Pawar Prashant, Shah Manan, Shah Nilen, Tiwari Anjali, Sahu Dipit, Bagaria Vaibhav
Department of Orthopaedic Surgery, Sir H N Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India.
Department of Orthopedics Surgery, MGM Medical College and Hospital, Kamothe, Raigad, Maharashtra, India.
J Orthop. 2022 Apr 22;31:103-109. doi: 10.1016/j.jor.2022.04.009. eCollection 2022 May-Jun.
The aim of this study is to assess the feasibility of the DACB in a clinical setting and compare the efficacy of postoperative pain relief after TKR in the patients administered DACB versus USG guided ACB. Also to see efficacy and safety of USACB in patients operated with medial parapatellar and subvastus approach.
250 consecutive patients operated with TKR between Jan 2019 to March 2022 were included. Group A included patients operated with medial parapatellar approach and received USACB, Group B included patients operated with medial parapatellar approach and received DACB while Group C included patients operated with subvastus approach and received USACB. VAS scores between three groups were compared at 12 and 24 h. All three groups of patients were otherwise treated identically in the hospital.
The mean age and BMI was not statistically significant between the three groups. The mean VAS pain score at rest at 12 h was 3.06 ± 1.49 (Group A) vs 1.58 ± 1.19 (Group B) [p < 0.0001] and 3.06 ± 1.49 (Group A) vs 1.88 ± 1.18 (Group C) [p < 0.0001]; and at 24 h was 1.88 ± 1.31 (Group A) vs 2.39 ± 1.27 (Group B) [p = 0.023] and 1.88 ± 1.31 (Group A) vs 2.19 ± 1.29 (Group C) [p = 0.16]. The mean theatre time was 151.9 ± 11.37 min (Group A) vs 141.02 ± 19.46 min (Group B) (p = 0.0003) and 151.9 ± 11.37 min (Group A) vs 150.4 ± 28.74 min (Group C) (p = 0.72). Hospital stay was 3.82 ± 0.80 (Group A) vs 4.0 ± 1.09 (Group B) [p = 0.30] and 3.82 ± 0.80 (Group A) vs 2.7 ± 0.69 (Group C) [p < 0.0001]. Group B and Group C had one complication each.
USG ACB irrespective of approach used remains the gold standard in providing consistent pain relief and thereby facilitating early discharge. However, increased operating room turnover time and repeated top-ups remain a disadvantage. Both the quantum of pain relief and the potential downsides remained the same irrespective of the surgical approach used and whether or not steroid was added to the cocktail used for infiltration. On the other hand, DACB provides a short lasting (24 h) adequate pain relief after TKR with similar low complication rates. The technique of DACB may have a potential for a wider use especially in centres where outpatient arthroplasties are performed, if newer longer acting anaesthetic/analgesic combinations are devised.
本研究旨在评估在临床环境中实施双重超声引导下关节周围阻滞（DACB）的可行性，并比较在接受DACB与超声引导下关节周围阻滞（USG引导ACB）的全膝关节置换术（TKR）患者中术后疼痛缓解的效果。同时观察在采用髌旁内侧和股直肌下入路进行手术的患者中超声辅助关节周围阻滞（USACB）的疗效和安全性。
纳入2019年1月至2022年3月期间连续接受TKR手术的250例患者。A组包括采用髌旁内侧入路并接受USACB的患者，B组包括采用髌旁内侧入路并接受DACB的患者，而C组包括采用股直肌下入路并接受USACB的患者。比较三组在12小时和24小时时的视觉模拟评分（VAS）。三组患者在医院的其他治疗均相同。
三组之间的平均年龄和体重指数无统计学差异。12小时时静息状态下的平均VAS疼痛评分，A组为3.06±1.49，B组为1.58±1.19（p<0.0001），A组为3.06±1.49，C组为1.88±1.18（p<0.0001）；24小时时，A组为1.88±1.31，B组为2.39±1.27（p = 0.023），A组为1.88±1.31，C组为2.19±1.29（p = 0.16）。平均手术时间，A组为151.9±11.37分钟，B组为141.02±19.46分钟（p = 0.0003），A组为151.9±11.37分钟，C组为150.4±28.74分钟（p = 0.72）。住院时间，A组为3.82±0.80，B组为4.0±1.09（p = 0.30），A组为3.82±0.80，C组为2.7±0.69（p<0.0001）。B组和C组各有1例并发症。
无论采用何种入路，USG引导ACB仍是提供持续疼痛缓解从而促进早期出院的金标准。然而，手术室周转时间增加和反复追加用药仍然是一个缺点。无论采用何种手术入路以及是否在用于浸润的混合液中添加类固醇，疼痛缓解的程度和潜在的不利方面都是相同的。另一方面，DACB在TKR术后提供短期（24小时）充分的疼痛缓解，并发症发生率也较低。如果设计出更新的长效麻醉/镇痛组合，DACB技术可能有更广泛应用的潜力，特别是在进行门诊关节置换术的中心。
