ハムストリングを用いた前十字靱帯再建時の疼痛管理方法の違いが術後3 カ月の膝伸展筋力に与える影響
（はじめに）前十字靱帯（ACL）再建術後には中等度以上の疼痛が生じ，患者満足度や臨床成績の低下の一因となり得る．そのため，神経ブロックなどを用いて術後疼痛を制御することが試みられている．しかし近年，大腿神経ブロック（FNB）が，術後の安全なスポーツ復帰に重要とされる膝伸展筋力を低下させる可能性が報告された．本研究の目的は，ハムストリング腱を用いたACL 再建術後の疼痛管理にFNB・内転筋管ブロック（ACB）・関節周囲多剤カクテル注射（PMDI）を用いた場合で術後3 カ月の膝伸展筋力に差が生じるかを検討することである．（対象と方法）ハムストリング腱を用いた初回ACL再建術を施行された患者132...
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| Published in | 日本臨床スポーツ医学会誌 Vol. 32; no. 2; pp. 295 - 302 |
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| Main Authors | , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本臨床スポーツ医学会
30.04.2024
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| Subjects | |
| Online Access | Get full text |
| ISSN | 1346-4159 2758-3767 |
| DOI | 10.57474/jjcsm.32.2_295 |
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| Abstract | （はじめに）前十字靱帯（ACL）再建術後には中等度以上の疼痛が生じ，患者満足度や臨床成績の低下の一因となり得る．そのため，神経ブロックなどを用いて術後疼痛を制御することが試みられている．しかし近年，大腿神経ブロック（FNB）が，術後の安全なスポーツ復帰に重要とされる膝伸展筋力を低下させる可能性が報告された．本研究の目的は，ハムストリング腱を用いたACL 再建術後の疼痛管理にFNB・内転筋管ブロック（ACB）・関節周囲多剤カクテル注射（PMDI）を用いた場合で術後3 カ月の膝伸展筋力に差が生じるかを検討することである．（対象と方法）ハムストリング腱を用いた初回ACL再建術を施行された患者132 名を対象とし，時期ごとで区分けした術中の疼痛管理方法によってFNB 群（66 名）・ACB 群（38 名）・PMDI 群（28 名）に群分けした．術後3 カ月時点の患側膝伸展筋力のピークトルク・膝伸展筋力ピークトルクの健患比（LSI）・患側膝伸展筋力ピークトルクの体重比（BWR）を 60̊/sec・180̊/sec で評価した．（結果）3 群間の患者背景に有意差はなく，術後3 カ月時点における患側膝伸展筋力のピークトルク・LSI・BWR のいずれの条件においても群間で差を認めなかった．（結論）ハムストリング腱を用いたACL 再建術時にFNB・ACB・PMDI を用いた場合，術後3 カ月の膝伸展筋力に差は生じないことが示唆された． |
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| AbstractList | （はじめに）前十字靱帯（ACL）再建術後には中等度以上の疼痛が生じ，患者満足度や臨床成績の低下の一因となり得る．そのため，神経ブロックなどを用いて術後疼痛を制御することが試みられている．しかし近年，大腿神経ブロック（FNB）が，術後の安全なスポーツ復帰に重要とされる膝伸展筋力を低下させる可能性が報告された．本研究の目的は，ハムストリング腱を用いたACL 再建術後の疼痛管理にFNB・内転筋管ブロック（ACB）・関節周囲多剤カクテル注射（PMDI）を用いた場合で術後3 カ月の膝伸展筋力に差が生じるかを検討することである．（対象と方法）ハムストリング腱を用いた初回ACL再建術を施行された患者132 名を対象とし，時期ごとで区分けした術中の疼痛管理方法によってFNB 群（66 名）・ACB 群（38 名）・PMDI 群（28 名）に群分けした．術後3 カ月時点の患側膝伸展筋力のピークトルク・膝伸展筋力ピークトルクの健患比（LSI）・患側膝伸展筋力ピークトルクの体重比（BWR）を 60̊/sec・180̊/sec で評価した．（結果）3 群間の患者背景に有意差はなく，術後3 カ月時点における患側膝伸展筋力のピークトルク・LSI・BWR のいずれの条件においても群間で差を認めなかった．（結論）ハムストリング腱を用いたACL 再建術時にFNB・ACB・PMDI を用いた場合，術後3 カ月の膝伸展筋力に差は生じないことが示唆された． |
| Author | 仙石, 拓也 石田, 善浩 中瀬, 順介 金山, 智之 水野, 雄伸 梁取, 祐介 |
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| References | 1) Renström PA. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport:recent evidence and a personal reflection. Br J Sports Med. 2013; 47: 367-372 doi: 10.1136/bjsports2012-091623. 3) Hurley ET, Danilkowicz RM, Toth AP. Editorial commentary: postoperative pain management after anterior cruciate ligament reconstruction can minimize opioid use and allow early rehabilitation. Arthroscopy. 2023; 39: 1296-1298 doi: 10.1016/j.arth ro.2023.01.018. 5) Nakase J, Shimozaki K, Asai K, et al. Usefulness of lateral femoral cutaneous nerve block in combina tion with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial. Arch Orthop Trauma Surg. 2021; 141: 455-460 doi: 10.100 7/s00402-020-03724-9. 2) Cristiani R, Mikkelsen C, Forssblad M, et al. Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3461-3470 doi: 10.1007/s00 167-019-05396-4. 10) Bailey L, Griffin J, Elliott M, et al. Adductor canal nerve versus femoral nerve blockade for pain con trol and quadriceps function following anterior cruciate ligament reconstruction with patellar tendon autograft : a prospective randomized trial. Arthroscopy. 2019; 35: 921-929 doi: 10.1016/j.arthro.20 18.10.149. 14) Nakase J, Toratani T, Kosaka M, et al. Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator. Knee. 2016;23: 91-96 doi: 10.1016/j.knee.2015.07.005. 7) Kurosaka K, Tsukada S, Nakayama H, et al. Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction : a randomized controlled trial. Arthroscopy. 2018; 34: 182-188 doi: 10.1016/j.arthro.20 17.08.307. 8) Davey MS, Hurley ET, Anil U, et al. Pain manage ment strategies after anterior cruciate ligament reconstruction: a systematic review with network meta-analysis. Arthroscopy. 2021; 37 : 1290-1300. e1296 doi: 10.1016/j.arthro.2021.01.023. 13) Undheim MB, Cosgrave C, King E, et al. Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med. 2015; 49: 1305-1310 doi: 10.1136/bjsports-2014-09396 2. 4) Secrist ES, Freedman KB, Ciccotti MG, et al. Pain management after outpatient anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Am J Sports Med. 2016; 44: 2435-2447 doi: 10.1177/0363546515617737. 11) Sengoku T, Nakase J, Morita Y, et al. Anterior cruciate ligament reconstruction with ultrasound guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively. Knee. 2022; 34: 252-258 doi: 10.1016/j.knee.2022.01.006. 15) Sengoku T, Nakase J, Asai K, et al. The effect of gracilis tendon harvesting in addition to semitendinosus tendon harvesting on knee extensor and flexor strength after anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg. 2022; 142:465-470 doi: 10.1007/s00402-021-03877-1. 12) Sengoku T, Nakase J, Mizuno Y, et al. Outcome comparison of femoral nerve block and adductor canal block during anterior cruciate ligament reconstruction: adductor canal block may cause an unexpected decrease in knee flexor strength at 6 months postoperatively. Arch Orthop Trauma Surg. 2023; 143: 6305-6313 doi: 10.1007/s00402-023-0 4980-1. 17) Oshima T, Nakase J, Kanayama T, et al. Ultra sound-guided adductor canal block is superior to femoral nerve block for early postoperative pain relief after single-bundle anterior cruciate ligament reconstruction with hamstring autograft. J Med Ultrason (2001). 2023; 50: 433-439 doi: 10.1007/s10396-0 23-01309-8. 9) Everhart JS, Hughes L, Abouljoud MM, et al. Femoral nerve block at time of ACL reconstruction causes lasting quadriceps strength deficits and may increase short-term risk of re-injury. Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1894- 1900 doi: 10.1007/s00167-019-05628-7. 6) Ogura T, Omatsu H, Fukuda H, et al. Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial. Arch Orthop Trauma Surg. 2021; 141: 1927-1934 doi: 10.1007/s00402-021-0 3823-1. 16) Sengoku T, Nakase J, Mizuno Y, et al. Limited preoperative knee extension in anterior cruciate liga ment reconstruction using a hamstring tendon affects improvement of postoperative knee extensor strength. Knee Surg Sports Traumatol Arthrosc. 2023; doi: 10.1007/s00167-023-07620-8. |
| References_xml | – reference: 11) Sengoku T, Nakase J, Morita Y, et al. Anterior cruciate ligament reconstruction with ultrasound guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively. Knee. 2022; 34: 252-258 doi: 10.1016/j.knee.2022.01.006. – reference: 16) Sengoku T, Nakase J, Mizuno Y, et al. Limited preoperative knee extension in anterior cruciate liga ment reconstruction using a hamstring tendon affects improvement of postoperative knee extensor strength. Knee Surg Sports Traumatol Arthrosc. 2023; doi: 10.1007/s00167-023-07620-8. – reference: 14) Nakase J, Toratani T, Kosaka M, et al. Technique of anatomical single bundle ACL reconstruction with rounded rectangle femoral dilator. Knee. 2016;23: 91-96 doi: 10.1016/j.knee.2015.07.005. – reference: 17) Oshima T, Nakase J, Kanayama T, et al. Ultra sound-guided adductor canal block is superior to femoral nerve block for early postoperative pain relief after single-bundle anterior cruciate ligament reconstruction with hamstring autograft. J Med Ultrason (2001). 2023; 50: 433-439 doi: 10.1007/s10396-0 23-01309-8. – reference: 12) Sengoku T, Nakase J, Mizuno Y, et al. Outcome comparison of femoral nerve block and adductor canal block during anterior cruciate ligament reconstruction: adductor canal block may cause an unexpected decrease in knee flexor strength at 6 months postoperatively. Arch Orthop Trauma Surg. 2023; 143: 6305-6313 doi: 10.1007/s00402-023-0 4980-1. – reference: 4) Secrist ES, Freedman KB, Ciccotti MG, et al. Pain management after outpatient anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Am J Sports Med. 2016; 44: 2435-2447 doi: 10.1177/0363546515617737. – reference: 1) Renström PA. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport:recent evidence and a personal reflection. Br J Sports Med. 2013; 47: 367-372 doi: 10.1136/bjsports2012-091623. – reference: 6) Ogura T, Omatsu H, Fukuda H, et al. Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial. Arch Orthop Trauma Surg. 2021; 141: 1927-1934 doi: 10.1007/s00402-021-0 3823-1. – reference: 10) Bailey L, Griffin J, Elliott M, et al. Adductor canal nerve versus femoral nerve blockade for pain con trol and quadriceps function following anterior cruciate ligament reconstruction with patellar tendon autograft : a prospective randomized trial. Arthroscopy. 2019; 35: 921-929 doi: 10.1016/j.arthro.20 18.10.149. – reference: 8) Davey MS, Hurley ET, Anil U, et al. Pain manage ment strategies after anterior cruciate ligament reconstruction: a systematic review with network meta-analysis. Arthroscopy. 2021; 37 : 1290-1300. e1296 doi: 10.1016/j.arthro.2021.01.023. – reference: 9) Everhart JS, Hughes L, Abouljoud MM, et al. Femoral nerve block at time of ACL reconstruction causes lasting quadriceps strength deficits and may increase short-term risk of re-injury. Knee Surg Sports Traumatol Arthrosc. 2020; 28: 1894- 1900 doi: 10.1007/s00167-019-05628-7. – reference: 2) Cristiani R, Mikkelsen C, Forssblad M, et al. Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3461-3470 doi: 10.1007/s00 167-019-05396-4. – reference: 15) Sengoku T, Nakase J, Asai K, et al. The effect of gracilis tendon harvesting in addition to semitendinosus tendon harvesting on knee extensor and flexor strength after anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg. 2022; 142:465-470 doi: 10.1007/s00402-021-03877-1. – reference: 5) Nakase J, Shimozaki K, Asai K, et al. Usefulness of lateral femoral cutaneous nerve block in combina tion with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial. Arch Orthop Trauma Surg. 2021; 141: 455-460 doi: 10.100 7/s00402-020-03724-9. – reference: 7) Kurosaka K, Tsukada S, Nakayama H, et al. Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction : a randomized controlled trial. Arthroscopy. 2018; 34: 182-188 doi: 10.1016/j.arthro.20 17.08.307. – reference: 3) Hurley ET, Danilkowicz RM, Toth AP. Editorial commentary: postoperative pain management after anterior cruciate ligament reconstruction can minimize opioid use and allow early rehabilitation. Arthroscopy. 2023; 39: 1296-1298 doi: 10.1016/j.arth ro.2023.01.018. – reference: 13) Undheim MB, Cosgrave C, King E, et al. Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med. 2015; 49: 1305-1310 doi: 10.1136/bjsports-2014-09396 2. |
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| Title | ハムストリングを用いた前十字靱帯再建時の疼痛管理方法の違いが術後3 カ月の膝伸展筋力に与える影響 |
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