Diwu Weilong, Tang Wenhao, Yan Ming, Ma Wenrui, Han Yisheng, Yang Min
Department of Orthopedics, Xijing Hospital of Air Force Medical University, Xi'an, Shaanxi, China.
Int J Surg Protoc. 2025 Aug 7;29(3):122-127. doi: 10.1097/SP9.0000000000000056. eCollection 2025 Sep.
Postoperative pain management remains a critical determinant of functional recovery following total knee arthroplasty (TKA). While local infiltration analgesia (LIA) is commonly employed, its clinical utility is limited by inconsistent analgesic duration (median duration of 8-12 hours), technical variability among surgeons, and systemic toxicity risks associated with high-volume injections. This phase II randomized controlled trial evaluates a dual-optimization strategy combining anatomic mapping-guided periarticular cutaneous nerve (PCN) blockade with a sustained-release triamcinolone-ropivacaine formulation to address these limitations.
In this single-center, assessor-blinded, 2 × 2 factorial design, 120 adults undergoing primary unilateral TKA were randomized to four intervention arms: Group 1: Conventional iPACK (interspace between the popliteal artery and posterior knee capsule) site + novel formulation (1% ropivacaine + 40 mg triamcinolone); Group 2: PCN block site + standard formulation (1% ropivacaine + 5 mg dexamethasone); Group 3: PCN block + novel formulation; Group 4: Control (iPACK + standard formulation). Triamcinolone acetonide replaces dexamethasone in the new formulation due to its prolonged anti-inflammatory effect and demonstrated efficacy in periarticular analgesia. Primary endpoints included: resting/movement-induced pain intensity (Visual Analog Scale) at 6, 24, and 48 h postoperatively, cumulative opioid consumption (morphine milligram equivalents), functional recovery metrics (knee flexion angle, Timed Up-and-Go test). Secondary outcomes assessed safety through adverse event rates (infection, neurologic symptoms, hemodynamic instability).
Anatomic mapping-guided PCN blockade combined with triamcinolone-ropivacaine formulation significantly improves postoperative analgesia and functional outcomes compared to conventional LIA techniques. This dual-optimization approach may redefine periarticular infiltration standards in TKA, particularly for patients at high risk of opioid-related complications.
全膝关节置换术（TKA）后疼痛管理仍然是功能恢复的关键决定因素。虽然局部浸润镇痛（LIA）被广泛应用，但其临床效用受到镇痛持续时间不一致（中位持续时间为8 - 12小时）、外科医生技术差异以及大容量注射相关的全身毒性风险的限制。这项II期随机对照试验评估了一种双重优化策略，该策略将解剖图谱引导的关节周围皮神经（PCN）阻滞与缓释曲安奈德 - 罗哌卡因制剂相结合，以解决这些局限性。
在这项单中心、评估者盲法的2×2析因设计中，120例接受初次单侧TKA的成年人被随机分为四个干预组：第1组：传统腘动脉后间隙（iPACK）部位 + 新型制剂（1%罗哌卡因 + 40毫克曲安奈德）；第2组：PCN阻滞部位 + 标准制剂（1%罗哌卡因 + 5毫克地塞米松）；第3组：PCN阻滞 + 新型制剂；第4组：对照组（iPACK + 标准制剂）。由于曲安奈德具有延长的抗炎作用且在关节周围镇痛中已证明有效，因此在新制剂中用曲安奈德代替地塞米松。主要终点包括：术后6、24和48小时的静息/运动诱发疼痛强度（视觉模拟量表）、累积阿片类药物消耗量（吗啡毫克当量）、功能恢复指标（膝关节屈曲角度、计时起立行走测试）。次要结局通过不良事件发生率（感染、神经症状、血流动力学不稳定）评估安全性。
与传统LIA技术相比，解剖图谱引导的PCN阻滞联合曲安奈德 - 罗哌卡因制剂显著改善了术后镇痛和功能结局。这种双重优化方法可能会重新定义TKA中的关节周围浸润标准，特别是对于有阿片类药物相关并发症高风险的患者。
