全膝关节置换术后三种镇痛方案的对比

[目的]评价不同镇痛方案在全膝关节置换术后的临床效果。[方法]全膝关节置换术90例,随机采用三组,分别采用"鸡尾酒"关节腔灌注(关节灌注组)、关节周围多点注射(多点注射组)及股神经阻滞(神经阻滞组),每组30例。比较三组间术后VAS评分、哌替啶使用例数、不良反应的发生和功能恢复情况。[结果]术后6 h及72 h,三组间VAS评分差异无统计学意义(P>0.05);术后24 h时,神经阻滞组后关节囊疼痛明显,VAS评分高于其他两组,差异有统计学意义(P<0.05)。术后加用哌替啶患者数三组间差异无统计学意义(P>0.05)。不良反应三组间差异有统计意义(P<0.05)。神经阻滞组诉股四头肌无力比例较高,自主直腿抬高及下地活动时间方面均不如其他两组,差异有统计学意义(P<0.05)。术后3个月三组间HSS评分的差异无统计学意义(P>0.05)。[结论]关节腔灌注"鸡尾酒"配方药物在全膝关节置换术后镇痛方面效果良好。可有效降低术后疼痛,且操作简单,在术后早期活动及不良反应发生率方面均有一定优势。     

全膝关节置换术后镇痛治疗的研究进展

背景 术后镇痛治疗是全膝关节置换术(total knee arthroplasty,TKA)后的基本辅助措施,直接关系到手术效果和术后膝关节功能的恢复.目的 综述国内外关于TKA镇痛治疗的研究进展.内容 TKA的镇痛疗法各有优缺点,新型镇痛药物及技术的应用使镇痛方案选择更加多元化,镇痛方式及药物的选择也更加注重利于患者术后膝关节功能的康复及个体化感受.趋向 以局部浸润镇痛(local infiltration analgesia,LIA)治疗为代表的多模式镇痛(multimodal analgesia,MMA)是近年来国内外提出并研究较多的新的镇痛治疗方式,通过已有的研究已经证实MMA的积极治疗作用,但如何制定个体化的MMA方案仍然是临床面临的重要问题之一.     

全膝关节置换术围手术期镇痛

目的探讨全膝关节置换术(TKA)围手术期镇痛效果,获得最佳的镇痛方案。方法2005年1月至2006年4月的82例单侧TKA手术患者随机分成两组,采用不同的镇痛方案进行围手术期镇痛治疗。对术后疼痛进行评分分析并观察并发症。结果两种镇痛方法均具有明显的镇痛效果,患者满意率及功能康复效果取得明显改善,并发症发生率较低。结论TKA围手术期采用积极的综合镇痛措施,具有重要意义。     

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。     

全膝关节置换围手术期镇痛进展

全膝关节置换术手术技术及术后功能锻炼是决定手术成功与否的两个重要因素,而术后功能锻炼很大程度上取决于围手术期镇痛的效果.目前研究较多的围手术期镇痛概念主要是超前镇痛和多模式镇痛,传统方法主要是口服或静注阿片药物、患者自控静脉镇痛、患者自控硬膜外镇痛、单次或连续股神经阻滞等,新的多模式镇痛方法及给药途径近年也不断涌现,包括患者自控硬膜外镇痛联合连续股神经阻滞镇痛、智能注射泵系统、一些非侵入途径如盐酸芬太尼透皮电刺激及患者自控经鼻给药途径等.该文就全膝关节置换术超前镇痛、术中术后镇痛等相关研究进展作一综述.     

连续股神经阻滞联合口服镇痛药用于全膝关节置换术术后镇痛的效果

目的观察连续股神经阻滞联合口服镇痛药用于全膝关节置换术患者术后镇痛的效果及其对膝关节早期康复的影响。方法选择择期行单侧全膝关节置换的患者60例,随机分为多模式镇痛组(M组)和静脉自控镇痛组(I组),每组30例。M组术前2d口服塞来昔布200mg/次、每天2次,羟考酮10mg/次、每天2次、持续2d,术后连续股神经阻滞镇痛并加服对乙酰氨基酚100mg/次、每天3次,羟考酮20mg/次、每天2次、持续3d;I组仅采用静脉自控镇痛。记录患者术后6、12、24、48h的静息状态、主动/持续被动功能训练时的VAS评分、主动/持续被动功能训练时患侧膝关节活动度、首次下床活动时间、住院时间、出院时患侧膝关节活动度及术后镇痛不良反应发生率。当VAS≥5分时,静脉注射地佐辛5mg,并予以记录。结果术后6、12、24、48h静息状态及主动/持续被动功能训练时M组VAS评分明显低于I组(P0.05);术后24、48、72h主动/持续被动功能训练时M组患侧膝关节活动度明显大于I组(P0.05);M组首次下床活动时间[(2.5±0.8)d]明显短于I组[(3.3±0.7)d](P0.05);M组住院时间[(9.1±2.3)d]明显短于I组[(10.8±2.0)d](P0.05);出院时M组患侧膝关节活动度[(95.6±17.2)°]明显大于I组[(82.5±15.2)°](P0.05);M组恶心呕吐1例(3.3%)及尿潴留2例(6.7%)明显低于I组恶心呕吐9例(30.0%)及尿潴留8例(26.7%)(P0.05);M组追加地佐辛1例(3.3%)明显低于I组12例(40.0%)(P0.05)。结论与静脉自控镇痛比较,连续股神经阻滞联合口服镇痛药的多模式镇痛方案能有效减轻全膝关节置换术患者术后疼痛,有利于膝关节功能的早期康复。     

洛索洛芬在全膝关节置换的围手术期镇痛与术后镇痛中的研究

目的分析洛索洛芬钠片剂对于全膝关节置换（TKA）术后短期临床效果的影响。方法 2009年1月至2009年12月因膝骨关节炎行单侧全膝关节置换手术患者197例,其中围手术期使用镇痛药物为洛索洛芬和（或）阿片类药物的患者84例。仅使用阿片类药物镇痛的患者为对照组,共27例（男9例,女18例）;仅术后使用洛索洛芬镇痛的患者为POST组,共31例（男9例,女22例）;术前和术后均使用洛索洛芬的患者为PERI组,共26例（男7例,女19例）。结果三组患者在平均年龄、体重指数、术前患病时间、术前疼痛评分、术前膝关节活动度、术前HSS评分、手术时间、术中止血带时间、术后引流量、术后2周疼痛评分、术后2周活动度、术后2周HSS评分及术后2周行走距离等指标方面无显著差异。但POST组和PERI组阿片类药物使用时长均短于对照组,阿片类药物末次使用时间也早于对照组（P〈0.05）。与POST组相比,PERI组洛索洛芬用药总量略少,但无统计学显著意义。结论洛索洛芬联合阿片类药物可有效地控制TKA术后疼痛,达到满意的临床效果。联合用药可减少阿片类药物的用量、缩短阿片类药物的使用时间。洛索洛芬围术期镇痛与术后镇痛相比具有基本相同的临床镇痛效果,但前者的用药量略少。     

全膝关节置换术后感染诊断研究进展

全膝关节置换术(TKA)后感染的诊断仍然是一个挑战。完整的诊断流程十分重要,术中组织培养是目前检测TKA后感染的金标准。采用~(111)铟-同位素标记白细胞(~(111)In-WBC)的单光子发射断层扫描(SPECT)/CT结合~(99m)锝-亚甲基二膦酸盐(~(99m)Tc-MDP)或~(99m)Tc-硫胶体骨髓图像检查,能有效提高检出率;正电子发射断层扫描(PET)的检出敏感性较高,花费时间较短;基于rRNA的逆转录定量PCR(RT-qPCR)的特异性与敏感性均较高,信号维持可探测水平时间较长;关节穿刺检查与术中冰冻组织切片检查虽尚无统一标准,但对于明确致病菌种的作用仍巨大。     

全膝关节置换术后中西医结合多模式镇痛的临床研究

目的探讨中药镇痛方对全膝关节置换术(TKA)术后镇痛的疗效。方法本组40例患者随机分为2组,每组20例。A组:仅使用西医多模式镇痛方案;B组:西医多模式镇痛方案下,加用中药镇痛方。记录各组术后各时间点疼痛最剧烈时的VAS评分、患者对镇痛效果的满意度、术后曲马多缓释片使用量、并发症情况及患者术后的被动活动度。结果 5、7天的疼痛最剧烈时的VAS评分B组明显低于A组。术后1、3及10天的VAS评分差异无统计学意义。两组病例术后1周对术后镇痛的总满意度评分B组明显高于A组。两组患者术后曲马多缓释片使用量B组明显少于A组。术后并发症发生率差异无统计学意义。术后7天和14天B组关节活动度明显高于A组。术后3天及42天两组间关节活动度差异无统计学意义。结论中药镇痛方结合西医多模式镇痛方案相比单纯西医多模式镇痛方案能更有效地减轻TKA术后早中期的疼痛,有利于尽早功能锻炼,恢复关节功能,且不增加相关并发症的发生率。     

Postoperative pain monitor after total knee replacement

Aim of this work was to study the postoperative pain within the first week of a total knee replacement by comparing three different forms of administration of analgesia. We proposed to verify the correspondence between a subjective pain assessment made by the patient on a Visual Analogic Scale (VAS) and an objective assessment made by assaying the serum algogenic cytokines interleukin-1 (IL1), interleukin-6 (IL6), and tumor necrosis factor-alpha (TNF-alpha). Statistical analysis of the data on the VAS and the three cytokine assays done preoperatively and on the third and seventh days postoperatively showed that while the VAS declined progressively postoperatively, IL6 tended to be higher on the third postoperative day and then lower on the seventh. The other two cytokines showed no differences preoperatively and postoperatively. On the basis of our results, we support the validity of IL6 dosage to monitor the postoperative pain during future studies.     

Epidural analgesia improves early rehabilitation after total knee replacement

STUDY OBJECTIVE: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement. DESIGN: Randomized prospective study. SETTING: Tertiary care, academic medical center. PATIENTS: Thirty-eight patients scheduled for total knee replacement. INTERVENTIONS: Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200,000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis. MEASUREMENTS: Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05. MAIN RESULTS: All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention. CONCLUSION: By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.     

术前口服罗非昔布对双膝关节置换术后疼痛和全身炎性反应的影响

目的探讨术前环氧化酶2抑制剂罗非昔布是否能增强双膝关节置换术后吗啡的镇痛作用,及其对术后全身炎性反应的影响.方法 30例因关节炎需行双膝关节置换手术患者,通过抓阄方法随机分为罗非昔布加硬膜外镇痛组(RE组)和硬膜外镇痛组(E组),每组15例.RE组在术晨口服罗非昔布25 mg,其余同E组.所有患者均以异氟醚、硬膜外0.75%布比卡因复合维持麻醉.术毕连接患者自控镇痛泵 (1.2 mg/ml布比卡因加0.1 mg/ml吗啡加0.02 mg/ml氟哌利多)镇痛72 h.分别在术前、术毕、及术后2、6、12、24、48 h时抽取股静脉血,检测白细胞总数及分类,以及炎性细胞因子白介素6、8、10和肿瘤坏死因子-α.术后24、48、72 h各进行疼痛评分,记录比较每日吗啡用量、镇痛满意度、镇痛期间副作用以及术中出血量和术后关节引流量.结果复合罗非昔布可明显降低术后24 h静息、48 h静息和活动时疼痛评分.RE组提高术后24 h镇痛满意度为100%,高于E组60%(χ2＝6.71,P<0.01).RE组术后24 h平均吗啡消耗量为6.8 mg明显低于E组8.1 mg,(t=-2.71,P<0.05).RE组血白细胞和嗜中性粒细胞数在12 h和24 h明显低于E组.RE组血浆白介素6含量在术后48 h,白介素8含量在术后24 h明显低于E组.RE组术毕、术后6 h、12 h肿瘤坏死因子-α明显低于E组(t值分别为-2.4、-2.25、-2.41,P值均<0.05).结论术前口服罗非昔布可明显改善双膝置换术后疼痛,增加镇痛满意度,减轻全身炎性反应,减少吗啡用量.     

Postoperative brachial plexus neuropathy after total knee replacement under spinal anaesthesia

We describe a case of idiopathic postoperative brachial plexus neuropathy. A 68-yr-old man underwent elective total knee replacement under spinal anaesthesia. Two days after surgery, there was sensory loss and weakness in the right forearm and hand, which suggested an ulnar nerve neuropathy. Two weeks later the patient complained of a dull ache between the scapulae, followed by a burning sensation in the forearm and severe pain in the elbow. A diagnosis of brachial plexus neuropathy was made based on clinical examination and nerve conduction studies. The pain disappeared after a few months, although weakness of the right arm persisted 9 months later. The differential diagnosis between brachial plexus neuropathy and ulnar nerve neuropathy is important, as the prognosis of brachial plexus neuropathy is generally good.      

Regional anaesthesia and analgesia for total knee replacement

Postoperative analgesia for total knee replacement with a continuous nerve catheter is more effective than any other form of systemic analgesia. For complete analgesia a combined technique of a femoral with a proximal sciatic nerve block is recommended. An easy and reliable way to achieve this is a femoral or a fascia iliaca compartment block together with a subgluteal sciatic nerve block.     

Postoperative pain after total knee arthroplasty

Pain, an uncommon complication following a total knee arthroplasty, has been associated with infections, loosening, reflex sympathetic dystrophy, and occasionally litigation. Radiographic abnormalities such as the anatomic alignment, size of the prosthesis, and tilt of the prosthesis after surgery have been implicated as other sources of pain. It is shown that there is no correlation between the above abnormalities and pain