膝神经阻滞与局部浸润镇痛对膝骨关节炎术后镇痛方案的比较研究

Comparative study of knee nerve block and local infiltration anesthesia for postoperative pain management in knee osteoarthritis

摘要:

目的 比较膝神经阻滞（GNB）与局部浸润镇痛（LIA）在全膝关节置换术（TKA）术后的镇痛效果，并评估其对患者术后康复的影响。方法 纳入2021年2月—2024年10月在联勤保障部队第九〇四医院常州医疗区接受TKA手术的82例膝骨关节炎（KOA）患者，采用随机数字表法分为GNB组与LIA组，各41例。比较两组术后4、8、12、24 h静息及运动状态下的视觉模拟评分法（VAS）评分；两组术后24、48 h的主、被动屈膝角度；两组最早下床活动时间和术后至出院时间；两组术后1 d的C反应蛋白（CRP）、白细胞介素-6（IL-6）水平；两组术前1 d、术后24 h、术后48 h、出院前股四头肌肌力、胫前肌肌力、小腿三头肌肌力评分；两组术后1个月膝关节功能（HSS）评分；记录两组不良反应。结果 GNB组与LIA组术后4、8、12、24 h静息状态下的VAS评分比较，结果 ①不同时间点静息状态下的VAS评分比较，差异无统计学意义（P >0.05）；②GNB组与LIA组静息状态下的VAS评分比较，差异有统计学意义（P <0.05）；③两组静息状态下的VAS评分变化趋势比较，差异有统计学意义（P <0.05）。GNB组与LIA组术后4、8、12、24 h运动状态下的VAS评分比较，结果 ①不同时间点运动状态下的VAS评分比较，差异有统计学意义（P <0.05）；②GNB组与LIA组运动状态下的VAS评分比较，差异有统计学意义（P <0.05），GNB组VAS评分较低，相对镇痛效果较好；③两组运动状态下的VAS评分变化趋势比较，差异无统计学意义（P >0.05）。GNB组患者术后24、48 h的主、被动屈膝角度均大于LIA组（P <0.05）。GNB组患者最早下床活动时间早于LIA组，术后至出院时间短于LIA组（P <0.05）。两组术后1 d的CRP、IL-6水平比较，差异均无统计学意义（P >0.05）。GNB组与LIA组术前1 d、术后24 h、术后48 h、出院前的股四头肌、胫前肌、小腿三头肌肌力评分比较，结果 ①不同时间点股四头肌、胫前肌、小腿三头肌肌力评分比较，差异均有统计学意义（P <0.05）；②GNB组与LIA组股四头肌、胫前肌、小腿三头肌肌力评分比较，差异均有统计学意义（P <0.05），术后24 h、术后48 h、出院前，GNB组股四头肌、胫前肌、小腿三头肌肌力评分较高；③GNB组与LIA组股四头肌、胫前肌、小腿三头肌肌力评分变化趋势比较，差异均有统计学意义（P <0.05）。两组术后1个月的HSS评分比较，差异均无统计学意义（P >0.05）。两组不良反应总发生率的比较，差异无统计学意义（P >0.05）。结论 GNB在TKA术后早期镇痛效果优于LIA，可更好地促进关节活动度的恢复、改善肌力并早期下床活动，有利于加速术后康复。两组远期功能及安全性无明显差异。

Abstract:

Objective To compare the analgesic efficacy of genicular nerve block (GNB) and local infiltration analgesia (LIA) after total knee arthroplasty (TKA), and to evaluate their impact on postoperative recovery.Methods A total of 82 patients with knee osteoarthritis (KOA) who underwent TKA at the Changzhou Medical District of the 904th Hospital of the Joint Logistics Support Force between February 2021 and October 2024 were enrolled and randomly assigned to either the GNB group or the LIA group, with 41 patients in each. Postoperative evaluation indicators included visual analogue scale (VAS) scores at rest and during movement at 4, 8, 12, and 24 hours after surgery; active and passive knee flexion angles at 24 and 48 hours postoperatively; lower limb muscle strength preoperatively and at 24h, 48h, and discharge postoperatively; rehabilitation parameters such as time to first ambulation and length of hospital stay; levels of C-reactive protein (CRP) and interleukin-6 (IL-6) on postoperative day 1; and Hospital for Special Surgery (HSS) knee scores at 1 month postoperatively, and recorded adverse reactions.Results Comparison of resting VAS scores at 4, 8, 12, and 24 hours postoperatively between the GNB group and the LIA group, analyzed by repeated-measures ANOVA, showed: (1)There was no statistically significant difference in resting VAS scores at different time points (P > 0.05). (2)There was a statistically significant difference in resting VAS scores between the GNB group and the LIA group (P < 0.05). (3)There was a statistically significant difference in the trend of change in resting VAS scores between the two groups (P < 0.05). Comparison of movement VAS scores at 4, 8, 12, and 24 hours postoperatively between the GNB group and the LIA group, analyzed by repeated-measures ANOVA, showed: (1)There was a statistically significant difference in movement VAS scores at different time points (P < 0.05). (2)There was a statistically significant difference in movement VAS scores between the GNB group and the LIA group (P < 0.05), with the GNB group having lower VAS scores, indicating a relatively better analgesic effect. (3)There was no statistically significant difference in the trend of change in movement VAS scores between the two groups (P > 0.05). The active and passive knee flexion angles at 24 and 48 hours postoperatively in the GNB group were greater than those in the LIA group (P <0.05). The time to earliest ambulation in the GNB group was earlier than that in the LIA group, and the postoperative hospital stay was shorter than that in the LIA group (P < 0.05). There were no statistically significant differences in CRP and IL-6 levels on postoperative day 1 between the two groups (P > 0.05). Comparison of quadriceps, tibialis anterior, and triceps surae muscle strength scores on preoperative day 1, and at 24 hours, 48 hours postoperatively, and before discharge between the GNB group and the LIA group, analyzed by repeated-measures ANOVA, showed: (1)here were statistically significant differences in quadriceps, tibialis anterior, and triceps surae muscle strength scores at different time points (P < 0.05). (2)There were statistically significant differences in quadriceps, tibialis anterior, and triceps surae muscle strength scores between the GNB group and the LIA group (P < 0.05). At 24 hours, 48 hours postoperatively, and before discharge, the quadriceps, tibialis anterior, and triceps surae muscle strength scores in the GNB group were higher. (3)There were statistically significant differences in the trends of change in quadriceps, tibialis anterior, and triceps surae muscle strength scores between the GNB group and the LIA group (P < 0.05). There were no statistically significant differences in HSS scores at 1 month postoperatively between the two groups (P > 0.05). There was no statistically significant difference in the overall incidence of adverse reactions between the two groups (P > 0.05).Conclusion GNB provides superior early postoperative analgesia compared to LIA, promotes better recovery of joint range of motion and muscle strength, facilitates earlier ambulation, and is beneficial for accelerating early postoperative rehabilitation. No significant differences were observed between the two groups in terms of long-term functional recovery or safety.