Since the beginning of the 21st century, the issue of population aging has gradually become one of the common concerns of today's society.
Osteoarthritis (OA) is a degenerative osteoarticular disease, also known as proliferative osteoarthritis, degenerative osteoarthritis or osteoarthropathy, which mainly affects joint cartilage, synovium and bone tissue, resulting in joint pain, deformity and dysfunction.
Knee osteoarthritis is not only a common and frequent clinical disease, but also the primary cause of motor function and chronic disability in middle-aged and elderly people. According to literature statistics, more than 80% of patients do not understand the cause and prevention methods of the disease, and in the elderly population aged 60-70, the number of people who can be clearly diagnosed with knee osteoarthritis can reach 60%-70%.
Treatment of knee osteoarthritis includes both non-surgical and surgical forms. Non-surgical treatment mainly includes (1) health education, through the education of patients with knee osteoarthritis to improve patients' awareness of the risk factors of the disease and the importance of daily protection, guide them to form healthy living and working habits, recommend them to choose appropriate shoes and socks, use joint protectors, appropriate weight loss, etc.
Teaching patients the basic principles and methods of daily joint protection can sometimes directly improve the quality of life of patients; (2) Lower limb functional exercise, moderate lower limb functional exercise such as quadriceps muscle strength exercise, knee range of motion exercise, physical adaptability and coordination exercise, can enhance quadriceps muscle strength and enhance joint stability.
And the joint cartilage is nourished by the synovial fluid during stress stimulation and joint activity, promoting joint cartilage repair and delaying degeneration, but the development of exercise training regimens should vary from person to person, and there is a positive correlation between quadriceps muscle strength and the risk of osteoarthritis progression in patients with knee osteoarthritis with abnormal lower limb lines of force and joint instability.
However, there is no link between quadriceps muscle strength and the progression of osteoarthritis in patients with normal lower limb force line and stable joints, so patients should consult orthopedic or rehabilitation doctors to develop a training plan suitable for themselves before performing functional exercises; (3) Physical therapy, the current clinical physical therapy forms are diverse, mainly including electrotherapy, magnetic therapy, wax therapy, hydrotherapy, hot compresses, infrared, acupuncture and tuina therapy.
It is mainly suitable for the chronic phase of knee osteoarthritis, but it also has a certain effect on alleviating joint pain in the subacute stage. Effective physical therapy can improve local microcirculation, relieve secondary inflammatory response, enhance joint cartilage nutrition, prevent collagen fibrogen breakage in cartilage, promote the synthesis of cartilage matrix, and delay cartilage degeneration; (4) Drug treatment, the drug treatment of knee osteoarthritis mainly uses non-retaining anti-inflammatory drugs.
However, traditional non-sparing anti-inflammatory drugs cause many adverse reactions, among which gastrointestinal reactions are more common. Selective inhibitors of cyclooxygenase-2 (Cyclo〇xygenaSe-2, C0X-2) can significantly reduce gastrointestinal adverse effects, and more and more elderly patients are being treated with C0X-2 inhibitors. Intra-articular injection of sodium hyaluronate can effectively lubricate the knee joint, and intra-articular injection of anesthetic drugs can also relieve joint pain symptoms in the short term.
Glucosamine hydrochloride is a class of cartilage nutrition drugs, which can improve the anabolic function and nutrition of cartilage tissue by stimulating the synthesis of mucopolysaccharides, and can also effectively improve and enhance the synthesis of synovial fluid in the joints, nourish cartilage and provide joint lubrication function to reduce symptoms.
The drug treatment of knee osteoarthritis also includes traditional Chinese medicine treatment, which should nourish the liver and kidneys, invigorate qi and blood, dispel wind and paralysis, disperse cold and dehumidify, which can help improve local microcirculation, promote the absorption of inflammatory substances to relieve symptoms and improve joint function. In general, non-surgical treatment can effectively relieve local joint symptoms and prevent and delay the progression of the disease, but the treatment of complicated end-stage knee osteoarthritis is still mainly surgery.
The surgical treatment techniques of knee osteoarthritis are mainly related to arthroscopic clearance, high tibial osteotomy, osteochondrograft, chondrocytes transplantation, and knee replacement. Knee replacement is further divided into knee monocondyle replacement and total knee arthroplasty (TKA).
Compared with other surgical procedures, total knee replacement has become the main means of treating end-stage knee diseases in middle-aged and elderly people. However, without effective perioperative pain prevention, approximately 60% of patients with total knee replacement experienced severe pain after surgery and 30% experienced moderate pain.
Pain stimulation can cause strong stress response in patients, easy to induce arrhythmia, hypertension, myocardial ischemia and other cardiovascular complications, postoperative pain prompts patients to actively immobilize, prolong bed time, and increase the incidence of postoperative lower extremity deep vein thrombosis and lung infection. The physiological function of the elderly has undergone degenerative changes of varying degrees, often accompanied by comorbidities such as hypertension, coronary heart disease, cerebrovascular lesions and diabetes.
Proper postoperative analgesia can inhibit or reduce the stress response of pain, reduce or even avoid complications, promote postoperative recovery, and improve the quality of life of patients after surgery, mainly including patient-controlled analgesia (PCA) technology and nurse-controlled analgesia (NCA) technology.
PCA technology has been compared to NCA technology since its introduction in the early eighties of the nineteenth century. Numerous studies have shown that PCA is a more ideal postoperative analgesia regimen than NCA. At the same dose, PCA has a more moderate analgesic effect than NCA, and PCA can reduce postoperative anxiety more effectively, and patients are more likely to choose PCA.
At the same time, patients who received PCA after surgery had a lower chance of developing postoperative respiratory complications such as atelectasis than those who received NCA after surgery. Clinically, PCA technology mainly includes epidural self-controlled analgesia (PCEA) or intravenous controlled analgesia (PCIA) two delivery methods.
At present, literature reports at home and abroad confirm that the perioperative analgesic effect of PCEA in orthopedic lower limb surgery patients is better than PCIA, but there is a lack of analysis and comparison of the perioperative analgesic effect of specific procedures such as total knee arthroplasty, and there is a lack of relevant clinical nursing work guidance programs and norms for clinical staff to learn and reference.
At the same time, because the main components of the drugs in the pump are sufentanil, morphine, ropivacaine or bupivacaine, in addition to analgesic effects, it can lead to patients with nausea and vomiting, drowsiness, dizziness, urinary retention, gastrointestinal peristalsis function, and even respiratory depression, blood pressure drop, dural hematoma, infection and other serious complications.
Because such adverse reactions can be detected early and blocked in time, clinical nursing evaluation and intervention are very important, but there is currently a lack of systematic reporting of relevant statistical data and guidance prevention and treatment programs at home and abroad. TKA is mainly used in the treatment of various end-stage knee diseases, and is an effective method to correct knee deformity, reduce pain in the affected limb, rebuild the lower limb strength line and restore joint function.
In recent years, with the continuous upgrading of prosthetic materials and the continuous improvement of surgical technology, TKA has been more and more widely used in clinical practice. However, the severe pain of patients after TKA surgery has become a thorny problem restricting the promotion and application of TKA. The pathophysiology of pain is complex, involving multiple peripheral, central receptors, and receptors.
Pain after TKA is an acute nociceptive pain, which is caused by the injury of bone and soft tissues in the joint and the implantation of artificial prostheses by the surgical operation itself, and on the other hand, due to early postoperative joint function exercise. Acute trauma caused by surgery leads to peripheral hyperalgesia and central nervous system sensitization, and changes the response threshold of the nervous system causes patients to develop postoperative hyperalgesia, and leads to a relative reduction of the pain threshold of damaged tissue and surrounding undamaged tissues.
Therefore, traditional, single analgesic drugs and methods are often difficult to completely eliminate such pain, if the analgesia is not good, it will increase the patient's pain, and affect the early functional exercise after surgery, prolong the time of discharge, increase the incidence of complications, and even affect the reconstruction of knee function after surgery.
The postoperative pain of TKA greatly restricts the active extension of the knee joint after surgery, and the active extension and flexion of the knee joint can reduce the swelling of the knee after surgery, and the recovery speed of the knee joint of patients with obvious knee swelling and pain after knee replacement surgery will be significantly slower than that of patients with mild knee swelling and pain.
At the same time, most of the physiological functions of the elderly who undergo knee replacement surgery have different degrees of degenerative changes, often accompanied by hypertension, coronary heart disease, cerebrovascular lesions and diabetes and other comorbidities, postoperative analgesia can not only reduce the release of catecholamines and other stress hormones in the patient's body, but also prevent the occurrence of postoperative hypertension by reducing the patient's heart rate, thereby reducing myocardial work and oxygen consumption.
Active postoperative analgesia can also effectively improve the patient's respiratory function, maintain the state of alveolar expansion, thereby facilitating the patient's cough and sputum, so that the patient can get out of bed as soon as possible, exercise, facilitate exhaust, and reduce the occurrence of postoperative urinary retention and other complications. Therefore, some scholars point out that a major breakthrough in artificial joint replacement in the future is likely to be the correct treatment of postoperative patients' pain.
This fully confirms the importance of postoperative analgesia after TKA. Effective postoperative analgesia can reduce or eliminate patients' pain while reducing their tension and anxiety, so that they can carry out postoperative rehabilitation exercises earlier in painless or as light as possible pain, improve postoperative knee function and improve postoperative quality of life.
Orthopedics, anesthesiology and pain departments have been seeking safe, effective and stable analgesia programs since the beginning of total knee replacement surgery, although in recent years there have been great developments in analgesic drug technology and analgesic theory, but the contradiction between acute pain after total knee replacement surgery and early necessary rehabilitation exercises is still a difficult problem for clinicians.
At present, the clinical application of postoperative analgesia after TKA includes oral or intramuscular opioids, intravenous analgesia (including intravenous single injection of analgesia, intravenous continuous analgesia or intravenous self-controlled analgesia), neuraxial block analgesia (mainly epidural block analgesia), periarticular injection of mixed drug solution analgesia (such as cocktail therapy), traditional Chinese medicine analgesia, etc., and various analgesic methods have their curative effects and disadvantages.
The analgesic effect of oral analgesic drugs is slow, and the systemic toxic side effects are large; Although intravenous painkillers can take effect quickly, because the drug needs to act on the whole body, the dose of the drug required to achieve the analgesic effect is large, and the systemic toxic side effects are also large; Inject drugs around the joint cavity. At the same dose, PCA has a more moderate analgesic effect than NCA, and PCA can reduce postoperative anxiety more effectively, and patients are more likely to choose PCA.
At the same time, patients who received PCA after surgery had a lower chance of developing postoperative respiratory complications such as atelectasis than those who received NCA after surgery. A variety of PCA techniques, including intravenous or nonvenous routes, have been widely used in clinical postoperative pain management.
Clinically, two main methods of administration are epidural analgesia pump (PCEA) or intravenous analgesia pump (PCIA). At present, although there are literature reports that continuous femoral nerve block analgesia has certain advantages for total knee replacement, the main analgesia methods after total knee replacement are still epidural analgesia and intravenous analgesia.
Epidural analgesia mainly plays an analgesic role by drugs blocking or inhibiting the nerve conduction pathways of pain, while opioids act on the central nervous system to raise the pain threshold to play an analgesic role. At the same time, because the main components of the drugs in the pump are sufentanil, morphine, bupivacaine, etc.
In addition to analgesic effect, nausea, vomiting, drowsiness, dizziness, urinary retention, gastrointestinal peristalsis dysfunction, and even respiratory depression, blood pressure drop, dural hematoma, infection and other serious complications often occur. However, such adverse reactions can be detected early and blocked in time, and clinical nursing evaluation and treatment are very important, but there is a lack of relevant statistical data and guiding programs at home and abroad.