比较(±s)
表4 两组术后并发症比较(例)
[1]
董佩龙,唐晓波,王健,等.富血小板血浆凝胶在人工全膝关节置换手术中的应用研究[J].中华外科杂志,2014,52(11):851-855.
[2]
Stowers MD, Manuopangai L, Hill AG, et al. Enhanced recovery after surgery in elective hip and knee arthroplasty reduces length of hospital stay[J]. ANZ J Surg, 2016, 86(6): 475-479.
[3]
中国加速康复外科专家组.中国加速康复外科围手术期管理专家共识(2016)[J].中华外科杂志,2016,54(6):413-418.
[4]
Senavongse W, Farahmand F, Jones J, et al. Quantitative measurement of patellofemoral joint stability: force-displacement behavior of the human patella in vitro[J]. J Orthop Res, 2003, 21(5): 780-786.
[5]
赵栋,马信龙,王文良,等.加速康复外科与传统治疗在单侧全膝关节置换术中的应用效果[J].中华医学杂志,2018,98(7):519-523.
[6]
Jorgensen CC, Kehlet H, Lundbeck Foundation Centre Fast-Track Hip and Knee Replacement Collaborative Group. Outcomes in smokers and alcohol users after fast-track hip and knee arthroplasty[J]. Acta Anaesthesiol Scand, 2013, 57(5): 631-638.
[7]
涂晓晴,宁宁,陈忠兰,等.快速康复流程模式下全膝关节置换术后延迟出院原因分析[J].华西医学,2016,31(4):739-742.
[8]
苏曼曼,周阳,曾必云,等.加速康复外科理念在全膝关节置换患者疼痛管理中的应用[J].华西医学,2017,32(9):1328-1332.
[9]
Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery[J]. Langenbecks Arch Surg, 2011, 396(5): 585-590.
[10]
Stambough JB, Nunley RM, Curry MC, et al. Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions[J]. J Arthroplasty, 2015, 30(4): 521-526.
[11]
谢小伟,岳辰,康鹏德,等.加速康复模式下初次全膝关节置换术后急性疼痛的相关因素分析[J].中华骨与关节外科杂志,2016,9(6):489-492.
[12]
雷一霆,黄强,曹国瑞,等.促红细胞生成素联合应用铁剂和氨甲环酸对减少全膝关节置换术围术期失血效果的研究[J].中国骨与关节杂志,2017,6(12):894-898.
[13]
Myles P, Bellomo R, Corcoran T, et al. Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF): rationale and design for a multicentre randomised trial [J/OL]. BMJ Open, 2017, 7(3): e015358. doi:10.1136/bmjopen-2016-015358.
[14]
Pang O, Liu H, Chen B, et al. Restrictive and Liberal fluid administration in major abdominal surgery[J]. Saudi Med I, 2017, 38(21): 123-131.
[15]
张少云,黄强,曹国瑞,等.加速康复外科模式下全膝关节置换术后围术期限制性输液的临床研究[J].中国矫形外科杂志,2017,25(17):1567-1571.
[16]
赵健,江志伟.加速康复外科与围术期营养管理[J].中华医学信息导报,2017,32(21):18.
[17]
Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery[J]. Eur Spine J, 2013, 22(9): 2089-2096.
[18]
Bruhn J, Gj S, Van Geffen GJ. Clinical application of perioperative multimodal analgesia[J]. Curr Opin Support Palliat Care, 2017, 11(2): 106-111.
[19]
Dong P, Tang X, Cheng R, et al. Comparison of the efficacy of different analgesia treatments for total knee arthroplasty: a network Meta-Analysis[J]. Clin J Pain, 2018, 34(11): 1047-1060.
[20]
Buvanendran A, Kroin JS, Tuman KJ, et al. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial[J]. JAMA, 2003, 290(18): 2411-2418.
[1] 陈晓玲, 钟永洌, 刘巧梨, 李娜, 张志奇, 廖威明, 黄桂武. 超高龄髋膝关节术后谵妄及心血管并发症风险预测[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 575-584.
[2] 马桥桥, 张传开, 郭开今, 蒋涛, 王子豪, 刘勇, 郝亮. 可降解止血粉减少初次全膝关节置换术失血量的研究[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 585-589.
[3] 刘鹏, 罗天, 许珂媛, 邓红美, 李瑄, 唐翠萍. 八段锦对膝关节炎疗效的初步步态分析[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 590-595.
[4] 李焕玺, 何淳诺, 田志敏, 周胜虎, 吴昊越, 张浩强. 全膝关节置换术后股骨远端假体周围骨折治疗现状[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 630-637.
[5] 王相迎, 杨长生, 曲铁兵. 固定平台单髁置换假体合适位置的研究进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 638-645.
[6] 苏介茂, 齐岩松, 王永祥, 魏宝刚, 马秉贤, 张鹏飞, 魏兴华, 徐永胜. 关节镜手术在早中期膝骨关节炎治疗的应用进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 646-652.
[7] 谢佳乐, 李琦, 芦升升, 姜劲松. 内侧膝骨关节炎伴胫股关节冠状半脱位的手术治疗[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 653-657.
[8] 郭艳波, 马亮, 李刚, 阎伟, 骆帝, 岳亮, 吴伟山. 全膝关节置换术后胫股关节脱位的研究进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 658-671.
[9] 陈翠萍, 李佩君, 杜景榕, 谢青梅, 许一宁, 卓姝妤, 李晓芳. 互联网联合上门护理在老年全髋关节置换术后的应用效果[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 676-681.
[10] 王振宇, 张洪美, 荆琳, 何名江, 闫奇. 膝骨关节炎相关炎症因子与血浆代谢物间的因果关系及中介效应[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(06): 467-473.
[11] 宋庆成, 郑占乐, 王天瑞, 王宇钏, 张凯旋, 纳静, 蔚佳昊, 杨思繁, 宋九宏, 张英泽. “人老膝不老”:膝关节健康管理的全方位探索与实践[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 321-324.
[12] 郑占乐, 王宇钏, 蔚佳昊, 宋庆成, 张凯旋, 纳静, 王天瑞, 宋九宏, 张英泽, 王娟. 保膝须“开膝”——“开膝”在膝骨关节炎中的临床应用价值[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 325-330.
[13] 茹江英, 廖启宇, 温国洪, 潘思华, 刘栋, 张皓琛, 牛云飞. 直接前方入路和后外侧入路半髋关节置换治疗老年痴呆股骨颈骨折的疗效比较[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(05): 287-293.
[14] 高广涵, 张耀南, 石磊, 王林, 王飞, 郑子天, 王鸿禹, 郭民政, 薛庆云. 膝骨关节炎患者前交叉韧带功能影像学影响因素分析[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(05): 301-307.
[15] 王松雷, 张贻良, 孟浩, 宋威, 白林晨, 袁心, 张辉. 股骨前髁预截骨髓外定位技术在全膝关节置换术中的应用[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 811-819.
阅读次数
全文


摘要