Martin Nikhil Joseph, Padmanabhan Vinod, Pindis Johny Joseph
Department of Orthopaedic Surgery, Sree Sudheendra Medical Mission Hospital, Chittoor Road, Cochin, Kerala India.
Indian J Orthop. 2020 Aug 20;54(6):811-822. doi: 10.1007/s43465-020-00230-3. eCollection 2020 Nov.
Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery.
Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period.
The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed.
Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.
全膝关节置换术（TKR）后的疼痛控制对于关节置换外科医生实现良好的术后功能结局至关重要。当这些大型手术在类风湿关节炎等免疫功能低下的患者中进行时，这一挑战变得更加严峻。良好的围手术期镇痛有助于早期康复，提高患者满意度，并缩短住院时间。通过局部使用镇痛合剂替代硬膜外镇痛或胃肠外阿片类药物所引起的不良反应。我们的前瞻性研究旨在评估在类风湿性关节炎患者单次双侧全膝关节置换术中进行关节周围合剂注射在疼痛和膝关节活动恢复方面的益处。
本研究纳入了64例同时进行初次全膝关节置换术的类风湿关节炎患者。总共128个膝关节被随机分组，一侧膝关节接受含有罗哌卡因、芬太尼、可乐定、头孢呋辛和肾上腺素的关节周围术中注射（A组），另一侧膝关节接受单纯罗哌卡因注射（B组）。围手术期和术后镇痛方案标准化。所有患者均接受相同的标准镇痛方案。在手术当天、术后第一天、术后第二天、出院日以及随访期间的第2周和第6周记录疼痛的视觉模拟评分、膝关节活动范围和股四头肌功能。在研究期间还记录了对急救镇痛的需求以及合剂注射的不良反应。
接受关节周围合剂注射的患者在疼痛评分和功能恢复方面表现更好。与B组相比，A组在术后6小时、12小时以及术后头24小时内使用的额外急救药物明显更少。未观察到心脏或中枢神经系统毒性。
在类风湿关节炎患者进行全膝关节置换术后，关节周围合剂注射可显著降低术后镇痛需求，提高患者满意度，且无明显风险。
