两种镇痛方法对全膝关节置换术后康复的影响

doi:10.3877/cma.j.issn.1674-134X.2021.02.008

目的

对比初次单侧全膝关节置换术(TKA)中两种不同镇痛方式的效果。

方法

回顾性分析因膝骨关节炎接受单侧TKA采用股三角阻滞(FTB)联合腘动脉与膝关节后囊之间注射局麻药(IPACK)阻滞镇痛40例，为FTB联合IPACK组，以随机数字表法选取同期同病因接受单侧TKA治疗采用鸡尾酒式镇痛混合剂局部注射40例，为常规组。所有患者术后48 h内均接受吗啡自控镇痛(PCA)。主要观察指标：术后膝关节静息和活动疼痛视觉模拟评分(VAS评分)以及患肢肌力；次要观察指标：麻醉药物用量、吗啡的总消耗量、活动度以及并发症(如恶心、呕吐)等。统计方法采用重复测量资料的方差分析、Student-t检验以及卡方检验或Fisher确切概率法分析。

结果

两组患者在人口统计、术前疼痛评分和基本生命体征等方面无统计学差异。与常规组相比，FTB联合IPACK组术后各时间点股四头肌肌力均较高，差异具有统计学意义(F＝186.10、37.47、56.65、53.16、39.14、56.04，均为P<0.05)。活动痛在术后2、6、12、24、48和72 h的6次观察中，FTB联合IPACK组比常规组的效果明显要好(F＝28.33、12.55、24.89、93.35、59.20、45.10，均为P<0.05)。静息痛仅在2、6、12、48和72 h小于常规组(F＝44.07、16.50、7.08、5.39、5.14，均为P<0.05)。吗啡消耗量、住院时间和麻醉药物用量明显低于常规组(P<0.05)。术后伤口愈合、感染发生率、皮疹、呼吸抑制、尿潴留和恶心呕吐(PONV)等，两组间差异均没有统计学意义(均为P>0.05)。

结论

FTB联合IPACK有助于增加患者股四头肌肌力、减轻术后早期疼痛和减少术后麻醉药物用量，促进患者早期康复。

关键词: 关节成形术, 膝, 镇痛, 康复

Objective

To study the efficacy of two different types of analgesic methods after unilateral primary total knee arthroplasty (TKA) to find an effective analgesic.

Methods

The present study retrospectively reviewed the medical records of 40 patients who were diagnosed as knee osteoarthritis and underwent unilateral primary TKA with the combining femoral triangle block (FTB) and the interspace between the popliteal artery and the capsule of the posterior knee (IPACK) as the combining FTB and IPACK group. A total of 40 patients with the same diagnosis underwent TKA with intra-articular cocktail analgesic mixture? injection at the same time as the conventional group. All the patients received the PCA pump for analgesia at postoperative 48 h. The main indexes were postoperative knee joint resting and activity pain (VAS), and muscle strength of the affected limb; secondary indexes were anesthetic consumption, total morphine consumption, range of motion, and complications (such as nausea and vomitting). The statistical methods included repeated measurement data analysis of variance, Student-t test, chi-square test or Fisher exact probability method analysis.

Results

There was no difference in the general data of each treatment group. Compared with the conventional group, the quadriceps muscle strength of the combining FTB and IPACK group was higher with statistical differences at post operation (F=186.10, 37.47, 56.65, 53.16, 39.14, 56.04 respectively, all P<0.05). At two, six, 12, 24, 48, and 72 h post operative, the active pain, in the six times observations after surgery, was better than that of the conventional group (F=28.33, 12.55, 24.89, 93.35, 59.20, 45.10, all P<0.05). Resting pain was smaller than the conventional group at postoperative two, six, 12, 48 and 72 h (F=44.07, 16.50, 7.08, 5.39, 5.14, all P<0.05). Morphine consumption, anesthetics consumption, and hospitalization time were lower than the conventional group, the difference being statistically significant (P<0.05). There were no differences between the two groups in postoperative wound healing, infection incidence, rash, respiratory depression, DVT, and urinary retention, and there were also no differences in PONV (all P>0.05).

Conclusion

Combining FTB and IPACK significantly increased the quadriceps muscle strength of patients, together, relieving early pain and reducing the amount of anesthetic consumption at postoperative different intervals.

Key words: Arthroplasty, Knee, Analgesia, Rehabilitation

表1 患者一般资料比较

分组	例数	年龄[岁，(±s)]	性别(男/女)	BMI[kg/m²，(±s)]	心率[次/min，(±s)]	手术时间[min，(±s)]
FTB联合IPACK组	40	67.8±7.5	15/25	25.4±2.4	70.7±4.7	98.6±10.2
常规组	40	70.8±6.7	18/22	24.3±2.9	70.8±4.7	97.8±10.5
t值		-1.89	0.46	1.92	-0.07	0.35
P值		0.06	0.50	0.058	0.94	0.73

表1 患者一般资料比较

分组	例数	年龄[岁，(±s)]	性别(男/女)	BMI[kg/m²，(±s)]	心率[次/min，(±s)]	手术时间[min，(±s)]
FTB联合IPACK组	40	67.8±7.5	15/25	25.4±2.4	70.7±4.7	98.6±10.2
常规组	40	70.8±6.7	18/22	24.3±2.9	70.8±4.7	97.8±10.5
t值		-1.89	0.46	1.92	-0.07	0.35
P值		0.06	0.50	0.058	0.94	0.73

表2 不同方法对股四头肌肌力的影响[N，(±s)]

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	3.85±0.60	3.09±0.17	3.27±0.22	3.49±0.20	3.66±0.19	3.85±0.20	4.00±0.25
常规组	40	3.76±0.59	2.64±0.20	3.02±0.14	3.20±0.13	3.40±0.12	3.61±0.14	3.66±0.13
F值		0.48	186.10	37.47	56.65	53.16	39.14	56.04
P值		0.49	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表2 不同方法对股四头肌肌力的影响[N，(±s)]

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	3.85±0.60	3.09±0.17	3.27±0.22	3.49±0.20	3.66±0.19	3.85±0.20	4.00±0.25
常规组	40	3.76±0.59	2.64±0.20	3.02±0.14	3.20±0.13	3.40±0.12	3.61±0.14	3.66±0.13
F值		0.48	186.10	37.47	56.65	53.16	39.14	56.04
P值		0.49	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表3 不同方法对静息痛VAS评分的影响(±s)

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	7.2±1.1	1.5±1.2	1.6±0.8	1.9±0.9	1.0±0.2	0.7±0.5	0.6±0.5
常规组	40	7.5±0.8	3.8±1.9	2.8±1.8	2.8±2.0	1.1±0.4	0.9±0.6	0.8±0.4
F值		1.55	44.07	16.50	7.08	2.12	5.39	5.14
P值		0.22	<0.001	<0.001	<0.05	0.15	<0.05	<0.05

表3 不同方法对静息痛VAS评分的影响(±s)

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	7.2±1.1	1.5±1.2	1.6±0.8	1.9±0.9	1.0±0.2	0.7±0.5	0.6±0.5
常规组	40	7.5±0.8	3.8±1.9	2.8±1.8	2.8±2.0	1.1±0.4	0.9±0.6	0.8±0.4
F值		1.55	44.07	16.50	7.08	2.12	5.39	5.14
P值		0.22	<0.001	<0.001	<0.05	0.15	<0.05	<0.05

表4 不同方法对活动痛VAS评分的影响(±s)

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	7.2±1.1	6.8±0.8	5.5±0.6	4.7±1.8	2.4±0.5	1.4±0.5	0.8±0.4
常规组	40	7.5±0.8	7.7±0.7	6.1±0.9	6.3±1.2	3.9±0.9	2.3±0.5	1.4±0.5
F值		1.57	28.33	12.55	24.89	93.35	59.20	45.10
P值		0.21	<0.001	0.001	<0.001	<0.001	<0.001	<0.001

表4 不同方法对活动痛VAS评分的影响(±s)

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	7.2±1.1	6.8±0.8	5.5±0.6	4.7±1.8	2.4±0.5	1.4±0.5	0.8±0.4
常规组	40	7.5±0.8	7.7±0.7	6.1±0.9	6.3±1.2	3.9±0.9	2.3±0.5	1.4±0.5
F值		1.57	28.33	12.55	24.89	93.35	59.20	45.10
P值		0.21	<0.001	0.001	<0.001	<0.001	<0.001	<0.001

表5 不同方法对活动度的影响[°，(±s)]

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	108±10	20±7	33±8	35±7	43±8	53±9	62±8
常规组	40	111±9	21±15	29±13	36±15	39±13	40±6	50±6
F值		2.47	0.19	3.62	0.18	3.62	60.12	64.76
P值		0.12	0.67	0.06	0.67	0.06	<0.001	<0.001

表5 不同方法对活动度的影响[°，(±s)]

分组	例数	术前	术后2 h	术后6 h	术后12 h	术后24 h	术后48 h	术后72 h
FTB联合IPACK组	40	108±10	20±7	33±8	35±7	43±8	53±9	62±8
常规组	40	111±9	21±15	29±13	36±15	39±13	40±6	50±6
F值		2.47	0.19	3.62	0.18	3.62	60.12	64.76
P值		0.12	0.67	0.06	0.67	0.06	<0.001	<0.001

表6 不同方法一般情况、药物用量及不良反应比较

分组	例数	住院时间[d，(±s)]	术中丙泊酚[ml，(±s)]	尿潴留[例(%)]	皮疹[例(%)]	吗啡使用量[mg，(±s)]
FTB联合IPACK组	40	4.0±0.8	42.6±5.4	1(2.5%)	1(2.5%)	7.2±2.3
常规组	40	5.0±0.8	52.0±8.0	2(5.0%)	1(2.5%)	13.4±4.3
t值		-5.79	-6.14	-	-	-7.95
P值		<0.001	<0.001	1^*	1^*	<0.001
分组	例数	伤口并发症[例(%)]	呼吸抑制[例(%)]	恶心呕吐[例(%)]	DVT[例(%)]	肌注吗啡[例(%)]
FTB联合IPACK组	40	2(5.0)	1(2.5)	15(37.5)	0	5(12.5)
常规组	40	2(5.0)	2(5.0)	18(45.0)	1(2.5)	13(32.5)
χ²值		-	-	0.46	-	4.59
P值		1^*	1^*	0.50	1^*	0.03

表6 不同方法一般情况、药物用量及不良反应比较

分组	例数	住院时间[d，(±s)]	术中丙泊酚[ml，(±s)]	尿潴留[例(%)]	皮疹[例(%)]	吗啡使用量[mg，(±s)]
FTB联合IPACK组	40	4.0±0.8	42.6±5.4	1(2.5%)	1(2.5%)	7.2±2.3
常规组	40	5.0±0.8	52.0±8.0	2(5.0%)	1(2.5%)	13.4±4.3
t值		-5.79	-6.14	-	-	-7.95
P值		<0.001	<0.001	1^*	1^*	<0.001
分组	例数	伤口并发症[例(%)]	呼吸抑制[例(%)]	恶心呕吐[例(%)]	DVT[例(%)]	肌注吗啡[例(%)]
FTB联合IPACK组	40	2(5.0)	1(2.5)	15(37.5)	0	5(12.5)
常规组	40	2(5.0)	2(5.0)	18(45.0)	1(2.5)	13(32.5)
χ²值		-	-	0.46	-	4.59
P值		1^*	1^*	0.50	1^*	0.03

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Effects of two analgesic methods on rehabilitation after total knee arthroplasty

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Effects of two analgesic methods on rehabilitation after total knee arthroplasty