局部浸润麻醉对全膝关节置换术后早期镇痛效果的影响

doi:10.3969/j.issn.1006-7795.2021.01.023

摘要/Abstract

摘要： 目的研究对膝关节不同部位进行局部浸润麻醉(local infiltration anesthesia,LIA),对全膝关节置换术(total knee arthroplasty, TKA)术后患者早期镇痛效果的影响。方法入组2017年3月至2018年6月因膝关节骨关节炎在首都医科大学附属北京朝阳医院骨科行单侧初次全膝关节置换术的患者,共100人,采用随机数分组法随机分为两组:后侧方浸润麻醉组(A组)及前方浸润麻醉组(B组),每组50例。其中A组在术中于后侧方结构[腘动脉与后关节囊间隙(interspace between the popliteal artery and posterior capsule of the knee,IPACK)]及内外侧副韧带附着区分别注射镇痛药物,并于前方结构[髌上囊滑膜、股四头肌肌腱及切口周围]分别注射0.9%(质量分数)氯化钠注射液(以下简称生理盐水)20 mL;B组在术中于后侧方结构分别注射生理盐水,并于前方结构分别注射镇痛药物。如患者出现不能耐受的疼痛则临时应用曲马多100 mg口服作为治疗补充。分析2组患者基线资料、术前及术后第5天视觉模拟评分(Visual Analogue Scale, VAS)、美国膝关节协会评分(American Knee Society Score, KSS)、美国骨关节炎指数(The Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC),并统计两组术后曲马多的用量。结果两组患者基线资料及术前VAS评分差异均无统计学意义(P>0.05),术后第5天在静息状态下,A组VAS明显优于B组(P<0.05);而在功能锻炼状态下,两组术后VAS差异无统计学意义(P>0.05)。两组患者的术前及术后KSS及WOMAC差异均无统计学意义(P>0.05)。A组患者的曲马多用量小于B组患者,但差异无统计学意义(P>0.05)。结论膝关节后侧方LIA对TKA术后患者的镇痛效果,在静息条件下明显优于膝关节前方LIA,并可减少术后口服阿片类药物的用量。对于TKA术后患者,建议加强膝关节后侧方区域的浸润镇痛而非单纯伤口等前方镇痛,能够有效控制患者术后早期的静息痛。

关键词: 全膝关节置换术, 疼痛管理, 麻醉, 浸润

Abstract: Objective To evaluate the efficacy of local infiltration anesthesia(LIA) in different injection regions after total knee arthroplasty(TKA). Methods In our hospital, from March 2017 to June 2018, 100 patients underwent unilateral primary TKA due to knee osteoarthritis were prospectively studied. Random number grouping method was used to randomly divide into 2 groups:posterior and lateral infiltration anesthesia group (Group A) and anterior infiltration anesthesia group (group B). Group A received analgesic drugs inposterior and lateral area [interspace between the popliteal artery and posterior capsule of the knee (IPACK) and attachment of medial collateral ligament(MCL) and lateral collateral ligament(LCL)] and received normal saline(NS) 20 mL in anterior area (synovium of suprapatellar bursa, quadriceps tendon and incision). On the contrary, group B received 20 mL NS in posterior and lateral area, and received analgesic drugs in anterior area. The baseline information, preoperative and postoperative Visual Analogue Scale(VAS), American Knee Society Score(KSS) and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were recorded. In addition, the postoperative dosage of tramadol was also recorded. Results There was no significant difference and preoperative VAS between two groups. There was significant difference in postoperative VAS score between two groups at rest (P<0.05), but not at dynamic state (P>0.05). There was no significant difference in preoperative and postoperative KSS and WOMAC between the two groups (P>0.05). The average dose of tramadol used in group A was lower than that in group B, but there was no statistically significant difference (P>0.05). Conclusion Posterior and lateral local infiltration anesthesia was obviously effective after TKA than the anterior LIA at rest and can reduce the dosage of oral analgesics. We recommend to strengthen the infiltration analgesia in the posterior and lateral area of the knee joint rather than simplely anterior analgesia, such as wounds. Posterior and lateral LIA can effectively control early postoperative pain of TKA patients at rest.

Key words: total knee arthroplasty, pain management, anesthesia, infiltration

中图分类号:

R687.4

赵潇雄, 张博, 任世祥, 马德思, 陈彤, 林源. 局部浸润麻醉对全膝关节置换术后早期镇痛效果的影响[J]. 首都医科大学学报, 2021, 42(1): 138-142.

Zhao Xiaoxiong, Zhang Bo, Ren Shixiang, Ma Desi, Chen Tong, Lin Yuan. Local infiltration anesthesia for early analgesic effect after total knee arthroplasty[J]. Journal of Capital Medical University, 2021, 42(1): 138-142.

参考文献

[1] Koyuncu S, Friis C P, Laigaard J, et al. A systematic review of pain outcomes reported by randomised trials of hip and knee arthroplasty[J]. Anaesthesia, 2020.
[2] Bonnefoy-Mazure A, Favre T, Praplan G, et al. Associations between gait analysis parameters and patient satisfaction one year following primary total knee arthroplasty [J]. Gait Posture, 2020, 80:44-48.
[3] Calvisi V, Camillieri G, Lupparelli S. Resurfacing versus nonresurfacing the patella in total knee arthroplasty: a critical appraisal of the available evidence [J]. Arch Orthop Trauma Surg, 2009,129(9):1261-1270.
[4] Erivan R, Jacquet C, Villatte G, et al. Epidemiology of painful knee after total knee arthroplasty in a tertiary care center: assessment by decision tree[J]. Knee, 2020, 27(3):1049-1056.
[5] Hinarejos P, Capurro B, Santiveri X, et al. Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty [J]. Knee Surg Sports Traumatol Arthrosc, 2016, 24(10):3299-3305.
[6] O'Neal J B, Freiberg A A, Yelle M D, et al. Intravenous vs oral acetaminophen as an adjunct to multimodal analgesia after total knee arthroplasty: a prospective, randomized, double-blind clinical trial [J]. J Arthroplasty, 2017,32(10):3029-3033.
[7] Shi S B, Wang X B, Song J M, et al. Efficacy of intravenous acetaminophen in multimodal management for pain relief following total knee arthroplasty: a meta-analysis [J]. J Orthop Surg Res, 2018, 13(1):250.
[8] Kerr D R, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients [J]. Acta Orthop, 2008, 79(2):174-183.
[9] Kim D H, Beathe J C, Lin Y, et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection enhances postoperative pain control in total knee arthroplasty: a randomized controlled trial[J]. Anesth Analg, 2019, 129(2):526-535.
[10]Abdallah F W, Chan V W, Gandhi R, et al. The analgesic effects of proximal, distal, or no sciatic nerve block on posterior knee pain after total knee arthroplasty: a double-blind placebo-controlled randomized trial [J]. Anesthesiology, 2014, 121(6):1302-1310.
[11]Kong D Y, Oh J H, Choi W R, et al. The Impact of Epinephrine in the periarticular injection cocktail using ropivacaine for total knee arthroplasty: a prospective, randomized, double-blind comparison study[J]. J Arthroplasty, 2020, 35(9):2439-2443.
[12]Michalik R, Rath B, Springorum H R, et al. Anterior knee pain after total knee arthroplasty: Causes, diagnosis and treatment [J]. Orthopade, 2016, 45(5):386-398.
[13]Fuzier R, Serres I, Bourrel R, et al. Analgesic drug consumption increases after knee arthroplasty: a pharmacoepidemiological study investigating postoperative pain [J]. Pain, 2014,155(7):1339-1345.
[14]Nakai T, Tamaki M, Nakamura T, et al. Controlling pain after total knee arthroplasty using a multimodal protocol with local periarticular injections [J]. J Orthop, 2013,10(2):92-94.
[15]齐新宇,黄蕊,朱斌,等.加速康复外科理念在人工全膝关节置换术麻醉管理中的应用进展[J].首都医科大学学报,2020,41(2):307-311.
[16]王敬,张亚美,罗珊,等.多模式镇痛方式对全膝关节置换术后患者镇痛效果分析[J].解放军医药杂志,2020,32(2):98-101.
[17]Kurtz S M, Ong K L, Lau E, et al. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021 [J]. J Bone Joint Surg Am, 2014, 96(8):624-630.
[18]Li C, Qu J, Pan S, et al. Local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis[J]. J Orthop Surg Res, 2018, 13(1):112-119.
[19]柴伟, 孙长鲛, 倪明, 等. 人工全膝关节置换术后早期胫骨内侧疼痛的病例对照研究 [J]. 中国骨伤, 2014, 27(4):269-273.
[20]Yan H, Cang J, Xue Z, et al. Comparison of local infiltration and epidural analgesia for postoperative pain control in total knee arthroplasty and total hip arthroplasty: A systematic review and meta-analysis [J]. Bosn J Basic Med Sci, 2016,16(4):239-246.
[21]Sankineani S R, Reddy A R C, Eachempati K K, 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.
[22]Thobhani S, Scalercio L, Elliott C E, 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.