Сложность выбора метода обезболивания после тотального эндопротезирования крупных суставов нижней конечности (случай из практики, обзор литературы)

Описан случай успешного лечения пациентки с перипротезным переломом бедренной кости, произошедшим через сутки после тотального эндопротезирования тазобедренного сустава в результате падения, возможно, связанного с послеоперационной проводниковой анальгезией. Эндопротезирование крупных суставов нижней конечности уже в нынешнем десятилетии может стать наиболее часто выполняемым видом планового хирургического вмешательства, объективной предпосылкой чему является всё более широкая распространённость остеопороза, остеоартрита, ревматоидных заболеваний и переломов бедра. Несмотря на все усилия, проблема контроля послеоперационной боли при этих вмешательствах в настоящее время остаётся нерешённой. «Золотого стандарта» обезболивания при тотальном эндопротезировании тазобедренного сустава и коленного сустава в настоящее время не существует. Отличное соотношение эффективности и безопасности демонстрируют программы мультимодального обезболивания на основе блокад периферических нервов. Однако, обладая несомненными преимуществами, проводниковая анестезия/анальгезия имеет критически важный недостаток. Краеугольным камнем послеоперационной реабилитации пациентов, перенёсших тотальное эндопротезирование тазобедренного или коленного суставов, является ранняя активизация. А все методы проводниковой анестезии ассоциируются с двигательной блокадой. В частности, блокада бедренного нерва вызывает слабость четырёхглавой мышцы бедра, провоцируя непреднамеренное падение пациентов при попытке встать или пойти. Ситуацию с выбором метода обезболивания после эндопротезирования крупных суставов нижней конечности можно охарактеризовать словами: «предстоит пройти ещё долгий путь».

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