膝关节置换后连续收肌管阻滞与连续股神经阻滞对早期活动影响的荟萃分析

A meta-analysis of the effects of continuous adductor canal block and continuous femoral nerve block on early activity after knee arthroplasty

目的:系统评估连续收肌管阻滞与连续股神经阻滞在全膝关节置换后的疼痛缓解和功能恢复效果。方法:按照主题词加自由词“arthroplasty,replacement,knee;continuous adductor canal block;adductor canal block;continuous femoral nerve block;femoral nerve block”“随机对照试验,膝关节置换,连续收肌管阻滞,股神经阻滞”检索国内外主要数据库(中国知网、万方、维普、CBM数据库和PubMed、Embase、Cochrane图书馆等),选择自建库至2021-08-31关于全膝关节置换后应用连续收肌管阻滞与连续股神经阻滞的随机对照临床试验,2名研究者各自独立进行文献筛选,用Cochrane行质量评估及偏倚风险评估后,提取相关结局指标,包括止痛疗效(静息痛与活动后疼痛评分、弱阿片类药物使用),功能恢复情况(股四头肌肌肉强度、起立-行走计时试验及住院天数),并发症(恶心呕吐发生及跌倒),用Revman 5.3软件进行汇总荟萃分析。结果:①共纳入9篇文献617例患者,纳入文献都是临床随机对照试验,文献质量评价提示总体质量较好;②与连续股神经阻滞相比,连续收肌管阻滞在股四头肌力量(MD=1.42;95%CI,0.32-2.52;P=0.01)、起立行走试验测试(MD=-1.23;95%CI,-2.03至-0.42;P=0.003)方面有统计学差异;③在休息和活动后疼痛评分(P>0.05)、术后阿片类药物的消耗量(MD=0.51;95%CI,0.20-1.30;P=0.16)、住院时间(MD=-0.42;95%CI,-1.24-0.40;P=0.32)方面无统计学差异;④此外,两种神经阻滞方法之间的并发症发生率,包括恶心呕吐(MD=1.04;95%CI,0.06-17.15;P=0.98)及跌倒(MD=0.45;95%CI,0.10-2.08;P=0.31)均无显著差异。结论:在全膝关节置换后应用连续收肌管阻滞与连续股神经阻滞的镇痛效果相似,但连续收肌管阻滞减小了对股四头肌肌力的影响并有利于置换后早期活动。

OBJECTIVE:To systematically evaluate the effects of continuous adductor canal block versus continuous femoral nerve block on pain relief and functional recovery after total knee arthroplasty.METHODS:The free words“arthroplasty,replacement,knee;continuous adductor canal block;adductor canal block;continuous femoral nerve block;femoral nerve block”were added according to the subject word.The main databases were searched,including CNKI,Wanfang,VIP,CBM,PubMed,Embase,Cochrane Library,etc.,for randomized controlled trials of continuous adductor canal block and continuous femoral nerve block after total knee arthroplasty published from inception to August 31,2021.Two researchers independently screened the literature,performed quality assessment and offset risk assessment with Cochrane.Relevant outcome indicators,containing analgesic effect(resting pain and post-activity pain score,use of weak opioids),functional recovery(quadriceps muscle strength,timed up&go test,and hospital stay),and complications(nausea,vomiting,and falls),were collected and meta-analyzed by Revman 5.3 software.RESULTS:(1)A total of 617 patients were included in 9 articles,all of which were randomized controlled trials.The evaluation of literature quality indicated that the overall quality was good.(2)Compared with continuous femoral nerve block,continuous adductor canal block had significant differences in quadriceps strength(MD=1.42;95%CI,0.32-2.52;P=0.01)and timed up&go test(MD=-1.23;95%CI,-2.03 to-0.42;P=0.003).(3)There was no significant difference in pain score after rest and activity(P>0.05),postoperative opioid consumption(MD=0.51;95%CI,0.20 to 1.30;P=0.16),and hospital stay(MD=-0.42;95%CI,-1.24 to 0.40;P=0.32)between continuous femoral nerve block and continuous adductor canal block.(4)In addition,there was no significant difference in the incidence of complications between the two block methods,including nausea and vomiting(MD=1.04;95%CI,0.06-17.15;P=0.98)and falls(MD=0.45;95%CI,0.10-2.08;P=0.31).CONCLUSION:The analgesic effect of continuous adductor canal block after total knee arthroplasty is similar to that of continuous femoral nerve block,but continuous adductor canal block reduces the effect on quadriceps muscle strength and is beneficial to early activity after total knee arthroplasty.