连续股神经阻滞对全膝关节置换术的镇痛及恢复效果

目的:比较探究全膝关节置换术应用连续股神经阻滞与关节周围注射镇痛对全膝关节置换术镇痛疗效及对早期膝关节功能康复的影响。方法:选取我院行单侧膝全膝关节置换术的患者90例,随机分为连续股神经阻滞(CFNB)组和关节周围注射镇痛(LIA)组。CFNB组予以股神经周围泵入罗哌卡因镇痛,LIA组予以关节腔注射罗哌卡因+吗啡镇痛。分别于手术前后记录两组患者的疼痛评分(VAS)、股四头肌肌力评分,并评价患者的膝关节功能。结果:术后6 h、12 h,两组患者静息与活动状态下,VAS评分无明显差异;术后24 h、48 h,CFNB组患者在静息与活动状态下VAS评分均明显低于LIA组患者(P0.05);第2 d-5 d,两组患者膝关节活动度比较,CFNB组明显优于LIA组(P0.05),第6 d、7 d,两组膝关节活动度无明显差异(P0.05);与LIA组比较,CFNB组患者完成主动直腿抬高实验时间明显较短(P0.05)。两组患者股四头肌肌力评分比较无明显差异(P0.05)。结论:连续股神经阻滞对全膝关节置换术的镇痛效果更明显,有助于早期膝关节功能恢复,且不影响股四头肌肌力。     

连续股神经阻滞联合帕瑞昔布对全膝置换患者术后镇痛效果观察

目的:探讨连续股神经阻滞(CFNB)联合帕瑞昔布对全膝关节置换术(TKA)患者术后镇痛效果。方法:选择2015年1月至2016年12月间我院行择期单侧TKA治疗的患者100例,按照随机数字表法分为对照组和研究组,每组各50例。两组患者术后分别接受CFNB和CFNB联合帕瑞昔布镇痛,镇痛时间2 d。观察两组患者术后6 h、12 h、24 h、48 h静息状态和运动状态视觉模拟疼痛评分(VAS)以及术后不良反应发生率。并于术前1 d、术后1 d、2 d、3 d应用美国特种外科医院膝关节评分表(HSS)评定两组患者膝关节功能。结果:术后6 h、12 h、24 h、48 h研究组患者静息状态VAS评分和运动状态VAS评分显著低于对照组患者(P0.05)。两组恶心/呕吐、呼吸抑制、导管相关问题、尿潴留发生率比较无统计学差异(P0.05)。两组患者术前1d HSS评分比较无统计学差异(P0.05),术后1 d、术后2 d、术后3 d两组患者HSS评分均较术前1 d显著升高,且研究组患者HSS评分显著高于对照组(P0.05)。结论:CFNB联合帕瑞昔布具有镇痛效果好、安全可靠的优点,应用TKA术后镇痛有利于患者早期进行膝关节功能锻炼,值得临床推广。     

连续股神经阻滞与静脉自控镇痛对全膝关节置换术后患者凝血功能的影响

目的:比较连续股神经阻滞(CFNB)与静脉自控镇痛(PCIA)在全膝关节置换术中的应用效果及对患者凝血功能的影响。方法:选取2014年1月至2015年12月间我院行单侧全膝关节置换术的患者80例,按照随机数字表法分为CFNB组和PCIA组,每组各40例,两组患者分别接受CFNB和PCIA治疗。观察两组患者术后6 h、12 h、24 h、48 h视觉模拟疼痛评分(VAS),两组患者分别于麻醉前(T1)、术毕(T2)、术后1 d(T3)、术后2 d(T4)进行血栓弹力图检查,观察两组凝血功能变化。并于术后随访1年,比较两组患者膝关节功能。结果:术后6 h、12 h、24 h、48 h CFNB组患者VAS评分显著低于PCIA组患者(P0.05)。T2、T3、T4时点CFNB组患者凝血反应时间(R)、血凝块形成时间(K)较T1升高,血凝块聚合形成速率(α角)、血凝块最大振幅(MA)较T1降低,PCIA组患者R、K较T1降低,α角、MA较T1升高,T2、T3、T4时点CFNB组患者R、K高于PCIA组患者,α角、MA低于PCIA组患者,差异均有统计学意义(P0.05)。两组患者术后均完成1年的随访,两组患者KSS评分、膝关节最大屈曲度、膝关节最大伸直度比较无统计学差异(P0.05)。结论:CFNB对于全膝关节置换术术后患者镇痛效果优于PCIA,有利于改善患者凝血功能,不影响术后患者膝关节功能的恢复。     

不同局部浸润镇痛技术对前交叉韧带重建术后患者的镇痛效果

目的:比较关节内与关节周围浸润镇痛对前交叉韧带重建术(ACLR)后患者的镇痛效果。方法:选择2014年1月至2015年11月在我院拟行ACLR的前交叉韧带断裂患者40例,将其随机分为关节内浸润镇痛组(IA组)与关节周围浸润镇痛组(PA组),每组20例。两组均于术前3d定时口服塞来昔布(200mg,bid),术前0.5h行股神经阻滞(3.3g/L罗哌卡因30mL)。术中IA组于关节内给予30mL复合镇痛药物,而PA组于关节周围滑膜内注射相同药物。术后均给予24h冰敷治疗。观察两组患者术后12-72h及出院时的静息与活动疼痛视觉模拟评分(VAS),术后24-72h及出院时膝关节活动度,记录患者术后吗啡用量及不良反应情况。结果:PA组术后12-72h在静息与活动时以及在出院当天的活动时,VAS评分均显著低于IA组(P0.05)。术后24-72hPA组关节活动度均优于IA组(P0.05)。术后IA组、PA组吗啡镇痛使用率分别为30%、15%,且IA组吗啡平均用量为(10.3±1.1)mg,明显高于PA组的(5.4±0.9)mg(P0.05)。两组不良反应率比较差异无统计学意义(P0.05)。结论:关节周围浸润镇痛为主的多模式镇痛对ACLR围手术期患者的镇痛效果更好,更有利于关节功能的康复,值得临床推广应用。     

关于连续股神经阻滞在膝关节置换术后镇痛的临床效果

目的研究连续股神经阻滞在膝关节置换术后中的镇痛效果。方法选取我院在2012年1月至2015年1月间收治的92例行膝关节置换术患者的临床资料,以数字随机分组法原则为依据,将患者分为观察组与对照组,观察组给予连续股神经阻滞镇痛,对照组给予静脉止痛泵镇痛,分析两组患者术后2h、24h、36h、72h的VAS疼痛评分情况与不良反应发生率。结果 1观察组术后2h、24h、36h、72h的VAS疼痛评分均低于对照组,两组对比有统计学意义(P0.05)。2观察组不良反应发生率为4.35%,对照组不良反应发生率为15.22%,对比有统计学意义(P0.05)。结论连续股神经阻滞在膝关节置换术后镇痛中应用效果显著,有着良好的安全性能,可有效控制不良反应率,对患者术后功能恢复有促进作用,值得临床推广应用。     

帕瑞昔布联合股神经阻滞用于膝关节置换术后镇痛的效果评价及其对患者免疫功能的影响

目的:探讨帕瑞昔布联合股神经阻滞用于膝关节置换术后镇痛的效果及对患者免疫功能的影响。方法:选择2016年10月-2017年10月我院骨科住院部收治并行单侧膝关节置换的患者108例,按镇痛方式分为对照组和观察组各54例。对照组患者采用单纯股神经阻滞,观察组采用股神经阻滞联合帕瑞昔布。比较两组静息及活动状态下术后VAS评分、术后膝关节HSS评分、不良反应的发生情况及免疫指标的变化情况。结果:静息及活动状态下,观察组术后VAS评分均明显低于对照组(P均0.05),膝关节HSS评分显著高于对照组(P0.05)。两组术后不良反应的发生情况比较差异无统计学意义(P0.05)。手术结束时,两组CD4~+较麻醉前均显著下降(P均0.05);术后72 h,两组CD4~+、CD8~+及CD4~+/CD8~+较麻醉前均无显著差异(P均0.05)。观察组术后72 h CD4~+比对照组高(P0.05),而CD4~+/CD8~+显著低于对照组(P0.05)。结论:帕瑞昔布联合股神经阻滞对膝关节置换术后镇痛临床效果好,利于保护和改善患者免疫功能,促进膝关节功能的康复。     

不同麻醉方式对老年糖尿病患者全膝置换术后糖代谢的影响

目的:探讨不同麻醉方式对老年糖尿病患者全膝置换术(total knee arthoplasty,TKA)后糖代谢的影响。方法:2018年2月到2020年3月选择在本院进行择期TKA的老年糖尿病合并膝关节骨性关节炎患者88例,随机原则分为研究组与对照组,各44例。对照组给予常规静吸复合全身麻醉,研究组在对照组麻醉的基础上给予复合股神经阻滞,检测两组术后空腹血糖值,并记录两组膝关节功能改善情况。结果:研究组术后1 d、3 d与7 d静息状态下和活动状态下的疼痛视觉模拟评分法(Visual Analogue Scale/Score,VAS)评分都显著低于对照组(P<0.05)。研究组术后1 d、3 d与7 d的空腹血糖值都显著低于对照组(P<0.05)。研究组术后1 d、3 d与7 d的患肢膝关节活动度都显著高于对照组(P<0.05)。结论:股神经阻滞联合全麻在老年糖尿病患者TKA中的应用能缓解术后疼痛,减低术后血糖水平,并且促进提高膝关节活动度有益预后。     

股神经阻滞自控镇痛用于全膝置换术后镇痛和功能恢复的疗效观察

目的:观察股神经阻滞自控镇痛用于全膝置换(total knee arthoplasty,TKA)术后镇痛和功能恢复的疗效。方法:选择2017年8月～2019年6月院骨科收治的膝关节骨性关节炎患者122例,根据随机数字表法将其分为观察组与对照组,每组61例患者。所有患者均采用静吸复合全身麻醉,观察组给予股神经阻滞自控镇痛,对照组给予静脉自控镇痛,记录和比较两组患者术后镇痛效果与功能恢复情况。结果:观察组术后1 d、3 d与7 d的疼痛视觉模拟评分法(Visual Analogue Scale/Score,VAS)评分、血清白细胞介素(Interleukin,IL)-6和C-反应蛋白(C-reactive protein,CRP)含量都显著低于对照组(P0.05),患肢膝关节活动度明显高于对照组(P0.05),术后7 d的恶心、头晕、嗜睡、心动过缓等并发症发生率(4.9%)显著低于对照组(21.3%,P0.05),术后1 d、1个月与3个月的患肢膝关节活动度显著高于对照组(P0.05)。结论:股神经阻滞自控镇痛用于TKA可提高术后镇痛效果,促进膝关节功能恢复,减少术后并发症的发生,可能与其有效抑制IL-6和CRP的释放有关。     

氨甲环酸联合利伐沙班对单侧全膝关节置换术后患者出血量、凝血功能以及膝关节功能的影响

目的:探讨氨甲环酸联合利伐沙班对单侧全膝关节置换术后患者出血量、凝血功能及膝关节功能的影响。方法:选取2015年1月-2016年1月在解放军425医院骨科初次行单侧全膝关节置换术的患者66例为研究对象,按照随机数字表法分为治疗组与对照组,每组各33例。治疗组患者在止血带释放前向关节腔内注射氨甲环酸,对照组患者则给予氯化钠注射液进行静脉滴注,在术后6-12h内两组患者均口服利伐沙班。记录并对比两组患者总失血量、隐性出血量、输血率、输血量,对比两组患者手术前后凝血功能指标、膝关节功能评分、膝关节活动度、疼痛视觉模拟评分(VAS),并观察两组患者并发症发生情况。结果:与对照组对比,治疗组患者的总失血量、隐性出血量、输血量及输血率均明显降低(P0.05);治疗组与对照组患者术前与术后3 d的活化部分凝血酶时间(APTT)、凝血酶原时间(PT)、纤维蛋白原(FG)水平比较均无显著差异(P0.05);术前两组患者的美国膝关节协会评分(AKSS)及膝关节活动度比较无显著差异(P0.05),术后7 d,治疗组与对照组患者的AKSS评分及膝关节活动度均较术前升高(P0.05),且治疗组患者的AKSS评分及膝关节活动度高于同时期对照组(P0.05);术前两组VAS评分比较无显著差异(P0.05),术后1 d,两组患者的VAS评分比较及与同组术前比较均无显著差异(P0.05),术后7 d,两组患者的VAS评分明显较术前及术后1 d降低(P0.05),但两组之间比较无显著差异(P0.05)。两组患者并发症总发生率对比无显著差异(P0.05)。结论:氨甲环酸联合利伐沙班可有效降低行单侧全膝关节置换术患者的出血量,加快关节功能的恢复,且不影响患者的凝血功能,值得临床推广。     

全膝关节置换术后多模式镇痛中非选择与选择性COX-2抑制剂 的对比应用研究

目的:评价全膝关节置换术后病人早期功能锻炼过程中应用选择性环氧化酶-2(COX-2)抑制剂帕瑞昔布钠与非选择性环氧化酶(COX)抑制剂氟比洛芬酯之间的镇痛效果是否存在差异,以及对早期功能锻炼结果的影响。方法:前瞻性、随机、双盲、平行对照研究,根据纳入/排除标准,连续选取2009年6月至2010年3月在我科行单侧人工全膝关节置换术的病人60名。手术均采用腰麻联合硬膜外阻滞麻醉,由同一组手术医师完成,术中假体安装前关节周围软组织注射"鸡尾酒"镇痛液(罗哌卡因注射液150mg+肾上腺素(1:1000)0.5ml,由生理盐水稀释为100ml)。手术结束后进行病人自控静脉镇痛(PCIA)。术后当天患者在护士的指导下进行股四头肌收缩功能锻炼及直腿抬高功能锻炼。术后第一天起行膝关节被动伸屈功能锻炼(CPM)及主动伸屈功能锻炼。术后第3至5天患者停PCIA镇痛后,进行试验干预。帕瑞昔布钠组给予注射用帕瑞昔布钠40mg,静注1/12小时。氟比洛芬酯组给予氟比洛芬酯注射液100mg,静注1/12小时。观察病人术后第3至5天静息状态下和活动锻炼时膝关节最大主动屈曲时的疼痛强度(VAS评分),手术侧膝关节的主动伸屈活动度及术后1月复查时的手术侧膝关节的主动伸屈活动度,KSS评分,术后第2天与第6天的血红蛋白值。结果:两组病人给药后在静息状态及膝关节最大主动屈曲时,在不同时间点的VAS评分、膝关节主动活动度及术后1月患者膝关节的主动活动度和KSS评分的差异均无统计学意义(P>0.05)。应用抗凝治疗后,帕瑞昔布钠组患者血红蛋白下降值与氟比洛芬酯组存在差异(P=0.042)。结论:尚不能认为人工全膝关节置换术后多模式镇痛中同时抑制COX-1和COX-2与选择性抑制COX-2之间存在差异。但应用选择性COX-2抑制剂(帕瑞昔布钠)镇痛更安全,因其有利于减少全膝关节置换术后患者抗凝治疗过程中的隐性失血。     

Development and Validation of a Questionnaire Assessing Fears and Beliefs of Patients with Knee Osteoarthritis: The Knee Osteoarthritis Fears and Beliefs Questionnaire (KOFBeQ)

Objective

We aimed to develop a questionnaire assessing fears and beliefs of patients with knee OA.

Design

We sent a detailed document reporting on a qualitative analysis of interviews of patients with knee OA to experts, and a Delphi procedure was adopted for item generation. Then, 80 physicians recruited 566 patients with knee OA to test the provisional questionnaire. Items were reduced according to their metric properties and exploratory factor analysis. Reliability was tested by the Cronbach α coefficient. Construct validity was tested by divergent validity and confirmatory factor analysis. Test–retest reliability was assessed by the intra-class correlation coefficient (ICC) and the Bland and Altman technique.

Results

137 items were extracted from analysis of the interview data. Three Delphi rounds were needed to obtain consensus on a 25-item provisional questionnaire. The item-reduction process resulted in an 11-item questionnaire. Selected items represented fears and beliefs about daily living activities (3 items), fears and beliefs about physicians (4 items), fears and beliefs about the disease (2 items), and fears and beliefs about sports and leisure activities (2 items). The Cronbach α coefficient of global score was 0.85. We observed expected divergent validity. Confirmation factor analyses confirmed higher intra-factor than inter-factor correlations. Test–retest reliability was good, with an ICC of 0.81, and Bland and Altman analysis did not reveal a systematic trend.

Conclusions

We propose an 11-item questionnaire assessing patients'' fears and beliefs concerning knee OA with good content and construct validity.     

Self-Reported Knee Symptoms Assessed by KOOS Questionnaire in Downhill Runners (Skyrunners)

Background

The knee is the weight-bearing joint most commonly associated with sports injuries, and therefore is most at risk of developing degenerative changes, including osteoarthritis. Skyrunners can be considered to be at risk of developing symptoms of post-traumatic osteoarthritis due to downhill running.

Aim

The aim of this study was to analyze the health of the knee joints of a large group of these athletes via a specific self-report questionnaire.

Methods

This study was carried out by asking the participants of seven official Skyraces (22.4±3.1 km length; 1596±393 m elevation) to fill out a questionnaire. Information regarding age, sex, downhill elevation (m) during training and competitions over the last month, and history of previous knee injury was also collected before the participants filled out the Knee injury and Osteoarthritis Outcome Score (KOOS), which is a reliable and validated instrument designed to assess patients’ opinions about their knees and associated problems that can result in post-traumatic osteoarthritis. Athletes were divided into six age groups (from 17 to 70 years) and 12 groups based on the downhill gradient they had covered over the last month (from 1,000 to 40,000 m).

Results

Six hundred twenty-one questionnaires were collected from 45% of the participants in the seven races. Multivariate analysis revealed that self-reported KOOS scores were unrelated to age, sex and monthly downhill gradient. Only 74 (12%) of the participants reported previous knee injuries. Significant differences in the five subscales of the KOOS were found between skyrunners with and without previous knee injuries (P<0.01).

Conclusions

In the studied population, regular training for downhill running and participation in Skyraces could not be considered risk factors for subjective knee symptoms. Skyrunners with self-reported histories of knee injuries scored worse on all five subscales of the KOOS.     

Mitochondrial DNA (mtDNA) Haplogroups Influence the Progression of Knee Osteoarthritis. Data from the Osteoarthritis Initiative (OAI)

Objective

To evaluate the influence of the mtDNA haplogroups on knee osteoarthritis progression in Osteoarthritis Initiative (OAI) participants through longitudinal data from radiographs and magnetic resonance imaging (MRI).

Methods

Four-year knee osteoarthritis progression was analyzed as increase in Kellgren and Lawrence (KL) grade, in addition to increase in OARSI atlas grade for joint space narrowing (JSN), osteophytes and subchondral sclerosis in the tibia medial compartment of 891 Caucasian individuals from the progression subcohort. The influence of the haplogroups on the rate of structural progression was also assessed as the four-year change in minimum joint space width (mJSW in millimetres) in both knees of (n = 216) patients with baseline unilateral medial-tibiofemoral JSN. Quantitative cartilage measures from longitudinal MRI data were those related to cartilage thickness and volume with a 24 month follow-up period (n = 381).

Results

During the four-year follow-up period, knee OA patients with the haplogroup T showed the lowest increase in KL grade (Hazard Risk [HR] = 0.499; 95% Confidence Interval [CI]: 0.261–0.819; p<0.05) as well as the lowest cumulative probability of progression for JSN (HR = 0.547; 95% CI: 0.280–0.900; p<0.05), osteophytes (HR = 0.573; 95% CI: 0.304–0.893; p<0.05) and subchondral sclerosis (HR = 0.549; 95% CI: 0.295–0.884; p<0.05). They also showed the lowest decline in mJSW (standardized response means (SRM) = −0.39; p = 0.037) in those knees without baseline medial JSN (no-JSN knees). Normalized cartilage volume loss was significantly lower in patients carrying the haplogroup T at medial tibia femoral (SRM = −0.33; p = 0.023) and central medial femoral (SRM = −0.27; p = 0.031) compartments. Cartilage thickness loss was significantly lower in carriers of haplogroup T at central medial tibia-femoral (SRM = −0.42; p = 0.011), medial tibia femoral (SRM = −0.32; p = 0.018), medial tibia anterior (SRM = +0.31; p = 0.013) and central medial femoral (SRM = −0.19; p = 0.013) compartments.

Conclusions

Mitochondrial genome seems to play a role in the progression of knee osteoarthritis. mtDNA variation could improve identification of patients predisposed to faster or severe progression of the disease.     

膝关节不稳对骨折愈合的影响(附3例临床分析)

目的:探讨膝关节不稳对骨折愈合的影响。方法:回顾性分析我院收治3例患者因早期未能准确诊治膝关节交叉韧带损伤,而导致同侧股骨干骨折术后不愈合的临床资料。我们从生物力学角度分析,交叉韧带对膝关节生理性制导及稳定作用,反之损伤后膝关节的生理运动一定程度的丧失,以及随之而来的载荷传导紊乱,从而导致膝关节不稳。膝关节不稳所引起骨折端应力改变,其对骨折愈合将产生怎样的影响。结果:如未能及时修复交叉韧带在患者股骨干骨折术后行CPM锻炼及部分负重行走时将传导以骨折断端以一种剪切、旋转的应力,同时下肢垂直的纵向压应力将难以传导至骨折端,可能导致股骨干骨折术后的延缓愈合甚至不愈合。结论:膝关节不稳定可引起同侧肢体骨折端的应力改变,可能导致骨折的延缓愈合甚至不愈合。