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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (02) : 216 -223. doi: 10.3877/cma.j.issn.1674-134X.2023.02.010

临床论著

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
冉伟, 王咫桥, 董军, 何开华, 高进†()   
  1. 400016　重庆医科大学附属第一医院麻醉科
  • 收稿日期:2021-10-03 出版日期:2023-04-01
  • 通信作者: 高进
  • 基金资助:
    国家重点临床专科(财社〔2011〕170号); 重庆市医学重点学科(渝卫科教〔2007〕2号)

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

Wei Ran, Zhiqiao Wang, Jun Dong, Kaihua He, Jin Gao†()   

  1. Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chognqing 400016, China
  • Received:2021-10-03 Published:2023-04-01
  • Corresponding author: Jin Gao
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引用本文：

冉伟, 王咫桥, 董军, 何开华, 高进. 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[J]. 中华关节外科杂志(电子版), 2023, 17(02): 216-223.

Wei Ran, Zhiqiao Wang, Jun Dong, Kaihua He, Jin Gao. Effect of modified continuous adductor canal block on patient mobility after total knee arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(02): 216-223.

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
4 h 8 h 12 h 24 h 48 h
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
术后4 h 4 h after surgery 术后8 h 8 h after surgery
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
术后1 d Postoperative fist day 术后3 d Postoperative third day
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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