收肌管阻滞与股神经阻滞在全膝关节置换术后镇痛疗效的Meta分析
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摘要
目的系统评价收肌管阻滞(ACB)与股神经阻滞(FNB)在全膝关节置换(TKA)术后镇痛及早期康复中临床疗效差异,为临床提供参考。方法检索Cochrane图书馆、Pub Med、EMbase、CNKI、维普资讯数据库及万方数据库等中英文数据库,检索截止日期为2016年8月。由两名评价员独立筛查文献、提取资料和方法学质量评估,采用Rev Man 5.2.0软件进行Meta分析,并绘制漏斗图评定有无发表偏倚。结果一共纳入12篇临床随机对照试验文献(9篇英文文献,3篇中文文献),共分析772膝,其中ACB组382膝,FNB组390膝。Meta分析结果显示:ACB组与FNB组患者视觉模拟(VAS)疼痛评分分别在术后2~4 h、6~8 h、24 h及48 h的静息评分[WMD=0.20,95%CI(-0.33,0.72);WMD=0.24,95%CI(-0.12,0.60);WMD=0.31,95%CI(-0.07,0.69);WMD=0.03,95%CI(-0.29,0.35)]和运动评分[WMD=0.10,95%CI(-0.41,0.62);WMD=0.64,95%CI(0.15,1.12);WMD=0.17,95%CI(-0.37,0.70);WMD=0.03,95%CI(-0.57,0.62)]差异均无统计学意义;ACB组患者的肌力在术后4~8 h、24 h及48 h[WMD=0.45,95%CI(0.25,0.64);WMD=0.38,95%CI(0.14,0.61);WMD=0.41,95%CI(0.18,0.63)]均显著优于FNB组;与FNB组比较,ACB组患者在术后24 h、48 h及72 h的膝关节活动度[WMD=5.01,95%CI(0.78,0.92);WMD=8.74,95%CI(3.54,13.93);WMD=6.65,95%CI(1.97,11.33)]、站立行走试验所需时间[WMD=-55.98,95%CI(-109.60,-2.35)]及术后平均住院时间[WMD=-0.049,95%CI(-0.96,-0.03)]等方面有优势,而在术后补救性阿片类药物用量及术后恶心呕吐发生率等方面差异均无统计学意义。结论收肌管阻滞与股神经阻滞在TKA术后镇痛疗效相当,同时收肌管阻滞对股四头肌肌力影响更小,从而有利于患者术后早期活动及功能康复。上述结果尚需更多高质量、大样本及多中心随机对照试验来进一步验证。
Objective To compare adductor canal block( ACB) with femoral nerve block( FNB)for postoperative analgesic effect and early rehabilitation after total knee arthroplasty( TKA). Methods The Cochrane Library,Pud Med,EMBASE,CNKI,VIP and Wan Fang were searched to identify randomized controlled trials( RCTs) articles comparing the ACB with the FNB in TKA up to August 2016. Study selection and assessment,data collection and analysis were undertaken by two authors independently. The meta-analysis was performed using Review Manager 5. 2. 0,and publication bias was evaluated through a funnel plot. Results Twelve studies were included,involving nine English studies and three Chinese studies.There was a total of 772 cases comparing ACB( n = 382) with FNB( n = 390). Meta-analysis suggested that the resting VAS scores[WMD = 0. 20,95% CI(-0. 33,0. 72); WMD = 0. 24,95% CI(-0. 12,0. 60);WMD = 0. 31,95% CI(-0. 07,0. 69); WMD = 0. 03,95% CI(-0. 29,0. 35) ] and motion VSA scores[WMD = 0. 10,95% CI(-0. 41,0. 62); WMD = 0. 64,95% CI( 0. 15,1. 12); WMD = 0. 17,95% CI(-0. 37,0. 70); WMD = 0. 03,95% CI(-0. 57,0. 62) ]were similar to the ACB group and FNB group at 2-4 h,6-8 h,24 h and 48 h. The quadriceps strength in the ACB group was better than that in the FNB group at 4 to8 h,24 h and 48 h[WMD = 0. 45,95% CI( 0. 25,0. 64); WMD = 0. 38,95% CI( 0. 14,0. 61); WMD = 0. 41,95% CI( 0. 18,0. 63) ]. The range of motion in the ACB group was also better than that in the FNB group at24 h,48 h and 72 h[WMD = 5. 01,95% CI( 0. 78,0. 92); WMD = 8. 74,95% CI( 3. 54,13. 93); WMD =6. 65,95% CI( 1. 97,11. 33) ]. Besides,ACB group had advantages in time-up-go test[WMD =-55. 98,95% CI(-109. 60,-2. 35) ] and length of hospital stay[WMD =-0. 049,95% CI(-0. 96,-0. 03) ].There was no difference in opioid consumption and side effect of nausea and vomiting. Conclusion When comparing with FNB,the ACB shows similar postoperative analgesia effects and has advantages in quadriceps strength recovery and promoting early postoperative rehabilitation,but more high-quality RCTs are required for further investigation.
Objective To compare adductor canal block( ACB) with femoral nerve block( FNB)for postoperative analgesic effect and early rehabilitation after total knee arthroplasty( TKA). Methods The Cochrane Library,Pud Med,EMBASE,CNKI,VIP and Wan Fang were searched to identify randomized controlled trials( RCTs) articles comparing the ACB with the FNB in TKA up to August 2016. Study selection and assessment,data collection and analysis were undertaken by two authors independently. The meta-analysis was performed using Review Manager 5. 2. 0,and publication bias was evaluated through a funnel plot. Results Twelve studies were included,involving nine English studies and three Chinese studies.There was a total of 772 cases comparing ACB( n = 382) with FNB( n = 390). Meta-analysis suggested that the resting VAS scores[WMD = 0. 20,95% CI(-0. 33,0. 72); WMD = 0. 24,95% CI(-0. 12,0. 60);WMD = 0. 31,95% CI(-0. 07,0. 69); WMD = 0. 03,95% CI(-0. 29,0. 35) ] and motion VSA scores[WMD = 0. 10,95% CI(-0. 41,0. 62); WMD = 0. 64,95% CI( 0. 15,1. 12); WMD = 0. 17,95% CI(-0. 37,0. 70); WMD = 0. 03,95% CI(-0. 57,0. 62) ]were similar to the ACB group and FNB group at 2-4 h,6-8 h,24 h and 48 h. The quadriceps strength in the ACB group was better than that in the FNB group at 4 to8 h,24 h and 48 h[WMD = 0. 45,95% CI( 0. 25,0. 64); WMD = 0. 38,95% CI( 0. 14,0. 61); WMD = 0. 41,95% CI( 0. 18,0. 63) ]. The range of motion in the ACB group was also better than that in the FNB group at24 h,48 h and 72 h[WMD = 5. 01,95% CI( 0. 78,0. 92); WMD = 8. 74,95% CI( 3. 54,13. 93); WMD =6. 65,95% CI( 1. 97,11. 33) ]. Besides,ACB group had advantages in time-up-go test[WMD =-55. 98,95% CI(-109. 60,-2. 35) ] and length of hospital stay[WMD =-0. 049,95% CI(-0. 96,-0. 03) ].There was no difference in opioid consumption and side effect of nausea and vomiting. Conclusion When comparing with FNB,the ACB shows similar postoperative analgesia effects and has advantages in quadriceps strength recovery and promoting early postoperative rehabilitation,but more high-quality RCTs are required for further investigation.
引文
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[5]臧学慧,孙辉,高立华,等.股神经阻滞镇痛对全膝关节置换术后早期功能的影响[J/CD].中华关节外科杂志(电子版),2016,10(2):26-29.
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[7]Paul JE,Arya A,Hurlburt L,et al.Femoral nerve block improves analgesia outcomes after total knee arthroplasty:a metaanalysis of randomized controlled trials[J].Anesthesiology,2010,113(5):1144-1162.
[8]Sakai N,Inoue T,Kunugiza Y,et al.Continuous femoral versus epidural block for attainment of 120 degrees knee flexion after total knee arthroplasty:a randomized controlled trial[J].J Arthroplasty,2013,28(5):807-814
[9]Albrecht E,Morfey D,Chan V,et al.Single-injection or continuous femoral nerve block for total knee arthroplasty[J].Clin Orthop Relat Res,2014,472(5):1384-1393.
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[14]Perlas A,Kirkham KR,Billing R,et al.The impact of analgesic modality on early ambulation following total knee arthroplasty[J].Reg Anesth Pain Med,2013,38(4):334-339.
[15]Jenstrup MT,Jaeger P,Lund J,et al.Effects of Adductor-CanalBlockade on pain and ambulation after total knee arthroplasty:a randomized study[J].Acta Anaesthesiol Scand,2012,56(3):357-364.
[16]Shah NA,Jain NP.Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty?Effect on ambulation ability,early functional recovery and pain control:a randomized controlled trial[J].J Arthroplasty,2014,29(11):2224-2229.
[17]Grevstad U,Mathiesen O,Valentiner LS,et al.Effect of adductor canal block versus femoral nerve block on quadriceps strength,mobilization,and pain after total knee arthroplasty:a randomized,blinded study[J].Reg Anesth Pain Med,2014,40(1):3-10.
[18]Zhang W,Hu Y,Tao Y,et al.Ultrasound-guided continuous adductor canal block for analgesia after total knee replacement[J].Chin Med J(Engl),2014,127(23):4077-4081.
[19]Elkassabany NM,Antosh S,Ahmed M,et al.The risk of falls after total knee arthroplasty with the use of a femoral nerve block versus an adductor canal block:a Double-Blinded randomized controlled study[J].Anesth Analg,2016,122(5):1696-1703.
[20]Sorensen JK,Jaeger P,Dahl JB,et al.The isolated effect of adductor canal block on quadriceps femoris muscle strength after total knee arthroplasty:a Triple-Blinded,randomized,PlaceboControlled trial with individual patient analysis[J].Anesth Analg,2016,122(2):553-558.
[21]Wiesmann T,Piechowiak K,Duderstadt SA,et al.Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment:a randomised and blinded clinical trial[J].Arch Orthop Trauma Surg,2016,136(3):397-406.
[22]Mudumbai SC,Kim TE,Howard SK,et al.Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA[J].Clin Orthop Relat Res,2014,472(5):1377-1383.
[23]Sztain JF,Machi AT,Kormylo NJ,et al.Continuous adductor canal versus continuous femoral nerve blocks:relative effects on discharge readiness following unicompartment knee arthroplasty[J].Reg Anesth Pain Med,2015,40(5):559-567.
[24]谭振,康鹏德,裴福兴,等.多模式镇痛下收肌管与股神经阻滞在全膝关节置换术后初期镇痛及早期康复中的作用[J].中华骨科杂志,2015,35(9):914-920.
[25]Jaeger P,Zaric D,Fomsgaard JS,et al.Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty a randomized,double-blind study[J].Reg Anesth Pain Med,2013,38(6):526-532.
[26]Machi AT,Sztain JF,Kormylo NJ,et al.Discharge readiness after tricompartment knee arthroplasty:adductor canal versus femoral continuous nerve blocks-a dual-center,randomized trial[J].Anesthesiology,2015,123(2):444-456.
[27]Memtsoudis SG,Yoo D,Stundner O,et al.Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement[J].Int Orthop,2015,39(4):673-680.
[28]张云慧,岳冬梅,刘清仁,等.持续收肌管阻滞对全膝关节置换术后早期活动的影响[J].临床麻醉学杂志,2015,31(10):966-968.
[29]刘玥,张燕姿,谭振,等.超声引导下收肌管阻滞与股神经阻滞对全膝关节置换术后镇痛的影响[J].华西医学,2014,29(12):2231-2235.
[30]Husted H,Jensen CM,Solgaard S,et al.Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009:from research to implementation[J].Arch Orthop Trauma Surg,2012,132(1):101-104.
[31]Valeberg BT,Hovik LH,Gjeilo KH.Relationship between selfreported pain sensitivity and pain after total knee arthroplasty:a prospective study of 71 patients 8 weeks after a standardized fasttrack program[J/OL].J Pain Res,2016,9:625-629.
[32]Chan EY,Blyth FM,Nairn L,et al.Acute postoperative pain following hospital discharge after total knee arthroplasty[J].Osteoarthritis Cartilage,2013,21(9):1257-1263.
[33]肖军,严格,罗裕强,等.疼痛对人工膝关节表面置换术后功能康复的影响[J/CD].中华关节外科杂志(电子版),2014,8(2):160-165.
[34]Kuang MJ,Xu LY,Ma JX,et al.Adductor canal block versus continuous femoral nerve block in primary total knee arthroplasty:a meta-analysis[J/OL].Int J Surg,2016,31:17-24.
[35]Vendittoli PA,Makinen P,Drolet P,et al.A multimodal analgesia protocol for total knee arthroplasty.A randomized,controlled study[J].J Bone Joint Surg Am,2006,88(2):282-289.
[36]Lavie LG,Fox MP,Dasa V.Overview of total knee arthroplasty and modern pain control strategies[J].Curr Pain Headache Rep,2016,20(11):59-64.
[37]Gao F,Ma J,Sun W,et al.Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty:a systematic review and meta-analysis[J].Clin J Pain,2017,33(4):356-368.
[38]Pelt CE,Anderson AW,Anderson MB,et al.Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter:can we reduce the incidence?[J].J Arthroplasty,2014,29(6):1154-1157.
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[43]Li D,Yang Z,Xie X,et al.Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block:a systematic review and meta-analysis[J].Int Orthop,2016,40(5):925-933.
[44]Ludwigson JL,Tillmans SD,Galgon RE,et al.A comparison of single shot adductor canal block versus femoral nerve catheter for total knee arthroplasty[J].J Arthroplasty,2015,2015,30(9Suppl):68-71.
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[2]Ibrahim MS,Khan MA,Nizam I,et al.Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty:an evidencebased review[J].BMC Med,2013,11:37-46.
[3]Webb CA,Mariano ER.Best multimodal analgesic protocol for total knee arthroplasty[J].Pain Manag,2015,5(3):185-196.
[4]廖荣宗,冯宗权,周观明,等.超声引导下连续股神经阻滞在全膝关节置换术后镇痛及功能锻炼的意义[J/CD].中华关节外科杂志(电子版),2014,8(6):708-712.
[5]臧学慧,孙辉,高立华,等.股神经阻滞镇痛对全膝关节置换术后早期功能的影响[J/CD].中华关节外科杂志(电子版),2016,10(2):26-29.
[6]Widmer BJ,Scholes CJ,Pattullo GG,et al.Is femoral nerve block necessary during total knee arthroplasty?a randomized controlled trial[J].J Arthroplasty,2012,27(10):1800-1805.
[7]Paul JE,Arya A,Hurlburt L,et al.Femoral nerve block improves analgesia outcomes after total knee arthroplasty:a metaanalysis of randomized controlled trials[J].Anesthesiology,2010,113(5):1144-1162.
[8]Sakai N,Inoue T,Kunugiza Y,et al.Continuous femoral versus epidural block for attainment of 120 degrees knee flexion after total knee arthroplasty:a randomized controlled trial[J].J Arthroplasty,2013,28(5):807-814
[9]Albrecht E,Morfey D,Chan V,et al.Single-injection or continuous femoral nerve block for total knee arthroplasty[J].Clin Orthop Relat Res,2014,472(5):1384-1393.
[10]Charous MT,Madison SJ,Suresh PJ,et al.Continuous femoral nerve blocks:varying local anesthetic delivery method(bolus versus basal)to minimize quadriceps motor block while maintaining sensory block[J].Anesthesiology,2011,115(4):774-781.
[11]Kwofie MK,Shastri UD,Gadsden JC,et al.The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk:a blinded,randomized trial of volunteers[J].Reg Anesth Pain Med,2013,38(4):321-325.
[12]Jaeger P,Nielsen ZJ,Henningsen MH,et al.Adductor canal block versus femoral nerve block and quadriceps strength:a randomized,double-blind,placebo-controlled,crossover study in healthy volunteers[J].Anesthesiology,2013,118(2):409-415.
[13]Kim DH,Lin Y,Goytizolo EA,et al.Adductor canal block versus femoral nerve block for total knee arthroplasty:a prospective,randomized,controlled trial[J].Anesthesiology,2014,120(3):540-550.
[14]Perlas A,Kirkham KR,Billing R,et al.The impact of analgesic modality on early ambulation following total knee arthroplasty[J].Reg Anesth Pain Med,2013,38(4):334-339.
[15]Jenstrup MT,Jaeger P,Lund J,et al.Effects of Adductor-CanalBlockade on pain and ambulation after total knee arthroplasty:a randomized study[J].Acta Anaesthesiol Scand,2012,56(3):357-364.
[16]Shah NA,Jain NP.Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty?Effect on ambulation ability,early functional recovery and pain control:a randomized controlled trial[J].J Arthroplasty,2014,29(11):2224-2229.
[17]Grevstad U,Mathiesen O,Valentiner LS,et al.Effect of adductor canal block versus femoral nerve block on quadriceps strength,mobilization,and pain after total knee arthroplasty:a randomized,blinded study[J].Reg Anesth Pain Med,2014,40(1):3-10.
[18]Zhang W,Hu Y,Tao Y,et al.Ultrasound-guided continuous adductor canal block for analgesia after total knee replacement[J].Chin Med J(Engl),2014,127(23):4077-4081.
[19]Elkassabany NM,Antosh S,Ahmed M,et al.The risk of falls after total knee arthroplasty with the use of a femoral nerve block versus an adductor canal block:a Double-Blinded randomized controlled study[J].Anesth Analg,2016,122(5):1696-1703.
[20]Sorensen JK,Jaeger P,Dahl JB,et al.The isolated effect of adductor canal block on quadriceps femoris muscle strength after total knee arthroplasty:a Triple-Blinded,randomized,PlaceboControlled trial with individual patient analysis[J].Anesth Analg,2016,122(2):553-558.
[21]Wiesmann T,Piechowiak K,Duderstadt SA,et al.Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment:a randomised and blinded clinical trial[J].Arch Orthop Trauma Surg,2016,136(3):397-406.
[22]Mudumbai SC,Kim TE,Howard SK,et al.Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA[J].Clin Orthop Relat Res,2014,472(5):1377-1383.
[23]Sztain JF,Machi AT,Kormylo NJ,et al.Continuous adductor canal versus continuous femoral nerve blocks:relative effects on discharge readiness following unicompartment knee arthroplasty[J].Reg Anesth Pain Med,2015,40(5):559-567.
[24]谭振,康鹏德,裴福兴,等.多模式镇痛下收肌管与股神经阻滞在全膝关节置换术后初期镇痛及早期康复中的作用[J].中华骨科杂志,2015,35(9):914-920.
[25]Jaeger P,Zaric D,Fomsgaard JS,et al.Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty a randomized,double-blind study[J].Reg Anesth Pain Med,2013,38(6):526-532.
[26]Machi AT,Sztain JF,Kormylo NJ,et al.Discharge readiness after tricompartment knee arthroplasty:adductor canal versus femoral continuous nerve blocks-a dual-center,randomized trial[J].Anesthesiology,2015,123(2):444-456.
[27]Memtsoudis SG,Yoo D,Stundner O,et al.Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement[J].Int Orthop,2015,39(4):673-680.
[28]张云慧,岳冬梅,刘清仁,等.持续收肌管阻滞对全膝关节置换术后早期活动的影响[J].临床麻醉学杂志,2015,31(10):966-968.
[29]刘玥,张燕姿,谭振,等.超声引导下收肌管阻滞与股神经阻滞对全膝关节置换术后镇痛的影响[J].华西医学,2014,29(12):2231-2235.
[30]Husted H,Jensen CM,Solgaard S,et al.Reduced length of stay following hip and knee arthroplasty in Denmark 2000-2009:from research to implementation[J].Arch Orthop Trauma Surg,2012,132(1):101-104.
[31]Valeberg BT,Hovik LH,Gjeilo KH.Relationship between selfreported pain sensitivity and pain after total knee arthroplasty:a prospective study of 71 patients 8 weeks after a standardized fasttrack program[J/OL].J Pain Res,2016,9:625-629.
[32]Chan EY,Blyth FM,Nairn L,et al.Acute postoperative pain following hospital discharge after total knee arthroplasty[J].Osteoarthritis Cartilage,2013,21(9):1257-1263.
[33]肖军,严格,罗裕强,等.疼痛对人工膝关节表面置换术后功能康复的影响[J/CD].中华关节外科杂志(电子版),2014,8(2):160-165.
[34]Kuang MJ,Xu LY,Ma JX,et al.Adductor canal block versus continuous femoral nerve block in primary total knee arthroplasty:a meta-analysis[J/OL].Int J Surg,2016,31:17-24.
[35]Vendittoli PA,Makinen P,Drolet P,et al.A multimodal analgesia protocol for total knee arthroplasty.A randomized,controlled study[J].J Bone Joint Surg Am,2006,88(2):282-289.
[36]Lavie LG,Fox MP,Dasa V.Overview of total knee arthroplasty and modern pain control strategies[J].Curr Pain Headache Rep,2016,20(11):59-64.
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