改良持续收肌管阻滞对全膝关节置换术后运动功能的影响

doi:10.3877/cma.j.issn.1674-134X.2023.02.010

目的

探讨改良持续收肌管阻滞对全膝关节置换(TKA)术后运动功能的影响。

方法

选择美国麻醉医师协会(ASA)分级Ⅰ~Ⅲ级、术前认知功能正常、择期接受全膝关节置换术的患者80例，排除对侧3个月内有膝关节手术史、6个月内有脊柱手术史、以及对局部麻醉药过敏的患者，随机分为改良收肌管组(改良组)和股神经组，每组40例。主要观察指标为术后4、8、12、24、48 h股四头肌肌力，术后第1、2天起立行走试验(TUG)时间；次要观察指标为术后4、8、12、24、48 h静息、膝关节屈曲45°以及活动视觉模拟评分(VAS)、术后48 h内腘窝痛觉减退和补救镇痛者数量；术后第1、3天静脉血液中C反应蛋白(CRP)、白介素6(IL-6)水平和髌骨中段周径变化，重复测量数据采用重复测量方差分析，组间比较采用独立样本t检验。

结果

改良组术后48 h内股四头肌肌力及TUG测试均优于股神经组(F＝11.680，t＝12.155、5.892, P<0.05)；改良组术后4 h腘窝痛觉减退患者有12例(34.3%)(χ²＝14.483，P<0.001)，术后8 h 5例(14.3%)，股神经组无腘窝痛觉减退者；两组患者术后VAS评分、罗哌卡因消耗量、补救镇痛人数、炎性反应和并发症发生率差异无统计学意义(均为P>0.05)。

结论

TKA术后改良持续收肌管阻滞对股四头肌肌力影响更小，术后早期产生腘窝镇痛效果，可以明显提高患者术后运动功能。

关键词: 神经阻滞, 关节成形术，置换，膝, 疼痛，手术后, 炎症

Objective

To investigate the effects of modified continuous adductor block on motor function after total knee arthroplasty (TKA).

Methods

A total of 80 patients were enrolled in the study. All the patients were in grade I to III of American Society of Anaesthesiologists (ASA), in normal preoperative cognitive function and assigned for elective total knee arthroplasty. Patients with history of contralateral knee surgery within three months, spinal surgery within six months and allergy to local anaesthetics were excluded from the study. The patients were randomly divided into a modified adductor canal block group (as modified group) and a femoral nerve block group (as femoral group), with 40 cases per group. The primary assessments of postoperative outcome were the muscle strength of quadriceps at four, eight, 12, 24 and 48 h, and the time-up-and-go test (TUG) on first and second day after surgery. Secondary assessments of postoperative outcome included resting at four, eight, 12, 24, and 48 h after surgery, 45° knee flexion and visual analogue scale (VAS) of activity, also the number of patients with popliteal hypoanalgesia and the number of patients received remedial analgesia within 48 h after surgery. Serum C-reactive protein (CRP) and interleukin-6 (IL-6), also the circumference of the middle patella were monitored on the first day and third day after surgery. Repeated measurement of variance was used to evaluate the repeated measurement data, and the independent sample t test was employed for comparison between groups.

Results

The muscle strength of quadriceps and TUG tests in the modified group were better than in the femoral group at 48 h after surgery (F=11.680, t=12.155, 5.892, all P<0.05). Twelve patients (34.3%) in the modified group had popliteal hypoalgesia at four hours after surgery (P<0.001) and five (14.3%) at eight hours. There was no popliteal hypoalgesia in the femoral nerve group. There was no statistically significant differences between the two groups in postoperative VAS score, ropivacaine dosage, and number of patients with remedial analgesics, inflammatory reaction and incidence of complications. (all P>0.05).

Conclusion

Modified continuous adductor canal block after TKA has less influence on quadriceps muscle strength, but to promote an early postoperative effect on popliteal analgesia. It can significantly improve the postoperative movement of patients.

Key words: Nerve block, Arthroplasty, replacement, knee, Pain, postoperative, Inflammation

图1 改良穿刺位置示意图注：^*-P<0.001

Figure 1 Schematic diagram of modified puncture site

图2 改良收肌管阻滞注：A为股内侧肌；B为局麻药；C为股动脉；D为缝匠肌；黄色三角标记线为穿刺针

Figure 2 Modified adductor canal blockNote: A is vastus medialis; B is local anesthetic; C is femoral artery; D is sartorius muscle; Puncture needle is marked by yellow dotted line

图3 股神经阻滞注：A为股神经；B为局麻药；C为股动脉；黄色三角标记线为穿刺针

Figure 3 Femoral nerve blockNote: A is femoral nerve; B is local anesthetics; C is femoral artery; Puncture needle is marked by yellow dotted line

图4 临床试验流程图

Figure 4 Flow chart of the clinical trial

表1 患者一般临床资料

Table 1 General information of patients

组别Group	例数Case number	男/女(例) Male/female	ASA分级(Ⅱ/Ⅲ) ASA classification	年龄Age [岁，M(P₂₅，P₇₅)]	BMI [kg/m²，(±s)]	舒芬太尼Sufentanil [μg，(±s)]	瑞芬太尼Remifentanil [μg，(±s)]	手术时间Operation duration [min，(±s)]
改良组Modified group	35	7/28	18/17	66(56, 76)	25.3±2.8	33.1±5.6	780.7±61.8	65.2±11.5
股神经组Femoral group	35	8/27	19/16	68(60, 76)	25.4±2.7	31.7±5.8	763.0±66.9	69.0±11.8
统计值		χ²＝0.085	χ²＝0.057	t＝0.933	t＝0.169	t＝1.050	t＝1.151	t＝1.362
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 患者一般临床资料

Table 1 General information of patients

组别Group	例数Case number	男/女(例) Male/female	ASA分级(Ⅱ/Ⅲ) ASA classification	年龄Age [岁，M(P₂₅，P₇₅)]	BMI [kg/m²，(±s)]	舒芬太尼Sufentanil [μg，(±s)]	瑞芬太尼Remifentanil [μg，(±s)]	手术时间Operation duration [min，(±s)]
改良组Modified group	35	7/28	18/17	66(56, 76)	25.3±2.8	33.1±5.6	780.7±61.8	65.2±11.5
股神经组Femoral group	35	8/27	19/16	68(60, 76)	25.4±2.7	31.7±5.8	763.0±66.9	69.0±11.8
统计值		χ²＝0.085	χ²＝0.057	t＝0.933	t＝0.169	t＝1.050	t＝1.151	t＝1.362
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表2 术后各时间点股四头肌肌力评级(±s)

Table 2 Muscle strength of quadriceps femoris at per measure points after surgery

组别Group	例数Case number	术前Before surgery	术后Postoperation					F值	P值
组别Group	例数Case number	术前Before surgery	4 h	8 h	12 h	24 h	48 h	F值	P值
改良组Modified group	35	4.8±0.4	3.0±0.7	3.5±0.6	3.7±0.5	4.3±0.5	4.6±0.5	50.308	<0.001
股神经组Femoral group	35	4.8±0.4	2.4±0.5	3.2±0.6	3.4±0.5	4.0±0.6	4.4±0.5	84.001	<0.001
F值		0.092	18.197	5.413	4.871	5.456	4.815
P值		>0.05	<0.001	0.023	0.031	0.022	0.032

表2 术后各时间点股四头肌肌力评级(±s)

Table 2 Muscle strength of quadriceps femoris at per measure points after surgery

组别Group	例数Case number	术前Before surgery	术后Postoperation					F值	P值
组别Group	例数Case number	术前Before surgery	4 h	8 h	12 h	24 h	48 h	F值	P值
改良组Modified group	35	4.8±0.4	3.0±0.7	3.5±0.6	3.7±0.5	4.3±0.5	4.6±0.5	50.308	<0.001
股神经组Femoral group	35	4.8±0.4	2.4±0.5	3.2±0.6	3.4±0.5	4.0±0.6	4.4±0.5	84.001	<0.001
F值		0.092	18.197	5.413	4.871	5.456	4.815
P值		>0.05	<0.001	0.023	0.031	0.022	0.032

表3 术后第1、2天TUG测试时间[s，(±s)]

Table 3 TUG tests on the first and second days after surgery

组别Group	例数Case number	TUG 1	TUG 2
改良组Modified group	35	35.4±3.1	53.1±6.2
股神经组Femoral group	35	43.8±2.7	60.7±4.4
t值		12.155	5.892
P值		<0.001	<0.001

表3 术后第1、2天TUG测试时间[s，(±s)]

Table 3 TUG tests on the first and second days after surgery

组别Group	例数Case number	TUG 1	TUG 2
改良组Modified group	35	35.4±3.1	53.1±6.2
股神经组Femoral group	35	43.8±2.7	60.7±4.4
t值		12.155	5.892
P值		<0.001	<0.001

表4 术后各时间点膝关节不同状态VAS评分(±s)

Table 4 Postoperative VAS scores for different knee status at time points

	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
静息At rest	改良组Modified group	35	1.5±0.6	1.7±0.6	1.7±0.7	1.9±0.8	1.8±0.5	1.721	>0.05
	股神经组Femoral group	35	1.3±0.5	1.5±0.9	1.5±0.7	1.7±0.8	1.6±0.7	2.361	>0.05
	F值		3.366
	P值		>0.05
	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
屈曲45° Flexion at 45°	改良组Modified group	35	1.7±0.7	1.9±0.5	2.1±0.9	2.5±0.9	2.6±0.7	11.461	<0.001
	股神经组Femoral group	35	1.9±0.7	2.0±0.5	2.2±0.9	2.4±0.9	2.4±0.7	3.252	0.017
	F值		0.033
	P值		>0.05
	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
活动Activity	改良组Modified group	35	2.0±0.7	2.3±0.7	2.8±0.9	3.1±0.9	2.9±0.7	10.928	<0.001
	股神经组Femoral group	35	2.1±0.9	3.2±0.8	2.8±0.9	3.1±0.8	2.8±0.8	8.942	<0.001
	F值		0.069
	P值		<0.001

表4 术后各时间点膝关节不同状态VAS评分(±s)

Table 4 Postoperative VAS scores for different knee status at time points

	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
静息At rest	改良组Modified group	35	1.5±0.6	1.7±0.6	1.7±0.7	1.9±0.8	1.8±0.5	1.721	>0.05
	股神经组Femoral group	35	1.3±0.5	1.5±0.9	1.5±0.7	1.7±0.8	1.6±0.7	2.361	>0.05
	F值		3.366
	P值		>0.05
	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
屈曲45° Flexion at 45°	改良组Modified group	35	1.7±0.7	1.9±0.5	2.1±0.9	2.5±0.9	2.6±0.7	11.461	<0.001
	股神经组Femoral group	35	1.9±0.7	2.0±0.5	2.2±0.9	2.4±0.9	2.4±0.7	3.252	0.017
	F值		0.033
	P值		>0.05
	组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	术后12 h 12 h after surgery	术后24 h 24 h after surgery	术后48 h 48 h after surgery	F值	P值
活动Activity	改良组Modified group	35	2.0±0.7	2.3±0.7	2.8±0.9	3.1±0.9	2.9±0.7	10.928	<0.001
	股神经组Femoral group	35	2.1±0.9	3.2±0.8	2.8±0.9	3.1±0.8	2.8±0.8	8.942	<0.001
	F值		0.069
	P值		<0.001

表5 术后腘窝痛觉减退比例和间接镇痛效应指标

Table 5 Incidence of postoperative popliteal hypoanalgesia and indirect analgesic effect index

组别Group	例数Case number	腘窝痛觉减退[例，(%)] Popliteal hypoalgesia		48 h罗哌卡因消耗Ropivacaine dosage within 48 h [mg，(±s)]	有效按压次数Number of effective press (±s)	补救镇痛需求[例(%)] Patients requested remedial analgesic
组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	48 h罗哌卡因消耗Ropivacaine dosage within 48 h [mg，(±s)]	有效按压次数Number of effective press (±s)	补救镇痛需求[例(%)] Patients requested remedial analgesic
改良组Modified group	35	12(34.3)	5(14.3)	442.5±24.7	3.6±1.0	8(22.9)
股神经组Femoral group	35	0	0	439.7±22.5	3.3±0.8	6(17.1)
统计值		χ²＝14.483	χ²＝5.385	t＝0.496	t＝1.273	t＝0.357
P值		<0.001	>0.05	>0.05	>0.05	>0.05

表5 术后腘窝痛觉减退比例和间接镇痛效应指标

Table 5 Incidence of postoperative popliteal hypoanalgesia and indirect analgesic effect index

组别Group	例数Case number	腘窝痛觉减退[例，(%)] Popliteal hypoalgesia		48 h罗哌卡因消耗Ropivacaine dosage within 48 h [mg，(±s)]	有效按压次数Number of effective press (±s)	补救镇痛需求[例(%)] Patients requested remedial analgesic
组别Group	例数Case number	术后4 h 4 h after surgery	术后8 h 8 h after surgery	48 h罗哌卡因消耗Ropivacaine dosage within 48 h [mg，(±s)]	有效按压次数Number of effective press (±s)	补救镇痛需求[例(%)] Patients requested remedial analgesic
改良组Modified group	35	12(34.3)	5(14.3)	442.5±24.7	3.6±1.0	8(22.9)
股神经组Femoral group	35	0	0	439.7±22.5	3.3±0.8	6(17.1)
统计值		χ²＝14.483	χ²＝5.385	t＝0.496	t＝1.273	t＝0.357
P值		<0.001	>0.05	>0.05	>0.05	>0.05

表6 术前和术后第1、3天CRP[mg/L，(±s)]

Table 6 Changes of CRP before surgery and on the first and third days after surgery

组别Group	例数Case number	术前Before surgery	术后1 d First day after surgery	术后3 d Third day after surgery	F值	P值
改良组Modified group	35	2.9±0.5	22.6±6.4	46.1±8.1	655.489	<0.001
股神经组Femoral group	35	3.1±0.5	24.8±6.6	48.40±9.7	745.471	<0.001
F值			3.710
P值			>0.05

表6 术前和术后第1、3天CRP[mg/L，(±s)]

Table 6 Changes of CRP before surgery and on the first and third days after surgery

组别Group	例数Case number	术前Before surgery	术后1 d First day after surgery	术后3 d Third day after surgery	F值	P值
改良组Modified group	35	2.9±0.5	22.6±6.4	46.1±8.1	655.489	<0.001
股神经组Femoral group	35	3.1±0.5	24.8±6.6	48.40±9.7	745.471	<0.001
F值			3.710
P值			>0.05

表7 术前和术后第1、3天IL-6[ng/L，(±s)]

Table 7 Changes of IL-6 before surgery and on the first and third days after surgery

组别Group	例数Case number	术前Before surgery	术后1 d First day after surgery	术后3 d Third day after surgery	F值	P值
改良组Modified group	35	2.6±0.7	23.0±5.4	13.4±3.6	248.243	<0.001
股神经组Femoral group	35	2.7±0.8	23.2±5.8	13.6±4.2	250.705	<0.001
F值			0.082
P值			>0.05

表7 术前和术后第1、3天IL-6[ng/L，(±s)]

Table 7 Changes of IL-6 before surgery and on the first and third days after surgery

组别Group	例数Case number	术前Before surgery	术后1 d First day after surgery	术后3 d Third day after surgery	F值	P值
改良组Modified group	35	2.6±0.7	23.0±5.4	13.4±3.6	248.243	<0.001
股神经组Femoral group	35	2.7±0.8	23.2±5.8	13.6±4.2	250.705	<0.001
F值			0.082
P值			>0.05

表8 术后髌骨中段周径变化和关节肿胀例数

Table 8 Peri-diameter alterations and knee joint swelling cases in the middle patella

组别Group	例数Case number	髌骨中段周径增加值[cm，(±s)] Increased peri-diameter of the middle patella		术后膝关节肿胀(例) Postoperative knee swelling
组别Group	例数Case number	术后1 d Postoperative fist day	术后3 d Postoperative third day	术后膝关节肿胀(例) Postoperative knee swelling
改良组Modified group	35	2.4±1.1	2.14±1.0	14
股神经组Femoral group	35	2.5±1.3	2.1±1.1	17
统计值		t＝0.100	t＝0.115	χ²＝0.521
P值		>0.05	>0.05	>0.05

表8 术后髌骨中段周径变化和关节肿胀例数

Table 8 Peri-diameter alterations and knee joint swelling cases in the middle patella

组别Group	例数Case number	髌骨中段周径增加值[cm，(±s)] Increased peri-diameter of the middle patella		术后膝关节肿胀(例) Postoperative knee swelling
组别Group	例数Case number	术后1 d Postoperative fist day	术后3 d Postoperative third day	术后膝关节肿胀(例) Postoperative knee swelling
改良组Modified group	35	2.4±1.1	2.14±1.0	14
股神经组Femoral group	35	2.5±1.3	2.1±1.1	17
统计值		t＝0.100	t＝0.115	χ²＝0.521
P值		>0.05	>0.05	>0.05

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Effect of modified continuous adductor canal block on patient mobility after total knee arthroplasty

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Effect of modified continuous adductor canal block on patient mobility after total knee arthroplasty