双膝关节同次置换术后的早期康复锻炼

Early rehabilitation after simultaneously bilateral total knee arthroplasty

目的:探讨双膝关节置换术前和术后功能锻炼的原则和方法。方法:自2005年1月至2008年6月共完成双膝关节置换72例144膝,男33例,女39例;年龄46～78岁,平均69岁。其中骨性关节炎54例,类风湿性关节炎17例,创伤性关节炎1例。屈曲挛缩大于30°者7例9膝,固定内翻畸形大于30°者10例15膝,固定外翻畸形大于15°者6例8膝。按照术前、术后早期和术后远期的分期为患者制定合理的锻炼计划,在多模式镇痛的前提下术后及早开始功能锻炼,通过增加关节活动度(ROM)和股四头肌及腘绳肌肌力的强化训练提高手术效果。使用WOMAC评分、ROM和6min行走距离以及VAS疼痛评分分别对术前、术后膝关节功能及疼痛程度进行评价,术后下肢血管超声判断血栓的形成,根据临床表现和D-二聚体水平诊断肺栓塞。结果:分别以术前2d、术后2d及术后1、2、8、24周作为观察点。失访3例6膝。术后WOMAC评分、VAS疼痛评分低于术前,术后ROM和6min持续行走距离高于术前。128膝可在术后2周内完全伸直,屈曲大于90°,135膝术后8周屈曲可达110°。发生单侧下肢静脉血栓2例2膝,双侧下肢血栓1例2膝,未见肺栓塞发生。结论:双侧膝关节同时置换应制定术前、术后早期和术后远期功能锻炼计划,并在多模式镇痛的前提下术后早期行功能锻炼,以提高膝关节功能并降低疼痛和肿胀。

Objective：To investigate the principle and methods of preoperative and postoperative rehabilitation for simultaneous bilateral total knee arthroplasty.Methods：From January 2005 to June 2008,72 patients （144 knees） were reviewed in the study,including 33 males and 39 females,ranging in age from 46 to 78 years,with an average age of 69 years.There were 54 patients with osteoarthritis,17 patients with RA,and 1 patient with traumatic osteoarthritis,including 10 cases （15 knees） of fixed varus deformity more than 30 degree and 6 cases （8 knees） of fixed vagus deformity more than 15 degree.Rehabilitation protocol was made for preoperative,early postoperative and late postoperative stages.Patients were encouraged to initiate the exercises at the early postoperative stage on the premise of multimodal analgesia.Knee function and pain were evaluated using WOMAC and VAS pain scores.Lower limb embolism was determined by ultrasonic scan and pulmonary embolism was diagnosed by clinical manifestation and D dimer level.Results：Sixty nine patiets（138 knees） were followed up at 2 d preoperatively and the second day,1,2,8 and 24 weeks postoperatively.The average postoperative WOMAC and VAS score were significantly lower than preoperative levels,while the postoperative knee ROM and 6 min walking distance were evidently higher than the preoperative ones,respectively.One hundred and twenty eight knees achieved full extension and flexion more than 90 degree at 2 weeks postoperatively,and 135 knees reached 110 degree in flexion.Unilateral lower limb embolism was found in 2 cases （2 knees） and bilateral ones were found in 1 case （2 knees）.No pulmonary embolism was confirmed.Conclusion：Rehabilitation protocols should be made for preoperative,early postoperative and late postoperative stages of simultaneous bilateral knee arthroplasty.Patients should be encouraged to exercise at the early postoperative stage on the premise of multimodal analgesia,in order to improve knee function and reduce edema.