不同镇痛方法对膝关节置换术术后疼痛和功能恢复的影响

Effect of different methods of analgesia on postoperative pain and functional recovery after total knee replacement

目的比较不同镇痛方法对全膝关节置换术（TKA）术后疼痛和功能恢复的影响。方法择期单侧TKA患者60例，随机均分为三组：硬膜外镇痛组（CEA组）、静脉镇痛组（CIA组）和连续股神经阻滞镇痛组（CFN组）；术中均采用全身麻醉。记录术前、术毕1、6h、1、2、3、4和5d静息时和术前、术毕2、3、4、5d活动时的VAS评分，记录患者曲马多用量、患者镇痛满意率、功能锻炼角度、术前、术后1个月、3个月采用膝关节手术患者评分（KSS）表对功能恢复情况进行评分及术后恶心呕吐、嗜睡等不良反应。结果与术前比较，静息时术毕6h、1dCEA组和CIA组VAS评分明显升高，术毕1h、3～5dCEA组和CFN组VAS评分明显降低，且术毕1、2dCFN组VAS评分明显降低（P〈0．05）；活动时术毕2dCFN组，术毕3dCEA组和CFN组，术毕4、5d三组VAS评分明显降低（P〈0．05）；三组术后1个月、3个月临床评分和术后3个月功能评分明显升高（P〈0．05）。与CIA组比较，静息时术毕1、6h、1～3d和活动时术毕2dCEA组和CFN组VAS评分明显降低（P〈0．05）；术后3个月CFN组功能评分明显升高（P〈0．05）。与CFN组比较，活动时术毕3～5dCEA组和CIA组VAS评分、术后1个月CEA组和CIA组临床评分明显升高（P〈0．05）。术后第2～4天主动功能锻炼、CFN组被动功能锻炼的角度明显大于CEA和CIA组，且术后第2～4天CEA组主动功能锻炼角度明显大于CIA组（P〈0．05）。CFN组曲马多额外使用次数为（0．6±0．5）次，明显低于CEA组（1．0±0．9）次和CIA组（1．4±0．5）次（P〈0．05）。CIA组患者镇痛满意率为10例（50．0％），明显低于CEA组18例（90．0％）和CFN组18例（94．7％）（P〈0．05）。CFN组术后恶心呕吐的发生1例（5．3％），明显少于CEA组的7例（35．0%）和CIA组的10例（50．0％）（P〈0．05），而CIA组嗜睡发生8例（40．0％），明显高于CEA组的2例（10．0％）和CFN组的2例（10．5％）（P〈0．05），CEA组、CFN组无导管相关感染等并发症。结论连续股神经阻滞的镇痛效果较硬膜外镇痛和静脉镇痛的效果好，不良反应少，膝关节功能恢复更好。

Objective To compare different methods of analgesia on postoperative analgesia and functional recovery after total knee arthroplasty （TKA）. Methods Sixty unilateral TKA patients were randomly divided into three groups（n=20） ： continuous epidural analgesia group （group CEA）, continuous intravenous analgesia group （group CIA）, and continuous femoral nerve block analgesia group （group CFN） ; All patients received total intravenous general anesthesia. Visual analogue scale （VAS）, tramadol dosage, patients＇ satisfaction, postoperative active and passive functional exercise maximum angle were observed and recorded. All patients were followed up for 3 months, using keen society score （KS.S） to assess knee function. Results One patient in group CFN was excluded because of catheter＇s extrusion. In 1, 6 h, 1, 2, 3, 4, 5 d postoperative resting state and in 2 d postoperative moving state, VAS score of group CIA were significantly higher than the other two groups （P〈 0.05）. In 3 to 5 days postoperative moving state, the VAS score of group CFN were significantly lower than the other two groups （P〈0. 05）. Tramadol dosage was significantly lower （P〈0.05） and patients＇ satisfaction was higher （P〈0.05） in group CFN. Postoperative adverse reactions such as nausea and vomiting were significantly less in group CFN. Maximum angle of group CFN were greater than those of other two groups （P〈0.05）, during postoperative active and passive functional exercise. Clinical score of KSS at one month follow up in group CFN were higher than that of other two groups, no significant difference was found in knee function evaluation at three months follow up. Conclusion Compared with epidural analgesia and intravenous analgesia, Continuous femoral nerve block has superior analgesic effect in TKA surgery, as well as less adverse reactions, higher satisfaction and better knee function recovery.