1University of Western Ontario, London, Ontario, Canada 2Northern Ontario School of Medicine, Sudbury, Ontario, Canada 3Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada 4Division of Orthopaedic Surgery (D.B., E.M.V., S.M., B.L., and J.L.H.) and Department of Anesthesiology and Perioperative Medicine (D.F.J. and S.G.), University Hospital-London Health Sciences Centre, London, Ontario, Canada.
J Bone Joint Surg Am. 2017 Aug 2;99(15):1274-1281. doi: 10.2106/JBJS.16.01266.
Pain following total knee arthroplasty (TKA) is often severe and can inhibit rehabilitation. Motor-sparing analgesic techniques such as periarticular infiltrations and adductor canal blocks have been popularized for knee analgesia since they preserve motor strength and permit early mobilization. Our primary objective was to compare the duration of analgesia from motor-sparing blocks with that of a standard periarticular infiltration. We used the time to first rescue analgesia as the end point.
We randomized 82 patients scheduled for elective TKA to receive either the preoperative motor-sparing block (0.5% ropivacaine, 2.5 μg/mL of epinephrine, 10 mg of morphine, and 30 mg of ketorolac) or intraoperative periarticular infiltration (0.3% ropivacaine, 2.5 μg/mL of epinephrine, 10 mg of morphine, and 30 mg of ketorolac). For the motor-sparing block, we modified the ultrasound-guided adductor canal block by combining it with a lateral femoral cutaneous nerve block and posterior knee infiltration. The patients, surgeons, anesthetists administering the blocks, and outcome assessors all remained blinded to group allocation. Our primary outcome was duration of analgesia (time to first rescue analgesia). Secondary outcomes included quadriceps strength, function, side effects, satisfaction, and length of hospital stay.
The duration of analgesia was significantly longer (mean difference, 8.8 hours [95% confidence interval = 3.98 to 13.62], p < 0.01) for the motor-sparing-block group (mean [and standard error], 18.1 ± 1.7 hours) compared with the periarticular infiltration group (mean, 9.25 ± 1.7 hours). The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no significant differences between groups with regard to any other secondary outcomes.
In patients undergoing a TKA, a motor-sparing block provides longer analgesia than periarticular infiltration with retention of quadriceps muscle strength, function, patient satisfaction, and a short hospital stay.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
全膝关节置换术后（TKA）的疼痛通常很严重，会妨碍康复。自从关节周围浸润和收肌管阻滞等保留运动的镇痛技术被推广用于膝关节镇痛以来，由于它们保留了运动力量并允许早期活动，因此已广受欢迎。我们的主要目的是比较保留运动的阻滞与标准关节周围浸润的镇痛持续时间。我们使用首次需要解救性镇痛的时间作为终点。
我们将 82 名择期行 TKA 的患者随机分为接受术前保留运动的阻滞（0.5%罗哌卡因、2.5μg/ml 肾上腺素、10mg 吗啡和 30mg 酮咯酸）或术中关节周围浸润（0.3%罗哌卡因、2.5μg/ml 肾上腺素、10mg 吗啡和 30mg 酮咯酸）。对于保留运动的阻滞，我们通过将股神经皮支阻滞与外侧股皮神经阻滞和膝关节后浸润相结合，对超声引导的收肌管阻滞进行了改良。患者、外科医生、实施阻滞的麻醉师和结果评估者均对分组保持盲态。我们的主要结局是镇痛持续时间（首次需要解救性镇痛的时间）。次要结局包括股四头肌力量、功能、副作用、满意度和住院时间。
与关节周围浸润组（平均[标准差]9.25 ± 1.7 小时）相比，保留运动的阻滞组（平均[和标准误差]18.1 ± 1.7 小时）的镇痛持续时间显著更长（平均差异 8.8 小时[95%置信区间=3.98 至 13.62]，p < 0.01）。在术后前 2 小时的静息疼痛和术后 2 小时和 4 小时的膝关节运动疼痛方面，浸润组的评分显著更高。在其他次要结局方面，两组之间没有显著差异。
在接受 TKA 的患者中，与关节周围浸润相比，保留运动的阻滞可提供更长的镇痛时间，同时保持股四头肌力量、功能、患者满意度和较短的住院时间。
治疗性 1 级。有关证据水平的完整描述，请参见作者说明。
