初次全膝关节置换术后膝关节皮温测定意义

目的探讨全膝关节置换术后正常情况下切口局部皮温变化规律,为鉴别全膝关节置换术后有无感染提供参考依据。方法对68例行初次单侧全膝关节置换的患者进行术前、术后各时间段双膝关节皮温的监测并统计分析。结果获随访60例,时间48～56周。初次全膝置换术后患侧膝关节切口局部皮温升高,双侧皮温差随着时间的推移逐渐降低。双膝平均皮温差:术后第3天为(2.9±0.9)℃,第6天为(2.7±0.8)℃,第9天为(2.6±0.8)℃,第12天为(2.5±0.7)℃,第4周为(2.3±0.7)℃,第12周为(1.8±0.7)℃,第24周为(1.2±0.6)℃,第36周为(0.5±0.3)℃,第48周为0.0℃。结论初次全膝关节置换术后,正常情况下患侧膝关节皮温较对侧会升高。随着术后时间的延长,两侧的温差会逐渐降低,至术后36周两侧差异无统计学意义,术后48周患侧皮温一般恢复正常。若手术区皮温过高或持续时间过长应引起重视,需进一步检查以排除感染的可能。     

鸡尾酒疗法联合硬膜外单次小剂量吗啡对全膝关节置换术后疼痛控制的研究

目的 研究鸡尾酒疗法联合硬膜外单次小剂量吗啡对全膝关节置换术（total knee arthroplasty, TKA）后疼痛的控制作用。方法 采用随机双盲对照研究,选取2018年2月至2018年9月我院收治的拟行初次单侧TKA的膝骨关节炎病人160例,随机分为4组,每组40例,麻醉方式均采用硬膜外麻醉。A组病人给予鸡尾酒疗法（含激素）联合硬膜外单次小剂量吗啡;B组病人给予鸡尾酒疗法（不含激素）联合硬膜外单次小剂量吗啡;C组病人给予单纯鸡尾酒疗法（含激素）;D组为对照组,给予单纯鸡尾酒疗法（不含激素）。记录4组病人术后2、6、12、24、48、72 h静息状态下及术后24、48、72 h活动状态下的疼痛视觉模拟量表（visual analogue score, VAS）评分,术后48 h、72 h、4 d、5 d的膝关节最大屈曲活动度以及术后不良反应。结果 4组病人术后静息状态下、活动状态下的VAS评分及膝关节活动度总体比较,差异均有统计学意义（F=10.798,P＜0.001;F=6.220,P=0.001;F=6.075,P=0.001）。A、B、C组术后静息状态、运动状态下的VAS评分均显著低于D组,且其膝关节活动度均显著大于D组,差异均有统计学意义（P均＜0.05）。C组病人静息状态下VAS评分的总体均数高于A组,差值为0.52,差异有统计学意义（P=0.005）。结论 鸡尾酒疗法联合硬膜外单次小剂量吗啡在TKA术后显示出更强且更协同的镇痛效果,可更好地改善术后膝关节活动度;在无激素禁忌及不良反应的条件下,建议“鸡尾酒”混合镇痛药中添加糖皮质激素。     

鸡尾酒疗法对全髋关节置换术后切口局部炎性因子的影响

目的:探讨鸡尾酒疗法对全髋关节置换术(THA)后早期切口局部炎性因子的影响。方法:选择2019年6月至2020年12月在岳阳市人民医院诊断为老年股骨颈骨折将行单侧、初次THA的61例患者,根据随机数表法分为鸡尾酒疗法组31例和对照组30例。鸡尾酒疗法组于术中假体安放完成后,在髋关节前后关节囊、周围肌肉、深筋膜及皮下等部...     

全膝关节置换术后膝关节疼痛原因分析

膝关节疼痛是全膝关节置换术(TKA)后最常见的症状,多数与手术失误有关,且常预示手术失败。了解疼痛发生机制有助于在术中加以预防,提高手术质量。除感染及关节外原因外,引起TKA后膝关节疼痛的常见原因是膝关节屈曲不稳定、假体对线不良和髌骨关节问题。只有准确判断疼痛原因,才能正确处理。在分析致痛原因时应按照询问病史、物理查体、实验室检查、影像学检查的顺序逐步进行,科学条理、思路清晰的诊断程序是正确诊断、防止遗漏和偏差的保证。该文通过总结近年来的相关文献,详细阐述了TKA后膝关节疼痛的关节内、关节外常见原因及诊断要点。     

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。     

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。     

全膝关节置换术并发感染的挽救措施

全膝关节置换术常见的失败原因是并发深部感染。风湿性关节炎，膝关节手术史，修正手术，铰链假体置换术，膝关节感染和糖尿病容易引起深部感染。挽救深部感染的措施有生素应用，切开清创术，关节切除成形术，假体再置技术，关节融合术和截肢术。现对假体再置换术以外的外种挽救措施作一详述。     

全膝关节置换术后感染的分类

全膝关节置换术后感染通常根据感染的来源和发生的时间来分类，分类方法有很多，常见的有如下几种：     

术中关节周围鸡尾酒注射在骨性关节炎患者初次全膝关节置换术后镇痛中的应用

目的探讨术中关节周围注射混合镇痛药物(鸡尾酒)在膝关节骨性关节炎初次全膝关节表面置换术后镇痛中的疗效。方法选取我院关节外科2017年1月～2017年12月收治的60例行单侧表面全膝关节置换术(TKA)的膝关节骨性关节炎患者为研究对象,按照是否注射鸡尾酒分为干预组、对照组,比较两组患者术后48 h、1周、1月、3月、6月的疼痛视觉模拟(VAS)评分、膝关节活动度(ROM)、美国膝关节协会评分(KSS评分)、患者满意度及不良反应、切口并发症。结果干预组术后48 h、1周的VAS评分低于对照组(P0.05),干预组术后48 h、1周ROM大于对照组(P0.05),干预组术后48 h、1周KSS评分高于对照组(P0.05),干预组术后48 h、1周满意度高于对照组(P0.05)。未发现切口并发症。以上指标在术后1月、3月、6月均无统计学差异(P0.05)。结论术中鸡尾酒注射在TKA术后早期镇痛疗效确切,可改善早期功能,改善住院体验,提高患者满意度,促进患者早期康复。     

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。     

全膝关节置换术后多模式镇痛的临床研究

目的探讨人工全膝关节置换(TKA)术后不同镇痛方法的镇痛效果和安全性,以及如何合理搭配使用,以实现多模式、个体化镇痛。方法选择符合纳入标准且在腰硬联合麻醉下手术的120例TKA,随机分为A、B、C、D 4组。A、B组术后使用自控静脉镇痛(PCIA),C、D组不使用PCIA;A、C组术后6 h口服西乐葆400 mg,此后每12 h口服西乐葆200 mg至术后2周或VAS评分3分;B、D组术后6 h肌注帕瑞昔布40 mg,此后每12 h肌注帕瑞昔布40 mg,连续3 d后改为每12 h口服西乐葆200 mg;如镇痛不足追加吗啡注射。记录48 h内镇痛药物的总用量,每日记录患者VAS评分、术后引流量及膝关节活动度、睡眠满意度,并观察患者是否存在药物不良反应。结果 A、B组术后6 h VAS评分明显低于C、D组(P0.05);术后12 h,A组VAS评分明显低于C组(P0.05),B组VAS评分明显低于D组(P0.05);无论是在静息状态下还是活动状态下,术后3 d内B、D组VAS评分明显低于A、C组(P0.05)。4组均有药物不良反应发生,使用PCIA的A、B组恶心呕吐、尿潴留、便秘并发症显著增加(P0.01)。4组术后引流量、睡眠满意度及术后第2、3、7 d膝关节活动度差异无统计学意义(P0.05)。结论对TKA术后患者应用超前镇痛联合多模式镇痛可取得满意临床镇痛效果,帕瑞昔布结合PCIA镇痛效果更为明显。患者膝关节功能恢复良好,且不增加失血风险。     

Effects of local infiltration analgesia for posterior knee pain after total knee arthroplasty: comparison with sciatic nerve block

Background

Although femoral nerve block provides good analgesia after total knee arthroplasty (TKA), residual posterior knee pain may decrease patient satisfaction. We compared the efficacy of periarticular infiltration analgesia (PIA) and sciatic nerve block (SNB) for posterior knee pain.

Methods

Forty-nine patients scheduled for TKA were prospectively randomized into the PIA group (n = 25) or SNB group (n = 24) and received general anesthesia with ultrasound-guided femoral nerve block (FNB). In the PIA group, 60 ml 0.5 % ropivacaine and 0.3 mg epinephrine were injected intraoperatively into the periarticular soft tissue before inserting the components. In the SNB group, patients received ultrasound-guided SNB with 20 ml 0.375 % ropivacaine and periarticular infiltration with 20 ml normal saline and 0.3 mg epinephrine. We evaluated postoperative pain scores, posterior knee pain, frequency of rescue analgesics for 36 h, and performance time of PIA and SNB.

Results

Visual analogue pain scores at 12–24 h were significantly lower in the PIA group than in the SNB group (p < 0.05). The majority of patients had no posterior knee pain. There were no significant differences between the groups in frequency and time of first administration of rescue analgesics and in side effects. Time for performance of periarticular infiltration was significantly shorter than that for SNB (p < 0.05). The dose of intraoperative remifentanil was significantly lower in the SNB group than in the PIA group (p < 0.001).

Conclusions

The combination of FNB and PIA provides sufficient analgesia after TKA. The rapid and convenient periarticular infiltration technique could be a good alternative to SNB.     

全膝关节置换术中注射鸡尾酒式镇痛混合剂对膝关节中期功能的影响

目的评价全膝关节置换(TKA)术中注射鸡尾酒式镇痛混合剂对膝关节中期功能和屈伸活动度的影响。方法笔者自2006-05—2007-05诊治80例行单侧全膝关节置换的膝关节骨性关节炎,随机分为试验组和对照组,对比2组术后中期随访时美国膝关节协会(KSS)评分和膝关节活动度(ROM)的差异。结果 64例获随访45~69个月,平均61个月,试验组有效随访31例,对照组有效随访33例。试验组KSS评分(91.9±4.4)分,屈膝角度(129.2±6.9)°,伸膝角度(0.5±1.2)°;对照组KSS评分(87.5±4.9)分,屈膝角度(121.5±7.1)°,伸膝角度(0.3±1.1)°,试验组KSS评分及主动屈膝活动度指标优于对照组,2组KSS评分(t=3.77,P=0.001)、主动屈膝活动度(t=4.40,P=0.001)比较差异有统计学意义,主动伸膝活动度2组比较差异无统计学意义(t=0.70,P=0.492)。结论鸡尾酒式镇痛混合剂改善TKA术后膝关节中期功能效果显著。     

全膝关节置换治疗膝关节炎术后早期镇痛的研究进展

因膝关节炎而行全膝关节置换术的患者在术后早期多会出现程度不一的疼痛,这直接影响术后膝关节早期的功能锻炼及康复。目前,常用的镇痛方法有静脉自控镇痛、硬膜外自控镇痛、连续股神经阻滞镇痛、关节周围注射药物镇痛以及一些非药物性镇痛等。本文对全膝关节置换术后早期镇痛方法研究进展进行综述。     

Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty

BACKGROUND: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. METHODS: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. RESULTS: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. CONCLUSION: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.     

全膝关节置换术后皮肤坏死的处理

目的探讨应用真空负压引流术（VSD）、内侧腓肠肌皮瓣转移术治疗全膝关节置换（TKA）术后皮肤坏死,挽救TKA的疗效。方法2007年至2009年本组共有4例患者采用内侧腓肠肌皮瓣转移术治疗TKA术后伤口皮肤坏死,平均随访19个月（12—32个月）,采用KSS膝关节评分系统进行功能评价,在最后随访时对患者的感染消除情况进行临床评价,测量患者活动度。结果根据KSS膝关节评分系统,4例患者结果优良。所有患者均有良好的股四头肌力量。患者不需要助步器行走,所有皮瓣一期愈合,无感染复发。结论内侧腓肠肌皮瓣能提供良好的覆盖,允许早期活动和快速康复,可以降低TKA术失败后关节僵硬的发生率。     

Intrathecal baclofen for postoperative analgesia after total knee arthroplasty

Study ObjectiveTo determine whether intrathecal baclofen is an effective adjunctive agent to decrease acute and chronic postoperative pain after total knee arthroplasty.DesignProspective, randomized, double-blind controlled trial.SettingOperating room and inpatient units of a university hospital.Patients60 adult, ASA physical status I, II, and III patients presenting for total knee arthroplasty.InterventionsAnesthesia was provided by spinal injection of 15 mg of 0.75% hyperbaric bupivacaine combined with either 100 mcg baclofen or saline. Sedation was provided with intravenous midazolam and propofol.MeasurementsData were collected on adverse effects, opioid usage, and verbal pain scale (VPS) from 0 to 10. The study period was divided into six discrete time intervals that included the 1^st 72-hour postoperative period and a three-month post-discharge follow-up telephone call.Main ResultsThe baclofen group used less morphine in the PACU than the control group (5 mg vs. 9.3 mg; P = 0.04). VPS were lower in the baclofen group than the treatment group, but significant differences could be demonstrated only in the time periods 48-72 hours and three months postoperatively. At three months, fewer patients in the baclofen group reported pain than the control group (8/27 vs. 19/29; P = 0.009). Regression analysis showed that the baclofen group was 4.5 times less likely to report pain at three months (95% CI: 1.5–16.6).ConclusionsIT baclofen used as an adjuvant to spinal anesthesia for total knee arthroplasty allows for less postoperative opioid usage and less chronic pain at three months.     

关节内置管局部浸润镇痛在全膝关节置换术的应用

[目的]观察使用关节内置管局部浸润镇痛对全膝关节置换术后镇痛的早期临床疗效.[方法]收集从2008年12月～2009年4月在本院行全膝关节置换术后采用置管镇痛者11例(12膝).其中男3例,女8例,单侧手术者10例,同期双侧手术者1例.术前诊断:退变性骨关节炎8例,类风湿性关节炎2例,创伤后关节炎1例.所有患者围手术期镇痛方案均统一,术中关节周围注射"鸡尾酒"镇痛药液,并关节内置管术后1 d单次追加推注镇痛药液.记录患者术后1～3 d疼痛VAS评分、总体满意度、膝关节活动度、主动直腿抬高时间及伤口并发症等.[结果]所有患者均未使用胃肠外阿片类药物,术后1～3 d休息痛和运动痛VAS评分均获得显著改善,主动直腿抬高时间平均为2.6 d,手术后第2 d和第3 d的膝关节平均主动活动度各为41°和55°,患者总体满意度高,无明显并发症.[结论]全膝关节置换术后经关节内置管多模式局部浸润镇痛,能显著延长术后镇痛时间,降低手术24 h以后的休息痛、运动痛以及VAS评分,促进关节早日锻炼,提高患者满意度,且简单、实用、安全、有效.