加速康复外科多学科协作模式的单侧全膝关节置换效果

doi:10.3877/cma.j.issn.1674-134X.2023.02.011

目的

探讨临床多学科团队(MDT)协作下实施加速康复外科(ERAS)模式对单侧全膝关节置换术(TKA)临床效果的影响。

方法

纳入2018年9月至2021年12月在晋江市医院骨科诊断为终末期膝骨关节炎、并接受单侧全膝关节置换术的患者，排除患侧膝关节手术史、合并感染或肿瘤或慢性疼痛疾病、不能配合试验评估者。共纳入102例，其中男21例，女81例，年龄40~89岁。随机数字表法分为ERAS-MDT模式治疗组(ERAS-MDT组)和传统模式治疗组(常规组)各51例。收集以下组间数据：基线资料、术后8、24、48、72 h运动疼痛视觉模拟评分(VAS)、术后2、5 d膝关节主动活动度(AROM)、术后2、5 d美国纽约特种外科医院(HSS)膝关节评分、术后1 d血C-反应蛋白(CRP)水平、输血率、术后并发症发生率。采用独立样本t检验、重复测量方差分析、Mann-Whitney秩和检验、卡方检验、Fisher确切概率法进行统计学分析。

结果

ERAS-MDT组术后8、24、48和72 h VAS评分均低于常规组(t＝-2.945、-4.894、-5.676、-5.055，均为P<0.05)；ERAS-MDT组术后2、5 d膝关节AROM分别为(68.8±19.1)°、(93.9±14.0)°，均优于常规组的(59.8±21.6)°、(86.2±14.0)°(t＝2.223、2.786，均为P<0.05)；ERAS-MDT组术后2、5 d膝关节HSS评分为(46.8±6.5)分、(59.8±6.8)分，均优于常规组的(43.4±6.8)分、(52.8±5.8)分(t＝2.620、5.575，均为P<0.05)；ERAS-MDT组术后1 d血CRP与常规组差异无统计学意义(Z＝-0.400，P>0.05)；两组在输血率和术后并发症发生率方面差异均无统计学意义(均为P>0.05)。

结论

ERAS-MDT模式较传统治疗模式能更有效缓解单侧TKA患者术后早期疼痛，改善关节功能，达到加速康复的临床效果。

关键词: 术后加速康复, 跨部门合作, 关节成形术，置换，膝

Objective

To investigate the impact of the enhanced recovery after surgery (ERAS) protocols under the collaboration of a clinical multidisciplinary team (MDT) on unilateral total knee arthroplasty (TKA).

Methods

From September 2018 to December 2021, the patients who were diagnosed as terminal knee osteoarthritis and underwent unilateral total knee arthroplasty in the orthopedic department of Jinjiang Municipal Hospital were enrolled. Exclusion criteria: history of knee surgery, concurrent infection or tumor, or chronic pain disease, and inability to cooperate with trial assessment. A total of 102 patients were enrolled, including 21 males and 81 females, aged from 40 to 89 years. Patients were randomly assigned into an ERAS-MDT treatment group (ERAS-MDT group, n=51) and a conventional treatment group (routine group, n=51) by random number table. The following data were collected: baseline data, visual analogue scale (VAS) scores for kinesalgia at eight hours, and 24, 48, and 72 h, active range of motion (AROM) of knee and the Hospital for Special Surgery (HSS) knee score on the second and fifth days after surgery, C-reactive protein (CRP) on the first day after surgery, transfusion rate, and postoperative complication rate. Independent t test, repeated measures ANOVA, Mann-Whitney test, chi square test and Fisher exact test were performed for data analysis.

Results

VAS scores at eight hours, and 24, 48, 72 h in ERAS-MDT group were significantly lower than those in routine group(t=-2.945, -4.894, -5.676, -5.055, all P<0.05). Knee AROM in the ERAS-MDT group was (68.8±19.1)° and (93.9±14.0)° on the second and fifth days after surgery, both significantly higher than those in the routine group (59.8±21.6)° and (86.2±14.0)°(t=2.223, 2.786, both P<0.05). HSS scores on the postoperative second and fifth days in ERAS-MDT group were (46.8±6.5), (59.8±6.8), which were higher than those in the routine group (43.4±6.8), (52.8±5.8)(t=2.620, 5.575, both P<0.05). CRP level on the day after surgery showed no statistically significant difference between ERAS-MDT group and routine group(Z=-0.400, P>0.05). No statistically significant difference was found in terms of transfusion rate and postoperative complication rate between the two groups(both P>0.05).

Conclusion

Compared with the traditional treatment protocols, the ERAS-MDT protocols can offer more postoperative pain relief and improve joint function in unilateral TKA patients, hence to promote a rapid recovery.

Key words: Enhanced recovery after surgery, Intersectoral collaboration, Arthroplasty, replacement, knee

表1 两组患者基线资料比较

Table 1 Comparison of baseline information between two groups

组别Group	例数Case number	性别(男/女) Gender(male/female)	年龄Age [岁，(±s)]	BMI [kg/m²，(±s)]	侧别(左/右) Side (lefg/right)	病程[年，(±s)] Disease duration
ERAS-MDT组ERAS-MDT group	51	12/39	69±9	27±6	23/28	7±6
常规组Routine group	51	9/42	68±9	26±5	22/29	8±6
统计值		χ²＝0.540	t＝0.508	t＝0.694	χ²＝0.040	t＝0.111
P值		>0.05	>0.05	>0.05	>0.05	>0.05

表1 两组患者基线资料比较

Table 1 Comparison of baseline information between two groups

组别Group	例数Case number	性别(男/女) Gender(male/female)	年龄Age [岁，(±s)]	BMI [kg/m²，(±s)]	侧别(左/右) Side (lefg/right)	病程[年，(±s)] Disease duration
ERAS-MDT组ERAS-MDT group	51	12/39	69±9	27±6	23/28	7±6
常规组Routine group	51	9/42	68±9	26±5	22/29	8±6
统计值		χ²＝0.540	t＝0.508	t＝0.694	χ²＝0.040	t＝0.111
P值		>0.05	>0.05	>0.05	>0.05	>0.05

表2 两组患者手术前后运动状态VAS评分比较(±s)

Table 2 Comparison of VAS scores in the state of motion before and after surgery between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery				F值	P值
组别Group	例数Case number	术前Before surgery	8 h	24 h	48 h	72 h	F值	P值
ERAS-MDT组ERAS-MDT group	51	5.6±1.4	3.8±0.9	3.4±0.9	3.6±1.1	2.8±0.9	34.939	<0.05
常规组Routine group	51	5.8±1.6	4.4±1.1	4.5±1.2	4.9±1.2	3.7±0.9	34.939	<0.05
t值		-0.396	-2.945	-4.894	-5.676	-5.055
P值		>0.05	<0.01	<0.001	<0.001	<0.001

表2 两组患者手术前后运动状态VAS评分比较(±s)

Table 2 Comparison of VAS scores in the state of motion before and after surgery between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery				F值	P值
组别Group	例数Case number	术前Before surgery	8 h	24 h	48 h	72 h	F值	P值
ERAS-MDT组ERAS-MDT group	51	5.6±1.4	3.8±0.9	3.4±0.9	3.6±1.1	2.8±0.9	34.939	<0.05
常规组Routine group	51	5.8±1.6	4.4±1.1	4.5±1.2	4.9±1.2	3.7±0.9	34.939	<0.05
t值		-0.396	-2.945	-4.894	-5.676	-5.055
P值		>0.05	<0.01	<0.001	<0.001	<0.001

表3 两组患者术前术后膝关节AROM比较[°，(±s)]

Table 3 Comparison of preoperative and postoperative knee AROM between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery		F值	P值
组别Group	例数Case number	术前Before surgery	2 d	5 d	F值	P值
ERAS-MDT组ERAS-MDT group	51	103±13	69±19	94±14	6.082	<0.05
常规组Routine group	51	102±16	60±22	86±14	6.082	<0.05
t值		0.495	2.223	2.786
P值		>0.05	0.028	<0.01

表3 两组患者术前术后膝关节AROM比较[°，(±s)]

Table 3 Comparison of preoperative and postoperative knee AROM between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery		F值	P值
组别Group	例数Case number	术前Before surgery	2 d	5 d	F值	P值
ERAS-MDT组ERAS-MDT group	51	103±13	69±19	94±14	6.082	<0.05
常规组Routine group	51	102±16	60±22	86±14	6.082	<0.05
t值		0.495	2.223	2.786
P值		>0.05	0.028	<0.01

表4 两组患者术前及术后膝关节HSS评分比较(±s)

Table 4 Comparison of preoperative and postoperative knee HSS scores between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery		F值	P值
组别Group	例数Case number	术前Before surgery	2 d	5 d	F值	P值
ERAS-MDT组ERAS-MDT group	51	55±11	47±7	60±7	9.918	<0.05
常规组Routine group	51	55±12	43±7	53±6	9.918	<0.05
t值		0.381	2.620	5.575
P值		>0.05	0.011	<0.001

表4 两组患者术前及术后膝关节HSS评分比较(±s)

Table 4 Comparison of preoperative and postoperative knee HSS scores between two groups

组别Group	例数Case number	术前Before surgery	术后After surgery		F值	P值
组别Group	例数Case number	术前Before surgery	2 d	5 d	F值	P值
ERAS-MDT组ERAS-MDT group	51	55±11	47±7	60±7	9.918	<0.05
常规组Routine group	51	55±12	43±7	53±6	9.918	<0.05
t值		0.381	2.620	5.575
P值		>0.05	0.011	<0.001

表5 两组患者术前及术后血CRP、输血率及术后并发症比较

Table 5 Comparison of preoperative and postoperative blood CRP, transfusion rate and postoperative complications between two groups

组别Group	例数Case number	CRP[mg/L, M(P₂₅，P₇₅)]		输血率[例(%)] Blood transfusion rate	术后并发症[例(%)] Postoperative complications
组别Group	例数Case number	术前Before surgery	术后1 d One day after surgery	输血率[例(%)] Blood transfusion rate	术后并发症[例(%)] Postoperative complications
ERAS-MDT组ERAS-MDT group	51	3.3(1.7，5.9)	23.7(15.4，58.4)	1(2.0)	2(3.9)
常规组Routine group	51	3.1(1.5，5.2)	27.7(15.8，57.8)	2(3.9)	3(5.9)
统计值		Z＝-0.318	Z＝-0.400	-	-
P值		>0.05	>0.05	1.000^*	1.000^*

表5 两组患者术前及术后血CRP、输血率及术后并发症比较

Table 5 Comparison of preoperative and postoperative blood CRP, transfusion rate and postoperative complications between two groups

组别Group	例数Case number	CRP[mg/L, M(P₂₅，P₇₅)]		输血率[例(%)] Blood transfusion rate	术后并发症[例(%)] Postoperative complications
组别Group	例数Case number	术前Before surgery	术后1 d One day after surgery	输血率[例(%)] Blood transfusion rate	术后并发症[例(%)] Postoperative complications
ERAS-MDT组ERAS-MDT group	51	3.3(1.7，5.9)	23.7(15.4，58.4)	1(2.0)	2(3.9)
常规组Routine group	51	3.1(1.5，5.2)	27.7(15.8，57.8)	2(3.9)	3(5.9)
统计值		Z＝-0.318	Z＝-0.400	-	-
P值		>0.05	>0.05	1.000^*	1.000^*

图1 TKA(膝关节置换术)典型病例手术前后临床资料。图A为术前双下肢全长正位X线片，图B为左膝关节正侧位X线片，示左股骨远端、胫骨平台骨质增生硬化，膝关节内侧间隙变窄；图C为术后1 d左膝关节正侧位X线片，示左膝内翻畸形矫正，人工关节假体位置良好；图D为左膝关节置换术后2 d，主动伸膝接近0°，屈膝>100°，关节主动活动度良好

Figure 1 Clinical data of typical patient with TKA before and after surgery. A is preoperative full-length X-ray of both lower limbs, anteroposterior view; B is anteroposterior and lateral views of the left knee, showing hyperostosis and narrowing of medial compartment of the knee joint in left distal femur and tibial plateau; C is anteroposterior and lateral views of left knee one day after surgery, showing that varus deformity of left knee was corrected and the prosthesis in good position; D is two days after left knee TKA, showing active extension near 0 ° and flexion>100 ° of left knee with good joint active mobility.

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Effect of enhanced recovery after surgery together with multidisciplinary team strategy on unilateral total knee arthroplasty

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Effect of enhanced recovery after surgery together with multidisciplinary team strategy on unilateral total knee arthroplasty