经关节注射阿片类药物用于膝关节置换后镇痛：现状与进展

摘要

背景：经关节药物注射在膝关节置换后镇痛中应用广泛，给药途径包括关节内注射和关节周围注射。近年研究表明常用于关节注射的麻醉剂、激素类和非类固醇类抗炎药具有潜在风险，阿片类药物相对安全，但是既往研究对其镇痛效果争议较大。　　目的：综述关节周围和关节内注射阿片类药物用于膝关节置换后镇痛的临床和基础研究现状及进展。　　方法：检索1967年1月至2015年5月PubMed数据库、Embase数据库中有关膝关节置换后阿片类药物经关节注射镇痛的临床研究和相关基础研究文献。英文检索词为“opioids；peri-articular injection；intra-articular injection；analgesia；knee arthroplasty”。排除与研究目的无关、相关性差或内容重复的研究。　　结果与结论：阿片类药物经关节注射的镇痛有效性存在争议，但部分研究认为阿片类可提供程度有效镇痛，其疗效呈剂量依赖性；经关节注射与全身用药相比，恶心呕吐不良反应发生率降低；基础研究指出关节内注射阿片类药物可避免麻醉剂、激素及非类固醇类抗炎药存在的软骨细胞和干细胞毒性，对今后预计将广泛开展的膝关节置换后镇痛有重要指导意义；未来重点研究方向是探索更合理用药方案，提高阿片类药物镇痛强度时间。%BACKGROUND:Articular injections of opioids are widely adopted for pain management of total knee arthroplasty, with both peri-articular and intra-articular administration routes. Recent studies have indicated that commonly used anesthetics, steroids and non-steroidal anti-inflammatory drugs are associated with potential adverse effects. Peripheral opioids are relatively safe with lower complication rates, but great controversy exits regarding the analgesic effects. OBJECTIVE:To introduce the current clinical application status and basic research progress in peri-articular and intra-articular opioid injections for postoperative analgesia of knee arthroplasties. METHODS:A computer-based search in PubMed and Embase databases was conducted for clinical and basic research articles related to pain management of knee arthroplasties using peri-articular and intra-articular injections of opioids published from January 1967 to May 2015, using the keywords of“opioids;peri-articular injection;intra-articular injection;analgesia;knee arthroplasty”in English. Irrelevant, poorly related and repetitive studies were excluded. RESULTS AND CONCLUSION:Peri-articular and intra-articular opioids injection plans vary greatly between different institutions, which does not support reliable quantitative data synthesis for a meta-analysis. Controversy exists regarding its efficacy, but there are studies supporting the usage of opioids for providing effective analgesia in a dose-dependent manner. The peri-articular administration route is associated with lower complication rates including nausea and vomiting compared to systematic injections. Applications of opioids help to avoid potential chondrocyte and stem cel cytotoxicity caused by other anesthetics, steroids and non-steroidal anti-inflammatory drugs, which is important for pain management of total knee arthroplasties. Future investigations are required to promote articular analgesic effects and time duration by exploring more advanced drug combinations and dosage forms.