. 骨科康復(fù) Orthopedic rehabilitation .

術(shù)前康復(fù)教育在全髖關(guān)節(jié)置換中的意義

徐國健 翁 東 謝明華 梁文清 錢 宇

目的探討術(shù)前康復(fù)教育在全髖關(guān)節(jié)置換 ( total hip arthroplasty，THA ) 中的意義。方法2012 年 1 月至 2013 年 1 月，我科行 THA 的患者 87 例，分為實(shí)驗(yàn)組 45 例和對(duì)照組 42 例。對(duì)照組給予常規(guī)治療護(hù)理，實(shí)驗(yàn)組給予常規(guī)治療護(hù)理外，術(shù)前由手術(shù)醫(yī)師和?？谱o(hù)士采用圖片和影像資料結(jié)合實(shí)際練習(xí)，教育患者預(yù)先掌握功能鍛煉方法。記錄術(shù)后兩組完成主動(dòng)規(guī)范功能鍛煉時(shí)間、肢體周徑增量值及術(shù)后并發(fā)癥發(fā)生率，并比較兩組各指標(biāo)組間及組內(nèi)的差異。結(jié)果實(shí)驗(yàn)組首次主動(dòng)完成踝泵鍛煉時(shí)間、股四頭肌等長收縮時(shí)間、直腿抬高時(shí)間分別為 ( 4.62±2.39 ) h、( 13.33±5.88 ) h、( 23.67±6.01 ) h，分別少于對(duì)照組 ( 6.12± 2.93 ) h、( 16.02±5.89 ) h、( 27.95±7.85 ) h，差異均有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 )；下肢周徑比較，實(shí)驗(yàn)組與對(duì)照組在術(shù)后第 1 天下肢周徑增量值差異無統(tǒng)計(jì)學(xué)意義 ( P＞0.05 )，但兩組術(shù)后第 2、3、5、7 天下肢周徑增量值均逐漸減少，實(shí)驗(yàn)組分別為 ( 3.76±0.75 ) cm、( 3.68±0.56 ) cm、( 3.46±0.53 ) cm、( 3.17±0.36 ) cm，分別小于對(duì)照組 ( 4.03±0.55 ) cm、( 3.92±0.51 ) cm、( 3.71±0.59 ) cm、( 3.48±0.36 ) cm，差異均有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 )；實(shí)驗(yàn)組術(shù)后并發(fā)下肢深靜脈血栓 ( deep vein thrombosis，DVT ) 1 例、感染 1 例，對(duì)照組術(shù)后并發(fā)下肢DVT 5 例、假體脫位 1 例、感染 5 例，且實(shí)驗(yàn)組術(shù)后并發(fā)癥發(fā)生率 4.5% 明顯低于對(duì)照組 26.2%，差異有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 )。結(jié)論術(shù)前康復(fù)教育可使 THA 患者預(yù)先掌握功能鍛煉的方法、術(shù)后早期主動(dòng)規(guī)范康復(fù)鍛煉，明顯減少首次主動(dòng)規(guī)范功能鍛煉的時(shí)間、減輕患肢腫脹和減少并發(fā)癥的發(fā)生，值得臨床推廣應(yīng)用。

手術(shù)前期間；健康教育；關(guān)節(jié)成形術(shù)，置換，髖；康復(fù)

人工全髖關(guān)節(jié)置換 ( total hip arthroplasty，THA )是治療髖關(guān)節(jié)嚴(yán)重疾病最終、最有效的方法[1]。術(shù)后康復(fù)訓(xùn)練在人工關(guān)節(jié)置換術(shù)中的作用毋庸置疑。隨著人工關(guān)節(jié)置換術(shù)的廣泛開展，術(shù)后康復(fù)訓(xùn)練得到越來越多的重視，近年來 CPM、下肢充氣泵等不少新型康復(fù)器材應(yīng)用于臨床，展現(xiàn)了良好的勢(shì)頭。其圍手術(shù)期的康復(fù)鍛煉日益受到重視，早期的康復(fù)鍛煉可明顯提高手術(shù)效果，減少并發(fā)癥的發(fā)生[2]。術(shù)后康復(fù)鍛煉效果與術(shù)前康復(fù)教育明顯相關(guān)，充分的術(shù)前康復(fù)教育可提高術(shù)后早期康復(fù)鍛煉質(zhì)量。2012 年以來，我們對(duì)行人工 THA 的患者在常規(guī)治療護(hù)理基礎(chǔ)上進(jìn)行術(shù)前康復(fù)教育，臨床療效滿意，現(xiàn)報(bào)道如下。

資料與方法

一、納入和排除標(biāo)準(zhǔn)

納入標(biāo)準(zhǔn)：( 1 ) 股骨頭缺血性壞死、髖關(guān)節(jié)骨關(guān)節(jié)炎及類風(fēng)濕性關(guān)節(jié)炎患者；( 2 ) 無下肢深靜脈血栓 ( deep vein thrombosis，DVT ) 或其它下肢血管疾病者；( 3 ) 無嚴(yán)重腦血管疾病或心衰者；( 4 ) 能耐受手術(shù)；( 5 ) 依從性好；( 6 ) 既往無髖部畸形。

排除標(biāo)準(zhǔn)：( 1 ) 股骨頸骨折行 THA 者；( 2 ) 腦血栓后遺癥者；( 3 ) 伴嚴(yán)重內(nèi)科疾病不能耐受手術(shù)者；( 4 ) 依從性差者；( 5 ) 有精神疾病者。

二、一般資料

2012 年 1 月至 2013 年 1 月，我科行 THA 的患者 87 例，分為實(shí)驗(yàn)組 45 例和對(duì)照組 42 例。兩組一般情況比較，差異無統(tǒng)計(jì)學(xué)意義 ( P＞0.05 ) ( 表 1 )。

三、康復(fù)教育方法

實(shí)驗(yàn)組除常規(guī)治療護(hù)理外，在手術(shù)前由手術(shù)醫(yī)師和?？谱o(hù)士用圖片和影像資料結(jié)合實(shí)際練習(xí)，教育患者預(yù)先掌握功能鍛煉方法，主要包括：踝泵練習(xí)[3]；股四頭肌等長收縮[4]；下肢直腿抬高鍛煉[5]；對(duì)術(shù)后體位、下床、便盆使用等注意事項(xiàng)給予指導(dǎo)[6]，直至患者熟練掌握并能獨(dú)立完成為止。由于患者的文化程度、認(rèn)知能力、配合程度不一，所以我們的教育不規(guī)定時(shí)間，也不作進(jìn)一步分組。

對(duì)照組術(shù)前不作指導(dǎo)，所有康復(fù)指導(dǎo)自術(shù)后開始。

四、評(píng)價(jià)指標(biāo)及方法

記錄術(shù)后首次主動(dòng)完成規(guī)范功能鍛煉時(shí)間 ( 距麻醉完全蘇醒時(shí)間 )，包括踝泵鍛煉時(shí)間、股四頭肌等長收縮時(shí)間、直腿抬高時(shí)間[7]；由 3 位醫(yī)務(wù)人員事前作預(yù)測(cè)量，統(tǒng)一標(biāo)準(zhǔn)，盡可能減小人為誤差，分別于術(shù)后 1、2、3、5、7 天在髕骨上緣 10 cm 部位測(cè)量肢體周徑，取平均值為此次周徑值，并計(jì)算術(shù)后肢體周徑增量值[8]；記錄發(fā)生與術(shù)后康復(fù)鍛煉相關(guān)的下肢 DVT ( 分別在術(shù)后 1 周、術(shù)后 3 個(gè)月行下肢深靜脈 B 超檢查 )、假體脫位、感染并發(fā)癥的例數(shù)。

五、統(tǒng)計(jì)學(xué)分析

采用 SPSS 12.0 軟件進(jìn)行統(tǒng)計(jì)分析。計(jì)數(shù)資料采用 χ2檢驗(yàn)，計(jì)量資料采用獨(dú)立樣本 t 檢驗(yàn)。檢驗(yàn)水準(zhǔn)：ɑ＝0.05。

表1 兩組一般資料比較 (±s )Fig.1 Comparison of the general data between the 2 groups (±s )

表1 兩組一般資料比較 (±s )Fig.1 Comparison of the general data between the 2 groups (±s )

性別 年齡 ( 歲 ) 疾病男 女 股骨頭壞死 骨關(guān)節(jié)炎 類風(fēng)濕性關(guān)節(jié)炎 其它實(shí)驗(yàn)組 45 27 18 63.07±5.47 16 22 4 3對(duì)照組 42 25 17 62.45±5.35 17 20 3 2 P 值 0.964 0.529 0.947組別 例數(shù)( n ) -

結(jié) 果

一、完成首次主動(dòng)規(guī)范功能鍛煉時(shí)間

對(duì)兩組術(shù)后首次主動(dòng)規(guī)范的功能鍛煉時(shí)間進(jìn)行比較。實(shí)驗(yàn)組的踝泵鍛煉時(shí)間、股四頭肌等長收縮時(shí)間、直腿抬高時(shí)間均少于對(duì)照組，且差異均有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 ) ( 表 2 )。

二、患肢腫脹改善情況

通過術(shù)后在相同部位重復(fù)測(cè)量下肢周徑結(jié)果顯示，實(shí)驗(yàn)組與對(duì)照組在術(shù)后第 1 天下肢周徑增量值的差異無統(tǒng)計(jì)學(xué)意義 ( P＞0.05 )，但術(shù)后第 2、3、5、7 天實(shí)驗(yàn)組的周徑增量值均比對(duì)照組小，差異均有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 ) ( 表 3 )。實(shí)驗(yàn)組小腿腫脹改善情況優(yōu)于對(duì)照組。

表2 兩組完成首次主動(dòng)規(guī)范功能鍛煉時(shí)間比較 (±s, h )Fig.2 Comparison of the duration of the active and standard functional exercises for the frst time between the 2 groups (±s, h )

表2 兩組完成首次主動(dòng)規(guī)范功能鍛煉時(shí)間比較 (±s, h )Fig.2 Comparison of the duration of the active and standard functional exercises for the frst time between the 2 groups (±s, h )

組別 例數(shù) 踝泵鍛煉 股四頭肌等長收縮 直腿抬高實(shí)驗(yàn)組 45 4.62±2.39 13.33±5.88 23.67±6.01對(duì)照組 42 6.12±2.92 16.02±5.89 27.95±7.85 P 值 0.010 0.036 0.005 -

表4 兩組術(shù)后并發(fā)癥比較 [ n ( % ) ]Fig.4 Comparison of the postoperative complications between the 2 groups [ n ( % ) ]

表3 兩組下肢周徑增量值比較 (±s, cm )Fig.3 Comparison of the incremental value of the lower limb circumference between the 2 groups (±s, cm )

表3 兩組下肢周徑增量值比較 (±s, cm )Fig.3 Comparison of the incremental value of the lower limb circumference between the 2 groups (±s, cm )

組別 例數(shù) 術(shù)后第 1 天 術(shù)后第 2 天 術(shù)后第 3 天 術(shù)后第 5 天 術(shù)后第 7 天實(shí)驗(yàn)組 45 3.55±0.61 3.76±0.75 3.68±0.56 3.46±0.53 3.17±0.36對(duì)照組 42 3.73±0.58 4.03±0.55 3.92±0.51 3.71±0.59 3.48±0.36 P 值 - 0.147 0.027 0.042 0.036 0.000

三、兩組術(shù)后并發(fā)癥情況

實(shí)驗(yàn)組術(shù)后并發(fā)下肢 DVT 1 例，感染 1 例；對(duì)照組并發(fā)下肢 DVT 5 例，假體脫位 1 例，感染 5 例。兩組術(shù)后并發(fā)癥比較，實(shí)驗(yàn)組并發(fā)癥發(fā)生率 4.5% 明顯低于對(duì)照組 26.2%，差異有統(tǒng)計(jì)學(xué)意義 ( P＜0.05 ) ( 表 4 )。

討 論

人工關(guān)節(jié)技術(shù)是 20 世紀(jì)骨科領(lǐng)域最重要的成就之一，而術(shù)后康復(fù)訓(xùn)練對(duì)人工關(guān)節(jié)置換術(shù)患者的功能恢復(fù)起非常重要的作用。術(shù)后康復(fù)鍛煉的效果與康復(fù)鍛煉開始的時(shí)間有關(guān)。越來越多的循證醫(yī)學(xué)證明，術(shù)后康復(fù)鍛煉開始越早，康復(fù)鍛煉效果越好[9]。雷燕等[10]將 70 例行 THA 患者隨機(jī)分為早期康復(fù)訓(xùn)練組和對(duì)照組，通過追蹤隨訪發(fā)現(xiàn)實(shí)驗(yàn)組 Harris評(píng)分優(yōu)于對(duì)照組，且實(shí)驗(yàn)組術(shù)后并發(fā)下肢 DVT、肺部及尿路感染發(fā)生率較對(duì)照組低 ( P＜0.05 )。

早期康復(fù)訓(xùn)練對(duì)促進(jìn)髖關(guān)節(jié)置換患者術(shù)后髖關(guān)節(jié)功能恢復(fù)、緩解疼痛、減少各種并發(fā)癥也有重要意義[11]。術(shù)后早期主動(dòng)康復(fù)訓(xùn)練較被動(dòng)鍛煉能調(diào)動(dòng)更多的肌肉參加鍛煉，有利于促進(jìn)肌力的恢復(fù)、調(diào)整關(guān)節(jié)的張力、提高肢體的靈活性和協(xié)調(diào)性、增進(jìn)關(guān)節(jié)的穩(wěn)定性，通過“肌肉泵”的作用，促進(jìn)靜脈血液的回流，可減輕肢體的腫脹，降低 DVT 的形成[3]。早期合理的運(yùn)動(dòng)易于恢復(fù)患者體力，使患者能有效地咳嗽，減少氣管內(nèi)痰液潴留導(dǎo)致的肺炎及肺不張。對(duì)體位，便盆使用及下床練習(xí)的具體指導(dǎo)能消除患者的恐懼心理，更積極地參與功能鍛煉，也能明顯減少后脫位的發(fā)生[6-7]。

雖然人工髖關(guān)節(jié)置換術(shù)后康復(fù)訓(xùn)練得到越來越多的重視，不少康復(fù)醫(yī)師加入人工關(guān)節(jié)團(tuán)隊(duì)，參與康復(fù)訓(xùn)練，但在大多數(shù)基層醫(yī)院，由于沒有專業(yè)的人工關(guān)節(jié)康復(fù)團(tuán)隊(duì)，康復(fù)訓(xùn)練工作仍由手術(shù)醫(yī)師和護(hù)理人員承擔(dān)[12]。臨床醫(yī)師由于工作繁重及慣性思維，重視“術(shù)后”，重視“具體”的康復(fù)訓(xùn)練方法，對(duì)術(shù)前康復(fù)教育重視不夠，沒能調(diào)動(dòng)患者主動(dòng)參與、配合康復(fù)鍛煉的積極性，往往“事倍功半”。

施行 THA 的大部分患者為老年人，而老年人的聽力減弱，記憶力減退，反應(yīng)遲鈍，文化水平低，掌握知識(shí)能力有限，對(duì)醫(yī)學(xué)“術(shù)語”理解較弱，依從性較差。尤其是術(shù)后創(chuàng)口疼痛及顧忌人工關(guān)節(jié)脫位，無法完成各種專業(yè)的康復(fù)動(dòng)作，影響術(shù)后康復(fù)效果。許多術(shù)后康復(fù)訓(xùn)練的方法如果不從術(shù)前開始、并“熟練掌握”，術(shù)后功能訓(xùn)練主動(dòng)配合就會(huì)不夠，動(dòng)作完成質(zhì)量就會(huì)不高，從而影響術(shù)后康復(fù)效果。術(shù)后早期的康復(fù)訓(xùn)練須以術(shù)前的康復(fù)教育為基礎(chǔ)。本研究結(jié)果表明，術(shù)前康復(fù)指導(dǎo)能明顯提高患者的從醫(yī)行為，術(shù)后的康復(fù)鍛煉無論從開始時(shí)間，還是完成質(zhì)量都得到了明顯改善。

總之，通過術(shù)前康復(fù)教育，能明顯提高患者的依從性，使患者預(yù)先掌握功能鍛煉的方法，可以為術(shù)后主動(dòng)康復(fù)鍛煉做好準(zhǔn)備，讓患者成為術(shù)后康復(fù)鍛煉的主角，起到“事半功倍”的作用。

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( 本文編輯：代琴 )

Signifcance of preoperative rehabilitation education in total hip arthroplasty XU Guo-jian, WENG Dong, XIE

XU Guo-jian, WENG Dong, XIE Ming-hua, LIANG Wen-qing, Qian Yu. Department of Orthopedics, Shaoxing People’s Hospital, Shaoxing, Zhejiang, 312000, PRC

ObjectiveTo investigate the role of preoperative rehabilitation education in total hip arthroplasty ( THA ).MethodsFrom January 2012 to January 2013, 87 patients receiving THA were randomly divided into experimental group ( n=45 ) and control group ( n=42 ). The patients in the control group received conventional treatment and care. Besides that, the patients in the experimental group grasped the functional training method before the operation under the guidance of surgeons and specialist nurses by using the pictures and videos combined with practical exercises. The duration of the active and standard functional exercises for the frst time, incremental value of limb circumference and postoperative complication rates were recorded in both groups, and the differences between them were compared.ResultsThe duration of the active ankle pump exercises for the frst time, contraction time of the musculi quadriceps femoris and straight leg raising time were ( 4.62±2.39 ) hr, ( 13.33±5.88 ) hr and ( 23.67±6.01 ) hr respectively in the experimental group, which were shorter than ( 6.12±2.93 ) hr, ( 16.02±5.89 ) hr and ( 27.95±7.85 ) hr in the control group. There were statistically signifcant differences between the 2 groups ( P＜0.05 ). No statistically signifcant differences in the incremental value of the lower limb circumference existed at 1 day after the operation between the 2 groups ( P＞0.05 ). However, the incremental values of the lower limb circumference were gradually reduced at 2, 3, 5 and 7 days after the operation, which was ( 3.76±0.75 ) cm, ( 3.68±0.56 ) cm, ( 3.46±0.53 ) cm and ( 3.17±0.36 ) cm in the experimental group and ( 4.03±0.55 ) cm, ( 3.92±0.51 ) cm, ( 3.71±0.59 ) cm and ( 3.48±0.36 ) cm in the control group. There were statistically significant differences between the 2 groups ( P＜0.05 ). There was 1 case of deep vein thrombosis ( DVT ) of the lower limb and 1 case of infections in the experimental group, and there were 5 cases of DVT of the lower limb, 1 case of prosthesis dislocation and 5 cases of infections in the control group. The postoperative complication rate was obviously lower in the experimental group ( 4.5% ) than that in the control group ( 26.2% ), and there were statistically significant differences between the 2 groups ( P＜0.05 ).ConclusionsThe preoperative rehabilitation education in THA is worthy of clinical application, with the advantages of obviously alleviated limb swelling and lower complication rates. The patients can grasp the functional training method in advance, so as to actively standardize rehabilitation exercises early.

Preoperative period; Health education; Arthroplasty, replacement, hip; Rehabilitation

10.3969/j.issn.2095-252X.2014.09.004

R687.4, R493

312000 浙江，紹興市人民醫(yī)院骨科

2014-05-30 )