两种关节周围局部注射配方对全膝关节置换术后镇痛效果的研究

目的 比较两种不同关节周围软组织局部注射配方对全膝关节置换术后的镇痛效果.方法 由同一组医师主刀完成的全膝关节置换术(TKA)治疗骨性关节炎(OA)66例(66膝),根据关节周围软组织注射镇痛药配方不同,随机分成两组,各33例(33膝).传统组注射布比卡因、甲基强的松龙、肾上腺素、吗啡和生理盐水混合液;改良组注射罗哌卡...     

全膝置换术后关节内注射鸡尾酒式镇痛混合剂对镇痛效果的评价

目的 评价全膝关节置换术后关节内注射鸡尾酒式镇痛混合剂的镇痛效果和安全性.方法 将80例行单侧TKA的骨关节炎患者进行随机分配:试验组关节内注射鸡尾酒式镇痛混合剂(吗啡、布比卡因、复方倍他米松),对照组注射生理盐水.术后48h内均经静脉镇痛泵滴注吗啡行自控镇痛,疼痛难以忍受时,肌内注射吗啡5~10mg.比较两组患者术后膝关节静息和活动VAS疼痛评分、吗啡使用情况、主动直腿抬高时间、屈膝90°时间、膝关节活动度以及并发症.结果 采用关节内鸡尾酒式镇痛混合剂注射后,可以显著减少术后0~36h各时间段和总的吗啡使用量,并推迟术后第一次肌内注射吗啡的时间.术后第6、10、24、36h试验组静息痛VAS评分显著小于对照组,术后24、36h试验组活动痛VAS评分显著小于对照组.患者主动直腿抬高时间、屈膝90°时间以及术后15天膝关节活动度比较,试验组均优于对照组.两组在术后伤口愈合、感染发生率、血压、心率、皮疹、呼吸抑制和尿潴留的监测等方面进行比较,差异均无统计学意义,恶心呕吐发生率试验组小于对照组.结论 关节内鸡尾酒式镇痛混合剂注射有助于减少术后麻醉镇痛剂使用量,减轻术后早期疼痛,且没有明显的不良反应.     

膝关节单髁置换术中关节周围注射镇痛混合剂的应用研究

目的探讨膝关节单髁置换术（UKA）中关节周围浸润注射＂鸡尾酒＂式镇痛混合剂的临床应用效果。方法将拟接受UKA的46例患者随机分成两组,23例术中关节周围浸润注射镇痛混合剂[吗啡5 mg,盐酸罗哌卡因注射液（施乐品）75 mg,复方倍他米松注射液（得宝松）1 ml,1∶10 000肾上腺素1 ml,加入生理盐水稀释至20 ml],其余23例注射生理盐水进行对照。评估并记录各患者手术前后静息和活动状态下的关节疼痛程度（VAS评分）、主动关节活动范围（ROM）,以及术后吗啡使用量、不良反应发生情况,并将两组进行比较。结果镇痛混合剂注射组在术后36 h内的静息和活动VAS评分均明显低于对照组（P〈0.05）,且术后48 h内的各时间段的吗啡使用量均低于对照组（P〈0.05）。镇痛混合剂注射组在术后24 h、48 h镇痛混合剂注射组的主动ROM值均大于对照组（P〈0.05）,而术后14 d、90 d两组间的主动ROM值差异无统计学意义（P〉0.05）。两组的不良反应发生率差别无统计学意义（P〉0.05）。结论在UKA术中使用＂鸡尾酒＂式镇痛药物进行局部浸润镇痛注射,能在术后早期达到较好的疼痛控制,有效减少术后吗啡的使用,使患者早期获得较大的关节活动度,临床应用较为安全有效。     

人工全膝关节置换术中关节周围注射镇痛药物和术后持续性冷冻压迫的疗效分析

目的研究人工全膝关节置换术（TKA）术中关节周围注射布比卡因、吗啡、肾上腺素等混合药物的止痛效果，同时观察术后冷冻压迫法的疗效。方法将80例TKA患者随机分为四组，记录VAS评分，比较周径变化，测量膝关节活动度。结果术中关节周围注射镇痛药物和术后持续性冷冻压迫在术后镇痛、术后减轻肿胀和增加关节活动度上效果显著。结论TKA术中关节周围镇痛药物注射和术后持续性冷冻压迫可以在术后早期控制疼痛、减轻肿胀、改善关节活动度、促进早期康复。     

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.     

人工全膝关节置换术中关节周围注射镇痛药物和术后持续性冷冻压迫的疗效分析

目的研究人工全膝关节置换术(TKA)术中关节周围注射布比卡因、吗啡、肾上腺素等混合药物的止痛效果,同时观察术后冷冻压迫法的疗效。方法将80例TKA患者随机分为四组,记录VAS评分,比较周径变化,测量膝关节活动度。结果术中关节周围注射镇痛药物和术后持续性冷冻压迫在术后镇痛、术后减轻肿胀和增加关节活动度上效果显著。结论TKA术中关节周围镇痛药物注射和术后持续性冷冻压迫可以在术后早期控制疼痛、减轻肿胀、改善关节活动度、促进早期康复。     

关节腔内注射酮咯酸氨丁三醇用于老年患者膝关节镜术后镇痛

目的 观察关节腔内注射酮咯酸氨丁三醇或吗啡复合罗哌卡因对老年患者膝关节镜术后的镇痛效果.方法 48例腰一硬联合阻滞下行膝关节镜手术的老年患者,随机均分为关节腔内注射吗啡复合罗哌卡因组(RM组)、酮咯酸氨丁三醇复合罗哌卡因组(RK组)和生理盐水对照组(C组),记录术后2、4、8、12、24和48 h患者屈膝关节90°状态下的VAS评分、镇痛满意度及术后8 h内按需注射曲马多用量.结果 术后2、4、8、12、24和48 h患者屈膝90°VAS评分RM、RK组均显著低于C组(P<0.01);术后镇痛满意度RM、RK组较C组高,而RK组高于RM组(P<0.05);RM、RK组术后8 h曲马多平均使用量较C组明显减少(P<0.05).结论 关节腔内注射酮咯酸氨丁三醇复合罗哌卡因可有效缓解老年患者膝关节镜术后疼痛,患者满意程度优于吗啡复合罗哌卡因.     

伴有心脏疾患病人全膝关节置换术中关节周围大剂量布比卡因注射镇痛的疗效和安全性

[目的]研究人工全膝关节置换术(TKA)中关节周围软组织注射含有大剂量布比卡因的混合药物进行术后镇痛对于伴有心脏疾患病人的临床疗效以及有无毒副反应。[方法]35例准备进行单侧TKA的骨关节炎病人根据是否伴发心脏疾患分为心脏病组(12例)和非心脏病组(23例)。在围手术期所有患者按相同镇痛方案治疗,术中关节周围注射Ranawat Cocktail镇痛药液(包含0.75%布比卡因250 mg,吗啡4 mg,肾上腺素0.3 mg,甲基强的松龙40 mg,头孢唑啉0.5 g,生理盐水57 ml)。记录患者术后疼痛VAS评分、满意度、膝关节活动度、主动直腿抬高时间、伤口并发症、术后住院天数、心电图异常及心血管并发症等。[结果]两组病人术后VAS评分、满意度、膝关节活动度、主动直腿抬高时间和术后住院天数均无统计学差异,所有病人无伤口并发症以及心血管并发症发生。[结论]在TKA术中,关节周围注射含有大剂量布比卡因的Ranawat Cocktail混合药物对伴发心脏疾患的病人同样可以提供很好的术后镇痛效果,并且具有良好的安全性。     

鸡尾酒疗法在全膝关节置换术后镇痛60例报告

目的研究鸡尾酒疗法对全膝关节置换(TKA)患者术后镇痛的疗效。方法单侧TKA患者60例,采用术中单纯关节周围组织局部注射得宝松、吗啡及罗哌卡因进行术后镇痛。结果鸡尾酒疗法在TKA患者术后镇痛中的总优良率为93.3%(56/60)。结论鸡尾酒疗法对TKA患者术后镇痛简便易行,疗效肯定,值得推荐。     

围手术期用药对降低人工膝关节置换术后疼痛的作用

目的探讨围手术期镇痛药物控制进行全膝关节置换（TKA）术后镇痛效果及临床疗效。方法选择64例单侧TKA的患者分为3组。A组：术前术后均口服塞来昔布,术中膝关节周围注射用药（2.5 mg/L布比卡因40 ml,1∶200 000的肾上腺素∶生理盐水30 ml。B组：术中未行膝关节周围注射,术前术后口服塞来昔布。C组：仅术中膝关节周围注射用药（同A组）。分别记录术前、术后静止与活动视觉模拟疼痛评分（VAS）和膝关节活动度。结果①VAS：A组术后6、12、24、36、48 h静止、运动VAS低于B、C组,差异有统计学意义（P〈0.05）;B、C组之间静止、运动VAS无明显差别（P〈0.05）;3组之间术后72 h静止和运动VAS间的差异无统计学意义。②膝关节活动度：A组术后第1、2、3天膝关节活动度均高于B、C组（P〈0.05）,而术后2周3组膝关节活动度比较差异无统计学意义。结论围手术期综合用药能有效控制TKA术后的疼痛,有利于关节功能早日恢复。     

人工全膝关节置换术后不同给药途径镇痛方式对比研究

目的对比研究2种不同给药途径镇痛方式在全膝关节置换（TKA）术后的镇痛效果。方法由同组医师完成的治疗骨性关节炎的TKA40例（40膝）,采用随机的方法分为术后静脉镇痛泵给药镇痛组（A组）和术后持续切口镇痛装置给药镇痛组（B组）,每组各20例。A组采用的药物为曲马多注射液和生理盐水混合,B组采用的药物为盐酸丁哌卡因注射液和生理盐水混合。比较2组在术后围手术期不同时间点疼痛视觉模拟评分（VAS）,辅助口服镇痛药物塞来昔布使用量及不良事件发生率。结果2组术后围手术期VAS评分不同时间点比较无统计学意义（P〉0．05）。辅助口服镇痛药物塞来昔布使用量及不良事件发生率方面B组明显优于A组（P〈0．05）。结论TKA术后采用术后持续切口镇痛装置给药镇痛明显优于传统静脉泵给药途径,可以明显降低辅助口服镇痛药物用量和不良事件发生率,获得了良好的镇痛疗效,镇痛的靶向性更强、使用更安全。     

Topical hemostatic procedures control blood loss in bilateral cemented single-stage total knee arthroplasty

Background Blood management is critical in total knee arthroplasty (TKA). In bilateral, single stage TKA, blood loss seems more prominent. We believe it is important to control all potential bleeding within the wound tissue.Purpose The purpose of the study was to evaluate a series of topical procedures used to reduce blood loss and transfusion in single-stage bilateral cemented total knee arthroplasty: antifibrinolysis with tranexamic acid, vasoconstriction with epinephrine, sealing of the bone section intraoperatively, and closure of the drainage tube within the first 4 h postoperatively.Materials and methods Patients with osteoarthritis of the knees were randomly divided into two groups. In group A, 5 ml (25 mg/ml) tranexamic acid (TXA) and 5 ml analgesic containing epinephrine (3 μg/ml) solution were injected at several points into the posterior capsule before installation of the prosthesis. The femoral medullar canal was closed with autograft bone and then sealed compressively with cement. Before the tourniquet was released, 10 ml TXA solution and 10 ml analgesic containing epinephrine were injected at several points into the periosteum, synovium, joint capsule, tendons, and deep fascia tissue (injection of analgesic containing epinephrine into subcutaneous fat and dermis was avoided). The residual nail holes in the bone and the uncovered bone section were covered with bone wax. The tourniquet was then removed, and active bleeding points were stanched. TXA solution (20 ml) was injected into the articular cavity after wound closure. The drainage tube was clamped for 4 h, then opened. In group B, injection of analgesic containing epinephrine into soft tissue, control of active bleeding, and clamping of the drainage tube for 4-h, only, were performed.Results Ninety patients were enrolled in the study. Compared with those in group B, intraoperative blood loss, drainage volume, total postoperative blood loss, and number of patients requiring allogenic blood transfusion were significantly reduced in group A. There was no significant difference between the incidence of complications in the groups.Conclusions Our topical procedures enable effective and safe reduction of blood loss and the number of patients requiring transfusion in single-stage bilateral osteoarthritic TKA.     

超声引导罗哌卡因复合地塞米松髂筋膜间隙阻滞应用于全膝关节置换术围术期的镇痛效果

目的 探讨超声引导罗哌卡因复合地塞米松髂筋膜间隙阻滞(FICB)在全膝关节置换术(TKA)围术期的镇痛效果.方法 将行TKA治疗的48例患者根据随机数字表法分为观察组和对照组,每组24例.两组术前0.5 h均在超声引导下行FICB,观察组注入0.375％罗哌卡因30 ml+地塞米松10 mg,对照组注入0.375％罗哌...     

股肌下结合微斜切入路全膝关节置换术治疗膝外翻

目的评估股肌下结合微斜切入路(SMOC)实施人工全膝关节置换术治疗膝关节外翻畸形的可行性及早期临床效果。 方法回顾性分析2015年4月至2017年10月在青岛大学附属医院关节外科50例(60膝)行初次人工膝关节置换术治疗并获得完整随访的膝外翻患者，排除年龄> 85岁、既往膝关节手术史及身体质量指数> 30 kg/m²的患者。男13例，女37例，年龄平均(60±8)岁。诊断为类风湿性关节炎42例52膝，骨关节炎5例5膝，创伤性关节炎3例3膝。采用SMOC入路行人工全膝关节置换术患者25例(31膝)，内侧髌旁入路者25例(29膝)。记录并比较两组患者的术前一般资料、血红蛋白、视觉模拟评分法(VAS)、美国特种外科医院(HSS)评分、膝关节被动活动度(ROM)、外翻角度；手术时间、术中出血量、外侧支持带松解率、术后2 d血红蛋白含量、术后引流量、输血率、直腿抬高时间、辅助镇痛药物使用情况、术后下肢力线、髌股适合角；24 h VAS，以及术后1周HSS评分及膝关节ROM，独立样本t检验或卡方检验比较分析两组差异。 结果术前一般资料两组无差异(P>0.05)，随访期间无感染及假体松动等并发症。术后外翻膝均得到矫正，两组在手术时间、术中出血量、术后引流量、术后2 d血红蛋白含量、输血率、术后下肢力线、髌股适合角方面两组差异无统计学意义(P>0.05)；SMOC组在直腿抬高时间(t＝10.500，P<0.01)、外侧支持带松解率(χ² ＝5.711，P<0.05)、辅助镇痛药使用(χ² ＝9.934，P<0.01)方面优于内侧髌旁入路。术后24 h VAS评分SMOC组低于髌旁组(t＝10.540，P<0.001)、1周HSS评分(t＝8.110，P<0.001)及ROM(t＝2.085，P<0.05)，SMOC组低于髌旁组。 结论利用SMOC入路全膝置换术可有效治疗膝外翻畸形，与髌旁入路相比，髌外侧支持带松解率更低，可获得更快速的近期康复效果。     

Evaluation of joint laxity against distal traction force upon flexion in cruciate-retaining and posterior-stabilized total knee arthroplasty

Background  Several studies have reported varus-valgus stability in the extension position after total knee arthroplasty (TKA). However, few studies have evaluated joint laxity in the flexion position postoperatively. The purpose of the study was to evaluate joint laxity against distal traction force on flexion after cruciate-retaining and posterior-stabilized total knee arthroplasties. Methods  A total of 44 knees (22 knees cruciate-retaining, 22 knees posterior-stabilized) in 40 patients with osteoarthritis were tested in this study. The subjects were seated at a table and their knee joints were fixed at 80° of flexion to avoid overlapping images of condyles and the femoral shaft. Tibial shafts were adjusted to be parallel to the radiographic films, and posteroanterior radiographs were obtained. Flexion stress tests were performed with a distal traction of 100 N at a neutral foot position. Radiographs were obtained at neutral and traction positions. The distance from the perpendicular line of the top of the polyethylene insert to the midpoint on the tangential line of the femoral condyle was measured (joint space distance) at each side. Results  In the flexion-neutral position, average joint space distances were 0.1 ± 0.2 mm in cruciate-retaining (CR) TKA knees and 0.2 ± 0.3 mm in posterior-stabilized (PS) TKA knees. With flexion-traction stress tests, the average joint space distances were 0.5 ± 0. 5 mm in CR TKA knees 2.4 ± 1.2 mm in PS TKA knees. Average changes of joint space distances between the two positions were 0.3 ± 0.4 mm (CR TKA) and 2.2 ± 1.5 mm (PS TKA). The changes in joint space distances between neutral and traction positions of PS TKA knees were significantly larger than those of CR TKA knees in flexion stress tests (P < 0.01). Conclusion  The posterior cruciate ligament acted as a stabilizer against distal traction force in the CR-TKA knees. However, the laxity of PS-TKA knees against distal force differed among individual cases.     

后交叉韧带保留型和后稳定型全膝关节置换术的临床疗效比较研究

目的 研究后交叉韧带保留(PCR)型和后稳定(PS)型全膝关节置换(TKA)的临床疗效,探讨两种不同假体置换术的临床相关问题.方法 回顾自2000年2月～2009年8月收治的36例(39膝)初次行TKA的资料,比较PCR和PS型假体的临床疗效,结合文献分析两者的优缺点及相关技术问题.结果 术后平均随访5年6个月,PCR型组和PS型组术后膝关节评分、疼痛评分、功能评分、髌骨评分差异均无统计学意义(P＞0.05),都明显改善了患膝的症状和功能.膝关节活动度PCR型组平均为106.6°,PS型组平均为107.6°,两组差异无统计学意义(P＞0.05).结论 后交叉韧带结构完整者可采用PCR型假体,但应松解PCL,原则上宁松勿紧;对于PS型假体,手术技术要求相对较低,容易掌握,临床适用范围更广.     

膝关节内翻屈曲畸形全膝关节置换的早期疗效

目的 探讨膝关节内翻屈曲挛缩畸形施行全膝关节置换(TKA)后的早期疗效.方法 回顾性分析自2007年7月～2009年5月,对膝关节内翻屈曲畸形49例(57膝)施行TKA的资料.行单膝TKA术41例,行双膝TKA 8例.术前平均膝关节内翻角、屈曲挛缩度数、膝关节HSS评分分别为(13.1±1.5)°、(18.55±0.6)°、(37.9±3.4)分.结果 患者获随访5～30个月,平均18个月.术后平均膝关节股胫角、屈曲挛缩度数分别为(174.2±1.9)°、(0.3±0.15)°.膝关节HSS评分术后为(88.3±5.1)分,与术前比较差异具有统计学意义(P＜0.05).无切口、深部感染及再翻修者.结论 人工全膝关节置换治疗膝关节屈曲挛缩畸形临床疗效较好.术中准确切骨、软组织平衡是矫正膝关节内翻屈曲挛缩畸形的关键.     

Periarticular multimodal drug injection is better than single anesthetic drug in controlling pain after total knee arthroplasty

Background

Postoperative pain is one of the issues that concern most patients after total knee arthroplasty (TKA). Periarticular multimodal drug injection and single anesthetic agent injection have been shown to effectively reduce postoperative pain. The purpose of this study was to compare the efficacy between multimodal drug injection and single anesthetic drug injection in controlling pain after TKA using a double-blinded randomized controlled trial.

Methods

Sixty-four osteoarthritic patients who underwent primary TKA were randomized into two groups. The multimodal drug injection group (group M) received levobupivacaine 150 mg, ketorolac 30 mg and morphine 5 mg, while the single anesthetic drug injection group (group S) received only levobupivacaine 150 mg. The primary outcomes were pain level (VAS), quantity of opioid consumption (mg) and time to request the first dose of analgesic drug (min).

Results

Multimodal drug injection provided lower pain level in the first 4 h after surgery (VAS rest: 30 vs 46, p = 0.02; VAS motion: 45 vs 66, p = 0.03). They consumed less morphine mostly in the first 8 h after surgery (5 vs 12 mg, p < 0.0001) and had approximately 2 h longer time to request the first dose of analgesic drug (254 vs 148 min, p = 0.02).

Conclusions

Multimodal drug injection decreases pain level, reduces morphine consumption in the early postoperative period and prolongs the analgesic effect compared to single anesthetic drug. One may consider using single anesthetic agent only in patients who have high risk of opioid or NSAIDs side effect.

     

Complex regional pain syndrome complicating total knee arthroplasty

PURPOSE. To compare the long-term outcome of patients diagnosed with complex regional pain syndrome-type 1 (CRPS-1) after total knee arthroplasty (TKA) with those of uncomplicated TKA knees and preoperative osteoarthritic knees. METHODS. Medical records of 1280 patients who underwent TKA for osteoarthritis were retrospectively reviewed; 8 were diagnosed as having symptoms and signs consistent with CRPS after TKA. Patients with primary inflammatory arthritis, signs of component loosening, malpositioning, or of infected arthroplasty were excluded. No patient had signs of CRPS prior to operative intervention. The 8 patients were compared with 2 groups of age- and sex-matched controls: uncomplicated TKA knees and preoperative osteoarthritic knees. Patients were followed up for a mean of 54 (range, 13-111) months and their range of movement, Western Ontario and McMaster Universities Osteoarthritis Index, SF-36 questionnaire scores, and Knee Society scores were assessed and compared. RESULTS. After appropriate treatment, most CRPS complicated patients had similar scores on SF-36, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society scores when compared with uncomplicated TKA patients. Scores for CRPS complicated patients were significantly improved when compared with preoperative osteoarthritic patients. The incidence of CRPS after TKA was 0.7%. CONCLUSION. When managed early, patients complicated with CRPS after TKA have a similar prognosis to patients with uncomplicated TKA.