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

[1]	Li JW, Ma YS, Xiao LK. Postoperative pain management in total knee arthroplasty[J]. Orthop Surg, 2019, 11(5): 755-761.
[2]	Sigirci A. Pain management in total knee arthroplasty by intraoperative local anesthetic application and one-shot femoral block[J]. Indian J Orthop, 2017, 51(3): 280-285.
[3]	Society KK. Guidelines for the management of postoperative pain after total knee arthroplasty[J]. Knee Surg Relat Res, 2012, 24(4): 201-207.
[4]	Davies AF, Segar EP, Murdoch J, et al. Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty[J]. Br J Anaesth, 2004, 93(3): 368-374.
[5]	Gao F, Ma J, Sun W, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty：a systematic review and meta-analysis[J]. Clin J Pain, 2017, 33(4): 356-368.
[6]	Kamenetsky E, Nader A, Kendall MC. Use of peripheral nerve blocks with sedation for total knee arthroplasty in a patient with contraindication for general anesthesia[J]. Case Rep Anesthesiol, 2015,2015(10):1-4.
[7]	Ohgoshi Y, Matsutani M, Kubo EN. Use of IPACK block with continuous femoral triangle block for total knee arthroplasty: a clinical experience[J]. J ClinAnesth, 2019, 54(3): 52-54.
[8]	Runge C, Børglum J, Jensen JM, et al. The analgesic effect of obturator nerve block added to a femoral triangle block after total knee arthroplasty: a randomized controlled trial[J]. Reg Anesth Pain Med, 2016, 41(4): 445-451.
[9]	Sankineani S, Reddy A, Eachempati KK, et al. Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period[J]. Eur J Orthop Surg Traumatol, 2018, 28(7): 1391-1395.
[10]	Feibel RJ, Dervin GF, Kim PR, et al. Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution[J]. J Arthroplasty, 2009, 24(6 Suppl): 132-137.
[11]	Kandarian B, Indelli PF, Sinha S, et al. Implementation of the IPACK (infiltration between the popliteal artery and capsule of the knee) block into a multimodal analgesic pathway for total knee replacement[J]. Korean J Anesthesiol, 2019, 72(3): 238-244.
[12]	Runge C, Bjørn S, Jensen JM, et al. The analgesic effect of a popliteal plexus blockade after total knee arthroplasty: a feasibility study[J]. Acta Anaesthesiol Scand，2018, 62(8): 1127-1132.
[13]	Berninger MT, Friederichs J, Leidinger W, et al. Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in unicompartmental knee arthroplasty[J/OL]. BMC Musculoskelet Disord, 2018, 19(1):249. doi: 10.1186/s12891-018-2165-9.
[14]	Jochum D, Iohom G, Choquet O, et al. Adding a selective obturator nerve block to the parasacral sciatic nerve block: an evaluation[J]. Anesth Analg, 2004, 99(5): 1544-1549.
[15]	Bjørn S, Nielsen TD, Moriggl B, et al. Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial[J]. Reg Anesth Pain Med, 2020,45:107-116.
[16]	Thobhani S, Scalercio L, Elliott CE, et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients[J]. Ochsner J, 2017, 17(3): 233-238.
[17]	Jules-Elysee KM, Wilfred SE, Memtsoudis SG, et al. Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement a prospective, double-blind, randomized controlled trial[J]. JBJS, 2012, 94(23): 2120-2127.
[18]	Si HB, Yang TM, Zeng Y, et al. Correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary total knee arthroplasty[J/OL]. BMC Musculoskelet Disord, 2017, 18(1): 265. doi: 10.1186/s12891-017-1597-y.
[19]	Turnbull ZA, Sastow D, Giambrone GP, et al. Anesthesia for the patient undergoing total knee replacement: current status and future prospects[J/OL]. Local Reg Anesth, 2017, 10(3): 1-7.doi:10.2147/LRA.S101373.
[20]	Lieutaud T, Billard V, Khalaf H, et al. Muscle relaxation and increasing doses of propofol improve intubating conditions[J]. Can J Anaesth, 2003, 50(2): 121-126.
[21]	Sahinovic MM, Struys MM, Absalom AR. Clinical pharmacokinetics and pharmacodynamics of propofol[J]. Clin Pharmacokinet, 2018, 57(12): 1539-1558.
[22]	Guida F, Palazzo E, Boccella S, et al. General anesthesia research[M]．First ed, New York: Humana, 2020: 133-145.

[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]	董红华, 郭艮春, 江磊, 吴雪飞, 马飞翔, 李海凤. 骨科康复一体化模式在踝关节骨折快速康复中的应用[J]. 中华关节外科杂志(电子版), 2023, 17(06): 802-807.
[4]	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.
[5]	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.
[6]	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.
[7]	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.
[8]	于智慧, 赵建军. 后路腰方肌阻滞复合全身麻醉在腹股沟斜疝经腹腹膜前手术中的应用效果[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 734-739.
[9]	田静, 方秀春. 超声引导下横筋膜平面阻滞在儿童腹股沟疝手术的应用效果[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 740-744.
[10]	李雪, 刘文婷, 窦丽婷, 刘叶红. 联合护理在腹腔镜食管裂孔疝修补中的应用效果分析[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 750-754.
[11]	段文忠, 白延霞, 徐文亭, 祁虹霞, 吕志坚. 七氟烷和丙泊酚在肝切除术中麻醉效果比较Meta分析[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 640-645.
[12]	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.
[13]	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.
[14]	李美娜, 宋艳丽, 杨姗姗, 李聚彩, 罗慧利, 吕杰. 三联预康复策略在退行性脊柱侧弯患者围术期的应用效果[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 356-364.
[15]	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.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Effects of two analgesic methods on rehabilitation after total knee arthroplasty

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Effects of two analgesic methods on rehabilitation after total knee arthroplasty