近端联合远端收肌管阻滞在全膝关节置换术患者术后镇痛和早期功能康复中的应用

Effects of proximal combined with distal adductor canal block on postoperative analgesia and functional rehabilitation in patients undergoing total knee arthroplasty

目的探讨近端联合远端收肌管阻滞在全膝关节置换术患者术后镇痛和早期功能康复中的应用。方法选取2019年1月至2020年12月在解放军总医院第六医学中心择期行单侧全膝关节置换术患者90例,按随机数字表法分为3组,每组30例。A组为对照组,于超声引导下行股神经联合腘窝上坐骨神经阻滞;B组为近端联合远端收肌管阻滞组,于超声引导下分别行收肌管近端和远端阻滞;C组为右美托咪定联合收肌管阻滞组,于超声引导下将罗哌卡因与右美托咪定混合液分别注射至收肌管近端和远端。比较3组患者术后6 h(T1)、12 h(T2)、24 h(T3)和48 h(T4)时静息VAS评分,术后T3和T4时运动VAS评分,48 h内羟考酮和氟比洛芬酯使用情况;以及术后24 h(T3)、48 h(T4)和72 h(T5)膝关节活动范围(ROM)和股四头肌肌力;记录3组患者术后首次直腿抬高≥10 cm时间,术后首次下床活动时间,术后72 h起立-行走计时时间(TUG)和膝关节社会评分(KSS)及不良反应的发生率。结果重复测量方差分析提示,3组患者术后T1~4时刻静息VAS评分不同时间点间差异有统计学意义(P<0.05),无组间和交互效应(P>0.05),与T1时相比,T2~4时3组患者术后静息VAS评分增加,差异有统计学意义(P<0.05);而术后T3和T4时刻运动VAS评分无组间、时间和交互效应(P>0.05)。与A组和B组相比,C组患者术后首次使用羟考酮和氟比洛芬酯时间推迟,48 h内使用剂量减少,差异均有统计学意义(P<0.05)。3组患者术后T3~5时刻ROM比较存在时间、组间和交互效应(P<0.05),与T3时相比,T4和T5时3组患者术后ROM值显著增加(P<0.05),与A组相比,B组和C组在T3和T4时ROM活动度增加,在T3时股四头肌肌力增加,术后首次直腿抬高时间和下床活动时间提前,术后72 h TUG时间缩短,差异均有统计学意义(P<0.05)。结论近端联合远端收肌管阻滞可缓解TKA患者术后疼痛,促进早期功能锻炼和康复,而复合右美托咪定镇痛效果更优。

Objective To evaluate the effect of proximal combined with distal adductor canal block(ACB)on postoperative analgesia and functional rehabilitation in patients undergoing total knee arthroplasty(TKA).Methods 90 patients scheduled for elective TKA were randomly divided into 3 groups:Group A(control group),Group B(proximal and distal ACB group)and Group C(Dexmedetomidine combined with ACB group).Patients in group A were treated with femoral nerve block(FNB)and sciatic nerve block(SNB);patients in group B were treated with proximal and distal ACB;and patients in group C were treated with proximal and distal ACB using dexmedetomidine and ropivacaine mixture.Visual analogue scores(VAS)-rest at 6 h(T1),12 h(T2),24 h(T3)and 48 h(T4)after surgery;VAS-movement at T3and T4after surgery;and the usage of oxycodone and flurbiprofen axetil within 48 h were recorded for the patients in the three groups.Range of motion(ROM)of knee and quadriceps strength at 24 h(T3),48 h(T4)and 72 h(T5)after surgery were measured.The timed up and go(TUG)and knee society score(KSS)were evaluated at 72h after surgery.And the first time for straight leg raising≥10 cm,and the first time for ambulation were also recorded.Results The results of VAS among the three groups were not statistically significant(P>0.05).Compared with patients in Group A and Group B,the first time to use oxycodone and flurbiprofen axetil of patients in Group C were postponed,and the doses of them were also reduced(P<0.05).Compared with patients in Group A,the ROM and quadriceps strength of patients in Group C were increased;the TUG,the first time for straight leg raising≥10 cm,and the first time for ambulation of patients in Group C were shortened(P<0.05).Conclusion Proximal combined with distal ACB could alleviate the pain and retain the muscle strength after TKA;combined with dexmedetomidine,it could prolong the block time,reduce the usage of analgesics,and promote the functional rehabilitation after TKA.