Kim Tae Woo, Park Sang Jae, Lim Se Hyeok, Seong Sang Cheol, Lee Sahnghoon, Lee Myung Chul
Department of Orthopaedic Surgery, Hallym University Hospital, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Korea.
Knee Surg Sports Traumatol Arthrosc. 2015 Mar;23(3):838-45. doi: 10.1007/s00167-014-3366-x. Epub 2014 Oct 7.
Although the analgesic effect of periarticular injection after total knee arthroplasty (TKA) has been well documented, the gold standard for drug combination has not yet been established. In this study, the analgesic effects of six different drug combinations were compared.
A total of 256 patients undergoing TKA for primary osteoarthritis were randomized into one of six groups: a control group (saline solution, epinephrine, and cefazolin, n = 42), Group 1 (ropivacaine, n = 43), Group 2 (ropivacaine + morphine, n = 43), Group 3 (ropivacaine + ketorolac, n = 42), Group 4 (ropivacaine + morphine + ketorolac, n = 43), and Group 5 (ropivacaine + morphine + ketorolac + methylprednisolone, n = 43). Pain level assessed by visual analogue scale (VAS) and opioid consumption were primary outcomes. The incidence of complications, range of motion (ROM), C-reactive protein (CRP) value, and the amount of post-operative blood drainage were also compared.
Patients in Groups 4 and 5 complained less pain than the control group for the first 12 h after surgery, and the patients in the other groups showed less pain only during the initial 6 h after surgery. Groups 4 and 5 also showed less opioid consumption than the control group during the 24 h period after surgery. Patients in Group 5 showed no significant difference in VAS score and opioid consumption compared with Group 4, but they had lower CRP value and greater ROM than any other groups at post-operative day 2 and day 4.
The combination of ropivacaine, morphine, and ketorolac showed a significantly stronger and sufficiently synergistic analgesic effect without adding methylprednisolone in periarticular injection after TKA. The clinical relevance of the study is that the combination of ropivacaine, morphine, and ketorolac can be a good option for periarticular injection following TKA in terms of synergistic analgesic effect and efficiency of drug combination.
尽管全膝关节置换术（TKA）后关节周围注射的镇痛效果已有充分记录，但药物联合使用的金标准尚未确立。在本研究中，比较了六种不同药物组合的镇痛效果。
总共256例因原发性骨关节炎接受TKA的患者被随机分为六组之一：对照组（生理盐水、肾上腺素和头孢唑林，n = 42），第1组（罗哌卡因，n = 43），第2组（罗哌卡因 + 吗啡，n = 43），第3组（罗哌卡因 + 酮咯酸，n = 42），第4组（罗哌卡因 + 吗啡 + 酮咯酸，n = 43），以及第5组（罗哌卡因 + 吗啡 + 酮咯酸 + 甲基强的松龙，n = 43）。通过视觉模拟量表（VAS）评估的疼痛程度和阿片类药物消耗量是主要结局指标。还比较了并发症发生率、活动范围（ROM）、C反应蛋白（CRP）值和术后引流量。
第4组和第5组患者在术后最初12小时内的疼痛程度低于对照组，其他组患者仅在术后最初6小时内疼痛程度较低。第4组和第5组在术后24小时内的阿片类药物消耗量也低于对照组。第5组患者与第4组相比，VAS评分和阿片类药物消耗量无显著差异，但在术后第2天和第4天，其CRP值较低，ROM大于其他任何组。
在TKA后关节周围注射中，罗哌卡因、吗啡和酮咯酸的联合使用显示出显著更强且充分协同的镇痛效果，无需添加甲基强的松龙。该研究的临床意义在于，就协同镇痛效果和药物联合效率而言，罗哌卡因、吗啡和酮咯酸的联合使用可能是TKA后关节周围注射的一个良好选择。
