局部浸润麻醉对全膝关节置换术后早期镇痛效果的影响

目的 研究对膝关节不同部位进行局部浸润麻醉(local infiltration anesthesia,LIA),对全膝关节置换术(total knee arthroplasty, TKA)术后患者早期镇痛效果的影响。方法 入组2017年3月至2018年6月因膝关节骨关节炎在首都医科大学附属北京朝阳医院骨科行单侧初次全膝关节置换术的患者,共100人,采用随机数分组法随机分为两组:后侧方浸润麻醉组(A组)及前方浸润麻醉组(B组),每组50例。其中A组在术中于后侧方结构腘动脉与后关节囊间隙(interspace between the popliteal artery and posterior capsule of the knee,IPACK)]及内外侧副韧带附着区分别注射镇痛药物,并于前方结构髌上囊滑膜、股四头肌肌腱及切口周围]分别注射0.9%(质量分数)氯化钠注射液(以下简称生理盐水)20 mL;B组在术中于后侧方结构分别注射生理盐水,并于前方结构分别注射镇痛药物。如患者出现不能耐受的疼痛则临时应用曲马多100 mg口服作为治疗补充。分析2组患者基线资料、术前及术后第5天视觉模拟评分(Visual Analogue Scale, VAS)、美国膝关节协会评分(American Knee Society Score, KSS)、美国骨关节炎指数(The Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC),并统计两组术后曲马多的用量。结果 两组患者基线资料及术前VAS评分差异均无统计学意义(P>0.05),术后第5天在静息状态下,A组VAS明显优于B组(P<0.05);而在功能锻炼状态下,两组术后VAS差异无统计学意义(P>0.05)。两组患者的术前及术后KSS及WOMAC差异均无统计学意义(P>0.05)。A组患者的曲马多用量小于B组患者,但差异无统计学意义(P>0.05)。结论 膝关节后侧方LIA对TKA术后患者的镇痛效果,在静息条件下明显优于膝关节前方LIA,并可减少术后口服阿片类药物的用量。对于TKA术后患者,建议加强膝关节后侧方区域的浸润镇痛而非单纯伤口等前方镇痛,能够有效控制患者术后早期的静息痛。

Local infiltration anesthesia for early analgesic effect after total knee arthroplasty

Objective To evaluate the efficacy of local infiltration anesthesia(LIA) in different injection regions after total knee arthroplasty(TKA). Methods In our hospital, from March 2017 to June 2018, 100 patients underwent unilateral primary TKA due to knee osteoarthritis were prospectively studied. Random number grouping method was used to randomly divide into 2 groups:posterior and lateral infiltration anesthesia group (Group A) and anterior infiltration anesthesia group (group B). Group A received analgesic drugs inposterior and lateral area interspace between the popliteal artery and posterior capsule of the knee (IPACK) and attachment of medial collateral ligament(MCL) and lateral collateral ligament(LCL)] and received normal saline(NS) 20 mL in anterior area (synovium of suprapatellar bursa, quadriceps tendon and incision). On the contrary, group B received 20 mL NS in posterior and lateral area, and received analgesic drugs in anterior area. The baseline information, preoperative and postoperative Visual Analogue Scale(VAS), American Knee Society Score(KSS) and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were recorded. In addition, the postoperative dosage of tramadol was also recorded. Results There was no significant difference and preoperative VAS between two groups. There was significant difference in postoperative VAS score between two groups at rest (P<0.05), but not at dynamic state (P>0.05). There was no significant difference in preoperative and postoperative KSS and WOMAC between the two groups (P>0.05). The average dose of tramadol used in group A was lower than that in group B, but there was no statistically significant difference (P>0.05). Conclusion Posterior and lateral local infiltration anesthesia was obviously effective after TKA than the anterior LIA at rest and can reduce the dosage of oral analgesics. We recommend to strengthen the infiltration analgesia in the posterior and lateral area of the knee joint rather than simplely anterior analgesia, such as wounds. Posterior and lateral LIA can effectively control early postoperative pain of TKA patients at rest.