Post-operative analgesia following total knee replacement: an evaluation of the addition of an obturator nerve block to combined femoral and sciatic nerve block

BACKGROUND: Femoral and sciatic nerve block may not provide complete post-operative analgesia following total knee replacement. This study was designed to evaluate whether the addition of an obturator nerve block to combined femoral and sciatic nerve block improves the quality of post-operative analgesia following primary total knee replacement. METHODS: Sixty patients were randomised into one of two groups: combined femoral and sciatic nerve block with 15 ml 0.75% ropivacaine to each nerve or combined femoral and sciatic nerve block with 15 ml 0.75% ropivacaine to each nerve and an obturator nerve block with 5 ml 0.75% ropivacaine. RESULTS: Peripheral nerve blocks were successful in 85% of patients. The group which received the obturator nerve block showed a significant increase in the time until their first request for analgesia (mean 257.0 vs. 433.6 min) and a significant reduction in the total requirements for morphine throughout the study period (mean 83.8 vs. 63.0 mg) (P<0.05). There were no systemic or neurological sequelae in any of the groups. CONCLUSIONS: The addition of an obturator nerve block to femoral and sciatic blockade improved post-operative analgesia following total knee replacement.     

全膝关节置换术后镇痛治疗

充分、有效的术后镇痛是全膝关节置换术(TKR)后功能锻炼的有力保证,直接关系到术后恢复和手术效果.目前TKR术后镇痛策略主要有超前镇痛和多模式复合术后镇痛.多数学者认为外周神经阻滞和硬膜外镇痛的效果更为可靠,而外周神经阻滞的术后并发症少,更为理想.     

连续股神经阻滞在全膝关节置换术后镇痛及早期康复锻炼中的作用

目的：前瞻性评价连续股神经阻滞在全膝关节置换术后镇痛及早期康复锻炼中的作用。方法：自2008年12月至2009年8月,将进行单侧全膝关节置换术的80例患者进行配对设计随机分组,每组40例。A组采用术后股神经阻滞,B组采用静脉止痛泵镇痛。A组男5例,女35例,平均年龄(65.0±4.2)岁;B组男5例,女35例,平均年龄(64.7±8.5)岁。两组患者术后镇痛持续3 d.记录VAS疼痛评分、睡眠状态、膝关节功能锻练情况和不良反应发生状况。结果：A组患者在术后2、6、24、36、48、56、72 h的VAS评分明显低于B组(P<0.05或P<0.01);A组睡眠状态好于B组。A组患者术后的膝关节主动活动早于B组,B组不良反应发生例数明显大于A组,并且B组止痛药的使用频率高于A组。结论：连续股神经阻滞术后镇痛,效果良好,安全性能好,不良反应发生率低,是全膝关节置换术后理想的镇痛方法也利于患膝关节术后的功能恢复。     

连续股神经阻滞镇痛与静脉镇痛用于全膝关节置换术后快速康复的比较

目的比较连续股神经阻滞（continuous femoral nerveblock,CFNB）镇痛与静脉镇痛用于全膝关节置换术（total knee arthroplasty,TKA）后的快速康复效果。方法择期行单侧TKA患者60例,年龄45。78岁,ASA分级I、Ⅱ级,采用随机数字表法分为两组（每组30例）：患者自控神经阻滞镇痛（patient controlled nerve block analgesia,PCNA）组与患者自控静脉镇痛（patient controlled intravenous analgesia,PCIA）组。两组均采用蛛网膜下腔顿膜外腔联合麻醉。观察患者术后静息和运动时VAS评分、患者自控镇痛（patient-contmlled analgesia,PCA）泵按压次数及补救性镇痛药应用次数,观察术后患肢膝关节主动屈曲角度、术后血糖变化、术后平均住院日、并发症、副作用及满意度。结果术后6、12、24、48h静息状态下,两组VAS评分差异无统计学意义（P〉O．05）;与PCIA组比较,PCNA组术后24、48h被动运动时VAS评分降低[（3．6±0．5）分比（4．7±0．6）分、（3．4±0．5）分比（4．5±0．4）分]（P〈O．05）,PCA泵按压次数及肌内注射哌替啶次数减少（P〈0．05）。与PCIA组比较,PCNA组术后24、48h患肢膝关节主动屈曲角度增大（P〈0．05）,术后各时点血糖水平降低（P〈O．05）,深静脉血栓形成并发症及嗜睡、呼吸抑制等副作用减少（P〈O．05）;PCNA组术后满意度评分高于PCIA组[（9．6±1．4）分比（7．9±1．2）分]（P〈O．05o结论与静脉镇痛比较,CFNB用于TKA术后镇痛效果确切、并发症及副作用少、住院时间缩短、术后恢复快、总体满意度高,符合快速康复外科理念。     

全膝关节置换术后应用连续股神经阻滞镇痛和静脉自控镇痛的效果比较

目的比较连续股神经阻滞镇痛（CFNB）和静脉患者自控镇痛（PCIA）在全膝关节置换手术（TKA）围手术期的镇痛效果及术后1年膝关节功能评估的随访结果。方法选取2008年11月至2009年10月因膝关节骨关节炎行TKA的患者60例,数字随机分成2组,每组30例（n=30）。分别给予PCIA和CFNB作为术后镇痛方式。两组患者均采用腰麻联合硬膜外麻醉方式。在围手术期,采用视觉模拟（VAS）评分法观察患者的疼痛评分。记录吗啡累计用量,观察患肢肌力,初次下地时间及镇痛相关并发症等指标。在术后1年随访时,根据膝关节学会评分系统（KSS）对患者膝关节功能进行评估。结果在术后6、12、24、36、48h静息状态下,CFNB组的疼痛评分（VAS评分）均比PCIA组明显低（P〈0.05）。术后24h,48h进行膝关节持续被动活动（CPM）时累计吗啡用量均比PCIA组明显低（P〈0.05）。嗜睡、恶心呕吐等不良反应也低于PCIA组。术后1年,两组在膝关节功能评价方面无显著差异（P〉0.05）。结论 CFNB在TKA术中的初期镇痛效果优于PCIA。与PCIA相比,CFNB患者术后不良反应较少,膝关节功能恢复更好,患者的满意程度更高。为TKA术后镇痛策略中一种安全、实用和有效的方法。术后1年,两组患者在功能评估方面无统计学差异。     

The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement

BACKGROUND AND OBJECTIVES: The benefit of adding a sciatic nerve block to the femoral block to improve analgesia after total knee replacement is controversial. The aim of this study is to address this controversy in a prospective, comparative, and randomized study. METHODS: Patients were allocated randomly to receive a continuous femoral nerve block or continuous blocks of both the femoral and sciatic nerves. Stimulating catheters were used in all cases. A loading dose of 15 mL ropivacaine 0.75% was injected into each catheter, followed by administration of ropivacaine 0.2% (2-5 mL/h infusion via the femoral catheter; bolus 10 mL repeated every 12 hours in the sciatic catheter). The primary outcome was visual analog scale (VAS) scores (0 = no pain, 100 mm = worst pain) in postanesthesia care unit and in the 48-hour period after surgery. The secondary outcomes were amplitude of knee flexion, morphine consumption, and occurrence of postoperative nausea and vomiting (PONV). RESULTS: The VAS scores at rest were significantly higher when there was only continuous femoral nerve block than when there was both continuous femoral and sciatic nerve blocks. This difference progressively decreased and disappeared at 36 hours after surgery. The combined femoral and sciatic blocks decreased the morphine consumption by 81% and significantly decreased the occurrence of PONV. CONCLUSION: During the 36 hours immediately after total knee replacement, the combination of continuous femoral and sciatic nerve blocks improves analgesia while decreasing morphine consumption and PONV.     

Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement.

We have investigated the value of a 3-in-1 nerve block, followed by a continuous low-dose infusion of bupivacaine into the femoral nerve sheath for postoperative analgesia after total knee replacement. Thirty-seven patients were randomly allocated to either a control group or a study group. The study group had a catheter placed in the ipsilateral femoral nerve sheath. A 3-in-1 nerve block was then performed in the study group with injection of 30 mL of 0.25% bupivacaine through the catheter. This was followed by a continuous infusion of 0.125% bupivacaine at 6 mL/h. The study group had significantly lower pain scores 4 and 24 h postoperatively (P less than 0.01) and required less postoperative opioid analgesic medication (P less than 0.01) than the control group. The authors conclude that a continuous low-dose infusion into the femoral nerve sheath results in better pain relief than conventional intramuscularly administered narcotics after total knee arthroplasty.     

神经阻滞在膝关节置换术后镇痛的应用研究

目的全膝关节置换术(TKA)是治疗终末期膝关节骨关节炎和类风湿性关节炎的最有效方法,而术后疼痛管理效果是直接影响患者功能康复的重要因素之一。因此,本研究试图探索股神经阻滞(FNB)联合膝关节周围局部浸润阻滞(PAI)在TKA术后早期的镇痛效果,并讨论分析其临床应用价值及前景。 方法根据纳入标准及排除标准,回顾性纳入2018年10月8日至2019年2月8日因骨关节炎和类风湿性关节炎在关节病院骨坏死与关节重建病区行TKA的126例患者,接受PNB＋PAI者为实验组,接受FNB＋内收肌管阻滞(ACB)者为对照组,每组63例,所有患者的手术均由同一术者完成。分别采用t检验比较两组患者术前、术后6、12、24、48、72 h膝关节视觉模拟疼痛评分(VAS)、阿片类药物用量及膝关节活动度(ROM),采用卡方检验比较两组恶心呕吐发生率。 结果两组患者术前人口学特征及术前VSA评分差异无统计学意义(P>0.05),所有患者均随访72 h。术后6、12、24 h实验组VAS评分低于对照组(t＝3.232、2.946、3.146,P<0.05),术后48、72 h两组VAS评分差异无统计学意义(t ＝0.527、1.108、P>0.05),术后24 h实验组膝关节活动度优于对照组(t＝3.082,P<0.05),术后48、72 h两组患者膝关节活动度(t＝0.543、0.902,P>0.05)、阿片类药物用量(t＝0.857,P>0.05)、恶心呕吐发生率(χ²＝52.29,P>0.05)在两组差异无统计学意义,两组患者均未出现股四头肌无力、局部血肿等不良并发症。 结论FNB＋PAI在TKA术后早期疼痛管理中效果确切,同FNB＋ACB相比,在术后24 h内的镇痛作用及膝关节活动度更优,因此,该方法可以作为FNB＋ACB的替代方法,并可以在TKA中推广应用。     

股神经阻滞用于全膝关节置换术患者术后镇痛的Meta分析

目的 采用Meta分析的方法评价股神经阻滞(femoral nerve block,FNB)对全膝关节置换术(total knee arthroplasty,TKA)患者术后镇痛的效果. 方法 检索PubMed、OVID、EMBASE、Cochrane图书馆,检索时间从建库至2014年11月.收集在TKA术后使用FNB与患者自控静脉镇痛(patient-controlled intravenous analgesia,PCIA)或患者自控硬膜外镇痛(patient-controlled epidural analgesia,PCEA)的临床随机对照实验(randomized controlled trial,RCT).采用Cochrane协作网系统评价法评价纳入文献的质量,采用RevMan5.2软件进行Meta分析评价. 结果 共纳入14项研究,包括1 157例患者,其中FNB组616例,PCIA组380例,PCEA组161例.与PCIA组比较,FNB有效减少了患者术后24 h[加权均数差(weighted mean difference,WMD)=-17.93,95％置信区间(confidence interval,CI)=-27.38～-8.49]及48 h(WMD=-25.70,95％CI:-41.67～-9.74)的吗啡累计消耗量,降低患者术后24 h活动时VAS(WMD=-1.99,95％CI:-3.14～-0.85)(P＜0.05);且FNB组患者术后恶心呕吐比值比(odds ratio,OR)(0.31,95％CI:0.22～0.44)、尿潴留(OR=0.24,95％CI:0.13～0.43,P＜0.05)及头晕的发生率(OR=0.27,95％CI:0.14～0.52)都较低(P＜0.05). 结论 比较PCIA及PCEA,FNB可能是TKA患者术后镇痛的一种更好的选择.     

Effectiveness of 3-in-1 continuous femoral block of differing concentrations compared to patient controlled intravenous morphine for post total knee arthroplasty analgesia and knee rehabilitation

We assessed the effectiveness of the 3-in-1 continuous femoral block as a form of postoperative pain relief for unilateral total knee arthroplasty (TKA). Sixty patients undergoing elective unilateral TKA under subarachnoid block were randomized into three groups. Postoperative analgesia was provided with a continuous 3-in-1 femoral nerve catheter with 0.15% ropivacaine in group A, a continuous 3-in-1 femoral nerve catheter with 0.2% ropivacaine in group B, or patient controlled intravenous morphine in group C (control group). Groups A and B received patient controlled intravenous morphine pumps for rescue analgesia. Patients in each group were followed for 72 hours postoperatively. Five patients were excluded after randomization. In the remaining 55 patients there was no statistical difference in pain score between the groups. Total morphine use was highest in group C (P < 0.05). No appreciable difference could be found with sensorimotor blockade, morphine usage and satisfaction scores when comparing groups A and B. Femoral catheter dislodgement rate was 7.9%. There was no statistical difference between the groups when comparing the day of first ambulation and the time to discharge from the hospital. Satisfaction scores were higher in group A (P = 0.028) and group B (P = 0.002) compared to group C. We conclude that a continuous 3-in-1 femoral nerve block with ropivacaine 0.15% or 0.2% for elective unilateral TKA has an opioid-sparing effect.     

The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement

PURPOSE: To compare the efficacy of a continuous posterior lumbar plexus (PSOAS) block to a continuous three-in-one femoral nerve (FEM) block in patients undergoing primary total knee replacement (TKR). METHODS: Sixty patients were randomly allocated to receive iv patient-controlled morphine analgesia (PCA), PCA plus a continuous FEM block with 30 mL ropivacaine 0.5% and epinephrine 1:200,000 bolus followed by an infusion of ropivacaine 0.2% at 12 mL.hr(-1) for 48 hr, or PCA plus a continuous PSOAS block with the same bolus and infusion regimen as the FEM group. Postoperative morphine consumption, verbal analogue scale pain scores at rest and during physiotherapy, and evidence of sensory and motor blockades were noted. RESULTS: Both regional techniques significantly reduced 48 hr morphine consumption (FEM 37.3 +/- 34.7 mg, P = 0.0002; PSOAS 36.1 +/- 25.8 mg, P < 0.0001) compared to PCA (72.2 +/- 26.6 mg). Pain scores at rest, six and 24 hr after TKR were lower in the FEM and PSOAS groups compared to the PCA group (P < 0.0001). Although sensory and motor blockades of the obturator nerve were achieved more often in the PSOAS group than in the FEM group (P < 0.0001), morphine consumption and pain scores did not differ between the two groups. CONCLUSION: Both continuous PSOAS block and continuous three-in-one FEM block provided better analgesia than PCA but no differences were seen between the two regional techniques.     

The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay after total knee replacement

BACKGROUND AND OBJECTIVES: Continuous-infusion femoral nerve block (FNB) improves analgesia and rehabilitation after total knee replacement. In this study, we investigated the efficacy of single-injection FNB to achieve similar results. METHODS: A total of 30 patients were prospectively and randomly assigned to receive 40-mL injections of either 0.25% bupivacaine (group B) or saline (group S) after total knee replacement. Blinded observers evaluated the patients for postoperative pain, morphine consumption, ambulating distances, and maximal knee flexion; pain was scored on the visual analog scale (VAS). RESULTS: Compared with group S patients, group B patients had significantly lower VAS pain scores (P <.01 in the postoperative anesthesia care unit, P <.05 on the day after surgery); group B patients also showed significantly lower total morphine use (P <.05) and a lower incidence of morphine-related side effects. Significantly more group B than group S patients could ambulate on the day after surgery (93% v 46%, P <.05), and mean ambulatory distance was significantly better for group B than group S patients at discharge (166 +/- 37 v 117 +/- 24 feet, P <.01). Knee flexion was significantly better for group B than group S patients on the second day after surgery (70 degrees v 60 degrees, P <.01), but the between-group difference was no longer statistically significant at discharge. Mean length of acute hospitalization was significantly shorter for group B (3 days; range, 3 to 5 days) than group S patients (4 days; range, 3 to 6 days, P <.05). CONCLUSIONS: Single-injection FNB provided effective analgesia, facilitated early ambulation, and reduced the length of acute hospitalization in patients undergoing total knee replacement.     

Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial

Because postoperative pain after total knee replacement (TKR) can be severe, we compared the analgesic efficacy of continuous femoral nerve blockade (CFNB) and continuous epidural analgesia (CEA) after TKR in this prospective randomized trial. Patients undergoing TKR under spinal anesthesia were randomized to receive either a femoral infusion of bupivacaine 0.2% (median infusion rate 9.3 mL/h) (n = 53) or an epidural infusion of ropivacaine 0.2% with fentanyl 4 microg/mL (median infusion rate 7.6 mL/h) (n = 55). Adjuvant analgesics were oral rofecoxib and oxycodone and IV morphine. Pain, nausea and vomiting, hypotensive episodes, motor block, range of knee movement, and rehabilitation milestones were assessed postoperatively. There were equivalent pain scores, range of movement, and rehabilitation in both groups. There was significantly less nausea and vomiting in the CFNB group (P < 0.002). The CFNB group received more rofecoxib (P < 0.04) and oxycodone (P < 0.005) than the CEA group. The operative limb displayed more motor block than the nonoperative limb in both groups at the level of the hip and knee for up to 48 h (P < 0.05, Mann-Whitney U-test), but there was no difference between groups in the nonoperative limb. CFNB is an effective regional component of a multimodal analgesic strategy after TKR.     

连续股神经阻滞镇痛对老年人全膝关节置换术后康复功能的影响

[目的] 比较连续股神经阻滞和硬膜外阻滞在全膝关节置换术后镇痛的效应和对康复功能的影响,寻求最佳的镇痛方案.[方法]选择ASA I～II拟行单侧全膝关节置换术老年患者50例,随机分为2组:连续股神经阻滞镇痛(CFNB)组和硬膜外镇痛(CEA)组.术后留置导管连接0.2%罗哌卡因+1ug/ml舒芬太尼止痛泵维持镇痛.记录术后6 h、12 h、24 h、48 h静息状态和术后24 h、48 h持续被动运动训练时VAS疼痛评分;观测术后12 h、24 h患肢主动关节屈曲角度;记录术后6 h储血罐内的引流量及术前、术后24 h、48 h血红蛋白浓度及副作用的发生率.[结果]术后各时点两组患者静息VAS无统计学差异,CFNB组术后24 h、48 h持续被动功能训练时的VAS疼痛评分(3.86±0.93和3.93±0.78),均明显低于CEA组患者(P<0.01);与CEA组比较,患肢主动关节屈曲角度、术后引流量和各时点血红蛋白浓度无统计学意义.两组副作用的发生率相似.[结论]连续股神经阻滞镇痛在持续被动运动时镇痛效应优于硬膜外镇痛,安全性高,操作简便,是TKA术后又一较为理想的镇痛方法.     

Continuous versus single-dose sciatic nerve block to complement a femoral block after total knee replacement surgery: a randomized clinical trial

INTRODUCTION: Performing a sciatic nerve block to complement a continuous femoral nerve block for analgesia after total knee arthroplasty is a subject of controversy. We compared the efficacy of a continuous sciatic nerve block to that of a single-dose block of the same nerve combined with a continuous femoral nerve block. MATERIAL AND METHODS: Patients received a continuous femoral nerve block by infusion of 0.2% ropivacaine, 0.4 mL x kg(-1), plus patient controlled analgesia and were randomized to receive a sciatic nerve block either by continuous infusion (0.5% ropivacaine, 20 mL, plus continuous infusion of 5 mh(-1)) or by a single 20 mL dose of 0.5% ropivacaine. The stimulating catheters remained indwelling for 72 hours after the operation. The main outcome measure was assessment of postoperative pain on a verbal numerical scale from 0 (no pain) to 10 (greatest pain) at rest and upon movement. RESULTS: The pain assessments upon movement of the operated joint were significantly greater after 24 hours in the group receiving a single dose of ropivacaine to block the sciatic nerve. The back of the knee was most often named as the location of pain. No adverse effects related to the analgesic technique were recorded, and the level of satisfaction was higher among patients receiving the continuous sciatic nerve block. CONCLUSION: Twenty-four hours after total knee replacement surgery, better analgesia was achieved with a continuous sciatic nerve block than with a single-dose block combined with a continuous femoral nerve block.