膝关节置换术后两种股神经阻滞镇痛比较

[目的]评价不同镇痛模式在全膝关节置换术后的镇痛效果。[方法]全膝关节置换手术40例,随机分为两种股神经阻滞方法进行术后镇痛,即连续股神经阻滞(连续组)(20例)和单次股神经阻滞联合患者自控静脉镇痛组(单次组)(20例)。连续组术前0.5%罗哌卡因30 ml行股神经阻滞并置管,术后0.2%罗哌卡因连续股神经自控镇痛;单次组术前行0.5%罗哌卡因30 ml单次股神经阻滞,术后0.2μg/kg舒芬太尼自控镇痛。观察指标:记录两组术后4、8、12、24、36及48 h术后静息、主动功能锻炼(AFE)及持续被动功能锻炼(CPM)状态下疼痛VAS评分情况,记录恶心、呕吐、嗜睡不良反应发生率、镇痛泵按压次数及追加哌替啶次数。[结果]术后4、8、12、24h静息VAS评分连续组和单次组比较差异无统计学意义(P0.05);术后36、48 h静息VAS评分连续组显著低于单次组,两组比较差异有统计学意义(P0.05)。术后24 h的AFE和CPM状态下VAS评分比较,两组差异无统计学意义(P0.05);而术后36、48 h,连续组显著低于单次组,两组比较差异有统计学意义(P0.05)。术后4、8、12 h按压次数两组差异无统计学意义(P),而术后24、48、36 h连续组按压次数明显低于单次组,差异有统计学意义(P0.05)。术后不良反应、追加哌替啶例数连续组明显高于单次组,两组比较差异有统计学意义(P0.05)。[结论]全膝关节置换术后,连续股神经阻滞镇痛优于单次股神经阻滞联合患者自控静脉镇痛,且前者不良反应少,患者满意度高。     

Thirty-day mortality after elective total hip arthroplasty

BACKGROUND: Previous reports on perioperative mortality associated with hip arthroplasty have not documented, to our knowledge, patient characteristics and surgical factors that increase the likelihood of death. The purpose of this study was to determine the prevalence of and associated risk factors for perioperative death after elective hip arthroplasty. METHODS: The records of 30,714 consecutive patients who had undergone elective hip arthroplasty at our institution from 1969 to 1997 were retrospectively reviewed to identify patients who had died within thirty days after the procedure. Mortality rates were determined according to age, gender, diagnosis, implant type, and fixation mode. RESULTS: Ninety deaths occurred within thirty days after elective total hip arthroplasty, for an overall mortality rate of 0.29% (ninety of 30,714). The thirty-day mortality rate was significantly higher for patients with preexisting cardiovascular disease (p < 0.0001), male patients (p < 0.0001), and patients who were seventy years of age or older (p < 0.0002). The mortality rate was slightly, but not significantly, higher for patients with an underlying diagnosis of rheumatoid arthritis (p < 0.36) and those receiving cemented implants (p < 0.57). There was no difference in the thirty-day mortality rate for revision as compared with primary hip arthroplasty (p < 0.92). CONCLUSIONS: Factors that are associated with an increased risk of mortality within thirty days after elective hip arthroplasty include an older age, male gender, and a history of cardiorespiratory disease. There has been a significant decline in the thirty-day mortality rate after elective hip arthroplasty in the last decade (p < 0.0002); during the 1990s, the overall rate at our institution was 0.15% (twenty-three of 14,989).     

Thromboelastography in elective total hip arthroplasty

BACKGROUNDHypercoagulability plays an important role in predisposing patients to venous thromboembolism (VTE) after total hip arthroplasty (THA). We used thromboelastography (TEG) to examine the coagulation status of patients undergoing THA.AIMTo examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with enoxaparin. METHODSAfter ethical approval, we performed a retrospective analysis of data collected in patients undergoing primary elective THA. We analyzed TEG data on samples performed before skin incision, intraoperatively and for 5 d postoperatively. Conventional coagulation tests were performed preoperatively and on postoperative day 5. RESULTSTwenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia (SA) were included. TEG demonstrated a progressively hypercoagulable state postoperatively, characterized by elevated maximum amplitude. TEG also demonstrated transient intraoperative hypercoagulability in patients receiving SA. In contrast, conventional coagulation tests were normal in all patients, pre- and postoperatively, except for an increase in plasma fibrinogen day 5 postoperatively. CONCLUSIONDespite VTE prophylaxis, patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional tests. This group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring, via TEG or otherwise.     

Peripheral nerve lesions after total hip endoprosthesis]

AIM OF THE STUDY: Lesions of peripheral nerves are serious complications associated with total hip replacements. Prognostic factors and treatment concepts have not been sufficiently defined. Improvements can occur spontaneously. This study aimed to evaluate risk factors and diagnostic aids, such as the velocity of nerve conduction (VNC) and electromyography (EMG). Furthermore, the effect of prognostic factors as well as conservative and invasive therapeutic measures on the regression of clinical symptoms was examined. METHOD: From 1990 to 1996 1833 patients underwent total hip replacement. 1447 procedures were primary total hip replacements and 386 were revisions. 14 femoral nerve lesions (0.8%), 7 sciatic nerve lesions (0.4%) and 8 peroneal nerve lesions (0.4%) occurred. 19 patients were examined clinically, electromyographically and by means of VNC, 10 patients only clinically. In 5 patients a neurolysis was performed within the first postoperative year. All 29 patients underwent a recall examination in 1997 to evaluate the development of the clinical symptoms and if possible, VNC and EMG were performed. RESULTS: Of the 7 patients with sciatic nerve lesions, two were free from symptoms at the time of recall, two still complained about residual symptoms and two showed no improvement of the lesion. One patient did not appear for follow-up. Of the 8 patients with peroneal nerve lesions, five were free from symptoms at the time of their recent examination, two showed residual symptoms and one patient did not appear. Of the 14 patients with femoral nerve lesions, four had recovered completely, eight showed residual symptoms, one patient did not improve and one patient had died. CONCLUSIONS: Prognostic statements regarding the improvement after nerve lesions are possible only to a limited degree. However, it was found that the motor function tended to recover earlier than sensibility. We could not determine with clinical evaluations why some patients showed an improvement of their lesion while others did not. As well no clear correlation between the EMG and VNC results and the recession of the symptoms could be established.     

Peripheral neuropathies following total hip arthroplasty

The authors reviewed the complication records following total hip arthroplasty at their institution between January 1976 and July 1989. Forty-two patients (12 men and 30 women) with 45 neurologic complications were identified following 7,133 consecutive total hip arthroplasties; an incidence rate of 0.63%. The average age of these patients was 58 years (range, 27–81 years). Thirty-four nerve injuries were noted in the lower extremity (0.48% incidence rate) and 11 in the upper extremity (0.15% incidence rate). The majority of patients (64%) with neurologic injury to the upper extremity had the diagnosis of inflammatory arthritis. The common peroneal was most often involved in the lower extremity. The ulnar nerve was most commonly involved in the upper extremity. The pathogenetic factors leading to neurologic injury in the majority of patients were not clearly established. Leg lengthening did not seem to be a major cause. The prognosis of patients with nerve palsy of the upper extremity is favorable compared with injury to the lower extremity. Similarly, the percentage of patients with a permanent neurologic deficit was lower in the primary surgery group (27%) compared with the revision/reoperation group (43%). The overall percentage of permanent nerve palsy was 33%. Female patients, for unclear reasons, appear to have a higher risk for neurologic injury. Also, the risk of neurologic injury following total hip arthroplasty appears to be higher with revisions/reoperations and with an inexperienced surgeon.     

Impact of lumbar arthrodesis on outcomes after elective total hip arthroplasty

BackgroundAcetabular component malpositioning has been associated with major complications including dislocation, edge-loading, stripe wear and squeaking. Anteversion is determined by pelvic orientation; flexion of the pelvis increases and extension decreases acetabular anteversion. The degree of pelvic movement is determined by lumbar spine sagittal balance and it is well established that lumbar arthrodesis procedures influence spinal and pelvic parameters including sagittal balance. The purpose of this study is to determine the impact of prior lumbar arthrodesis and revision lumbar arthrodesis on complications after primary elective THA.MethodsA database review using the entire Medicare sample within the PearlDiver database was performed using International Classification of Diseases, 9th Edition codes. The search identified 14,439 patients who underwent primary THA after prior lumbar arthrodesis and 1,157 patients who underwent primary THA after prior revision lumbar arthrodesis. A search for patients who underwent primary THA without prior history of lumbar or revision lumbar fusion yielded 749,403 patients who served as a control. Incidence (IN), odds ratios (ORs) and their respective 95% confidence intervals (CIs) for 30-day, 90-day and overall complications were calculated.ResultsThe following complications reached statistical significance (p < 0.001) for THA after primary lumbar arthrodesis: bleeding (IN:9.7%, OR:2.33, CI:2.21–2.47), dislocation (IN:5.6%, OR:1.95, CI:1.81–2.09), infection (IN:3.6%, OR:1.99, CI:1.85–2.12), mechanical complication (IN:0.7%, OR:1.42, CI:1.16–1.73), mechanical loosening (IN:2.3%, OR:1.74, CI:1.56–1.94), other mechanical complication (IN:2.1%, OR:2.13, CI:1.90–2.39), DVT/PE (IN:8.4%, OR:1.50, CI:1.42–1.60), acute renal failure (IN:22%, OR:1.20, CI:1.15–1.25), periprosthetic fracture (IN:1.6%, OR:1.45, CI:1.27–1.65), and prosthetic-related complication (IN:30%, OR:1.85, CI:1.78–1.91). Higher complications rates were observed in patients who had revision lumbar arthrodesis: bleeding (IN:12.4%, OR:3.06, CI:2.57–3.65), dislocation (IN:9.7%, OR:3.54, CI:2.92–4.31), infection (IN:5%, OR:3.32, CI:2.71–4.06), mechanical complication (IN:6.9%, OR:14.94, CI:11.88–18.79), mechanical loosening (IN:3.2%, OR:2.41, CI:1.74–3.35), other mechanical complication (IN:3.5%, OR:3.56, CI:2.61–4.87), DVT/PE (IN:10.7%, OR:1.96, CI:1.63–2.36), acute renal failure (IN:25.5%, OR:1.46, CI:1.28–1.66), periprosthetic fracture (IN:2.7%, OR:2.47, CI:1.72–3.52), and prosthetic-related complication (IN:40%, OR:2.88, CI:2.56–3.24).ConclusionsLumbar arthrodesis and revision lumbar arthrodesis significantly negatively impact postoperative complication rates after THA. Level of Evidence: Therapeutic Level III     

Delayed transient sciatic nerve palsy after total hip arthroplasty

Sciatic nerve palsy after total hip arthroplasty is a well-known complication, but delayed sciatic nerve palsy is rare. We report such a case with profound clinical manifestations and well-documented electrophysiologic changes. We found no helpful guidance to managing delayed palsy in the literature. We also are unaware of any previous cases reported in which nearly full recovery has occurred.     

Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch

STUDY OBJECTIVE: To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN: Randomized, prospective study. SETTING: University hospital. PATIENTS: 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS: Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS: Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS: Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P<0.0001). Visual analog scores on arrival in the PACU were 37+/-22 mm in group T versus 73+/-13 mm in group P (P<0.0001). Cumulative morphine consumption at the 24th hour was 43+/-16 mg in group P and 4+/-3 mg in group T (P<0.0001). Cumulative morphine consumption at the 48th hour was 54+/-26 mg in group P and 5+/-4 mg in group T (P<0.0001). Intraoperative sufentanil consumption was 38+/-15 microg in group T versus 30+/-5 microg in group P (not significant). The sedation score was 0 in both groups during the first 48 postoperative hours. CONCLUSIONS: Preoperative TFP application decreases pain scores and morphine consumption in the PACU and appears to have prolonged effects spanning the first 48 postoperative hours.     

改良自控式镇痛泵的使用方法对全髋关节置换术后镇痛效果的影响

目的 探讨全髋关节置换术后使用自控式镇痛泵(patient-controlled analgesia,PCA)的患者引入超前镇痛的观念,超前定时预防性加注镇痛泵药物镇痛效果.方法 将2014年1~12月我科收治的113例全髋关节置换术后使用PCA的患者按数字表法随机分为两组:对照组58例,术后常规使用PCA;改良组55例,术后由责任护士对患者实施全程一对一宣教及护理,全面负责PCA操作过程,并从手术结束后6 h起,每间隔1.5 h由责任护士给予按压加注按钮超前镇痛,严密观察并比较镇痛效果和不良反应.结果 改良组在术后12 h、18 h和24 h疼痛评分明显低于对照组,差异均有统计学意义(均P<0.05);两组术后在恶心呕吐、尿潴留、呼吸抑制、血压下降等不良反应方面比较,差异均无统计学意义(均P>0.05).结论 全髋关节置换术后使用PCA患者,定时预防性加注镇痛泵药物,镇痛效果确切.     

Unsuspected non-Hodgkin's lymphoma discovered with routine histopathology after elective total hip arthroplasty

The utility and cost-effectiveness of routine histologic examination of specimens from elective total joint procedures continues to be a source of debate. We describe a case of unsuspected non-Hodgkin's lymphoma discovered after routine histopathologic examination of a femoral head with osteoarthritis. The evidence both for and against routine tissue submission after elective arthroplasty cases is outlined in a review of the literature. By illustrating a neoplasm that would have been missed without routine pathologic examination, this case underscores a need for continued scrutiny of methods to effectively reduce medical costs while maintaining quality of care.