超声引导下近端收肌管阻滞联合远端腘动脉与膝关节后囊间隙阻滞对全膝关节置换术后镇痛的影响

Effect of ultrasound-guided proximal adductor canal block combined with distal interspace between the popliteal artery and the capsule of the posterior knee block on analgesia after total knee arthroplasty

目的探讨超声引导下近端收肌管阻滞联合远端腘动脉与膝关节后囊间隙(IPACK)阻滞用于全膝关节置换术后的镇痛效果,以及对术后早期功能锻炼和炎性因子的影响。方法选择于全麻下首次行单侧全膝关节置换术老年患者87例,男16例,女71例,年龄65~75岁,BMI 18~35 kg/m^(2),ASAⅠ—Ⅲ级。将患者随机分为三组:近端收肌管阻滞联合远端IPACK阻滞组(A组,n=29)、股神经阻滞组(F组,n=30)和对照组(C组,n=28)。超声引导下采用0.25%罗哌卡因实施相应神经阻滞,A组行联合阻滞各15 ml,F组行股神经阻滞30 ml,C组不行神经阻滞。术毕均采用静脉自控镇痛。记录术后6、12、24、48、72 h静息和活动时的NRS疼痛评分,术后12、24、48、72 h股四头肌肌力和术后24、48、72 h膝关节活动度。记录术前1 d、术后2、15 h血清IL-6浓度。结果与C组比较,A组术后6、12、24、72 h静息和活动时NRS疼痛评分明显降低(P<0.05),术后24、48 h膝关节活动度明显增加(P<0.05),术后2、15 h IL-6浓度明显降低(P<0.05);F组术后6、12、24 h静息和活动时NRS疼痛评分明显降低(P<0.05),术后12、24 h股四头肌肌力明显减小(P<0.05)。与F组比较,A组术后6、12、24 h活动时NRS疼痛评分明显降低(P<0.05),术后12、24 h股四头肌肌力明显增大(P<0.05),术后24、48 h膝关节活动度明显增加(P<0.05),两组术后IL-6浓度差异无统计学意义。结论超声引导下近端收肌管阻滞联合远端IPACK阻滞可为全膝关节置换术后提供良好的镇痛效果,对股四头肌肌力和膝关节活动度影响小且能减轻手术应激相关炎症反应,有利于患者早期康复。

Objective To investigate the ultrasound-guided proximal adductor canal block combined with distal infiltration of the interspace between the popliteal artery and posterior capsule of the knee(IPACK)block on postoperative analgesic effect,and its effects on early postoperative functional exercise and the level of inflammatory factor expression after suffering total knee arthroplasty.Methods Eighty-seven patients,16 males and 71 females,aged 65-75 years,BMI 18-35 kg/m^(2),ASA physical statusⅠ-Ⅲ,who planned to undergo the first unilateral total knee arthroplasty under general anesthesia were included.Patients were randomized into three groups:proximal adductor canal block combined with distal IPACK block group(group A,n=29),femoral nerve block group(group F,n=30),and control group(group C,n=28).0.25%ropivacaine was used for nerve block under ultrasound guidance.Group A received IPACK block(15 ml)and adductor canal block(15 ml);femoral nerve block(30 ml)was performed in group F.Group C had no nerve block operation.Patient controlled intravenous analgesia were used after surgery.NRS scores at rest and during exercise were recorded at the 6,12,24,48,and 72 hours after operation.The quadriceps muscle strength was counted at 12,24,48 and 72 hours after surgery,and the maximal active flexion angle of knee joint on were compared at 24,48 and 72 hours after operation.The expression levels of interleukin-6(IL-6)in venous serum were assessed at 1 day before operation,2,15 hours after operation.Results Compared with group C,group A showed a significant decrease in NRS pain score at rest and during exercise at 6,12,24,and 72 hours after surgery(P<0.05),increased in the maximal active flexion angle of knee joint at 24 and 48 hours after operation(P<0.05),reduced in IL-6 concentration at 2 and 15 hours postoperatively.Compared with group C,the NRS pain scores at rest and during activities at 6,12 and 24 hours after surgery were significantly reduced(P<0.05),the quadriceps muscle strength at 12 and 24 hours after surgery was greatly weaker in group F(P<0.05).Compared with group F,in group A the NRS pain score was lower at 6,12 and 24 hours after operation(P<0.05),the quadriceps femoris muscle strength was significantly powerful at 12 and 24 hours after operation(P<0.05),and the maximal active flexion angle of knee joint was remarkably increased at 24 and 48 hours after operation(P<0.05),there was no statistical difference in IL-6 at each observation time point between groups A and F.Conclusion Ultrasound-guided proximal adductor canaloblock combined with distal IPACK block can provide good analgesia after total knee replacement,have little effect on quadriceps muscle strength and range of knee motion,and can reduce surgical stress related inflammatory response,which is more conducive to early recovery of patients.