股神经阻滞和收肌管阻滞在全膝关节置换中疗效对比的Meta分析
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摘要
目的相比股神经阻滞,收肌管阻滞是否能够更好地缓解全膝关节置换(totalknee arthroplasty,TKA)术后疼痛和功能恢复。方法英文数据库以femoral nerve block,adductor canal block,total knee athroplasty,total knee replacement为关键词,中文数据库以股神经阻滞,收肌管阻滞,膝关节置换为关键词对Web of Science,Embase,PubMed,Cochrane Controlled Trials Register、Cochrane Library、Highwire数据库、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、中国科技期刊全文数据库(VIP)、中国万方数据库进行检索。截止日期为2017年12月。最终15项RCT研究,969例纳入研究。采用Review Manager软件和推荐分级的评价、制定与评估系统(GRADE)进行评估。结果两组在术后8、24、48 h静止时视觉模拟疼痛评分(VAS)分值、术后24、48 h运动时的VAS分值、术后8 h股四头肌肌力(MMT)、术后24 h内收肌肌力、阿片类药物使用量、患者满意度和住院时间、术后1、2、14天时的最大屈曲度上、恶心或呕吐发生率差异均无统计学意义(P>0.05)。两组在术后8 h活动时VAS分值差异有统计学意义[MD=-0.15;95%CI,(-0.28,-0.01);P=0.03],收肌管阻滞分值更低。两组在术后24 h股四头肌肌力(MMT)[MD=-0.78;95%CI,(0.45,1.11);P<0.00001],术后48 h股四头肌肌力(MMT),(MD=0.49;95%CI,(0.19,0.78);P=0.001),术后48 h股四头肌肌力(MVIC)[MD=37.85;95%CI,[29.49,46.21];P<0.00001]差异有统计学意义,收肌管阻滞组肌力恢复更好。两组在术后24 h定时起身行走测试[MD=-10.19;95%CI,(-17.11,-3.28);P=0.004],和术后48 h定时起身行走测试[MD=-9.60;95%CI,(-15.28,-4.63);P=0.02],差异有统计学意义,收肌管阻滞组所需时间更少。两组在术后3天的最大屈曲度上差异有统计学意义(P=0.02),收肌管阻滞组最大屈曲度更大。结论收肌管阻滞使TKA术后功能恢复更好,而不影响疼痛控制。考虑到TKA术后需要早期行走,推荐收肌管阻滞作为一种替代的镇痛方法。
Objective To investigate if adductor canal block (ACB) provides better pain relief and functional recovery after TKA than femoral nerve block (FNB). Methods We conducted a meta-analysis to identify relevant randomized controlled trials involving ACB and FNB after total knee arthroplasty in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI,VIP, Wanfang database, up to December 2017. Finally, 15 randomized controlled trials involving 969 knees were included in our study. Review Manager Software and Grading of Recommendations Assessment, Development, and Evaluation profiler were used to perform the meta-analysis. Results There were no significant differences in resting VAS 8 h, 24 h, 48 h after surgery, active VAS 24 h, 48 h after surgery, quadriceps muscle strength (MMT) 8 h after surgery, adductor muscle strength 24 h after surgery, opioid consumption, patient satisfaction, length of hospital stay,angles of the maximum flexion (1 d, 2 d, 14 d), incidence of nausea or vomiting (P > 0.05). There were significant differences in VAS scores between the 2 groups at 8 h postoperatively [ MD =-0.15; 95% CI,(-0.28,-0.01); P = 0.03 ],and the scores of the ACB were lower. There were significant differences in quadriceps muscle strength (MMT) 24 h after surgery [ MD =-0.78; 95% CI, (0.45, 1.11); P < 0.00001 ], 48 h (MMT) after surgery [ MD = 0.49; 95% CI, (0.19, 0.78); P = 0.001 ], 48 h (MVIC) after surgery [ MD = 37.85; 95% CI, (29.49, 46.21); P < 0.00001], and the muscle strength recovery was better in the ACB group. There were significant differences in Time Up and Go Test (TUG) 24 h after surgery [ MD =-10.19; 95% CI,(-17.11,-3.28); P = 0.004] and 48 h after surgery [ MD =-9.60;95% CI,(-15.28,-4.63); P = 0.02 ], and ACB need shorter time. There were significant differences in the angle of the maximum flexion 3 days after surgery (P = 0.02), and ACB group had better performance. Conclusions ACB achieves better functional recovery after TKA without compromising pain control. Therefore, concerning the early ambulation after TKA, ACB is recommended as an alternative analgesic method.
Objective To investigate if adductor canal block (ACB) provides better pain relief and functional recovery after TKA than femoral nerve block (FNB). Methods We conducted a meta-analysis to identify relevant randomized controlled trials involving ACB and FNB after total knee arthroplasty in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, CNKI,VIP, Wanfang database, up to December 2017. Finally, 15 randomized controlled trials involving 969 knees were included in our study. Review Manager Software and Grading of Recommendations Assessment, Development, and Evaluation profiler were used to perform the meta-analysis. Results There were no significant differences in resting VAS 8 h, 24 h, 48 h after surgery, active VAS 24 h, 48 h after surgery, quadriceps muscle strength (MMT) 8 h after surgery, adductor muscle strength 24 h after surgery, opioid consumption, patient satisfaction, length of hospital stay,angles of the maximum flexion (1 d, 2 d, 14 d), incidence of nausea or vomiting (P > 0.05). There were significant differences in VAS scores between the 2 groups at 8 h postoperatively [ MD =-0.15; 95% CI,(-0.28,-0.01); P = 0.03 ],and the scores of the ACB were lower. There were significant differences in quadriceps muscle strength (MMT) 24 h after surgery [ MD =-0.78; 95% CI, (0.45, 1.11); P < 0.00001 ], 48 h (MMT) after surgery [ MD = 0.49; 95% CI, (0.19, 0.78); P = 0.001 ], 48 h (MVIC) after surgery [ MD = 37.85; 95% CI, (29.49, 46.21); P < 0.00001], and the muscle strength recovery was better in the ACB group. There were significant differences in Time Up and Go Test (TUG) 24 h after surgery [ MD =-10.19; 95% CI,(-17.11,-3.28); P = 0.004] and 48 h after surgery [ MD =-9.60;95% CI,(-15.28,-4.63); P = 0.02 ], and ACB need shorter time. There were significant differences in the angle of the maximum flexion 3 days after surgery (P = 0.02), and ACB group had better performance. Conclusions ACB achieves better functional recovery after TKA without compromising pain control. Therefore, concerning the early ambulation after TKA, ACB is recommended as an alternative analgesic method.
引文
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[3]Hadzic A,Houle TT,Capdevila X,et al.Femoral nerve block for analgesia in patients having knee arthroplasty[J].Anesthesiology,2010,113(5):1014-5.DOI:10.1097/ALN.0b013e3181f4b43d.
[4]Ilfeld BM,Duke KB,Donohue MC.The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty[J].Anesth Analg,2010,111(6):1552-4.DOI:10.1213/ANE.0b013e 3181f b9507.
[5]Muraskin SI,Conrad B,Zheng N,et al.Falls associated with lower-extremity-nerve blocks:a pilot investigation of mechanisms[J].Reg Anesth Pain Med,2007,32(1):67-72.DOI:10.1016/j.rapm.2006.08.013.
[6]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):774-81.DOI:10.1097/ALN.0b013e3182124dc6.
[7]Brodner G,Buerkle H,Van Aken H,et al.Postoperative analgesia after knee surgery:a comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade[J].Anesth Analg,2007,105(1):256-62.DOI:10.1213/01.ane.0000 26555 2.43299.2b
[8]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):409-15.DOI:10.1097/ALN.0b0 13e318279fa0b.
[9]Burckett-St Laurant D,Peng P,et al.The nerves of the adductor canal and the innervation of the knee:an anatomic study[J].Reg Anesth Pain Med,2016,41(3):321-7.DOI:10.1097/AAP.0000000000000389.
[10]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):526-32.DOI:10.1097/AAP.0000000000000015.
[11]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):540-50.DOI:10.1097/ALN.0000000000000119.
[12]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):2224-9.DOI:10.1016/j.arth.2014.06.010.
[13]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,2015,40(1):3-10.DOI:10.1097/AAP.0000000000000169.
[14]Patterson ME,Bland KS,Thomas LC,et al.The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study[J].J Clin Anesth,2015,27(1):39-44.DOI:10.1016/j.jclinane.2014.08.005.
[15]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):673-80.DOI:10.1007/s00264-014-2527-3.
[16]Wiesmann T,Piechowiak K,Duderstadt S,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.DOI:10.1007/s00402-015-2403-7.
[17]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):925-33.DOI:10.1007/s00264-015-2998-x.
[18]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):321-5.DOI:10.1097/AAP.0b013e318295df80.
[19]Jaeger P,Koscielniak-Nielsen ZJ,Hilsted KL,et al.Adductor canal block with 10 mL versus 30 mL local anesthetics and quadriceps strength a paired,blinded,randomized study in healthy volunteers[J].Reg Anesth Pain Med,2015,40(5):553-8.DOI:10.1097/AAP.0000000000000298.
[20]Moher D,Liberati A,Tetzlaff J,et al.Preferred reporting items for systematic reviews and meta-analyses:the PRISMAstatement[J].Int J Surg,2010,8(5):336-41.DOI:10.1016/j.ijsu.2010.02.007.
[21]Atkins D,Best D,Briss PA,et al.Grading quality of evidence and strength of recommendations[J].BMJ,2004,19;328(7454):1490.DOI:10.1136/bmj.328.7454.1490
[22]Higgins J.Cochrane handbook for systematic reviews of interventions version 5.0.1.Cochrane Db Syst Rev.2011.p.2011.http://handbook.cochrane.org/v5.0.2/.
[23]Chapman CR,Casey KL,Dubner R,et al.Pain measurement:an overview[J].Pain,1985,22(1):1-31.
[24]Shumway-Cook A,Brauer S,Woollacott M.Predicting the probability for falls in community-dwelling older adults using the Timed Up&Go Test[J].Phys Ther,2000,80(9):896-903.
[25]Stark T,Walker B,Phillips JK,et al.Hand-held dynamometry correlation with the gold standard isokinetic dynamometry:a systematic review[J].PM R,2011,3(5):472-9.DOI:10.1016/j.pmrj.2010.10.025.
[26]Sapega AA.Muscle performance evaluation in orthopaedic practice[J].J Bone Joint Surg Am,1990,72(10):1562-1574.
[27]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 doubleblinded randomized controlled study[J].Anesth Analg,2016,122(5):1696-703.DOI:10.1213/ANE.0000000000001237.
[28]Zhang W,Hu Y,Tao Y,et al.Ultrasound-guided continuous adductor can alblock for analgesia after total knee replacement[J].Chin Med J(Engl),2014,127(23):4077-4081.
[29]Macrinici GI,Murphy C,Christman L,et al.Prospective,double-blind,randomized study to evalua tesing l einjection adductor canal nerve block versus femoral nerve block:postoperative functional outcomes after total knee arthroplasty[J].Reg Anesth Pain Med,2017,42(1):10-16.DOI:10.1097/AAP.0000000000000507.
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