肢体预处理是否能减少全膝关节置换术后的疼痛？一项随机、双盲研究。
Does limb preconditioning reduce pain after total knee arthroplasty? A randomized, double-blind study.
机构信息
Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA,
出版信息
Clin Orthop Relat Res. 2014 May;472(5):1467-74. doi: 10.1007/s11999-013-3106-4.
BACKGROUND
Total knee arthroplasty (TKA) can be associated with considerable postoperative pain. Ischemic preconditioning of tissue before inducing procedure-related underperfusion may reduce the postoperative inflammatory response, which further may reduce associated pain.
QUESTIONS/PURPOSES: In this prospective, randomized study, we aimed at evaluating the impact of ischemic preconditioning on postoperative pain at rest and during exercise; use of pain medication; levels of systemic prothrombotic and local inflammatory markers; and length of stay and achievement of physical therapy milestones.
METHODS
Sixty patients undergoing unilateral TKA under tourniquet were enrolled with half (N = 30) being randomized to an episode of limb preconditioning before induction of ischemia for surgery (tourniquet inflation). Pain scores, analgesic consumption, markers of inflammation (interleukin-6 [IL-6], tumor necrosis factor [TNF]-α in periarticular drainage), and periarticular circumference were measured at baseline and during 2 days postoperatively. Changes in prothrombotic markers were evaluated.
RESULTS
Patients in the preconditioning group had significantly less pain postoperatively at rest (mean difference = -0.71, 95% confidence interval [CI] = -1.40 to -0.02, p = 0.043) and with exercise (mean difference = -1.38, 95% CI = -2.32 to -0.44, p = 0.004), but showed no differences in analgesic consumption. No differences were seen between the study and the control group in terms of muscle oxygenation and intraarticular levels of IL-6 and TNF-α as well as levels of prothrombotic markers. No differences were found between groups in regard to hospitalization length and time to various physical therapy milestones.
CONCLUSIONS
Ischemic preconditioning reduces postoperative pain after TKA, but the treatment effect size we observed with the preconditioning routine used was modest.
CLINICAL RELEVANCE
Given the ease of this intervention, ischemic preconditioning may be considered as part of a multimodal analgesic strategy. However, more study into the impact of different preconditioning strategies, elucidation of mechanisms, safety profiles, and cost-effectiveness of this maneuver is needed.
背景
全膝关节置换术（TKA）可能会引起相当大的术后疼痛。在引起与手术相关的灌注不足之前，对组织进行缺血预处理可能会减轻术后炎症反应，从而进一步减轻相关疼痛。
问题/目的：在这项前瞻性、随机研究中，我们旨在评估缺血预处理对术后静息和运动时疼痛、止痛药物使用、全身促血栓形成和局部炎症标志物水平、住院时间和达到物理治疗里程碑的影响。
方法
60 例接受止血带单侧 TKA 的患者入组，其中一半（N=30）随机分为在手术缺血诱导前进行肢体预处理（止血带充气）。在基线和术后 2 天测量疼痛评分、镇痛药消耗、关节周围引流液中的炎症标志物（白细胞介素 6 [IL-6]、肿瘤坏死因子 [TNF]-α）和关节周围周长。评估促血栓形成标志物的变化。
结果
预处理组患者术后静息时疼痛明显减轻（平均差值=-0.71，95%置信区间[CI]=-1.40 至-0.02，p=0.043）和运动时疼痛减轻（平均差值=-1.38，95%CI=-2.32 至-0.44，p=0.004），但镇痛药消耗无差异。研究组和对照组在肌肉氧合、关节内 IL-6 和 TNF-α水平以及促血栓形成标志物水平方面无差异。两组在住院时间和各种物理治疗里程碑的时间方面无差异。
结论
缺血预处理可减少 TKA 后的术后疼痛，但我们观察到的预处理常规治疗效果较小。
临床相关性
鉴于这种干预的简便性，缺血预处理可以考虑作为多模式镇痛策略的一部分。然而，需要更多的研究来探讨不同预处理策略的影响、阐明机制、这种操作的安全性概况和成本效益。
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