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中华损伤与修复杂志(电子版)

中华损伤与修复杂志(电子版) ›› 2019, Vol. 14 ›› Issue (05) : 330 -338. doi: 10.3877/cma.j.issn.1673-9450.2019.05.003

所属专题： 文献；

论著

人工全膝关节置换术结合加速康复外科理念治疗膝关节骨关节炎的临床效果
杨朝君1, 孙智文1,†(), 张爱民1, 朴俊杰1, 牛爽1, 周琪1, 郑宏梅1   
  1. 1. 024000　赤峰市医院骨关节科
  • 收稿日期:2019-08-26 出版日期:2019-10-01
  • 通信作者: 孙智文
  • 基金资助:
    内蒙古自治区卫生和计划生育委员会科研基金项目(201703214)

Clinical effect of total knee arthroplasty combined with enhanced recovery after surgery on knee osteoarthritis

Zhaojun Yang1, Zhiwen Sun1,†(), Aimin Zhang1, Junjie Piao1, Shuang Niu1, Qi Zhou1, Hongmei Zheng1   

  1. 1. Department of Joint Surgery, Chifeng Municipal Hospital, Chifeng 024000, China
  • Received:2019-08-26 Published:2019-10-01
  • Corresponding author: Zhiwen Sun
  • About author:
    Corresponding author: Sun Zhiwen, Email:
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引用本文：

杨朝君, 孙智文, 张爱民, 朴俊杰, 牛爽, 周琪, 郑宏梅. 人工全膝关节置换术结合加速康复外科理念治疗膝关节骨关节炎的临床效果[J/OL]. 中华损伤与修复杂志(电子版), 2019, 14(05): 330-338.

Zhaojun Yang, Zhiwen Sun, Aimin Zhang, Junjie Piao, Shuang Niu, Qi Zhou, Hongmei Zheng. Clinical effect of total knee arthroplasty combined with enhanced recovery after surgery on knee osteoarthritis[J/OL]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2019, 14(05): 330-338.

探讨人工全膝关节置换术(TKA)结合加速康复外科(ERAS)理念治疗膝关节骨关节炎(KOA)的疗效。

方法

选取赤峰市医院骨关节科2018年1月至11月收治的KOA患者220例，按随机数字表法分为2组，加速康复组(n＝108)，遵循围手术期应用ERAS理念，严格执行加速康复程序；对照组(n＝112)，沿袭传统手术管理模式。制定相同的出院标准，比较2组患者术后早期疼痛数字评分法(NRS)评分，术后输血率，恶心、呕吐发生率，口渴、饥饿发生率，达到出院标准的时间，术后2周的满意度评分，术后3个月美国特种外科医院(HSS)膝关节评分，术后并发症发生率等。数据比较采用t检验和χ2检验。

结果

术后12、24、48 h,加速康复组术后早期疼痛NRS评分分别为(2.13±1.21)、(2.42±1.11)、(2.83±1.18)分，低于对照组[(3.24±1.45)、(3.35±1.23)、(3.78±1.25)分]，差异均有统计学意义(t＝3.9498、3.7689、3.7088，P＝0.0002、0.0003、0.0004)；加速康复组术后输血率6.5%(7/108)，低于对照组[27.7%(31/112)]，差异有统计学意义(χ2＝17.2887，P<0.05)；加速康复组术后恶心、呕吐发生率为14.8%(16/108)，低于对照组[38.4%(43/112)]，差异有统计学意义(χ2＝15.5741，P<0.05)；加速康复组术后口渴、饥饿发生率为12.0%(13/108)，低于对照组[41.1%(46/112)]，差异有统计学意义(χ2＝23.6163，P<0.05)；加速康复组达到出院标准的时间平均为(2.9±1.3) d，少于对照组[(5.7±1.6) d]，差异有统计学意义(t＝9.1301，P<0.05)；加速康复组术后2周的满意度评分为(9.8±1.2)分，高于对照组[(8.9±1.1)分]，差异有统计学意义(t＝3.7042，P<0.05)；加速康复组、对照组术后3个月HSS膝关节评分分别为(88.2±13.2)、(87.7±16.6)分，2组比较差异无统计学意义(t＝0.1585，P＝0.8744)；加速康复组并发症发生率为2.7%(3/108)，低于对照组[9.8%(10/112)]，差异有统计学意义(t＝4.5779，P＝0.0324)。

结论

采用人工TKA结合ERAS理念治疗KOA，可以减轻术后应激反应，加速患者康复进程，减少手术并发症，缩短住院时间，提高患者满意度，是一种安全、可靠的选择，值得临床推广应用。

关键词: 康复, 关节成形术，置换，膝, 骨关节炎，膝, 围手术期管理
Objective

To evaluate the effect of total knee arthroplasty (TKA) combined with enhanced recovery after surgery (ERAS) in knee osteoarthritis (KOA).

Methods

Two hundred and twenty patients with KOA of the Department of Joint Surgery, Chifeng Municipal Hospital from January 2018 to November 2018 were divided into enhanced recovery group and control group according to the random number table method. The enhanced recovery group(n=108)was applied the ERAS concept and strictly implemented the enhanced recovery program. In contrast group, conventional surgical management mode was followed.Identical discharge standards were established for patients in two groups to evaluate the recovery time.The early postoperative pain numerical rating scale(NRS), blood transfusion rate, nausea and vomiting incidence, thirst, hunger and abdominal distension incidence rate, the time of discharge, the satisfaction of 2 weeks after operation, 3 months′ Hospital for special surgery(HSS) knee score after operation, and the incidence of postoperative complications were compared between the two groups. The data were analyzed by t test and chi-square test.

Results

At 12, 24, and 48 h after operation, the NRS score of patients in the enhanced recovery group were (2.13±1.21), (2.42±1.11), (2.83±1.18) points, which were lower than those in the control group[(3.24±1.45), (3.35±1.23), (3.78±1.25) points], the differences were statistically significant(t=3.9498, 3.7689, 3.7088; P=0.0002, 0.0003, 0.0004); postoperative blood transfusion rate was 6.5%(7/108) in the enhanced recovery group, it was considerably lower than the 27.7%(31/112) in control group, the difference was statistically significant(χ2=17.2887, P<0.05). The incidence of postoperative nausea and vomiting was 14.8%(16/108)in the enhanced recovery group, which was lower than that in the control group[38.4%(43/112)], the difference was statistically significant(χ2=15.5741, P<0.05). The rate of thirst and hunger in the enhanced recovery group was 12.0%(13/108), which was lower than that in the control group[41.1%(46/112)], the difference was statistically significant(χ2=23.6163, P<0.05). The average time for the enhanced recovery group to reach the discharge standard was (2.9±1.3) days, which was shorter than that of the control group[(5.7±1.6) days]. The difference was statistically significant(t=9.1301, P<0.05). The patients′ satisfaction degree at 2 weeks after operation in the enhanced recovery group was(9.8±1.2) points, which was higher than that of the control group[(8.9±1.1) points], the difference was statistically significant(t=3.7042, P<0.05). The HSS knee scores were (88.2±13.2), (87.7±16.6) points in the enhanced recovery group and control group at 3 months postoperatively, there was no significant difference between the two groups(t=0.1585, P=0.8744). The incidence of complications in the enhanced recovery group was 2.7% (3/108), which was lower than that in the control group[9.8% (10/112)], the difference was statistically significant(t=4.5779, P=0.0324).

Conclusions

ERAS in osteoarthritis of knee joint patients with TKA can reducing postoperative stress reaction, accelerate the recovery process of patients, reducing postoperative complications, shorten the lenth of hospital stay and effectively enhance the degree of satisfaction of the patients. It′s a safe and reliable choice and worthy to popularization and application in clinical.

Key words: Rehabilitation, Arthroplasty, replacement, knee, Osteoarthritis, knee, Perioperative management
表1 加速康复组与对照组KOA患者术前一般资料比较
组别 例数 年龄(岁，±s) 性别（例） 手术部位(左侧)[例(%)] 体重指数(kg/m2, ±s) 术前血红蛋白(g/dL, ±s) HSS膝关节评分(分，±s) 术前疼痛NRS评分(分，±s)
男/女
加速康复组 108 62.5±6.6 27/81 58(53.7) 21.2±3.9 11.9±1.3 40.5±5.3 6.3±2.3
对照组 112 61.9±7.2 30/82 63(56.3) 22.1±4.4 12.3±1.4 41.7±6.2 6.6±2.1
t值 ? 0.6436 ? ? 1.0280 1.4053 0.9884 0.6453
χ2值 ? ? 0.0913 0.1440 ? ? ? ?
P值 ? 0.5205 0.7625 0.7043 0.3068 0.1634 0.3257 0.5204
表2 加速康复组与对照组KOA患者术前恶心、呕吐发生风险评估[例(%)]
组别 例数 无 低危 中危 高危
加速康复组 108 13(12.0) 25(23.1) 55(50.9) 15(13.9)
对照组 112 15(13.4) 27(24.1) 58(51.8) 12(10.7)
χ2值 ? 0.0910 0.0280 0.0163 0.5147
P值 ? 0.7630 0.8671 0.8985 0.4731
表3 加速康复组与对照组KOA患者治疗措施比较
项目 加速康复组 对照组
入院前 门诊初筛：诊断明确，近期无感染性疾病发生，无严重心肺疾病病史；完善术前检查：心电图、胸片正常，排除下肢静脉血栓，C反应蛋白检查结果≤正常高值的3倍，经麻醉门诊评估合格的患者，安排入院 直接入院
术前 向患者及其家属就住院时间、治疗目标及出院情况进行详细的术前告知，个性化的心理辅导 术前简单宣教
? 疼痛宣教，向患者及其家属介绍手术方案和康复措施 无疼痛宣教
? 强调主动功能锻炼的重要性，指导患者踝泵练习，直腿抬高练习 ?
? 非甾体类药物超前镇痛 需要时予以非甾体类或阿片类镇痛药
? 营养支持，如无禁忌，术前口服铁剂；术前禁饮2 h，口服碳水化合物400 mL，禁食6 h；识别恶心、呕吐中、高危患者，并于手术当天早晨预防性给予甲氧氯普胺片10 mg加盐酸昂丹司琼片16 mg；手术当天早晨口服枸橼酸莫沙必利片 术前禁饮6 h，禁食12 h
? 术前睡眠障碍者根据情况给予镇静催眠、抗焦虑药物(艾司唑仑片、地西泮片、唑吡坦片) ?
术中 除非蛛网膜下腔麻醉禁忌，常规使用蛛网膜下腔麻醉＋股神经阻滞或收肌管阻滞 由麻醉医师决定具体麻醉方式
? 输入液体加温 室温，输入液体无加温措施
? 术中控制降压，减少使用止血带时间或不使用止血带 全程使用止血带
? 切口关闭前15～20 mg/kg氨甲环酸注射液静脉滴注完毕，关闭切口时氨甲环酸注射液2 g局部关节腔灌注 未使用止血药物
? 采用微创手术技术；切口周围注射镇痛药物罗哌卡因200 mg，地塞米松5 mg，肾上腺素0.2 mL 常规手术技术；局部未使用镇痛药物
? 应用糖皮质激素10 mg 不常规应用地塞米松
? 不常规应用尿管；不常规采用引流管 常规应用尿管；常规放置引流管
术后 控制性输液(<1 500 mL) 静脉输液量>2 000 mL
? 全身麻醉患者清醒后先进饮再进食，细针蛛网膜下腔麻醉者返回病房后可进饮、进食 去枕平卧6 h后进食、水
? 保持头高40°～50°、脚高30°的预防呕吐体位 ?
? 缩短术后监护仪使用时间，尽量减少监护仪对睡眠质量的影响，仍有睡眠障碍者给予镇静催眠药物 常规应用监护仪至术后第1天晨起
? 间断冰敷、抬高患肢 ?
? 麻醉清醒后立即行下肢主动活动并鼓励患者尽早下床 术后1 d患肢主动活动，术后2～3 d下床活动
? 应用糖皮质激素10 mg(术后4～6 h，术后第1天早晨) 术后不使用糖皮质激素
? 使用多模式镇痛，患者自控镇痛，术后静脉滴注、口服非甾体抗炎药，据NRS评分给予阿片类药物，必要时给予镇静、抗抑郁药物 口服非甾体类药物，必要时给予肌内注射阿片类镇痛药物
? 恶心、呕吐患者使用与预防用药不同种类的抗呕吐药物，达到多种药物的联合使用：(1)甲氧氯普胺注射液10～20 mg，3次/d；(2)地塞米松2.5～5 mg，2次/d；(3)氟哌利多1～1.5 mg，2次/d; (4)昂丹司琼4 mg，4次/d，或其他5－羟色胺受体拮抗药 术后恶心、呕吐常规应用甲氧氯普胺注射液10 mg，肌内注射，必要时待患者切口引流量每24 h小于50 mL，拔出引流管；保留尿管2～4 d，训练患者排尿后拔出导尿管
? 继续口服枸橼酸莫沙必利片3 d；继续口服铁剂至出院 未服用相关药物
? 出院后密切随访(主动随访时间：术后1周、2周、1个月、3个月；患者反馈式随访：必要时) 出院后随访(术后2周、1个月、3个月)
表3 加速康复组与对照组KOA患者术后不同时相点疼痛NRS评分比较(分，±s)
组别 例数 术后12 h 术后24 h 术后48 h
加速康复组 108 2.13±1.21 2.42±1.11 2.83±1.18
对照组 112 3.24±1.45 3.35±1.23 3.78±1.25
t值 ? 3.9498 3.7689 3.7088
P值 ? 0.0002 0.0003 0.0004
表4 加速康复组与对照组KOA患者临床疗效的比较
组别 例数 输血率[例(%)] 恶心、呕吐发生率[例(%)] 口渴、饥饿发生率[例(%)] 住院时间(d, ±s) 术后2周满意度(分，±s) 术后3个月HSS膝关节评分(分，±s) 并发症发生生率[例(%)]
加速康复组 108 7(6.5) 16(14.8) 13(12.0) 2.9±1.3 9.8±1.2 88.2±13.2 3(2.7)
对照组 112 31(27.7) 43(38.4) 46(41.1) 5.7±1.6 8.9±1.1 87.7±16.6 10(9.8)
t值 ? ? ? ? 9.1301 3.7042 0.1585 ?
χ2值 ? 17.2887 15.5741 23.6163 ? ? ? 4.5779
P值 ? <0.05 <0.05 <0.05 <0.05 <0.05 0.8744 0.0324
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