曲音音 綜述 徐 懋 審校

(北京大學(xué)第三醫(yī)院麻醉科，北京 100083)

·文獻(xiàn)綜述·

快速康復(fù)外科理念下全膝關(guān)節(jié)置換術(shù)圍術(shù)期鎮(zhèn)痛進(jìn)展*

曲音音 綜述 徐 懋**審校

(北京大學(xué)第三醫(yī)院麻醉科，北京 100083)

全膝關(guān)節(jié)置換術(shù)圍術(shù)期鎮(zhèn)痛向多模式鎮(zhèn)痛轉(zhuǎn)變。作為快速康復(fù)外科(fast track surgery，F(xiàn)TS)中極其重要的一部分，圍術(shù)期鎮(zhèn)痛是影響患者快速康復(fù)很重要的一環(huán)。本文綜述FTS理念下全膝關(guān)節(jié)置換術(shù)前、術(shù)中、術(shù)后各種鎮(zhèn)痛方案的優(yōu)缺點(diǎn)及最新進(jìn)展。

全膝關(guān)節(jié)置換術(shù)； 圍術(shù)期鎮(zhèn)痛； 快速康復(fù)外科

Kehlet[1]1997年首次提出快速康復(fù)外科(fast track surgery，F(xiàn)TS)理念，涵蓋術(shù)前宣教、營養(yǎng)狀況最佳化、標(biāo)準(zhǔn)化鎮(zhèn)痛麻醉配方等眾多圍術(shù)期處理措施的綜合優(yōu)化，最終達(dá)到降低應(yīng)激反應(yīng)、減少并發(fā)癥和早期恢復(fù)的目的[2～4]。全膝關(guān)節(jié)置換術(shù)(total knee arthroplasty，TKA)是治療嚴(yán)重膝關(guān)節(jié)疾病的主要方法，通過手術(shù)可以解除膝關(guān)節(jié)疼痛，重建膝關(guān)節(jié)功能。但TKA術(shù)后15%～20%的患者對鎮(zhèn)痛不滿意[5]，患者因疼痛不能進(jìn)行功能鍛煉，延遲出院，且易出現(xiàn)深靜脈血栓、肺栓塞、感染、術(shù)后關(guān)節(jié)強(qiáng)直等并發(fā)癥。疼痛程度嚴(yán)重制約FTS方案的實(shí)施，影響關(guān)節(jié)活動度、開始功能鍛煉時間和平均住院日等重要評價指標(biāo)[6]。因此，TKA圍術(shù)期鎮(zhèn)痛是FTS理念下亟待改善的重要課題。本文對目前FTS理念下TKA術(shù)前、術(shù)中、術(shù)后各種鎮(zhèn)痛方案的優(yōu)缺點(diǎn)進(jìn)行綜述，旨在為TKA圍術(shù)期鎮(zhèn)痛方案的選擇和完善提供參考。

1 術(shù)前預(yù)防性鎮(zhèn)痛

FTS強(qiáng)調(diào)基礎(chǔ)藥物的應(yīng)用，術(shù)前應(yīng)用非甾體抗炎藥(NSAIDs)如氟比洛芬酯[7]和選擇性環(huán)氧化酶2(COX-2)抑制劑如帕瑞昔布，能抑制前列腺素合成，減輕炎癥反應(yīng)，減輕外周敏化和中樞敏化導(dǎo)致疼痛，有效緩解術(shù)后疼痛。Straube等[8]的meta分析納入22項(xiàng)隨機(jī)對照研究共2246例，與安慰劑組相比，有15個研究結(jié)果顯示術(shù)前應(yīng)用COX-2抑制劑組術(shù)后疼痛評分顯著降低，患者滿意度提高并且鎮(zhèn)痛藥用量顯著減少。姜天樂等[9]研究顯示，與連續(xù)股神經(jīng)阻滯組比較，帕瑞昔布鈉聯(lián)合連續(xù)股神經(jīng)阻滯組TKA術(shù)后24 h膝關(guān)節(jié)后部靜息VAS評分明顯降低(均值4.0分 vs. 5.5分), 被動活動時膝關(guān)節(jié)前部(均值3.0分 vs. 4.0分)及后部(均值6.0分 vs. 8.0分)VAS評分均明顯降低。

盡管NSAIDs可以應(yīng)用于TKA鎮(zhèn)痛，但仍應(yīng)注意相關(guān)風(fēng)險。非選擇性NSAIDs藥物有可能損傷胃腸黏膜，影響血小板、腎功能和增加圍術(shù)期出血量，選擇性COX-2抑制劑相關(guān)不良反應(yīng)較少，但是有心腦血管風(fēng)險的顧慮。Utvag等[10]研究顯示無論非選擇性還是選擇性COX-2抑制劑，臨床常規(guī)劑量并不影響骨折的愈合。但Wang等[11]對1993～2012年骨折不愈合發(fā)生率與NSAIDs、COX-2抑制劑處方量的分析提示，藥物處方量增加與骨折不愈合發(fā)病率呈正比。因此，對于高?；颊呷砸?jǐn)慎使用NSAIDs和COX-2抑制劑。我們認(rèn)為術(shù)前預(yù)防性鎮(zhèn)痛聯(lián)合宣教可增加患者的配合度和認(rèn)知度，有助于圍術(shù)期疼痛管理及患者早期康復(fù)。

2 術(shù)中綜合處理

2.1 改善手術(shù)技巧

Liu等[12]Meta分析顯示，股內(nèi)側(cè)肌下入路不損傷股四頭肌和伸膝裝置，與內(nèi)側(cè)髕旁入路和經(jīng)股內(nèi)側(cè)肌入路相比，可減少不必要的手術(shù)組織創(chuàng)傷，術(shù)后1周關(guān)節(jié)活動度明顯改善；經(jīng)股內(nèi)側(cè)肌入路能夠降低VAS評分，增加關(guān)節(jié)活動度。另外，盡量減少止血帶的使用時間和降低止血帶壓力也有利于患者早期恢復(fù)。Dennis等[13]研究顯示，與TKA全程使用止血帶相比，不用或只在置入假體時使用止血帶組患者術(shù)后股四頭肌肌力明顯改善，疼痛減輕，更有利于早期鍛煉和功能恢復(fù)，而術(shù)后早期活動正是FTS理念強(qiáng)調(diào)的重要內(nèi)容。因此，術(shù)中應(yīng)注意手術(shù)入路選擇，盡量減少止血帶的使用時間。

2.2 關(guān)節(jié)周圍注射或囊內(nèi)藥物應(yīng)用(“雞尾酒”療法)

“雞尾酒”療法發(fā)揮不同鎮(zhèn)痛藥物的協(xié)同作用和多環(huán)節(jié)作用，提高鎮(zhèn)痛特異性，減少單種藥物的劑量和副作用，可有效緩解術(shù)后疼痛[14]。常用藥物包括鹽酸羅哌卡因、鹽酸嗎啡、酮洛酸和腎上腺素等。聯(lián)合股神經(jīng)阻滯，關(guān)節(jié)周圍局麻藥注射與坐骨神經(jīng)阻滯相比，術(shù)后疼痛評分、患者滿意度、鎮(zhèn)痛藥用量、康復(fù)時間和住院日等指標(biāo)均無顯著差異[15，16]。關(guān)節(jié)周圍組織注射局麻藥的發(fā)展也對外周神經(jīng)阻滯提出挑戰(zhàn)，在疼痛評分、康復(fù)進(jìn)度和住院時間等FTS重點(diǎn)關(guān)注指標(biāo)上，多項(xiàng)研究表明即使單獨(dú)應(yīng)用關(guān)節(jié)周圍局麻藥注射，效果類似于單次股神經(jīng)阻滯[17]、連續(xù)硬膜外阻滯[18]和股神經(jīng)阻滯聯(lián)合硬膜外自控鎮(zhèn)痛[19]。Fan等[20]Meta分析結(jié)果顯示，注射局麻藥組在術(shù)后疼痛數(shù)字評分(numerical rating scale, NRS)、嗎啡用量、關(guān)節(jié)活動度及住院時間等指標(biāo)與外周神經(jīng)阻滯組相近。與外周神經(jīng)阻滯相比，局部藥物注射操作簡單，可在術(shù)中由手術(shù)醫(yī)師完成，不需要另行操作，此外，對股四頭肌肌力影響小，有利于早期功能鍛煉，有助于早期恢復(fù)，在FTS理念下更有優(yōu)勢[21, 22]。關(guān)節(jié)周圍局麻藥注射鎮(zhèn)痛的不足是受藥物時效影響，不能達(dá)到長時間鎮(zhèn)痛，留置導(dǎo)管可延長鎮(zhèn)痛時間，但有增加切口感染發(fā)生率的可能[23]。Moghtadaei等[24]比較單次股神經(jīng)阻滯與關(guān)節(jié)周圍局麻藥注射，結(jié)果顯示局麻藥注射組術(shù)后6 h內(nèi)嗎啡使用量明顯降低(中位數(shù)10 mg vs. 12.5 mg)，VAS評分也降低(中位數(shù)3分 vs. 4分)，患者滿意度更高，但12 h VAS評分相對更高(中位數(shù)6分 vs. 5分)。可見，關(guān)節(jié)周圍或囊內(nèi)局麻藥注射效果較可靠，與傳統(tǒng)鎮(zhèn)痛方案相比優(yōu)勢明顯，但既往薈萃分析中所納入研究異質(zhì)性較高，鎮(zhèn)痛方案和評價指標(biāo)不完全一致，且注射藥物配方較多樣，包含多種藥物的“雞尾酒”目前尚無統(tǒng)一配方，還有待進(jìn)一步深入研究。

新型布比卡因(布比卡因脂質(zhì)體)可實(shí)現(xiàn)手術(shù)部位單次注射鎮(zhèn)痛效果長達(dá)72 h，而且延長術(shù)后到第1次輔助應(yīng)用阿片類藥物時間(14.3 h vs. 1.2 h)[25，26]。布比卡因脂質(zhì)體注射用懸浮液(EXPAREL)2011年經(jīng)FDA批準(zhǔn)應(yīng)用于單次局部浸潤，目前國內(nèi)尚未引進(jìn)或應(yīng)用。長效布比卡因(POSIDUR)是布比卡因的緩釋注射劑，目前處于試驗(yàn)階段，尚未獲得FDA批準(zhǔn)。新型布比卡因的應(yīng)用尚需大量研究指導(dǎo)臨床的應(yīng)用，但是已經(jīng)顯示出良好的應(yīng)用前景。

3 術(shù)后鎮(zhèn)痛

3.1 硬膜外自控鎮(zhèn)痛

持續(xù)硬膜外鎮(zhèn)痛效果可靠，廣泛應(yīng)用于臨床術(shù)后鎮(zhèn)痛，但可能引起低血壓、尿潴留等并發(fā)癥[27]。對于TKA而言，可能影響肌力和運(yùn)動功能，延遲術(shù)后康復(fù)鍛煉，導(dǎo)致患者延遲出院[18]。Spreng等[28]研究表明，與羅哌卡因局部浸潤鎮(zhèn)痛對比，硬膜外鎮(zhèn)痛組患者恢復(fù)運(yùn)動能力更慢且住院時間更長(均值5.5 d vs.3.5 d)。另外，TKA大多需要抗凝治療，硬膜外鎮(zhèn)痛由于有硬膜外血腫的顧慮，應(yīng)用也受到影響。鑒于對肌力影響和血腫方面的考量，在FTS理念下，硬膜外自控鎮(zhèn)痛逐漸被其他鎮(zhèn)痛方案替代。

3.2 靜脈自控鎮(zhèn)痛

靜脈自控鎮(zhèn)痛操作方便，肌力影響小，在臨床鎮(zhèn)痛管理中應(yīng)用廣泛，但阿片類藥物的應(yīng)用，會增加惡心、嘔吐、呼吸抑制等阿片類藥物相關(guān)不良反應(yīng)發(fā)生率，延長患者住院時間并增加費(fèi)用支出[29]。阿片類藥物不能有效抑制導(dǎo)致疼痛的炎癥反應(yīng)及痛覺過敏，而且不良反應(yīng)相對較多，與神經(jīng)阻滯等其他鎮(zhèn)痛方式相比無明顯優(yōu)勢。Peng等[30]研究顯示，與連續(xù)股神經(jīng)阻滯相比，靜脈自控鎮(zhèn)痛組術(shù)后慢性疼痛發(fā)生率(50.7% vs.37.1%)、補(bǔ)救藥物用量(帕瑞昔布均值31.5 mg vs.22.4 mg)及術(shù)后3、9、12個月關(guān)節(jié)屈曲角度上均明顯處于劣勢，外周神經(jīng)阻滯更有助于患者康復(fù)，其他研究也有類似的結(jié)果[31,32]。因此，靜脈自控鎮(zhèn)痛在TKA圍術(shù)期不作為首選鎮(zhèn)痛方案，多作為多模式鎮(zhèn)痛的一種補(bǔ)充手段。

3.3 連續(xù)股神經(jīng)阻滯

股神經(jīng)阻滯鎮(zhèn)痛效果相對可靠，不引起惡心、嘔吐、瘙癢和鎮(zhèn)靜等并發(fā)癥，與硬膜外鎮(zhèn)痛及靜脈自控鎮(zhèn)痛比可增大屈膝角度, 有利于早期活動。Chan等[33]的Meta分析顯示,與靜脈自控鎮(zhèn)痛比較，股神經(jīng)阻滯鎮(zhèn)痛顯著減輕術(shù)后24 h靜息痛(標(biāo)準(zhǔn)均數(shù)差-0.72)和活動痛(標(biāo)準(zhǔn)均數(shù)差-0.94)，惡心嘔吐風(fēng)險低(相對危險度0.47)，膝關(guān)節(jié)活動度更大(均數(shù)差6.48°)；與硬膜外鎮(zhèn)痛比較，盡管在疼痛評分和膝關(guān)節(jié)活動度無明顯差異，但惡心、嘔吐風(fēng)險低(相對危險度0.63)。近年來，由于超聲和神經(jīng)刺激器的應(yīng)用，股神經(jīng)阻滯在臨床膝關(guān)節(jié)鎮(zhèn)痛應(yīng)用日趨廣泛，神經(jīng)損傷的發(fā)生率也明顯降低[34]。Chan等[35]報道與單次股神經(jīng)阻滯相比，連續(xù)股神經(jīng)阻滯VAS評分更低(均數(shù)差-0.57，P<0.05)，阿片類藥物用量更少(術(shù)后第1日晨均數(shù)差-18.5 mg；術(shù)后第2日晨均數(shù)差-24.4 mg)，惡心、嘔吐等阿片相關(guān)不良反應(yīng)更少(優(yōu)勢比0.24)。但連續(xù)股神經(jīng)阻滯也存在導(dǎo)管脫落[31]、導(dǎo)管相關(guān)感染、降低股四頭肌肌力進(jìn)而影響患者術(shù)后活動和增加患者跌倒風(fēng)險(1.6%～2.7%)等問題[23，36～38]，部分患者需要再次手術(shù)(0.4%)。另外，由于神經(jīng)支配區(qū)域限制，對于膝關(guān)節(jié)后側(cè)坐骨神經(jīng)支配區(qū)域疼痛需要聯(lián)合阻滯，由此增加操作時間，可能增大對肌力的影響。近年來，隨著局部浸潤技術(shù)的發(fā)展，以及FTS理念下追求更快的患者恢復(fù)和功能鍛煉，股神經(jīng)阻滯的地位也受到挑戰(zhàn)。

3.4 收肌管阻滯

收肌管阻滯主要阻滯隱神經(jīng)，對股四頭肌影響極小[39]。Grevstad等[40]報道收肌管阻滯組患者最大等長隨意收縮肌力增加到基線值的193%，而股神經(jīng)阻滯組減少到基線值的16%，有顯著性差異。與股神經(jīng)阻滯相比，行收肌管阻滯的患者術(shù)后第1、2天運(yùn)動距離均顯著延長，且平均住院時間為2.67 d，明顯短于股神經(jīng)組3.01 d[41]。而連續(xù)收肌管阻滯與連續(xù)股神經(jīng)阻滯相比，患者的運(yùn)動功能明顯增強(qiáng)，計(jì)時起立行走測試、10 m行走試驗(yàn)、30 s椅子測試及行走距離等指標(biāo)均有顯著差異，患者可以更早進(jìn)行康復(fù)鍛煉，加快恢復(fù)[42, 43]。但是收肌管阻滯中由于隱神經(jīng)辨識存在一定難度，要求操作者更富有經(jīng)驗(yàn)；同時，藥物在收肌管內(nèi)擴(kuò)散也有影響肌力的可能，Chen等[44]報道隱神經(jīng)阻滯造成股四頭肌運(yùn)動阻滯的現(xiàn)象。

3.5 坐骨神經(jīng)阻滯

坐骨神經(jīng)阻滯可有效緩解膝關(guān)節(jié)后側(cè)牽拉痛和屈膝運(yùn)動疼痛，通常作為多模式鎮(zhèn)痛的一部分與其他方案聯(lián)合應(yīng)用，具有外周神經(jīng)阻滯的優(yōu)點(diǎn)，可避免硬膜外鎮(zhèn)痛相關(guān)并發(fā)癥[27,45]。Tanikawa等[15]對比股神經(jīng)阻滯分別聯(lián)合坐骨神經(jīng)阻滯和關(guān)節(jié)局部藥物浸潤的研究結(jié)果顯示，2組術(shù)后1～21 d疼痛評分和關(guān)節(jié)活動度、到達(dá)康復(fù)目標(biāo)的時間(如直腿抬高時間2.5 d vs. 3.0 d，P=0.44)和住院時間(33.0 d vs.37.0 d，P=0.95)均無明顯差異。坐骨神經(jīng)阻滯和關(guān)節(jié)局部藥物浸潤均可作為股神經(jīng)阻滯的一種補(bǔ)充[16]。作為股神經(jīng)阻滯/腰叢阻滯的一種補(bǔ)充，持續(xù)輸注相比單次注射VAS評分(靜息及被動運(yùn)動)更低，并發(fā)癥發(fā)生率也更低，有效運(yùn)動更多，更有助于患者早期恢復(fù)[46]。但坐骨神經(jīng)阻滯與局部藥物浸潤相比操作復(fù)雜，2個部位神經(jīng)阻滯所需操作時間更長。

3.6 其他

口服或肌注鎮(zhèn)痛藥，如塞來昔布、曲馬多、哌替啶等，可作為其他鎮(zhèn)痛方案的補(bǔ)救措施，也可以作為多模式鎮(zhèn)痛的一部分在圍術(shù)期應(yīng)用。但嗎啡等阿片類藥物用量過大存在惡心、嘔吐等風(fēng)險，不利于患者早期恢復(fù)。Zhu等[47]對100例TKA的研究結(jié)果顯示，與鹽水對照組相比，術(shù)后應(yīng)用COX-2抑制劑帕瑞昔布可顯著降低術(shù)后6、12、24、48、72 h各時間點(diǎn)VAS評分(P<0.01)，顯著增加術(shù)后24、48、72 h各時間點(diǎn)關(guān)節(jié)活動度(P<0.01)，并減少24 h嗎啡用量(均值8.40 mg vs. 14.18 mg)。Lin等[48]的薈萃分析顯示，TKA圍術(shù)期應(yīng)用COX-2抑制劑可顯著降低術(shù)后VAS評分，改善關(guān)節(jié)活動度。另外，芬太尼透皮貼劑[49]、冷凍療法[50]及舒芬太尼舌下含服[51]等其他方案也可用于術(shù)后鎮(zhèn)痛。

4 多模式鎮(zhèn)痛

多模式鎮(zhèn)痛指應(yīng)用2種或2種以上不同作用機(jī)制的鎮(zhèn)痛藥或方法，前述鎮(zhèn)痛方法或藥物可以進(jìn)行互補(bǔ)性聯(lián)合應(yīng)用改善鎮(zhèn)痛效果，減少單藥用量，避免單藥過量所致不良反應(yīng)，是FTS著重強(qiáng)調(diào)的圍術(shù)期鎮(zhèn)痛模式，大量研究證實(shí)多模式鎮(zhèn)痛的優(yōu)勢。Sarridou等[52]研究顯示帕瑞昔布聯(lián)合股神經(jīng)阻滯相比單獨(dú)股神經(jīng)阻滯術(shù)后VAS評分更低(術(shù)后4、12、24 h，P<0.01)，嗎啡用量更少(P=0.054)，有利于患者早期康復(fù)。Perlas等[53]研究顯示與單獨(dú)應(yīng)用連續(xù)股神經(jīng)阻滯相比，局部浸潤和局部浸潤聯(lián)合收肌管阻滯可明顯改善術(shù)后第1天可行走距離(中位數(shù)20 m vs.30 m vs.0 m，P<0.0001)，疼痛評分低且阿片類藥物應(yīng)用更少；聯(lián)合應(yīng)用相對單獨(dú)局部浸潤，患者出院后直接返家而非進(jìn)入康復(fù)中心的比例更高(88.2% vs.73.2%,P=0.018)。多模式鎮(zhèn)痛聯(lián)用可以改善圍術(shù)期鎮(zhèn)痛效果，降低不良反應(yīng)，已經(jīng)得到臨床廣泛認(rèn)可，但是具體聯(lián)合藥物和方法仍有一定爭議，不同地區(qū)和中心的方案不盡相同，新的方法和藥物的出現(xiàn)也提供了更多的選擇和更好的效果。

5 小結(jié)

TKA圍術(shù)期鎮(zhèn)痛是FTS理念下的重要組成部分，直接關(guān)系到患者能否早期進(jìn)行康復(fù)鍛煉，快速恢復(fù)和及早出院。目前,FTS理念下多模式鎮(zhèn)痛已成基本共識，多模式鎮(zhèn)痛是從術(shù)前、術(shù)中到術(shù)后的一系列嚴(yán)格方案，但各中心的方案不盡相同，麻醉方式、靜脈鎮(zhèn)痛藥物、外周神經(jīng)阻滯和局部浸潤麻醉配方不同，至今也尚未有統(tǒng)一的最佳方案。關(guān)節(jié)周圍注射是近年研究的熱點(diǎn)，在多模式疼痛控制方案中顯示出優(yōu)勢。關(guān)于局部浸潤所采用的最佳藥物配方、藥物注射部位，如何與其他方案聯(lián)用，尚需進(jìn)一步研究。新的局麻藥的應(yīng)用可能有助于改善圍術(shù)期的鎮(zhèn)痛效果，減少相關(guān)不良反應(yīng)，但尚需大量研究證實(shí)。

1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth,1997,78(5):606-617.

2 Melnyk M, Casey RG, Black P, et al. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J,2011,5(5):342-348.

3 Varadhan KK, Neal KR, Dejong CH, et al. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr,2010,29(4): 434-440.

4 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. Arch Orthop Trauma Surg, 2012,132(1):101-104.

5 Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res, 2010,468(1):57-63.

6 Husted H, Lunn TH, Troelsen A, et al. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop,2011,82(6):679-684.

7 張勁軍,孫來保,徐康清,等.氟比洛芬酯減少膝關(guān)節(jié)置換術(shù)后硬膜外鎮(zhèn)痛的嗎啡用量.中國疼痛醫(yī)學(xué)雜志,2008,14(5):317-318.

8 Straube S, Derry S, McQuay HJ, et al. Effect of preoperative Cox-Ⅱ-selective NSAIDs (coxibs) on postoperative outcomes: a systematic review of randomized studies. Acta Anaesthesiol Scand,2005,49(5):601-613.

9 姜天樂, 鄧 瑩, 賈東林,等.帕瑞昔布鈉對全膝關(guān)節(jié)置換術(shù)后股神經(jīng)阻滯鎮(zhèn)痛及膝關(guān)節(jié)功能恢復(fù)的影響——前瞻、雙盲、隨機(jī)對照研究.中國微創(chuàng)外科雜志, 2014,14(4):334-337.

10 Utvag SE, Fuskevag OM, Shegarfi H, et al. Short-term treatment with COX-2 inhibitors does not impair fracture healing. J Invest Surg,2010,23(5):257-261.

11 Wang Z, Bhattacharyya T. Trends of non-union and prescriptions for non-steroidal anti-inflammatory drugs in the United States, 1993-2012. Acta Orthop,2015,86(5):632-637.

12 Liu HW, Gu WD, Xu NW, et al. Surgical approaches in total knee arthroplasty: a meta-analysis comparing the midvastus and subvastus to the medial peripatellar approach. J Arthroplasty, 2014,29(12):2298-2304.

13 Dennis DA, Kittelson AJ, Yang CC, et al. Does tourniquet use in tka affect recovery of lower extremity strength and function? A randomized trial. Clin Orthop Relat Res, 2015, DOI: 10.1007/s11999-015-4393-8.

14 Andersen LO, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth,2014,113(3):360-374.

15 Tanikawa H, Sato T, Nagafuchi M, et al. Comparison of local infiltration of analgesia and sciatic nerve block in addition to femoral nerve block for total knee arthroplasty. J Arthroplasty, 2014, 29(12):2462-2467.

16 Gi E, Yamauchi M, Yamakage M, et al. Effects of local infiltration analgesia for posterior knee pain after total knee arthroplasty: comparison with sciatic nerve block. J Anesth, 2014, 28(5):696-701.

17 Ashraf A, Raut VV, Canty SJ, et al. Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block. Knee, 2013, 20(5):324-327.

18 Andersen KV, Bak M, Christensen BV, et al. A randomized, controlled trial comparing local infiltration analgesia with epidural infusion for total knee arthroplasty. Acta Orthop, 2010, 81(5):606-610.

19 Yadeau JT, Goytizolo EA, Padgett DE, et al. Analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade: a prospective, randomised pragmatic trial. Bone Joint J,2013, 95-B(5):629-635.

20 Fan L, Zhu C, Zan P, et al. The Comparison of local infiltration analgesia with peripheral nerve block following tka: a system review with meta-analysis. J Arthroplasty, 2015, DOI: 10.1016/j.arth.2015.04.006.

21 Surdam JW, Licini DJ, Baynes NT, et al. The use of exparel (liposomal bupivacaine) to manage postoperative pain in unilateral total knee arthroplasty patients. J Arthroplasty, 2015, 30(2):325-329.

22 Chaumeron A, Audy D, Drolet P, et al. Periarticular injection in knee arthroplasty improves quadriceps function. Clin Orthop Relat Res,2013, 471(7): 2284-2295.

23 Stathellis A, Fitz W, Schnurr C, et al. Periarticular injections with continuous perfusion of local anaesthetics provide better pain relief and better function compared to femoral and sciatic blocks after TKA: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc,2015,DOI: 10.1007/s00167-015-3633-5.

24 Moghtadaei M, Farahini H, Faiz SH, et al. Pain Management for Total Knee Arthroplasty: Single-Injection Femoral Nerve Block versus Local Infiltration Analgesia. Iran Red Crescent Med J,2014,16(1):e13247.

25 Gorfine SR, Onel E, Patou G, et al. Bupivacaine extended-release liposome injection for prolonged postsurgical analgesia in patients undergoing hemorrhoidectomy: a multicenter, randomized, double-blind, placebo-controlled trial. Dis Colon Rectum, 2011, 54(12):1552-1559.

26 Skolnik A,Gan TJ. New formulations of bupivacaine for the treatment of postoperative pain: liposomal bupivacaine and SABER-Bupivacaine. Expert Opin Pharmacother,2014,15(11):1535-1542.

27 Patel N, Solovyova O, Matthews G, et al. Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-day bilateral total knee arthroplasty.J Arthroplasty, 2015,30(2):330-334.

28 Spreng UJ, Dahl V, Hjall A, et al. High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth,2010,105(5):675-682.

29 Oderda GM, Gan TJ, Johnson BH, et al. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother, 2013,27(1):62-70.

30 Peng L, Ren L, Qin P, et al. Continuous Femoral Nerve Block versus Intravenous Patient Controlled Analgesia for Knee Mobility and Long-Term Pain in Patients Receiving Total Knee Replacement: A Randomized Controlled Trial. Evid Based Complement Alternat Med,2014,DOI: 10.1155/2014/569107.

31 Ng FY, Chiu KY, Yan CH, et al. Continuous femoral nerve block versus patient-controlled analgesia following total knee arthroplasty. J Orthop Surg (Hong Kong), 2012,20(1):23-26.

32 Lee RM, Lim Tey JB,Chua NH. Postoperative pain control for total knee arthroplasty: continuous femoral nerve block versus intravenous patient controlled analgesia. Anesth Pain Med,2012,1(4):239-242.

33 Chan EY, Fransen M, Parker DA, et al. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev, 2014, DOI: 10.1002/14651858.CD009941.pub2.

34 賀端端,賈東林,郭向陽,等.超聲聯(lián)合神經(jīng)刺激器引導(dǎo)連續(xù)股神經(jīng)阻滯用于全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛的對比研究.中國微創(chuàng)外科雜志,2011,11(4):304-307.

35 Chan EY, Fransen M, Sathappan S, et al. Comparing the analgesia effects of single-injection and continuous femoral nerve blocks with patient controlled analgesia after total knee arthroplasty. J Arthroplasty, 2013, 28(4):608-613.

36 Sharma S, Iorio R, Specht LM, et al. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res, 2010,468(1):135-140.

37 Wasserstein D, Farlinger C, Brull R, et al. Advanced age, obesity and continuous femoral nerve blockade are independent risk factors for inpatient falls after primary total knee arthroplasty. J Arthroplasty,2013,28(7): 1121-1124.

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 Arthroplasty, 2014,29(6):1154-1157.

39 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. Reg Anesth Pain Med, 2013,38(6):526-532.

40 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. Reg Anesth Pain Med,2015,40(1):3-10.

41 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 Arthroplasty, 2015, DOI: 10.1016/j.arth.2015.03.044.

42 Shah NA and 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 Arthroplasty,2014,29(11):2224-2229.

43 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. Clin Orthop Relat Res,2014,472(5):1377-1383.

44 Chen J, Lesser JB, Hadzic A, et al. Adductor canal block can result in motor block of the quadriceps muscle. Reg Anesth Pain Med,2014,39(2):170-171.

45 Al-Zahrani T, Doais KS, Aljassir F, et al. Randomized clinical trial of continuous femoral nerve block combined with sciatic nerve block versus epidural analgesia for unilateral total knee arthroplasty. J Arthroplasty,2015,30(1): 149-154.

46 Sato K, Adachi T, Shirai N, et al. Continuous versus single-injection sciatic nerve block added to continuous femoral nerve block for analgesia after total knee arthroplasty: a prospective, randomized, double-blind study. Reg Anesth Pain Med,2014,39(3):225-229.

47 Zhu Y, Wang S, Wu H, et al. Effect of perioperative parecoxib on postoperative pain and local inflammation factors PGE2 and IL-6 for total knee arthroplasty: a randomized, double-blind, placebo-controlled study. Eur J Orthop Surg Traumatol,2014,24(3):395-401.

48 Lin J, Zhang L,Yang H. Perioperative administration of selective cyclooxygenase-2 inhibitors for postoperative pain management in patients after total knee arthroplasty. J Arthroplasty, 2013,28(2):207-213.

49 Sathitkarnmanee T, Tribuddharat S, Noiphitak K, et al. Transdermal fentanyl patch for postoperative analgesia in total knee arthroplasty: a randomized double-blind controlled trial. J Pain Res, 2014,7:449-454.

50 Ewell M, Griffin C,Hull J. The use of focal knee joint cryotherapy to improve functional outcomes after total knee arthroplasty: review article. PM R, 2014,6(8):729-738.

51 Jove M, Griffin DW, Minkowitz HS, et al. Sufentanil sublingual tablet system for the management of postoperative pain after knee or hip arthroplasty: a randomized, placebo-controlled study. Anesthesiology,2015,123(2):434-443.

52 Sarridou DG, Chalmouki G, Braoudaki M, et al. Intravenous parecoxib and continuous femoral block for postoperative analgesia after total knee arthroplasty. A randomized, double-blind, prospective trial. Pain Physician, 2015,18(3):267-276.

53 Perlas A, Kirkham KR, Billing R, et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med, 2013,38(4):334-339.

(修回日期：2015-12-01)

(責(zé)任編輯：李賀瓊)

Progress of Perioperative Analgesia of Total Knee Arthroplasty in Fast Track Surgery Protocol

QuYinyin,XuMao.

DepartmentofAnesthesiology,PekingUniversityThirdHospital,Beijing100083,China

Correspondingauthor:XuMao,E-mail:anae@163.com

【Summary】 In total knee arthroplasty, perioperative analgesia is transforming into multimodal analgesia. As a significantly important part of fast track surgery (FTS) protocol, perioperative analgesia does affect the recovery of patients. We reviewed the advantages and disadvantages of perioperative (pre-operative, intra-operative and post-operative) analgesia in FTS protocols in total knee arthroplasty, including the latest progress of the field.

Total knee arthroplasty; Perioperative analgesia; Fast track surgery

北京大學(xué)第三醫(yī)院臨床重點(diǎn)項(xiàng)目青年項(xiàng)目(項(xiàng)目編號：BYSY2014019)

A

1009-6604(2016)02-0172-05

10.3969/j.issn.1009-6604.2016.02.021

2015-08-27)

**通訊作者，E-mail:anae@163.com