全膝关节置换术后患者早期疼痛的特点及其影响因素

doi:10.19723/j.issn.1671-167X.2024.01.026

摘要/Abstract

摘要：

目的: 研究快速康复模式下全膝关节置换术后患者早期疼痛的特点，并分析其影响因素。方法: 选取北京市某三级甲等医院骨关节科142例接受全膝关节置换术的患者进行调查，采用视觉模拟评分(visual analogue scale, VAS) 描述患者术后3 d内疼痛程度(包括静息痛和活动痛)，并记录患者疼痛性质、部位以及对镇痛效果的满意程度。纳入的影响因素包括年龄、性别、居住地、受教育程度、体重指数(body mass index, BMI)、疼痛年限、慢性病史、手术史、手术时长、是否留置引流管、陪护种类、疾病严重程度、睡眠质量、焦虑、抑郁、术前疼痛程度等。影响因素的调查工具为患者一般资料调查表、疼痛评估问卷、匹兹堡睡眠质量调查问卷(Pittsburgh sleep quality index, PSQI)、焦虑自评量表(self-rating anxiety scale, SAS) 和抑郁自评量表(self-rating depression scale, SDS)。首先对纳入的影响因素进行单因素分析，然后将差异有统计学意义的变量进行多元逐步回归分析，明确全膝关节置换术后患者早期疼痛的主要影响因素。结果: 患者疼痛峰值出现在术后第1天夜间和第2天下午，静息痛评分分别为(2.5±1.2)分和(2.7±1.1)分，活动痛评分分别为(3.8±1.5)分和(4.0±1.6)分；疼痛部位以膝后侧痛最为常见(68例，47.9%)，其余部位依次为膝前侧合并后侧痛(32例，22.5%)、膝前侧痛(27例，19.1%)、膝前侧合并内侧痛(10例，7.0%)、膝前侧合并外侧痛(5例，3.5%)；疼痛性质多为酸痛合并胀痛(58例，40.8%)，其余包括单纯酸痛(26例，18.3%)、单纯胀痛(24例，16.9%)、热灼痛(10例，7.0%)、刺痛(9例，6.3%)、痉挛牵扯痛(5例，3.5%)、撕裂痛(4例，2.8%)、刀割痛(3例，2.2%)、刺痛合并酸痛(3例，2.2%)；对镇痛效果满意及非常满意的患者有114例(80.3%)。多元逐步回归分析结果显示，影响患者术后早期疼痛的主要因: 素是术前睡眠质量、抑郁情况、疾病严重程度和陪护种类(P=0.002)。结论: 大部分患者对术后镇痛效果较为满意，医护人员可以在改善患者睡眠质量、抑郁情绪和选择家属陪护方面进行预见性干预，以改善患者术后早期疼痛体验。

关键词: 膝关节置换术, 快速康复模式, 疼痛, 影响因素

Abstract:

Objective: To investigate the current status of early pain in patients after total knee arthroplasty under enhanced recovery mode and analyze the influencing factors. Methods: In the study, 142 patients with total knee arthroplasty of a hospital in Beijing were investigated by convenient sampling. Visual analog scale (VAS) was used to describe the degree of pain (including resting pain and activity pain) within 3 days after operation, and the nature and location of pain and satisfaction with the analgesic effect of the patients were recorded. The influencing factors included age, gender, place of residence, education level, body mass index (BMI), years of pain, chronic medical history, surgical history, surgical duration, whether to indwell a drainage tube, type of carer, severity of the disease, sleep quality, anxiety, depression, and preoperative pain level. The investigation tools of influencing factors were the general information questionnaire of patients, pain assessment questionnaire, Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Firstly, single factor analysis was carried out on the included influencing factors, and then multiple stepwise regression analysis was carried out on the statistically significant variables to clarify the main influencing factors of early pain in patients after total knee arthroplasty. Results: The peak pain of the patient occurred at night on the first postoperative day and in the afternoon on the second postoperative day, with resting pain scores of (2.5±1.2) and (2.7±1.1), and activity pain scores of (3.8±1.5) and (4.0±1.6); the most common pain site was posterior knee pain (68, 47.9%), followed by anterior knee combined with posterior knee pain (32, 22.5%), anterior knee pain (27, 19.1%), anterior knee combined with medial knee pain (10, 7.0%), and anterior knee combined with lateral knee pain (5, 3.5%); the nature of pain was mostly composed of soreness combined with swelling pain (58, 40.8%), while the rest included simple soreness (26, 18. 3%), simple swelling pain (24, 16.9%), hot burning pain (10, 7.0%), pricking pain (9, 6.3%), spasmodic traction pain (5, 3.5%), tearing pain (4, 2.8%), knife cutting pain (3, 2.2%), and stabbing pain combined with soreness (3, 2.2%); the patients who were satisfied and very satisfied with the analgesic effect were 114 (80.3%). The results of univariate analysis showed that there were significant differences in sleep quality, disease severity, types of care-givers and depression score (P<0.05). The results of multiple stepwise regression analysis showed that the main factors affecting the patients' early postoperative pain were preoperative sleep quality, depression, the Knee Society score and the type of care (P=0.002). Conclusion: Most patients under enhanced recovery after surgery are satisfied with the effect of pain control after operation. Medical staff can carry out predictive intervention in patients' sleep quality, depression to reduce the patients' early postoperative pain. At the same time, the research results suggest that choosing family members to accompany the patients can effectively improve the patients' early postoperative pain experience.

Key words: Knee arthroplasty, Enhanced recovery after surgery, Pain, Influencing factors

中图分类号:

R684.7

安思兰,郑群怡,王锴,高姗. 全膝关节置换术后患者早期疼痛的特点及其影响因素[J]. 北京大学学报（医学版）, 2024, 56(1): 167-173.

Silan AN,Qunyi ZHENG,Kai WANG,Shan GAO. Characteristics and influencing factors of early pain in patients after total knee arthroplasty[J]. Journal of Peking University (Health Sciences), 2024, 56(1): 167-173.

图/表 3

表1

研究对象的一般资料及单因素分析结果"

Items	Cases, n(%)	Statistic value	P value	Items	Cases, n(%)	Statistic value	P value
Age/years		2.419^a	0.069	Preoperative resting pain		1.001^a	0.370
<55	11 (7.7)			0	68 (47.9)
55-64	34 (23.9)			1	69 (48.6)
65-75	66 (46.5)			2	5 (3.5)
>75	31 (21.9)			PSQI score		20.986^a	0.000
Gender		-1.736^b	0.085	1-5	39 (27.5)
Male	24 (16.9)			6-10	69 (48.6)
Female	118 (83.1)			<11-15	28 (19.7)
Level of education		0.412^a	0.800	16-21	6 (4.2)
Primary school	32 (22.5)			Pain time/years		0.780^a	0.540
Junior high school	60 (42.3)			0-5	38 (26.8)
Senior high school	18 (12.7)			6-10	55 (38.7)
College	23 (16.2)			11-15	16 (11.3)
Postgraduate	9 (6.3)			16-20	21 (14.8)
Place of residence		1.585^b	0.117	>20	12 (8.5)
Cities and towns	104 (73.2)			KSS score		6.905^a	0.000
Rural area	38 (26.8)			0-19	9 (6.3)
BMI/(kg/m²)		0.561^a	0.642	20-39	72 (50.7)
<18.5	3 (2.1)			40-59	45 (31.7)
18.5-23.9	34 (23.9)			60-69	12 (8.5)
24.0-27.9	48 (33.8)			70-84	4 (2.8)
≥28	57 (40.1)			Drainage tube		-2.320^b	0.022
Operation history		1.644^b	0.103	Yes	89 (62.7)
Yes	62 (43.7)			No	53 (37.3)
No	80 (56.3)			Types of caregivers		-2.222^b	0.028
Chronic illness		1.235^b	0.219	Nurse’s aide	105 (73.9)
Yes	84 (59.2)			Family	37 (26.1)
No	58 (40.8)			Depression score		-5.250^b	0.000
Preoperative activity pain		2.501^a	0.062	<53	100 (70.4)
0	19 (13.4)			≥53	42 (29.6)
1	41 (28.9)			Anxiety score		-1.596^b	0.113
2	65 (45.8)			<50	119 (83.8)
3	17 (11.9)			≥50	23 (16.2)

表1

表2

表3

参考文献 33

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Independent variable	Assignment method
Age/years	<55 =1, 55-64 =2, 65-75 =3, >75 =4
Gender	Male=1, Female=2
Level of education	Primary school =1, Junior high school =2, Senior high school =3, College =4, Postgraduate =5
Place of residence	Cities and towns =1, Rural area =2
BMI/(kg/m²)	<18.5=1, 18.5-23.9=2, 24.0-27.9=3, ≥28=4
Operation history	Yes=1, No=2
Chronic illness	Yes=1, No=2
Pain score	0=1, 1=2, 2=3, 3=4
PSQI score	1-5=1, 6-10=2, 11-15=3, 16-21=4
KSS score	0-19=1, 20-39=2, 40-59=3, 60-69=4, 70-84=5
Drainage tube	Yes=1, No=2
Operation time	Substitution of original value
Types of caregivers	Nurse’s aide =1, Family=2
Pain time/year	0-5=1, 6-10=2, 11-15=3, 16-20=4, >20=5
Anxiety score	<53=1, ≥53=2
Depression score	<50=1, ≥51=2

Independent variable	B	SE	β	t	P
Constant	11.725	14.309		0.819	0.414
PSQI score	24.484	2.994	0.484	8.177	0.000
KSS score	-15.355	2.829	-0.321	-5.428	0.000
Depression score	25.538	5.342	0.288	4.780	0.000
Types of caregivers	16.474	5.127	0.187	3.313	0.002

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