Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
J Arthroplasty. 2021 Oct;36(10):3421-3431. doi: 10.1016/j.arth.2021.05.014. Epub 2021 May 19.
This study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA).
Patients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications.
Compared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates.
Adding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.
本研究旨在探讨两种独特的神经阻滞组合在全膝关节置换术后（TKA）疼痛和功能恢复方面的疗效。
拟行 TKA 的患者随机分为接受收肌管阻滞（ACB）+股动脉与膝关节后囊之间浸润（IPACK）+假闭孔神经阻滞（ONB）+假股外侧皮神经阻滞（LFCNB）（对照组），或 ACB+IPACK+ONB+假 LFCNB（三联神经阻滞组），或 ACB+IPACK+ONB+LFCNB（四联神经阻滞组）。所有患者均接受局部浸润镇痛。主要结局为术后吗啡消耗量。次要结局为首次解救镇痛时间、术后视觉模拟评分（VAS）、QoR-15 评分、膝关节功能恢复情况和术后并发症。
与对照组相比，三联和四联神经阻滞组术后吗啡消耗量明显降低（17.2 ± 9.7 mg 比 11.2 ± 7.0 mg 比 11.4 ± 6.4 mg，P =.001）。这两组首次解救镇痛时间也明显延长（分别采用 Kaplan-Meier 法分析，P =.007 和.010），术后第 1 天 VAS 评分明显降低（P <.01），术后第 1、2 天 QoR-15 评分明显提高（P <.001），膝关节功能恢复包括关节活动度（P =.002 和.001，术后第 1、2 天）和日常活动距离（P <.001 和 P =.004，术后第 1、2 天）也明显改善。然而，吗啡消耗量、VAS 评分和 QoR-15 评分的绝对变化并未超过报道的最小临床重要差异（MCID）（吗啡消耗量：10 mg；VAS 评分：静息时 1.5，活动时 1.8；QoR-15 评分：8.0）。文献中尚未报道其他结局的 MCID。三联和四联神经阻滞组之间这些结局的绝对变化无显著差异。三组之间并发症发生率无显著差异。
在 ACB+IPACK 的基础上增加 ONB 或 ONB+LFCNB 可在统计学上减少吗啡的消耗，改善早期疼痛缓解和功能恢复。然而，吗啡消耗量、VAS 评分和 QoR-15 评分的绝对变化并未超过 MCID。基于我们的发现，并考虑到本研究的样本量，没有足够的临床证据支持在 TKA 后多模式镇痛途径中使用三联或四联神经阻滞。
