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

doi:10.3877/cma.j.issn.1673-9450.2019.05.003

Abstract

Abstract:

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

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]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2019, 14(05): 330-338.

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References 42

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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)
组别	例数	年龄(岁，±s)	男/女	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)
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

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)
组别	例数	年龄(岁，±s)	男/女	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)
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

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

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

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)

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