本文選題：冰敷 + 全膝置換��； 參考：《北京中醫(yī)藥大學(xué)》2014年碩士論文

【摘要】：背景： 本論文涉及兩個重要的概念,首先是膝關(guān)節(jié)骨性關(guān)節(jié)炎(英:arthritis of knee, KOA),是以膝關(guān)節(jié)軟骨為主并影響到軟骨下骨、滑膜及關(guān)節(jié)周圍支持組織的一種慢性疾病。按病因可分為原發(fā)性膝關(guān)節(jié)骨關(guān)節(jié)炎和繼發(fā)性骨關(guān)節(jié)炎兩大類,后者病因明確,包括創(chuàng)傷、先天性和遺傳性因素、感染和非感染性關(guān)節(jié)病等均可造成關(guān)節(jié)軟骨破壞而最終發(fā)生骨性關(guān)節(jié)炎,這類KOA診斷不難,多與原發(fā)病相關(guān)。但前者更加常見,且致病原因和機制比較復(fù)雜,多數(shù)研究認為并不是單一因素所致,總結(jié)起來有這樣幾個因素：年齡因素,多發(fā)生在65歲以上老年人,且女性多于男性；遺傳因素,有研究證明原發(fā)性全身性骨關(guān)節(jié)炎遺傳傾向與HLA-A1B8和HLA-β8單倍性及α1抗胰蛋白異構(gòu)性相關(guān)；肥胖因素,臨床上可見到大量中老年肥胖婦女患膝關(guān)節(jié)骨性關(guān)節(jié)炎；累積性應(yīng)力：膝關(guān)節(jié)是全身受力最多的關(guān)節(jié),臨床上可見到大量長期體力勞動者患膝關(guān)節(jié)骨性關(guān)節(jié)炎。 全膝關(guān)節(jié)置換術(shù)(英：Total knee arthroplasty,簡稱：TKA)是治療晚期重度膝關(guān)節(jié)骨關(guān)節(jié)炎最有效的方法之一,該手術(shù)能夠有效的解決長期慢性骨關(guān)節(jié)炎帶來的膝關(guān)節(jié)屈曲畸形、內(nèi)外翻畸形及活動受限等方面問題,該方法因此而被廣大臨床醫(yī)生及患者所接受�，F(xiàn)階段,膝關(guān)節(jié)假體種類眾多：有僅適用于膝關(guān)節(jié)前內(nèi)側(cè)間室病變、且操作簡便創(chuàng)傷小的單髁關(guān)節(jié)；有用于重度骨關(guān)節(jié)炎伴有膝關(guān)節(jié)失穩(wěn)的鉸鏈式人工膝關(guān)節(jié)；有方便運動需求高的活動平臺人工膝關(guān)節(jié)；而目前更普遍被采用的是全髁型人工膝關(guān)節(jié),他能夠有效的減輕疼痛、矯正畸形、保持膝關(guān)節(jié)運動的穩(wěn)定性,主要用于嚴重關(guān)節(jié)疼痛、不穩(wěn)、畸形及日常功能嚴重受限的患者。但是全膝置換術(shù)后最關(guān)鍵的是鎮(zhèn)痛,鎮(zhèn)痛的效果直接影響著術(shù)后功能康復(fù)情況,更決定著手術(shù)的成敗,所以全膝置換圍手術(shù)期鎮(zhèn)痛是一個大難題。 目的： 通過分別記錄患者術(shù)后不同階段的疼痛評分、膝關(guān)節(jié)活動度、術(shù)肢腫脹程度、鎮(zhèn)痛藥物的使用劑量及術(shù)后隨訪記錄,來分析手法附加持續(xù)冰敷治療對患者疼痛評分和術(shù)后康復(fù)情況的影響,進而發(fā)掘中醫(yī)保守治療在全膝關(guān)節(jié)置換領(lǐng)域的可行性。 方法： 觀察2012年3月-2013年10月在衛(wèi)計委中日友好醫(yī)院骨關(guān)節(jié)外科住院治療并入組的64例因重度膝關(guān)節(jié)骨性關(guān)節(jié)炎而行單側(cè)全膝關(guān)節(jié)手術(shù)的患者。將這些患者隨機分成中西醫(yī)結(jié)合組(試驗組)和常規(guī)治療組(對照組)進行臨床對照研究,試驗組32人,對照組共32人。分別對兩組患者的性別、年齡、病程、HSS (Hospital of Special Surgery,美國特種外科醫(yī)院)評分、膝關(guān)節(jié)活動度、術(shù)前活動時和靜息時VAS評分(Visual analogue score,視覺模擬評分法),術(shù)前大腿和小腿周徑以及無痛行走距離等進行分析。 兩組患者的手術(shù)均由一組醫(yī)生完成,術(shù)中采用膝關(guān)節(jié)正中切口,在髕骨內(nèi)側(cè)分離股四頭肌肌腱,并將髕骨翻向外側(cè)。兩組患者均采用由美國Zimmer廠商生產(chǎn)的非限制性固定平臺全髁型膝關(guān)節(jié)假體。 兩組患者均采用的常規(guī)治療方法,包括：(藥物方面)口服氨酚羥考酮(本產(chǎn)品含5mg羥考酮和325mg對乙酰),每次一片,每日兩次,用至出院時；靜點氟比洛芬酯,每次100mg,每日兩次；每日一次皮下注射低分子肝素鈣0.4ml,用于常規(guī)抗凝。(康復(fù)方面)從術(shù)后第一日開始指導(dǎo)患者進行踝泵練習(xí),鍛煉股四頭肌肌力,主動屈曲膝關(guān)節(jié)等運動；術(shù)后第二日起增加對患者被動屈伸膝關(guān)節(jié)的指導(dǎo)及練習(xí)；術(shù)后第四日起鼓勵患者進行直腿抬高,并在助行器的幫助下進行下地行走；以上操作方法持續(xù)到患者出院時。(其他方面)兩組患者均在麻醉結(jié)束后放置股神經(jīng)阻滯鎮(zhèn)痛泵,該泵持續(xù)到術(shù)后48h；兩組患者均在從回病房開始應(yīng)用持續(xù)冰敷,冰袋大小為5×10cm大小,冰袋持續(xù)到術(shù)后第二日,與股神經(jīng)阻滯鎮(zhèn)痛泵一齊撤除；兩組患者均從術(shù)后第一天換藥后穿著抗血栓彈力襪,用以預(yù)防深靜脈和肌間血栓。 不同點在于,試驗組患者冰袋并不停用,一直持續(xù)到出院時,從持續(xù)冰敷改為間斷冰敷,更改冰敷方式的指征是患者可以自行下地行走,冰敷的時間是患者休息時；另外,試驗組患者從術(shù)后第二日股神經(jīng)阻滯鎮(zhèn)痛泵撤除之后開始采用中醫(yī)推拿按摩治療。 本研究采用北京中醫(yī)藥大學(xué)第三附屬醫(yī)院脊柱關(guān)節(jié)科對膝關(guān)節(jié)骨性關(guān)節(jié)炎的手法方法,并根據(jù)全膝置換術(shù)后的特點對該套推拿手法進行了適當(dāng)改良,對患者進行手法推拿的同時應(yīng)注意手法的輕柔,并且盡量避開手術(shù)區(qū)域,以防加重出血,加劇患者疼痛。 觀察并記錄兩組患者的術(shù)前、術(shù)后第二日、術(shù)后第三日、術(shù)后第五日、術(shù)后第七日進行康復(fù)鍛煉時和靜息時的VAS評分以及膝關(guān)節(jié)活動度和腫脹程度等數(shù)據(jù)。 記錄住院期間患者應(yīng)用鎮(zhèn)痛藥物的總量,這一總量包括常規(guī)藥物氨酚羥考酮的藥量、非甾體抗炎藥物的總量以及患者極度疼痛時臨時給予的鎮(zhèn)痛藥物的劑量；另記錄因阿片類藥物引起的不良反應(yīng)的事件的發(fā)生概率。 在患者出院時,對患者及家屬進行臨床宣教及術(shù)后康復(fù)指導(dǎo)。對試驗組患者指導(dǎo)其回家后繼續(xù)進行間斷冰敷及手法按摩,治療持續(xù)到術(shù)后一個月。在藥物治療上,每日口服塞來昔布膠囊,服用劑量和服用頻率以患者自身疼痛程度進行靈活調(diào)節(jié)。 治療周期：自術(shù)后第二日起至出院時止 統(tǒng)計軟件：SPSS17.0 首先采用兩組獨立樣本非參數(shù)檢驗對兩組患者性別、年齡、病程、HSS評分、膝關(guān)節(jié)活動度、術(shù)前活動時和靜息時VAS評分,術(shù)前大腿和小腿周徑以及無痛行走距離等指標進行分析,證明兩組患者基本數(shù)據(jù)無明顯差異。 采用重復(fù)測量設(shè)計對兩組患者術(shù)后第二日、術(shù)后第三日、術(shù)后第五日、術(shù)后第七日進行康復(fù)鍛煉時和靜息時的VAS評分。另對患者的膝關(guān)節(jié)活動度、術(shù)肢腫脹度、鎮(zhèn)痛藥物的使用劑量及術(shù)后隨訪記錄進行統(tǒng)計學(xué)分析。 結(jié)果： 最終納入患者60人,試驗組一例在術(shù)后第三日即回家休養(yǎng)而退出實驗,另外三例為住院時間超過30天的患者。各兩組患者術(shù)后VAS評分：A組和B組在術(shù)后第三日(活動6.55±0.910vs7.80±1.240；靜息3.50±1.318vs4.40±0.883)、術(shù)后第五日(活動4.35±1.268vs7.10±1.553；靜息2.15±1.089vs4.00±0.858)、術(shù)后第七日(活動2.65±0.813vs4.20±1.056；靜息1.75±0.716vs2.30±0.801),各組數(shù)據(jù)P值均小于0.05,各組數(shù)據(jù)差異具有統(tǒng)計學(xué)意義。 兩組患者在疼痛評分下降的同時,術(shù)肢周徑也有所變化,術(shù)后第三日(髕上46.54±3.09vs47.01±4.15；髕下43.65±2.18vs43.97±2.70)、術(shù)后第五日(髕上45.94±2.70vs46.55±2.38；髕下42.92±2.51vs43.52±3.04)、術(shù)后第七日(髕上44.08±2.13vs45.62±3.04；髕下42.05±1.39vs43.52±43.10±2.21),各組數(shù)據(jù)P值均小于0.05,各組數(shù)據(jù)差異具有統(tǒng)計學(xué)意義。 在術(shù)肢疼痛和腫脹緩解的同時,膝關(guān)節(jié)活動度也在發(fā)生變化,兩組患者術(shù)后第七日80.83±11.148vs72.67±11.798；術(shù)后一個月91.83±7.598vs86.50±7.895。兩組患者住院期間鎮(zhèn)痛藥物用藥量比較,術(shù)后7日用藥總量9.90±1.971vsl2.30±2.437；術(shù)后一個月用藥總量(不含前七日)28.27±5.065vs40.20±8.010；并對兩組患者住院期間鎮(zhèn)痛藥物不良反應(yīng)事件進行分析,結(jié)果示：消化系統(tǒng)癥狀6.7%vs40.0%；循環(huán)系統(tǒng)癥狀3.3%vs30.0%；其他系統(tǒng)癥狀Ovs6.7%。另對兩組患者術(shù)后三個月康復(fù)情況進行隨訪,并按HSS標準進行評分,結(jié)果示67.60±6.516vs67.40+5.491。以上各組數(shù)據(jù)P值均小于0.05,各組數(shù)據(jù)間差異具有統(tǒng)計學(xué)意義。 結(jié)論： 手法治療附加持續(xù)冰敷的試驗組鎮(zhèn)痛效果優(yōu)于未使用該組合方法的對照組。試驗組患者在鎮(zhèn)痛效果優(yōu)于對照組的同時,術(shù)肢周徑也小于對照組,并且取得了良好的康復(fù)效果。與此同時,試驗組患者在鎮(zhèn)痛藥物的使用劑量、藥物不良反應(yīng)發(fā)生率以及術(shù)后隨訪指標上均優(yōu)于對照組。綜上,全膝置換術(shù)后采用手法治療配合持續(xù)冰敷這一中西醫(yī)組合治療方案,能夠有效減輕全膝關(guān)節(jié)置換術(shù)后疼痛,并在患者術(shù)后康復(fù)中起到積極作用。
[Abstract]:Background:
This paper involves two important concepts, first of all is osteoarthritis of the knee (arthritis of knee, KOA). It is a chronic disease of the knee joint cartilage, which affects the subchondral bone, synovium and the supporting tissue around the joints. According to the etiology, it can be divided into two major categories, primary osteoarthrosis and secondary osteoarthritis, and the latter disease It is clear, including trauma, congenital and hereditary factors, infection and non infectious joint disease, which can cause articular cartilage destruction and ultimately osteoarthritis. This kind of KOA diagnosis is not difficult to be associated with the primary disease. But the former is more common, and the cause and mechanism of the disease are complex. Most studies think that it is not a single factor. There are several factors: age factors, more than 65 years old, and more women than men. Genetic factors have proved that the genetic tendency of primary systemic osteoarthritis is associated with HLA-A1B8 and HLA- beta 8, and alpha 1 isomerism; obesity is a clinical manifestation of a large number of middle-aged and elderly obese women. Osteoarthritis of the knee joint; cumulative stress: the knee is the most stressed joint in the whole body. A large number of long term manual labourers can be seen with osteoarthritis of the knee.
Total knee arthroplasty (Total knee arthroplasty, for short: TKA) is one of the most effective methods for the treatment of advanced osteoarthritis of the knee joint. This operation can effectively solve the problems of knee flexion deformity, internal and external deformity and activity limit caused by chronic osteoarthritis of chronic osteoarthritis. This method is therefore widely used in clinical medicine. At the present stage, there are many types of knee joint prosthesis: the single condyle, which is only suitable for the anterior medial compartment lesion of the knee and easy to operate with small trauma, and a hinged artificial knee joint for severe osteoarthritis with the knee joint instability; an artificial knee joint with high movement demand; and now more The total condyle type of knee joint is widely used. He can effectively relieve pain, correct malformation and keep the stability of the knee joint movement. It is mainly used in patients with severe joint pain, instability, deformity and severe limitation of daily function. However, the most important thing after total knee replacement is pain relief. The effect of analgesia directly affects postoperative functional rehabilitation. The situation determines the success or failure of the operation. Therefore, perioperative analgesia for total knee arthroplasty is a big problem.
Objective:
By recording the pain scores at different stages of the patients, the degree of knee motion, the degree of swelling of the limbs, the dosage of the analgesic drugs and the follow-up records, the effects of the treatment on the pain score and the postoperative recovery were analyzed, and the conservative treatment of traditional Chinese medicine in the field of total knee replacement was further explored. Sex.
Method錛，

本文編號：1839680