收肌管神经阻滞联合环氧合酶2选择性抑制剂在人工全膝关节置换术后的序贯应用及疗效

EFFICACY OF SEQUENTIAL TREATMENT WITH ADDUCTOR CANAL NERVE BLOCK AND CYCLOOXYGENASE 2 SELECTIVE INHIBITOR AFTER TOTAL KNEE ARTHROPLASTY

目的探讨人工全膝关节置换术(total knee arthroplasty,TKA)后收肌管神经阻滞(adductor canal nerve block,ACNB)联合环氧合酶2(cyclooxygenase 2,COX-2)选择性抑制剂(帕瑞昔布+塞来昔布)序贯应用的镇痛效果。方法将2015年1月-12月收治并符合选择标准的90例骨关节炎患者,随机分成3组(n=30),分别为ACNB+COX-2组(A组)、COX-2组(B组)及对照组(C组)。3组患者性别、年龄、体质量指数、侧别以及病程等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。TKA术毕时A组行ACNB。术后前3 d每12小时A、B组静脉注射帕瑞昔布40 mg,之后每12小时口服塞来昔布200 mg至6周;对应时间点C组给予生理盐水和安慰剂。3组患者术后疼痛视觉模拟评分(VAS)≥4分时,予口服曲马多,必要时追加注射吗啡。比较3组手术时间、术后24 h内关节引流量、住院时间及6周内不良反应发生情况;术前以及术后1、2、3 d,1、2、4、6周,运动及静息VAS评分、膝关节活动度(range of motion,ROM)以及相关炎性指标;术后24 h内以及24 h^6周吗啡使用量;术前及术后1、2、4、6周膝关节美国特种外科医院(HSS)评分;术前及术后1、3、14 d凝血功能相关指标。结果A、B组术后住院时间较C组显著缩短、恶心呕吐发生率较C组显著降低(P<0.05)。A、B组术后1、2、3 d静息VAS评分显著低于C组(P<0.05);术后1 d,A组运动VAS评分最低,3组间比较差异有统计学意义(P<0.05);2、3 d及1、2、4、6周,A、B组显著低于C组(P<0.05)。3组术后24 h内吗啡用量比较差异均有统计学意义(P<0.05),其中A组最少;A、B组术后24 h^6周期间吗啡用量显著少于C组(P<0.05)。术后1、2、4、6周,3组HSS评分比较差异有统计学意义,A组最高(P<0.05)。术后1、2 d,A组ROM最高(P<0.05),3 d及1、2、4、6周A、B组高于C组(P<0.05)。术后2、3 d及1、2、4、6周,A、B组红细胞沉降率均显著低于C组(P<0.05);术后1、2、3 d,A、B组C-反应蛋白水平均显著低于C组(P<0.05);术后各时间点A、B组IL-6及TNF-α水平均显著低于C组(P<0.05);术后2、3 d,A、B组IL-8水平显著低于C组(P<0.05)。3组术后24 h内关节引流量及各时间点凝血指标比较,差异均无统计学意义(P>0.05)。结论 ACNB联合COX-2选择性抑制剂序贯应用是安全、有效的TKA术后疼痛管理方案,可明显减轻TKA术后疼痛、促进关节功能康复,降低不良反应发生率。

Objective To investigate the efficacy of sequential treatment with adductor canal nerve block（ACNB） and cyclooxygenase 2（COX-2） selective inhibitor（parecoxib and celecoxib） after primary total knee arthroplasty（TKA）. Methods Between January 2015 and December 2015, 90 osteoarthritis patients who met the inclusion criteria were treated, and randomly divided into 3 groups： ACNB＋COX-2 group（group A, n=30）, COX-2 group（group B, n=30）, and control group（group C, n=30）. There was no significant difference in gender, age, body mass index, side, and osteoarthritis duration between groups（P0.05）, and the data were comparable. ACNB was used in group A at the end of TKA. Intravenous injection of parecoxib（40 mg per 12 hours） was administrated at the first three postoperative days, and followed by oral celecoxib（200 mg per 12 hours） until 6 weeks after operation in groups A and B; while placebo was given at the same time point in group C. Oral tramadol or intravenous morphine, as remedial measures, were introduced when patients had a visual analogue scale（VAS） score more than 4. The following indicators were compared between groups： the operative time, drainage volume at 24 hours after operation, length of hospital stay, and incidence of side effect; VAS pain scores, morphine consumption, range of motion（ROM） of the knee joint, and inflammatory cytokines levels at preoperation and at 1 day, 2 days, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks after operation; morphine consumption within first 24 hours and at 24 hours to 6 weeks after operation; the American Hospital for Special Surgery（HSS） score at 1, 2, 4, and 6 weeks after operation; and the serum coagulation parameters at pre-operation, and at 1, 3, and 14 days after operation. Results The length of hospital stay was significantly shorter and the incidence of postoperative nausea and vomiting was significantly lower in groups A and B than group C（P0.05）. The VAS scores at rest（VASR） of groups A and B were significantly lower than that of group C at 1, 2, and 3 days after operation（P0.05）; difference in the VAS scores at walking（VASW） was significant between groups at 1 day after operation（P0.05）, and group A had the lowest VASW; and the VASW of groups A and B were significantly lower than that of group C at 2 and 3 days and at 1, 2, 4, and 6 weeks after operation（P0.05）. The difference in morphine consumption was significant between groups within the first 24 hours after operation（P0.05）, and group A exhibited the lowest consumption; and the morphine consumption in groups A and B was significantly lower than that in group C at 24 hours to 6 weeks after operation（P0.05）. Significant difference was found in HSS scores between groups at 1, 2, 4, and 6 weeks after operation, and group A showed the highest score（P0.05）. At 1 and 2 days after operation, group A showed the highest ROM（P0.05）, and ROM of groups A and B was significantly higher that of group C at 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks after operation（P0.05）. Groups A and B were significantly lower than group C in the serum erythrocyte sedimentation rate at 2 days, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks, in C-reactive protein levels at 1, 2, and 3 days, in interleukin 6（IL-6） and TNF-α levels at 1 day to 6 weeks, and in IL-8 level at 2 and 3 days（P0.05）. The drainage volume within the first 24 hours and the serum coagulation parameters within the 2 weeks after operation showed no significant difference between groups（P0.05）. Conclusion Sequential treatment with ACNB and COX-2 selective inhibitor is a safe and effective approach for postoperative pain management after primary TKA, and it can alleviate postoperative pain, promote the joint function recovery, and reduce the risk of adverse reactions.