全髋、全膝关节置换术围术期多模式镇痛方法的临床观察

全髋关节置换术(total hip arthroplasty,THA)和全膝关节置换术(total knee arthroplasty,TKA)后的疼痛直接影响功能恢复.围术期采用多模式镇痛方法可取得更好的镇痛效果,减少阿片类麻醉性镇痛药的用量,降低不良反应的发生率.笔者对一组行THA和TKA的患者进行回顾性观察.现报告如下.     

全髋、全膝关节置换术围术期多模式镇痛方法的临床观察

全髋关节置换术(total hip arthroplasty,THA)和全膝关节置换术(total knee arthroplasty,TKA)后的疼痛直接影响功能恢复.围术期采用多模式镇痛方法可取得更好的镇痛效果,减少阿片类麻醉性镇痛药的用量,降低不良反应的发生率.笔者对一组行THA和TKA的患者进行回顾性观察.现报告如下.     

帕瑞昔布钠用于腹部小手术后镇痛效果的临床观察

 目的 探讨帕瑞昔布钠用于腹部小手术后镇痛的有效性及安全性.方法 择期硬膜外腔阻滞下行腹股沟疝修补、阑尾切除手术患者240例,随机等分为3组:实验组帕瑞昔布钠20mg组(PL组)、帕瑞昔布钠40mg组(PH组)及对照组(N组),每组80例.实验组于缝皮时静脉注入帕瑞昔布钠20mg、40mg;12 h后重复给予;对照组给予同等剂量生理盐水.采用视觉模拟量表(visual analogue scale,VAS)对术后2、4、8、12、18、24h进行疼痛评分,同时观察术后各种不良反应及对凝血功能的影响.结果 PL组和PH组在术后各时点的VAS评分均明显低于N组,对疼痛治疗满意度明显高于N组(P＜0.05);而PH组在术后12和24 h,2个时间点VAS评分明显低于PL组,对疼痛治疗满意度明显高于PL组(P＜0.05).结论 帕瑞昔布钠用于成年患者腹部小手术后每日两次可起到明显的镇痛效果、不良反应少,而且帕瑞昔布钠40mg较20 mg更有效.     

帕瑞昔布钠辅助应用于甲状腺手术局部麻醉效果观察

目的:观察帕瑞昔布钠在甲状腺手术局部麻醉中的麻醉效果及安全性。方法:选择甲状腺手术60例,随机分为局部麻醉组(A组)和局部麻醉联合帕瑞昔布钠组(B组)各30例。采用0.75%利多卡因行局部麻醉,麻醉前10min B组给予静脉注射帕瑞昔布钠40mg(用生理盐水稀释到2ml);A组给予静脉注射生理盐水2ml。观察并记录两组麻醉手术前后SBP、DBP、HR、SO2的变化,同时观察两组VAS评分和患者满意度。结果:B组不同时间节点的SBP、DBP及HR值显著低于A组,(P<0.05),SO2水平两组差异不显著(P>0.05)。B组VAS评分和患者对麻醉满意度均优于A组。结论:帕瑞昔布钠辅助应用于甲状腺手术局部麻醉效果优于单用利多卡因。     

术中静注帕瑞昔布钠对老年患者髋关节置换术术后疼痛的影响

目的观察和评价帕瑞昔布钠对老年患者接受全髋关节置换术术后急性疼痛的缓解程度。方法 50名病人随机分两组:P组,在缝合切口时给予帕瑞昔布钠40 mg静注;C组,给予5 ml的生理盐水静注。术后1 h内不追加镇痛药。两组患者在手术结束送出手术室时(T1)、术后1 h(T2)、术后6 h(T3)进行VAS疼痛评估。如病人术后追加镇痛药的时间不足6 h,则在追加镇痛药之前对患者作一次疼痛评分,此时的评分记作T3。结果患者术后各时点的VAS评分,T2、T3均有统计学意义(P<0.05)。两组病人在术后追加镇痛药的平均时间上相比,有统计学差异(P<0.05)。结论术中给予40 mg帕瑞昔布钠静注能够有效地缓解全髋关节置换术老年患者的术后急性疼痛。     

帕瑞昔布钠超前镇痛对颌面外科手术患者炎性细胞因子和凝血功能的影响

目的观察帕瑞昔布钠超前镇痛对颌面外科手术患者炎性细胞因子和凝血功能的影响。方法将60例在全麻下行颌面外科手术患者随机分为Ⅰ、Ⅱ两组,每组30例:Ⅰ组于手术开始前30 min静脉注射帕瑞昔布钠40 mg,Ⅱ组静脉注射生理盐水10 ml,术中给予靶控输注丙泊酚和瑞芬太尼静脉全麻,维持其血浆浓度分别为3.5～5.0 mg/L和3.0μg/L。于麻醉诱导前(T1)、术毕(T2)、术后6 h(T3)、术后24 h(T4)测定血浆TNF-α、IL-6、IL-10浓度及出凝血时间,记录术毕即刻、术后6、24 h视觉模拟镇痛评分(visual analogue scale,VAS)。结果术毕及术后6h VAS评分Ⅰ组为(1.8±0.7)分和(2.1±0.8)分,显著低于Ⅱ组(2.9±0.9)分和(3.8±0.8)分(P<0.05);术后24 h VAS评分两组差异无统计学意义(P>0.05);两组T2～4时TNF-α、IL-6、IL-10水平均较T1时明显升高(P<0.05);Ⅰ组与Ⅱ组比较,T2～4时TNF-α、IL-6水平明显降低(P<0.05),IL-10水平明显升高(P<0.05);两组凝血功能比较差异无统计学意义(P>0.05)。结论帕瑞昔布钠超前镇痛效果好,能减轻手术引起的过度炎性反应且不影响凝血功能。     

环氧化酶-2抑制剂控制全膝关节置换术后疼痛的临床研究

目的 观察环氧化酶-2(COX-2)抑制剂联合自控镇痛(PCA)控制伞膝关节置换术(TKA)后疼痛的效果,探索TKA术后疼痛控制的新方法.方法 选取研究纳入标准:膝关节病变需要行TKA手术的患者,年龄58-75岁,美国麻醉师协会(ASA)分级为Ⅰ或Ⅱ级,能耐受全身静脉复合麻醉.术后常规根据患者体重采用相同配方配制自控镇痛溶液,关闭切口结束同时随机静脉注射2 ml等渗盐水或帕瑞昔布钠40 mg+等渗盐水2 ml,由研究者甲记录并开具医嘱,间隔12 h连续用相同试剂静脉注射,48 h后结束.第72小时起口服赛来昔布或安慰胶囊连续服用至2周.观察术前、术后3,7,15 d膝关节功能.结果 共完成60例,其中用瑞昔布钠、赛来昔布序贯疗法组30例,安慰剂组30例.两组患者一般情况差异无统计学意义(P>0.05),术前膝关节功能评分差异无统计学意义(P>0.05).术后第3,7,15天膝关节功能评分差异有统计学意义(P<0.05,0.01).结论 COX-2抑制剂联合自控镇痛TKA术后疼痛疗效确切,且与TKA术后早期改良HSS评价成正相关.

Abstract：

Objective To observe the analgesic effect of COX-2 inhibitors combined with PCA in treatment of the pain after total knee arthroplasty(TKA)and explore novai method for pain control after TKA. Methods This study was,a double blind,controlled,randomized,placebo-controlled,parallelgroup and single center study and obtained the consent of the Medical Ethics Committee of Chongqing Medical University.Inclusion criteria:the patients with severe trauma or degenerative knee,at age of 58-75 vears.ASA Ⅰ or Ⅱ, tolerance of the intravenous anesthesia.The same solvent formula of PCA was routinely prepared based on body weight after TKA.Intravenous injection of 40 mg Parecoxib plus 2 ml normal saline or injection of only 2 ml normal saline was done when closing the incision.which was recorded and prescribed by the researcher A.The same reagent waft,used continually every other 12 hours till48 hours.Celecoxib or placebo capsules was not usod orally at 72 hours until two weeks later.The knee ioint function was observed preoperatively and at days 3,7 and 15 after TKA. Results The study was completed in 60 patients including 30 patients in the group treated with Parecoxib and Celecoxib sequential therapy and 30 patients in placebo-control group.There was no statistical difference in aspects of general condition in both groups(P>0.05).There was no statistical difference in aspect of preoperative knee score between two groups(P>0.05).The analysis showed statistical difference in the knee function score at days 3.7 and 15 after operation(P<0.05 or0.01).Conclusions The COX2 inhibitors combined with PCA has definite analgesic effect on the pain after TKA,which positively correlates with early modified HSS evaluation of TKA.     

帕瑞昔布钠联合术后自控镇痛在上腹部手术患者的临床应用

目的观察帕瑞昔布钠联合静脉自控镇痛对上腹部手术患者术后的镇痛疗效。方法 78例上腹部手术患者,年龄23～68（58±12）岁,随机均分为A、B组。两组均以丙泊酚、芬太尼、维库溴铵诱导插管,丙泊酚、瑞芬太尼持续泵注并持续吸入七氟醚维持麻醉。A组于手术结束前30 min静注帕瑞昔布钠40 mg,B组注射生理盐水2 ml作为空白对照。两组均以芬太尼（总量0.8～1.0 mg）实施患者自控镇痛（PCA）。记录患者术后2 h疼痛视觉模拟评分（VAS）及24 h的PCA有效按压次数。结果 A组术后2 h VAS评分及24 h的PCA按压次数均低于B组（P〈0.05）。结论上腹部手术患者手术结束前静注帕瑞昔布钠40 mg可有效减轻术后疼痛,并减少术后芬太尼的用量。     

帕瑞昔布钠超前镇痛用于小儿鼾症腺样体及扁桃体切除术

目的观察帕瑞昔布钠超前镇痛在小儿鼾症腺样体及扁桃体切除术后的镇痛效果及不良反应。方法选择2011年1—9月,静脉复合吸入气管插管全身麻醉下择期行小儿鼾症腺样体及扁桃体切除手术的患儿60例。随机分为帕瑞昔布钠组(A组)、芬太尼组(B组)和对照组(C组),每组20例患儿。于手术麻醉结束前30 min分别注射帕瑞昔布钠1 mg/kg、芬太尼1μg/kg或生理盐水。三组患儿的年龄、性别、体质量、失血量、手术时间和术中麻醉药用量等一般情况无统计学差异(P>0.05)。观察拔除气管导管后患儿10 min的躁动评分。记录术后1、2、4、8 h各时间点患儿的疼痛评分、镇静评分。观察术后24 h内的不良反应。结果术后各个时间点的A组疼痛评分显著低于B组和C组。B组的镇静评分在术后1、2 h显著高于A组和C组。B组患儿术后恶心呕吐发生率显著高于A组和C组。三组患儿均无明显呼吸抑制、血压剧烈波动等不良反应。结论帕瑞昔布钠超前镇痛用于小儿鼾症腺样体及扁桃体切除手术可产生较好的镇痛作用,可预防全麻恢复期躁动的发生,恶心呕吐等不良反应发生率显著低于芬太尼。     

颈丛神经阻滞联合瑞芬太尼或帕瑞昔布钠用于甲状腺手术镇痛效果观察

目的:观察颈丛神经阻滞联合瑞芬太尼或帕瑞昔布钠用于甲状腺手术的镇痛效果。方法:选择择期行甲状腺部分切除60例,随机分为瑞芬太尼组(R组)、帕瑞昔布钠组(P组)和联合组(R+P组)各20例。R组颈浅丛神经阻滞后,持续静脉靶控输注瑞芬太尼,血浆靶控浓度1.0ng/ml;P组颈浅丛神经阻滞后,静脉注射帕瑞昔布钠40mg;R+P组静脉注射帕瑞昔布钠40mg,同时持续靶控输注瑞芬太尼,血浆靶控浓度0.5ng/ml。观察3组手术切皮时(t1)、分离甲状腺(t2)、部分切除甲状腺(t3)、缝皮时(t4)和离室时(t5)的血氧饱和度(SO2)、心率(HR)、血压(BP)、呼吸频率(RR)、痛觉视觉模拟评分(VAS),以及不良反应发生情况。结果:R组t1~t5时间节点的RR、SO2水平均显著低于P组和R+P组同时间节点(P<0.05);P组和R+P组比较,差异不显著(P>0.05)。R+P组t1~t5时间节点的HR、SBP、DBP、VAS水平均显著低于P组和R组同时间节点(P<0.05);P组和R组比较,差异不显著(P>0.05)。R组不良反应发生率显著高于P组和R+P组(P<0.05);P组和R+P组比较,差异不显著(P>0.05)。结论:颈丛神经阻滞联合瑞芬太尼和帕瑞昔布钠用于甲状腺手术效果优于颈丛神经阻滞联合单用瑞芬太尼或帕瑞昔布钠。     

Periarticular multimodal drug injection in total knee arthroplasty

Purpose

A systematic review and meta-analysis based on randomized controlled trials (RCTs) were conducted to evaluate the efficiency and safety of periarticular multimodal drug injection in total knee arthroplasty (TKA).

Methods

Periarticular injection with the use of multimodal drugs is an efficient alternative for postoperative analgesia in TKA. A systematical electronic search was performed to identify the eligible RCTs in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science and the Chinese Biomedical Literature Database. Two independent reviewers completed data collection and assessment of methodological quality. The quality of evidence of outcomes was judged using GRADE criteria. Meta-analysis was performed for the outcomes of pain, straight leg raise, operating time, hospital stay and complications.

Results

Ten RCTs including eight studies with 1,216 TKAs in 835 patients met the inclusion criteria. Periarticular injection with multimodal drugs in TKA was associated with short-term benefits in terms of pain relief, straight leg raise, narcotic consumption, and the rates of nausea, vomiting, rash and pruritus. There were no statistically significant differences in operating time, hospital stay, wound complications and deep vein thrombosis between both groups.

Conclusions

The current evidence suggests that periarticular multimodal drug injection in TKA provides short-term advantages in pain relief, straight leg raise and postoperative complications.

Level of evidence

Therapeutic study, Level I.     

全膝关节置换术两种入路效果比较

 目的  比较经股内侧肌入路与内侧髌旁入路行全膝关节置换术的临床疗效。 方法 25例行同期双侧全膝关节置换术,每例患者随机一侧采用经股内侧肌入路,另一侧采用内侧髌旁入路,观察两组手术时间、术后引流量、术后6周关节活动度、直腿抬高恢复时间,术后第1、2、3、6天对每例患者双侧膝关节进行视觉模拟疼痛评分（visual analog scale,VAS）。 结果 经股内侧肌入路组在直腿抬高恢复时间［（2.2±0.8） d vs （4.4±1.4）d］、VAS评分方面明显优于内侧髌旁入路组( P <0．05 ),两组在术后引流量、手术时间、术后6周膝关节活动度方面差异无统计学意义( P >0．05)。 结论 经股内侧肌入路行全膝关节置换术与髌旁入路相比,可以减轻术后的疼痛,减少直腿抬高恢复时间,较早恢复膝关节功能,值得临床推广和应用。     

Benefits of early ambulation within 24 h after total knee arthroplasty:a multicenter retrospective cohort study in China

Background:Postoperative care has been evolving since the concept of enhanced recovery after surgery (ERAS) was introduced in China.This study aimed to evaluate the effects of early ambulation within 24h after unilateral total knee arthroplasty (TKA) on postoperative rehabilitation and costs in a Chinese population.Methods:This cohort study of patients with knee osteoarthritis who had undergone TKA at 24 large teaching hospitals between January 2014 and November 2016 involved 2687 patients who began ambulating within 24h (Group A) and 3761 patients who began ambulating later than 24h (Group B).The outcome measurements,such as length of stay (LOS),total hospitalization costs,dynamic pain level,knee flexion range of motion (ROM),results of the 12-Item Short Form Survey (SF-12),incidence of thromboembolic events and other complications,were recorded and compared.Results:The early ambulation group (Group A) had a shorter LOS and lower hospitalization costs and pain levels than the late ambulation group (Group B).There was a favorable effect in enhancing ROM for patients in Group A compared with patients in Group B.In Group A,patients had significantly higher postoperative SF-12 scores than those in Group B.The incidence of deep venous thrombosis (DVT) and pulmonary infection was significantly lower in Group A than in Group B.The incidence of pulmonary embolism (PE) and other complications did not differ between the two groups.Conclusions:Early ambulation within 24h after TKA was associated with reduced LOS,improved knee function,lower hospitalization costs and lower incidence of DVT and pulmonary infection in the Chinese population.     

Preoperative flexion does not influence postoperative flexion after rotating-platform total knee arthroplasty

Purpose

Preoperative range of motion (ROM) has been regarded as one of the most important factors in predicting postoperative ROM following total knee arthroplasty (TKA). Mobile-bearing TKA designs have been suggested to possibly improve the knee kinematics compared to fixed-bearing designs. The purpose of this study was to examine the difference in postoperative flexion as a function of preoperative flexion in a consecutive series of TKAs done using a posterior-stabilized rotating-platform prosthesis.

Methods

ROM was assessed in 153 consecutive TKAs done using a rotating-platform posterior cruciate-substituting design. Patients were divided into two groups based on their preoperative ROM (Group 1 < 95°, Group 2 > 95°). The Knee Society Score (KSS) and ROM were assessed preoperatively, 3 months and 12 months postoperatively.

Results

There was no difference in flexion 12 months after surgery between groups (mean 120° and 123°, respectively. n.s.). After 3 month follow-up, no increase in ROM was experienced by either group. Patients in Group 1 experienced significantly greater increases in both ROM (p < 0.001) and KSS (p < 0.05). There was no difference in the KSS at 12 months after surgery between groups.

Conclusion

In this series of patients undergoing TKA with a rotating-platform prosthesis, the preoperative ROM was not predictive of the postoperative ROM. Patients with stiff knees preoperatively may benefit from a mobile-bearing design prosthesis.

Level of evidence

Case–control study, Level III.     

A public health perspective on physical activity after total hip or knee arthroplasty for osteoarthritis

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common treatments for osteoarthritis (OA) with good-to-excellent outcomes. As the US population ages, rates of OA and THA/TKA will continue to rise. People with OA and THA/TKA are less active than those without arthritis or arthrosplasty, respectively. With the numerous documented health benefits obtained from physical activity, it is imperative from a public health perspective that patients are sufficiently active to maintain health after surgery. Increasing moderate-intensity physical activity is a safe, efficacious, and cost-effective mechanism for improving health and reducing health care costs in this population. The return to leisure/sporting activities after THA/TKA is not as well studied as other aspects of functional recovery. In particular, no evidence-based guidelines for physical activity after THA/TKA are available. Most recommendations have been derived from cross-sectional surveys of orthopedic surgeons. Based on the literature, the general consensus for recommendations appears to be to: 1) return to low- to moderate-intensity activities and no-, low-, or intermediate-impact activities within 3 to 6 months postoperatively, 2) discourage high-impact activities, 3) avoid high-contact athletic activities, and 4) educate rather than dissuade patients from resuming leisure/sporting activities. Sports medicine physicians are in an ideal position to counsel patients in regard to leading active lifestyles. The physician can evaluate and treat any remaining functional limitations postoperatively, as well as prescribe the appropriate dose (ie, type, intensity, frequency, and duration) of physical activity. The 2008 Physical Activity Guidelines for Americans can help guide physicians in prescribing the appropriate dose of activity. Finally, physicians can refer patients to evidence-based, community-delivered group exercise and/or behavioral change interventions that are approved by the Centers for Disease Control and Prevention for people with arthritis.     

全膝关节置换术后应用局部间断冰敷治疗效果分析

目的探讨全膝关节置换术后应用局部间断冰敷治疗的临床效果。方法选取2012年11月至2016年11月行全膝关节置换术的患者51例(51膝),其中,术后应用局部间断冰敷治疗(冰敷组)29例,常规治疗(常规组)22例。观察并比较两组患者术后第1、2、3天的膝关节术前术后髌骨中点周径差、视觉模拟疼痛评分(VAS)及总引流量。结果术后第2、3天冰敷组膝关节术前术后髌骨中点周径差明显小于常规组(P<0.05),术后第1、2、3天冰敷组VAS明显低于常规组(P<0.05),术后冰敷组总引流量明显少于常规组(P<0.05)。结论全膝关节置换术后应用局部间断冰敷治疗可明显促进患肢局部消肿,缓解术区疼痛,减少术后出血。     

同期双侧全髋置换术的临床报告

目的 对同期与分期双侧全髋关节置换术进行比较,了解同期双侧关节置换的安全性和有效性。方法 1997年3月～2003年1月进行的双侧髋关节置换病人中共118例(236个关节)获随访,将其分为2组,A组为同期置换组87例(174个髋关节),B组为分期置换组31例(62个髋关节)。对比A组与B组之间手术时间、总出血量、总输血量、术前与术后Harris评分及术后并发症等方面的差异。结果 两组各项指标之间均无统计学差异。从住院时间、总治疗费用、总出血量、总输血量、并发症及功能等多方面考虑,同期双侧全髋关节置换明显要优于分期双侧全髋关节置换。结论 同期双侧全髋关节置换安全可行,与分期置换相比具有一定优越性。     

Physical functioning four years after total hip and knee arthroplasty

Our previous study showed that 6 months after total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients reported having less difficulty with daily activities, showed better functional capacity, and performed activities in their natural environment faster compared to preoperatively. However, their actual daily activity level was not significantly improved. Six months is a rather short follow-up period and the discrepancy in recovery among different aspects of functioning might be explained by this limited duration of follow-up. The objective of the present study was to examine the recovery of different aspects of physical functioning at a follow-up nearly 4 years after THA/TKA. Special attention was given to the actual daily activity level, and whether it had increased 4 years after THA/TKA compared to 6 months postoperatively.Seventy-seven (35 hip, 42 knee) patients who were measured preoperatively and postoperatively (6 months after surgery) in a previous study were invited to participate; 44 patients (23 hip, 21 knee) agreed to participate. The 4-year follow-up data were compared with the preoperative and 6-month postoperative data.The daily activity level after 4 years was found to be actually lower than at 6 months post-surgery (128 min vs. 138 min activity per 24 h; p-value 0.48). However, the patients continued to improve in other aspects of physical functioning.In conclusion, 4-year post-surgery patients continued to improve on perceived physical functioning, capacity, and performance of activities in daily life. However, even in this relatively healthy study population, patients did not adopt a more active lifestyle 4 years after surgery.     

Midvastus approach in total knee arthroplasty: a randomized, double-blinded study on early rehabilitation

The medial parapatellar approach has become the standard technique in total knee arthroplasty (TKA). However, recent studies have reported superior results regarding functional recovery when using the midvastus approach. It was the aim of this study to evaluate the early functional outcome of both surgical techniques. In a prospective, double-blinded, randomized study, 50 patients for TKA were consecutively operated on either by the medial parapatellar or the midvastus approach. Exclusion criteria were defined as previous open knee surgery and leg deformity of more than 10° varus or valgus. TKA was performed in all patients by one surgeon using the same type of implants in both groups. Pain scores (VAS) were documented and follow-up data including quadriceps strength and proprioception were obtained 3 weeks and 6 weeks postoperatively. Both groups were comparable in preoperative demographic data. Postoperatively, patients in the midvastus group demonstrated significantly lower pain in rest (VAS: mean 2.25 vs. 3.03) and under movement (VAS: mean 2.92 vs. 3.13). Further, they showed superior isometric quadriceps strength at 3 weeks (41.4 vs. 27.6 Nm) and 6 weeks (47.6 vs. 35.5 Nm). Moreover, this group showed a superior postoperative proprioception, while the range of motion was similar in both groups. The midvastus approach offers advantages over the standard parapatellar arthrotomy, in the early rehabilitation period. No adverse effects were observed associated with this approach. Therefore, the midvastus approach should be considered as a valuable alternative in TKA.