关节镜下前交叉韧带重建术后早期疼痛管理的研究进展

目的 总结前交叉韧带重建（anterior cruciate ligament reconstruction,ACLR）术后早期疼痛管理方式,为促进ACLR术后功能康复选择合理且有效的疼痛管理方案。方法 广泛查阅近年国内外关于ACLR术后早期疼痛管理方案相关文献,并从改善术后疼痛效果方面进行综述。结果 目前物理治疗和口服药物有经济、简便等优势,但改善术后疼痛效果并不佳,常需要联合静脉注射或静脉泵等方式,也是目前缓解疼痛的常用方式;但为了满足患者镇痛需求,镇痛药物使用量往往较大,增加了各种不良反应发生风险。局部浸润镇痛（local infiltration analgesia,LIA）包括关节周围或关节内注射药物,可显著改善ACLR术后早期疼痛,达到与神经阻滞相似的术后疗效;LIA可作为代替神经阻滞的一种镇痛技术,并避免神经阻滞带来的相应支配肌肉无力,从而增加术后跌倒风险。其中关节周围注射镇痛效果更优,可避免关节内注射对软骨损伤的风险。但LIA的术后镇痛效果和时效性仍有待提升,可考虑将多模式混合药物LIA（联合关节内和关节周围）联合其他疼痛干预方式,发挥协同作用,以避免单一药物或单途径给...     

超声引导下左旋布比卡因复合硫酸镁股神经阻滞对前交叉韧带重建术后镇痛效果的影响

目的探讨左旋布比卡因复合硫酸镁用于超声引导下股神经阻滞对前交叉韧带重建术后镇痛效果的影响。方法选择择期行关节镜下前交叉韧带重建术患者107例,男66例,女41例,年龄25~60岁,ASAⅠ或Ⅱ级。将患者随机分为研究组(n=56)和对照组(n=51)。两组均在全麻诱导前实行超声引导患侧股神经阻滞,研究组给予0.25%左布比卡因和2%硫酸镁混合液20ml,对照组给予0.25%左布比卡因20ml。记录股神经感觉和运动阻滞情况,记录术后4、6、12、24和48h的静息和运动时VAS评分,记录术后48h内追加镇痛药情况、曲马多用量、术后48h满意度评分和术后48h内恶心呕吐等不良反应的发生情况。结果术后12h硫酸镁组静息和运动时VAS评分明显低于对照组(P0.05)。硫酸镁组需追加镇痛药5例(8.9%),明显少于对照组的10例(19.6%)(P0.05);硫酸镁组曲马多用量明显少于对照组(P0.05)。硫酸镁组股神经感觉和运动阻滞起效时间明显短于,感觉和运动阻滞持续时间明显长于,满意度评分明显高于对照组(P0.05)。两组恶心呕吐发生率差异无统计学意义。结论左旋布比卡因复合硫酸镁应用于超声引导股神经阻滞,可以缩短阻滞起效时间,延长阻滞持续时间,提高术后镇痛效果及患者的满意度,减少镇痛药物应用,并且不增加不良反应的发生。     

全膝关节置换术不同方法术后镇痛效果的比较

人工膝关节置换术(total knee arthroplasty TKA)后重度疼痛发生率很高,主要是由于手术引起的神经刺激及炎症反应所致.本研究对全膝关节置换术病人实施关节腔内及关节周围注射药物复合硬膜外吗啡镇痛,并与实施硬膜外阻滞者比较,观察其镇痛效果,现报道如下.     

3种多模式镇痛对全膝关节置换术后疼痛及关节功能的对比研究

目的探讨3种多模式镇痛方案对全膝关节置换术后疼痛及膝关节功能的影响。方法使用平行对照(组间相互对照)的方法,将因骨性关节炎行单侧全膝关节置换术的90例患者采用完全随机的方法分为3组,每组30例,并分配不同的多模式镇痛方案。术前所有患者均口服塞来昔布进行预防性镇痛,术后返回病房均采用多模式镇痛静滴帕瑞昔布钠和冰敷。关节注射组:术中膝关节周围注射混合药物;神经阻滞组:手术完毕后行单次股神经阻滞和坐骨神经阻滞;联合组:术中膝关节周围注射混合药物与术后股神经阻滞和坐骨神经阻滞联合镇痛。采用视觉模拟评分法(visual analog scale,VAS)对患者入院时、术后6、12、24、48、72 h膝关节静息及运动状态疼痛评分;比较患者入院时、术后第3 d、术后1周及术后1个月关节活动度;记录术后不良反应、镇痛药物补救次数及镇痛满意度。结果采用神经阻滞组和联合组在术后不同时间点的静息及运动状态的疼痛评分、镇痛药物补救次数低于关节注射组(P<0.05),神经阻滞组及联合组之间无统计学差异(P>0.05);神经阻滞组和联合组术后不同时间的关节活动度、镇痛满意度高于关节注射组(P<0.05),神经阻滞组及联合组之间无统计学差异(P>0.05);3组患者术后不良反应发生率无统计学差异(P>0.05)。结论神经阻滞多模式镇痛方案能有效控制全膝关节置换术患者术后疼痛,恢复关节功能,节约医药资源,值得临床推广应用。     

股神经阻滞复合局部麻醉下膝关节置换术的镇痛效果

目的探讨连续股神经阻滞复合局部浸润麻醉在膝关节置换术后中的镇痛效果,同时观察该镇痛方式对患者血清皮质醇(Cor和P物质(SP)及炎症因子的影响。方法选取2016年2月至2019年2月于医院择期行单侧膝关节置换术的78例患者按照随机数字表法分为2组,各39例。对照组于超声引导下实施连续股神经阻滞镇痛;观察组采用连续股神经阻滞复合局部浸润麻醉镇痛。评价两组病人术后不同状态、不同时点时疼痛程度,记录两组镇痛期间额外使用镇痛药物次数及不良反应,评价两组镇痛满意度。检测两组麻醉前后血清Cor、SP及炎症因子(IL-6、hs-crp)水平。结果观察组静息、运动状态下不同时点(12、24、48、72小时)VAS评分均明显低于对照组,P0.05。观察组额外使用镇痛药物次数平均为(0.54±0.21)次明显少于对照组(1.79±0.75)次,t=10.023,P=0.000;观察组镇痛满意度为97.44%(38/39)明显高于对照组84.62%(33/39),χ~2=3.924,P=0.048。两组患者麻醉后血清Cor、SP、IL-6、hs-crp水平明显高于麻醉前,而对照组升高较观察组显著,P0.05。两组镇痛期间未出现呕吐等不良反应。结论连续股神经阻滞复合局部浸润麻醉应用膝关节置换术后镇痛效果显著,且可减少应激反应和炎症反应,具有较高安全性。     

超声引导下不同入路髂筋膜间隙阻滞用于老年患者股骨近端防旋髓内针内固定术围术期镇痛效果的比较

目的 比较超声引导下腹股沟韧带上髂筋膜间隙阻滞（S-FICB）与腹股沟韧带下髂筋膜间隙阻滞（I-FICB）在行股骨近端防旋髓内针内固定术老年患者围术期的镇痛作用。
方法 限期行股骨近端防旋髓内针内固定术的股骨粗隆间骨折患者80例,男43例,女37例,年龄65～85岁,ASA Ⅰ—Ⅲ级,随机分为两组：S-FICB组（S组）和I-FICB组（I组）,每组40例。S组和I组分别注射0.4%罗哌卡因40 ml行S-FICB和I-FICB。记录阻滞操作时间、股神经及股外侧皮神经阻滞起效时间及阻滞效果。记录术后2、6、12、24、48 h静息及运动时VAS疼痛评分、自控镇痛按压次数及补救镇痛情况。记录术后不良反应的发生情况。
结果 两组阻滞操作时间、股神经阻滞效果差异无统计学意义。S组股神经及股外侧皮神经阻滞起效时间明显短于I组（P<0.05）,股外侧皮神经阻滞效果明显优于I组（P<0.05）。S组术后2、6、12 h运动时VAS疼痛评分明显低于I组（P<0.05）。两组术后自控镇痛、补救镇痛及不良反应发生率差异无统计学意义。
结论 与I-FICB比较,S-FICB阻滞起效更快,股外侧皮神经阻滞效果更好,患者术后变换体位时镇痛效果更好。     

罗哌卡因复合液关节周围注射对膝关节置换术后镇痛的效果评价

背景：屈曲畸形骨关节炎患者行全膝关节置换术中进行大范围软组织松解,术后存在较严重的急性疼痛,导致早期功能恢复不佳而影响手术效果。目前有多种围手术期镇痛模式,其中关节周围注射复合镇痛药物简单易行,可较好控制置换术后的早期疼痛,减少不良反应。目的：观察罗哌卡因复合液关节周围注射在屈曲畸形骨关节炎患者行全膝关节置换术后的镇痛效果及其对早期功能恢复的作用。方法：60例屈曲畸形骨关节炎患者均接受初次单侧全膝关节置换术,随机分为2组：对照组（n=30）接受术后静脉自控镇痛治疗,实验组（n=30）接受术后静脉自控镇痛治疗,同时术中在关节周围注射复合麻醉药物（盐酸罗哌卡因＋肾上腺素）。评估手术前后患膝静止和活动时的视觉模拟疼痛评分（VAS）及活动范围,比较两组术后早期镇痛效果及早期功能恢复情况。结果：实验组术后4、8、12、24、36h患膝静息时和活动时VAS评分均小于对照组（P〈0.05）,活动范围大于对照组（P〈0.05）;实验组术后48h、3d运动时VAS评分小于对照组（P〈0.05）,静息时VAS评分与对照组比较无显著性差异（P〉0.05）,活动范围大于对照组（P〈0.05）;术后7d两组间VAS评分及活动范围无统计学差异（P〉0.05）。结论：关节周围注射罗哌卡因复合液可减轻屈曲畸形骨关节炎患者行全膝关节置换术后的早期疼痛,提高关节活动度,有助于早期功能恢复。     

局部注射含氯诺昔康的镇痛药物抑制痛觉致敏作用对全膝关节置换手术后疼痛控制的影响研究

目的探讨术中局部注射含氯诺昔康的镇痛药物配方与传统布比卡因配方对全膝关节置换术（TKA）术后疼痛控制的影响.方法 选择2008年1月～2009年8月在第三军医大学西南医院关节外科中心行TKA术的骨关节炎患者.将符合双盲对比研究的患者随机分为两组,传统布比卡因组（A组）78例,加用氯诺昔康组79例（B组）.所有患者施行标准化围手术期口服药物和神经阻滞PCA持续镇痛,每12小时记录术患者后疼痛评估结果,包括：（1）患者静息和被动活动VAS评分;（2）股四头肌肌力;（3）镇痛泵药品消耗量.结果 157例患者中共有12例被剔除.术后12 h两组间的指标无统计学差异（P〉0.05）;术后12～48 h,A组镇痛泵药物用量与B组有统计学差异（P〈0.05）;术后24～96 h,B组被动活动痛VAS评分与A组有统计学差异（P〈0.05）.两组患者间肌力无统计学差异（P〉0.05）.结论 TKA术区局部镇痛药物配方中NSAIDS药物的使用对术后早期镇痛的效果明显优于传统的布比卡因配方.其镇痛作用延长至术后96 h仍明显优于传统布比卡因配方,可能与消除了痛觉致敏有关.     

股神经和硬膜外自控镇痛在全膝关节置换术后的效果比较

目的：比较股神经和硬膜外自控镇痛在膝关节置换术后的效果和副作用。方法：选择ASAⅠ～Ⅱ级行单侧膝关节置换术患者50例,随机分为股神经自控镇痛组（PCFNA,n=25）和硬膜外自控镇痛组（PCEA,n=25）。均在单侧蛛网膜下腔阻滞麻醉下施术,术后通过留置导管连接0.2%罗哌卡因、2μg/mL芬太尼止痛泵镇痛。结果：两组在术后各时点静息VAS和吗啡用量、副作用的发生率无统计学差异。PCFNA组持续被动功能训练时的VAS疼痛评分均明显低于PCEA组患者（P〈0.01）;PCFNA组术后24h患肢股四头肌的肌力略低,非手术侧肌力略高（P〈0.000）。结论：股神经自控镇痛在持续被动运动镇痛效果优于硬膜外自控镇痛,不影响非手术侧股四头肌肌力,有利于早期下床活动。     

连续股神经阻滞镇痛与自控静脉镇痛在全膝关节置换术后镇痛的Meta分析（英文）

[目的]比较连续股神经阻滞镇痛和自控静脉镇痛在全膝关节置换术后的镇痛效果。[方法]运用计算机检索PubMed,Cochrane Library,EMBASE,BIOSIS,Ovid databases,中国知网和万方数据库以及手工检索方法收集自收录至2013年02月01日的相关参考文献。严格评价纳入研究的方法学质量并提取资料,统计软件采用RevMan5.0。[结果]共纳入23个随机对照试验,入选文献为10篇英文,13篇中文。Meta分析结果显示,连续股神经阻滞镇痛组的视觉模拟评分优于自控静脉镇痛组,术后24 h静息时视觉模拟评分(WMD=-1.38,95%CI:-2.66^-2.14,P<0.000 01),术后48 h活动时视觉模拟评分(WMD=-1.27,95%CI:-1.70-2.14,P<0.000 01),术后48 h活动时视觉模拟评分(WMD=-1.27,95%CI:-1.70^-0.85,P<0.00001)。然而,数据分析结果还表明连续股神经阻滞镇痛组的恶心呕吐发生率(RR=0.35,95%CI:0.09-0.85,P<0.00001)。然而,数据分析结果还表明连续股神经阻滞镇痛组的恶心呕吐发生率(RR=0.35,95%CI:0.09⁰.64,P=0.000 2)和头晕嗜睡发生率(RR=0.22,95%CI:0.120.64,P=0.000 2)和头晕嗜睡发生率(RR=0.22,95%CI:0.12⁰.42,P<0.000 01)比自控静脉镇痛组高。但是,连续股神经阻滞镇痛组和自控静脉镇痛组的低血压发生率(RR=1.06,95%CI:0.540.42,P<0.000 01)比自控静脉镇痛组高。但是,连续股神经阻滞镇痛组和自控静脉镇痛组的低血压发生率(RR=1.06,95%CI:0.54².07,P=0.87)、需要追加镇痛药例数(RR=0.56,95%CI:0.222.07,P=0.87)、需要追加镇痛药例数(RR=0.56,95%CI:0.22¹.48,P=0.24)和对镇痛效果满意例数(RR=1.92,95%CI:0.961.48,P=0.24)和对镇痛效果满意例数(RR=1.92,95%CI:0.96³.84,P=0.06)差异无统计学意义。[结论]连续股神经阻滞镇痛比自控静脉镇痛的镇痛效果好,但是连续股神经阻滞镇痛的副作用相对更多,由于患者对两者镇痛效果满意度及需要追加镇痛药物无明显差异,建议在全膝关节置换术后使用自控静脉镇痛,同时进一步探讨疼痛管理方案。     

Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES: Arthroscopic anterior cruciate ligament (ACL) reconstruction of the knee is a painful procedure requiring intensive postoperative pain management. This prospective study investigates analgesic quality after a femoral block as compared with intra-articular injection of local anesthetic. METHODS: Eighty patients scheduled for elective ACL repair under general anesthesia were included in our study. Upon completion of surgery, the patients were randomly assigned into 1 of 2 groups: femoral group (n = 40) received a femoral block with 20 mL 1% ropivacaine; intra-articular group (n = 40) received 20 mL 1% ropivacaine injected intra-articularly. During the first 24 hours after surgery, all patients received 2 g propacetamol and 100 mg ketoprofen, intravenously. Additional postoperative analgesia was available with parenteral morphine if required. Analgesic duration was defined as the time from end of surgery to the first requirement for a supplemental analgesic. Data collection included patient demographics, visual analog scale (VAS) scores, analgesic duration, and morphine use. Analysis of variance (ANOVA) test was used to compare the 2 groups. RESULTS: VAS score in the recovery room and during rehabilitation was higher in the intra-articular group than in the femoral group (P <.001). Morphine use was lower in the femoral group than in the intra-articular group (P <.001). Similarly, analgesic duration was longer in the femoral group than the intra-articular group (P <.0001). CONCLUSIONS: Compared with intra-articular injection of local anesthetic, femoral nerve block (FNB) provides better analgesia and allows a significant morphine-sparing effect after ACL repair.     

手法松解联合关节腔注射对前交叉韧带重建术术后关节僵硬患者关节功能的影响

目的 探讨手法松解联合关节腔注射对前交叉韧带（ACL）重建术后关节僵硬患者关节功能的影响。方法 回顾分析我院ACL重建术后关节僵硬性手法松解患者59例,根据是否行关节腔注射分成观察组和对照组,其中对照组27例,观察组32例。对照组患者行手法松解,观察组患者先行关节腔内注射,再行手法松解。记录两组患者治疗前和治疗后2周、4周、8周主动关节活动度（ROM）、活动时疼痛视觉模拟评分（VAS）、Lysholm膝关节评分和国际膝关节文献委员会（IKDC）膝关节评分,同时记录治疗时患者疼痛VAS评分。结果 观察组患者治疗后2周、4周和8周ROM、Lysholm评分和IKDC评分均显著高于对照组患者（P<0.05）。观察组患者治疗时、治疗后2 w、4 w和8 w 患膝疼痛VAS评分均显著低于对照组患者（P<0.05）。结论 手法松解联合关节腔注射可减轻ACL重建术后关节僵硬患者疼痛,增加膝关节活动度,改善膝关节功能。     

Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient arthroscopic anterior cruciate ligament repair

BACKGROUND AND OBJECTIVES: Femoral nerve block is effective in reducing postoperative pain after inpatient knee surgery. We studied its efficacy compared with standard analgesia following outpatient anterior cruciate ligament repair, including the duration of analgesia and the effect of different concentrations of bupivacaine. METHODS: After Institutional Review Board approval and informed consent, we prospectively randomized patients to receive, in a blinded fashion, either a sham block, a femoral nerve block with 25 mL 0.25% bupivacaine, or with 25 mL 0.5% bupivacaine after anterior cruciate ligament repair under epidural anesthesia. Verbal analog pain scores were evaluated by a blinded observer at 20 and 40 minutes after injection. Patients with pain >4 (out of 10) were assessed for the presence of a block and offered a supplemental block if no anesthesia was present at either evaluation. By prospective agreement, any study group with 6 failures was excluded from further recruitment. After discharge, patients recorded pain scores and analgesic consumption in a diary, and estimated the time at which they perceived that analgesia and sensory block from the femoral nerve block resolved, based on an increase in pain, sensation, and strength in the leg. RESULTS: In the sham block group, 6 of 12 patients reported inadequate analgesia in the postanesthesia care unit (4 at 20 minutes, 2 at 40 minutes; greater than other groups, P <.003) and were excluded from further study. Patients with sham blocks had higher pain scores 20 minutes after the block, and requested intravenous analgesia more often. Bupivacaine 0.25% and 0.5% provided 23.2 +/- 7 and 25.7 +/- 11 hours of analgesia, respectively. CONCLUSIONS: Femoral nerve block with 0.25% bupivacaine contributes significantly to multimodal postoperative analgesia in the immediate postoperative period following outpatient anterior cruciate ligament repair. Both doses of bupivacaine studied provided analgesia for the first night after surgery.     

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.     

内侧副韧带Ⅱ度损伤保守或手术修复对前交叉韧带重建后膝关节前后稳定性的影响

目的 探讨Ⅱ度内侧副韧带（MCL）损伤手术或保守治疗对前交叉韧带（ACL）重建前后稳定性的影响.方法 以54例膝关节ACL合并急性Ⅱ度MCL损伤患者为研究对象,所有患者受伤时间均〈1周,术前MRI检查示ACL连续性中断,MCL股骨、胫骨止点高信号,术前查体示前抽屉试验阳性,0°外翻应力试验阴性,30°外翻应力试验阳性.对所有患者术前行KT1000测量胫骨相对股骨前移度,膝关节活动度（ROM）,IKDC主观评分.将所有患者随机分为A、B两组,对A组患者采取关节镜下ACL异体单束重建＋MCL切开修复术;B组行单纯ACL异体单束重建,MCL采取支具固定保守治疗6周.术后1年对所有患者行IKDC评分、ROM测量、KT1000评价临床效果.结果 所有患者术后1年IKDC评分、KT 1000测量较术前均有统计学差异 （ t=13.699,9.553;P〈0.05）;A组患者IKDC主观评分与B组比较结果无统计学差异（2=6.273,P〉0.05）,两组患者术前术后关节活动度无统计学差异（t=0.672,P〉0.05）,A组患者术后膝关节前后稳定性改善（KT 1000测量值）较B组明显改善,且结果比较有统计学意义（t=0.932,P〈0.05）.结论 膝关节Ⅱ度MCL损伤合并ACL损伤建议MCL修复＋ACL重建一期手术完成.     

内侧副韧带Ⅱ度损伤保守或手术修复对前交叉韧带重建后膝关节前后稳定性的影响

目的 探讨Ⅱ度内侧副韧带（MCL）损伤手术或保守治疗对前交叉韧带（ACL）重建前后稳定性的影响.方法 以54例膝关节ACL合并急性Ⅱ度MCL损伤患者为研究对象,所有患者受伤时间均〈1周,术前MRI检查示ACL连续性中断,MCL股骨、胫骨止点高信号,术前查体示前抽屉试验阳性,0°外翻应力试验阴性,30°外翻应力试验阳性.对所有患者术前行KT1000测量胫骨相对股骨前移度,膝关节活动度（ROM）,IKDC主观评分.将所有患者随机分为A、B两组,对A组患者采取关节镜下ACL异体单束重建＋MCL切开修复术;B组行单纯ACL异体单束重建,MCL采取支具固定保守治疗6周.术后1年对所有患者行IKDC评分、ROM测量、KT1000评价临床效果.结果 所有患者术后1年IKDC评分、KT 1000测量较术前均有统计学差异 （ t=13.699,9.553;P〈0.05）;A组患者IKDC主观评分与B组比较结果无统计学差异（2=6.273,P〉0.05）,两组患者术前术后关节活动度无统计学差异（t=0.672,P〉0.05）,A组患者术后膝关节前后稳定性改善（KT 1000测量值）较B组明显改善,且结果比较有统计学意义（t=0.932,P〈0.05）.结论 膝关节Ⅱ度MCL损伤合并ACL损伤建议MCL修复＋ACL重建一期手术完成.     

The effect of intra-articular methadone on postoperative pain following anterior cruciate ligament reconstruction

BACKGROUND: Intra-articular narcotics have proven efficacy for providing pain relief following knee arthroscopy. This effect is short-lived. Methadone, with its long serum half-life (thirty-five hours, compared with two hours for morphine) could provide improved and prolonged pain relief. The purpose of the present study was to examine the effects of an intra-articular injection of methadone on postoperative analgesia following arthroscopic anterior cruciate ligament reconstruction. METHODS: Sixty-five skeletally mature patients undergoing primary anterior cruciate ligament reconstruction were randomly assigned to one of three groups, all of which received an intra-articular injection consisting of 9.5 mL of 0.5% bupivacaine with 1:200,000 epinephrine at the completion of the procedure. In addition, the remaining 0.5 mL of the syringe was filled with one of three substances. The study group (twenty-five patients) received 5 mg of methadone, the comparison group (twenty-one patients) received 5 mg of morphine, and the control group (nineteen patients) received 0.5 mL of saline solution. All supplemental pain medications were given on an as-needed basis, recorded, and converted to morphine equivalents. Specific variables that were measured included supplemental analgesia requirements during both the inpatient period and the outpatient period (from the time of discharge to the seventh postoperative day) and pain scores. RESULTS: There was no significant difference in inpatient (p = 0.998) or outpatient (p = 0.887) supplemental analgesic requirements or pain scores between the methadone group (Group 1) and the control group (Group 3). The morphine group (Group 2) required significantly less inpatient (p = 0.014) and outpatient (p = 0.044) supplemental analgesia compared with the control group (Group 3). There were no complications. CONCLUSIONS: The present report represents the first known study of the use of intra-articular methadone and establishes that this analgesic is safe at a single dose of 5 mg. At this dose, however, methadone does not provide improved postoperative analgesia following arthroscopic anterior cruciate ligament reconstruction. In contrast, intra-articular morphine does appear to be effective for decreasing postoperative pain.     

Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: a randomized clinical trial

BACKGROUND: Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. METHODS: Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1-4 and 7 to determine NRS scores (scale 0-10). RESULTS: Data from 233 participants were analyzed. On days 1-2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1-4, group II was the only factor predicting lower pain scores (odds ratios, 0.3-0.5; P = 0.001-0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1-7 (odds ratios, 3.3-5.2; P < 0.001). CONCLUSIONS: Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.     

脱蛋白骨复合牛骨形态发生蛋白（BMP）对前交叉韧带重建术后骨隧道扩大的影响

目的探讨兔异体脱蛋白松质骨（deproteined bone,DPB）复合骨形态发生蛋白（bone morphogenetic protein,BMP）对前交叉韧带重建术后骨隧道扩大的影响。方法取96只成年新西兰大白兔用自体半腱肌腱进行膝关节前交叉韧带重建,共分4组,DPB＋BMP组在股骨隧道内植入DPB-BMP复合体,DPB组和BMP组分别在股骨隧道内植入DPB、BMP,空白对照组的股骨隧道内不植入任何材料。于术后4、8、12、16周时分别处死各组中的6只动物,切取标本,测量股骨隧道的宽度,计算隧道扩大率。结果术后4周时,DPB＋BMP组、DPB组、BMP组及空白对照组的骨隧道扩大率分别为（23.52±0.43）%、（34.83±0.52）%、（51.57±0.76）%、（56.90±0.81）%,术后8周为（22.21±0.34）%、（35.35±0.46）%、（60.97±0.63）%、（67.18±0.70）%,术后12周为（21.94±0.37）%、（33.01±0.41）%、（50.56±0.54）%、（54.61±0.55）%,术后16周为（20.96±0.35）%、（32.11±0.50）%、（49.29±0.66）%、（53.31±0.59）%,各时点骨隧道扩大率DPB＋BMP组〈DPB组〈BMP组〈空白对照组，差异均有显著性（P〈0．05）。结论脱蛋白骨复合BMP能减轻前交叉韧带重建术后的骨隧道扩大程度。