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EFFICACY AND SAFETY OF REGIONAL ANALGESIC TECHNIQUES ON EARLY

POSTOPERATIVE KNEE REHABILITATION AFTER TOTAL REPLACEMENT

AL– SAYYED HASSAN FAHMY AL-SAYYAD, MOHAMMAD HASSAAN ALY* AND ABDUL-SALAAM MOHAMMAD HEFNY**

Rheumatology @ Rehabilitation, Anesthesiology* and Orthopedic Surgery** Departments, Zagazig University Faculty of Medicine

KEY WORDS: TOTAL KNEE REPLACEMENT, POST-OPERATIVE REHABILITATION OF PAIN.

ABSTRACT Objective: Because the choice of the analgesic technique

should be based on a careful evaluation of the benefits and risks, so this work aimed to evaluate the efficacy and safety of different analgesic techniques on early postoperative knee rehabilitation after total knee arthroplasty (TKR).

Methodology: Thirty two patients (13 males, 19 females) undergoing unilateral TKR under general anesthesia (GA) were included in this study. They were randomly divided into 4 groups; each group included 8 patients. Group A: Postoperative analgesia was administered with continuous epidural infusion technique. Group B: Postoperative analgesia was administered by continuous epidural infusion technique together with high frequency low intensity transcutaneous electrical nerve stimulation (TENS). Group C: Postoperative analgesia was administered with continuous femoral 3-in-1 block. Group D: postoperative analgesia was administered with continuous femoral 3-in-1 block together with high frequency low intensity transcutaneous electrical nerve stimulation. Postoperative pain was assessed in all groups at rest and during continuous passive motion (CPM); using a visual analogue scale (0: no pain, 100 severe pain) at 24 and 48 h. Postoperative maximal amplitude of knee flexion was measured at 24 h, 48 h, 7th day, 14th day and at one month with a plastic goniometer. Supplemental postoperative analgesia was standardized in the 4 groups. All

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supplementary subcutaneous injections of morphine administered were recorded. Side effects arising from analgesic techniques application of the 4 groups were recorded at 24 and 48 hours.

Results: The efficacy in controlling pain and improvement of knee flexion after knee surgery (TKR) was evident in our results in all 4 groups; with a marked improvement in group B and group D (B Vs A; p < 0.001 and D Vs C; p < 0.001) ; who had been administered TENS therapy as an adjuvant analgesia. Also our results demonstrated that the analgesic effect induced by continuous epidural infusion (group A, B) was more greater than achieved by application of continuous 3-in-1 block “group C, D” (where group A Vs C; p < 0.001 and group B Vs D; p < 0.01). Also our results demonstrated that continuous 3-in-1 block technique was safer than continuous epidural infusion technique to provide postoperative analgesia after TKR.

Conclusions: The efficacy of the tested analgesic techniques in all groups in controlling pain after knee surgery (TKR) was evident in our results. TENS adjuvant therapy groups (B, D) had been shown to have a more significant effect on postoperative pain and early knee mobilization than the non adjuvant TENS therapy groups (A, C); and this reflect the significant effect of TENS in relieving of postoperative pain and increasing the range of motion leading to early restoration of active muscle movement. The efficacy of continuous 3-in –1 block appeared less than continuous epidural infusion analgesia. The more safe analgesic technique was found in our study is continuous 3-in-1 block.

Recommendations: Because TENS (which is very safe analgesic tool) was found to have a valuable effect in controlling postoperative pain. So to obtain satisfied quality regarding the efficacy and safety; we recommend to use two techniques together to provide analgesia after TKR i.e. Continuous 3-in-1 block together with transcutaneous electrical nerve stimulation.

INTRODUCTION Total knee replacement is performed in patients with severe,

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incapacitating pain in the knees due to osteoarthritis, osteonecrosis; or rheumatoid arthritis after failure of conservative management (Netter et al., 1990). The knee is innervated by the lumbosacral plexus. The femoral and obturator nerves innervate the anterior aspect of the knee and the sciatic nerve innervates the posterior aspect (Serpell et al., 1991).

Perioperative pain management is an extremely important aspect of orthopedic procedures; as ineffective pain management will lead to a dissatisfied patient and can also lead to medical complications, wound and surgical site healing problems and difficulty with rehabilitation. Recent advances in perioperative pain management have apparently enhanced pain control and decreased adverse outcomes. TKA refers to replacement of the medial, lateral, and patello-femoral compartments of the knee (Aluisio et al., 1999).

Postoperative pain is a major concern after total knee arthroplasty (TKA). It is severe in 60% of patients and moderate in 30% (Bonica, 1990). Several authors have reported the importance of pain management in controlling postoperative complications in high-risk patient populations (Beattie & Buckley, 1993 and Yeager et al., 1987). After knee surgery, poorly managed pain if not adequately treated, it intensified reflex responses, which can cause serious complications such as pulmonary or urinary problems, thromboembolism hyperdynamic circulation and increased oxygen consumption (Kehlet, 1989). It also may inhibit the early ability to mobilize the knee joint. This in turn, may result in adhesions, capsular contracture and muscles atrophy, all of which may delay or permanently impair the ultimate functional outcome (Akeson et al., 1987).

The addition of non-steroidal anti-inflammatory drugs (NSAID) improves analgesia after total knee replacement, but pain control during the immediate postoperative period remains difficult (Etches et al., 1995 & Fragen et al., 1995).

After total knee arthroplasty, postoperative pain relief can be achieved by a variety of techniques such as IV patient-controlled analgesia (PCA), epidural analgesia with narcotics and/or local anesthetics and lumbar plexus blockade (Singelyn et al., 1998), and transcutaneous electrical nerve stimulation “TENS” (Pike, 1978). The use of electrical stimulation for pain relief has been widely spread throughout the medical history. Electrical fishes were used as a generator to provide pain relief (Long & Carolan, 1974). Transcutaneous electrical nerve stimulation (TENS) for pain relief is an ancient technique and it refers to the application of an electrical current through the skin to a peripheral nerve or nerves for control of pain and this

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method of treatment is based on the “gate control theory” (Melzack & Wall, l965). Transcutaneous electrical nerve stimulation is effective for post-tonsillectomy pain management in pediatric patients (Yonei et al., 1998). TENS has a great effect in the relief of acute traumatic pain especially those that arise from musculo-skeletal tissues (Gersh, 1981).

Aim of Work: Because the choice of the analgesic technique should be based on a

careful evaluation of the benefits and risks, so this work was aimed to evaluate the efficacy and safety of different analgesic techniques on early postoperative knee rehabilitation after total knee arthroplasty.

PATIENTS AND METHODS Thirty two patients (13 males and 19 females) undergoing unilateral

TKR under general anesthesia were included in this study. The patients were randomly divided into 4 groups of 8 patients.

Group A: Postoperative analgesia was administered by continuous epidural infusion technique.

Group B: Postoperative analgesia was administered by continuous epidural infusion technique together with high frequency low intensity transcutaneous electrical nerve stimulation.

Group C: Postoperative analgesia was administered by continuous femoral 3-in-1 block.

Group D: Postoperative analgesia was administered by continuous femoral 3-in-1 block together with high frequency low intensity transcutaneous electrical nerve stimulation.

High frequency-low intensity transcutaneous electrical nerve stimulation (10-100 HZ) electrodes were placed at the site of affection with pain as mentioned by Loeser et al. (1975), Krowing (1976) and Mannheimer, (1978); the clinical setting duration was one hour twice daily for each patient.

Continuous 3-in-1 block (femoral nerve, obturator and lateral cutaneous nerve block) was performed before inducing general anesthesia following the guidelines of Winnie et al. (1973). The femoral artery was located below the inguinal ligament and an 18-gauge, short beveled cannula was inserted just lateral to the artery. The femoral nerve was accurately located with a peripheral nerve stimulator (because paresthesias of the femoral nerve are sometimes difficult to obtain and as it is essential for the needle to be in the femoral sheath, the use of a nerve locator stimulator may

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be indicated for this block, Katz et al. (1995). A 20-gauge catheter was threaded 10-15 cm into the psoas compartment (Fig. 1). After a negative aspiration test for blood and cerebrospinal fluid (Singelyn et al., 1995), 40 ml of 0.25% bupivacaine with epinephrine 1:200 000 was injected, followed by a continuous infusion of 0.125% bupivacaine with fentanyl 0.5 μg/ml (fentanyl allows a rapid onset of the block; Morgan et al. (2002) and clonidine 1 μg/ml (clonidine prolongs the duration of both anesthesia and analgesia; Singelyn et al. (1996) at the rate of 10ml/h during 48 hours.

To verify the correct position of the catheter, the cutaneous sensibility in the area of the femoral nerve (anterior thigh/knee/and a small part of the medial foot) was assessed by using a cold test before the induction of general anesthesia.

Epidural analgesia was performed before inducing GA at L2-3 or L 3-4 level. An 18-gauge catheter was threaded 4-5cm into the epidural space. After a negative test dose of 3ml of 0.25% bupivacaine with epinephrine 1:200 000, a bolus dose of 10ml of the same solution and 50 μg of fentanyl were injected, followed by a continuous infusion of 0.125% bupivacaine with fentanyl 0.5 μg/ml and clonidine 1 μg/ml at the rate of 10ml/h. The extent of upper sensory blockade was assessed by cold testing before inducing GA.

In all groups; GA was induced with 1.5 μg/kg fentanyl, 3-5 mg/kg thiopentone, and 0.5mg/kg atracrium. The trachea was intubated and controlled ventilation was started. Anesthesia was maintained with fentanyl infused at a rate of 0.0125 μg/kg/min. (stopped 45 min before the end of the procedures) and a mixture of nitrous oxide (70%) and isoflurane (0.2%-1%) in oxygen. Postoperative pain was assessed in the-4 groups using a visual analogue scale (0: no pain, 100 severe pain) at 24 and 48 h at rest and during 20-min onset period of CPM. Also postoperative maximal amplitude (tolerated by each patient) of knee flexion was measured by plastic goniometer at day one, day two, one week and at one month.

Supplemental postoperative analgesia was standardized in the 4 groups. (During 2 days after surgery; 2 gm paracetamol “Prodafalgan” and 100mg ketoprofen were given to all patients by I.V. infusion. All supplementary subcutaneous injections of morphine administered were recorded.

Side effects arising from the analgesic techniques of the 4 groups in the first 2 days were recorded. Postoperative physical therapy program:

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- Immediately after knee surgery patients in all 4 groups started similar physical therapy methods. During the first 2-3 days postoperatively, a continuous passive motion machine “CPM” was applied with the range of motion set at levels tolerated well by the patient. From the day after surgery until discharge, the patients performed active and assisted knee and hip flexion and extension exercises against gravity twice daily. Getting up from bed was encouraged as soon as possible, followed by ambulation with a walker. Statistics:

- Comparison between the data of different 4 groups was done by several means; one way analysis of variance, least significant difference (LSD) for multiple comparison and Chi-square test. Results are expressed as mean ± SD.

RESULTS Table (1): Clinical data and supplemental morphine consumption in all groups.

Group A (No. 8)

Group B (No. 8)

Group C (No. 8)

Group D (No. 8)

Sex (No.) Male 3 1 6 4 Female 5 7 2 5 Age (years) Mean ± SD 63.3 ± 2.3 64.0 ± 3.5 62.0 ± 3.8 62.4 ± 3.9 Weight (kg) Mean ± SD 79 ± 3.4 82 ± 3 77 ± 3.2 85 ± 3.8 Height (cm) Mean ± SD 170 ± 4.2 175 ± 2.9 170 ± 3.1 172 ± 5.2 Morphine consumption (No.) 1 3

One patient in group A and 3 patients in group C were administered

only one subcutaneous morphine injection as a supplementary analgesia in the first day of operation. No patient in group B or group D required any subcutaneous morphine injection as a supplementary analgesia.

The incidence of the side effects observed in patients managed by continuous epidural infusion (group A and B) were high when compared with the incidence of the side effects observed in patients managed by continuous 3-in-1 block (group C, D) ; p < 0.05 (Chi-square test).

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Table (2): General and local side effects in the 4 groups; continuous epidural analgesia (group A, B) and continuous 3-in-1 block (group C, D).

continuous epidural analgesia (No 16)

continuous 3-in-1 block (No 16)

Side effect No. % No. %

p

General Arterial hypotension 8 50 2 12.5 < 0.05 Nausea/vomiting 9 56.25 3 18.75 < 0.05 Urinary retention 5 31.25 0 0 < 0.05 Allergy (Pruritis) 6 37.5 0 0 < 0.05 Local 5 31.25 0 0 < 0.05 Table (3): Postoperative follow up of knee flexion (values are expressed as degrees by means ± SD).

Group A (No. 8)

Group B (No. 8)

Group C (No. 8)

Group D (No. 8)

Hospital stay: First day 50 ± 3.4 45 ± 3.4 64.7 ± 3.1 52.7 ± 3.1 Second day 69 ± 3.6 67.7 ± 3.2 76.5 ± 3.8 71.7 ± 3.2 First week 89 ± 3.7 94.8 ± 2.8 85 ± 3.5 89.7 ± 3.7 Second week (discharge) 106 ± 4.5 107 ± 3.7 103.4 ± 7.1 106 ± 5.6 One month follow up 119.5 ± 8.1 120.6 ± 7.2 111.3 ± 13 114.7 ± 10.7 P* (difference between first day till one month) <0.001 <0.001 <0.001 <0.001

P** (difference between 2nd week and one month) 0.23 0.23 0.23 0.23

P* by general linear models of repeated measures (ANOVA for repeated measures). P** by one way analysis of variance.

- Marked improvement of knee flexion was found in all groups from first day of the operation until one month follow up (p< 0.001).

- Insignificant differences were noted for knee flexion values among the 4 groups at one month follow up examination (p 0.23 NS.).

Highly significant effect in controlling pain during rest and during movement was observed from the first to the second day of operation (p< 0.001). Improvement in pain score was marked in group B than A where (P(R) < 0.001 and p(M) < 0.001) and in group D than C where (p(R) < 0.001 and p(M) < 0.001). Improvement of pain in epidural analgesia groups

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(A, B) was marked than continuous 3-in-1 block groups (C, D) where: A Vs C (P(R) < 0.001 and p(M) < 0.001) and B Vs D (P(R) < 0.001 and p(M) < 0.001) [by using least significant difference (LSD) of comparison]. Table (4): Pain scores in the 4 groups by visual analogue scale (values are expressed as means ± SD).

Group A (No. 8)

Group B (No. 8)

Group C (No. 8)

Group D (No. 8)

Pain (R): First day 27 ± 3.4 30 ± 2.9 22 ± 3.9 26 ± 4 Second day 19 ± 3.2 14 ± 3.5 18 ± 3.6 16 ± 3.5 P value < 0.001 < 0.001 < 0.001 < 0.001 Pain (M): First day 65 ± 3.4 45 ± 2.2 60 ± 3.5 48 ± 3.4 Second day 57 ± 3.5 35 ± 3.7 56 ± 3.8 40 ± 2.5 P value < 0.001 < 0.001 < 0.001 < 0.001 (R) = rest. (M) = movement.

Fig. (1): Three –in-one block (Katz et al., 1995).

DISCUSSION Total knee replacement (TKR) produces severe postoperative pain

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and the using of different regional analgesic techniques must be based on the balance between their benefits and their side effects, so this work was designed to compare the efficacy and the safety of different analgesic modalities on associated postoperative severe pain and early knee mobilization after TKR.

Pike (1978) found that TENS is effective in pain relief of artificial joint replacement operations especially if done for hip or knee joints. TENS is effective for pain relief which arise during tooth extraction (Strasburg & Krainick, 1997).

The explanation for relief of pain may be due to the analgesic effect of TENS which would be transmitted along large-diameter afferents, which in turn, would activate the inhibitory substantia gelatinosa (SG) interneurons, thus closing the gate to the transmission of nociceptive information (Melzack & wall, 1965). On the other hand the release of morphine like substances (encephalin and endorphin) may have some role in the relief of pain (Pomeranz, 1978).

After knee surgery TENS increases the range of motion and leads to early restoration of active muscular movement (Harvie, 1979). Spinal and epidural anesthesia are most often employed for regional anesthesia of the lower extremities. Peripheral nerve block in the lower extremity can also provide excellent surgical anesthesia for some procedures (Morgan et al., 2002).

The last decade has been the rapid recognition of epidural analgesia as an efficacious method of acute pain management (Jastrzab et al., 2001). Numerous studies have demonstrated the superiority of epidural analgesia over conventional opioid techniques (Capdevila et al., 1999 and Mann et al., 2000).

Continuous epidural infusion techniques offer pain relief, reduce drug requirements (compared with intermittent boluses), minimize side effects and decrease the likelihood of catheter occlusion (Morgan et al., 2002). A femoral nerve block (3-in-1 block) can used to provide anesthesia for the anterior thigh, knee and a small part of the medial foot. It may also be for postoperative pain relief following knee surgery (Morgan et al., 2002).

The efficacy in controlling pain and improvement of knee flexion after knee surgery (TKR) was evident in our results in all 4 groups; with a highly significant differences in groups B and D; “who had been administered TENS therapy as an adjuvant analgesia”, than in groups A and

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C; “who did not administered adjuvant TENS therapy”. Also our results demonstrate that the analgesic effect induced by continuous epidural infusion (group A and B); was greater than achieved by application of continuous 3-in-1 block (group C and D).

In agreement of our results Singelyn et al. (1998) who concluded that after open knee surgery, pain can be associated with severe reflex spasms of the quadriceps muscle, causing further pain and impaired muscle function; with regional anesthesia the massive afferent nociceptive input is blocked; consequently these reflex responses do not occur. Also Allen et al. (1998) found that femoral nerve block improves analgesia and decreases the need for morphine after total knee replacement surgery.

Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion, thereby hastening convalescence (Capdevila et al., 1999).

After TKR, the effect of both epidural analgesia and continuous 3-in-1 block provided marked pain relief (Singelyn & Gouverneur, 1997).

Follow up examination at one month from surgery showed no significant differences among our patients regarding flexion movement degree. In agreement of our results Pettine & Wedel (1989).

The analgesic effect of the regional techniques on pain during early mobilization facilitates the rehabilitative advantages of CPM to be more effective.

Kehlet (1994) and Kehlet & Dahi (1993), showed the importance of analgesia in optimizing postoperative rehabilitation.

Singelyn & Gouverneur (1997) found that both analgesic techniques (CFB and CEI) allowed the best postoperative knee mobilization not only during administration of the analgesic technique but also afterwards (from day 1 to 10).

Continuous femoral nerve block reduce morphine use and improve range of motion of knee joint following total knee arthroplasty in the early postoperative period; and these benefits did not affect outcome at 6 weeks (Ganapathy et al., 1997).

TENS is non invasive and non addictive and does not produce any adverse irreversible changes in the body (Mannhiemer & Lampe, 1984).

In the small number of patients (32); of our study we found that the incidence of observed side effects was high in patients managed by continuous epidural infusion (group A and B); comparing with patients

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managed by continuous 3-in-1 block (group C and D). Singlyn and Gouverneur (1997) found that continuous 3-in-1 block

was safer than continuous epidural infusion technique to provide postoperative analgesia after TKR. Conclusions: • The efficacy of the tested analgesic techniques in all groups in controlling pain after knee surgery (TKR) was evident in our results. • TENS adjuvant therapy groups (B, D) had been shown to have a more significant effect on postoperative pain and early knee mobilization than the non adjuvant TENE therapy groups (A, C) and this reflect the significant effect of TENS in controlling of postoperative pain and increasing the range of motion leading to early restoration of active muscles movement. • The efficacy of continuous 3-in-1 block appeared less than continuous epidural infusion. • The more safe regional analgesic techniques in our study are continuous 3-in-1 block.

Recommendations: Because TENS (which is very safe analgesic tool) was found to have

a valuable effect in controlling postoperative pain; so to obtain satisfied quality regarding the efficacy and safety; we recommend using two techniques together to provide analgesia after TKR i.e. continuous 3-in-1 block together with transcutaneous electrical nerve stimulation.

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Fragen RJ, Stuberg SD, Wixson R et al. (1995): Effect of ketorolac tromethamine on bleeding and on requirements for analgesia after total knee arthroplasty. J. Bone Joint Surg Am 77: 998-10.

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endogenous opiate system in chronic intractable pain syndromes. Houghton, Mifflin. Professional publishers, Medical division, Boston. P: 253-259.

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Pomeranz B (1978): Do endorphins mediate acupuncture analgesia. Advances in biochemical psychopharmacology 18, 351-359.

Serpell MG, Millar FA and Thomson MF (1991): Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement. Anesthesia; 46: 275-7.

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Singelyn FJ and Gouverneur JM (1997): Influence of the postoperative Analgesic technique on knee mobilization after total knee Replacement (TKR).

Singelyn FJ, Deyaert M, Joris D et al. (1998): Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg; 87: 88-92.

Singelyn FJ, Gouverneur JM and Rober T (1996): A minimum dose of clonidine added to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block. Anesth. Analg 83.

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تقييم آفاءة وأمان طرق موضعية مختلفة لتسكين الألم مفصل ل التأهيل المبكر للرآبة بعد عملية التغيير الكلى لفي **حفنى محمد السلام وعبد *على حسان محمد ،الصياد فهمى حسن السيد

جامعة الزقازيق –آلية الطب ** جراحة العظام-* التخدير–أقسام الروماتيزم والتأهيل ة إ :ف من البحث الهد ذه الطريق ختيار طريقة تسكين الألم يجب أن تبنى على التقييم الدقيق لفائدة ه

م وأخطارها ولذلك الهدف من البحث هو تقييم آفاءة وأمان سكين الأل ة لت ل طرق موضعية مختلف ى التأهي عل .المبكر لمفصل الرآبة بعد عملية التغيير الكلى لمفصل الرآبة

من الإناث ممن سوف 19 من الذآور و 13 مريضا، 32 هذه الدراسة على شتملتإ :طرق البحث ستبدال صناعى آامل لمفصل الرآبة وقد قسموا عشوائيا إلى أربعة مجموعات ضمت آل إتجرى لهم عملية

ة مرضى ة ثماني ى .مجموع ة الأول ة هى الإ :المجموع د العملي دهم بع م عن سكين الأل ة ت ت طريق سكاب آان نة .ات خارج الأم الجافية المستمر للمسكن ة هى :المجموعة الثاني د العملي دهم بع م عن سكين الأل ة ت آانت طريق

ى للعصب عن طريقة الإ ه الكهرب ة التنبي ى طريق ة بالإضافة إل نسكاب المستمر للمسكنات خارج الأم الجافية هى طريق :المجموعة الثالثة .طريق الجلد د العملي دهم بع ة التخدير الموضعى آانت طريقة تسكين الألم عن

ة هى :المجموعة الرابعة .للعصب الفخذى بطريقة ثلاثة فى واحد آانت طريقة تسكين الألم عندهم بعد العمليه الكهرب ة التنبي ى طريق د بالإضافة إل ى واح ة ف ة ثلاث دير الموضعى للعصب الفخذى بطريق ة التخ يطريق

ى . أثناء الراحة والحرآة السالبة المستمرة بجهاز سىوتم تقييم ألم ما بعد العملية .للعصب عن طريق الجلد باس – از قي ة بجه اء مفصل الرآب اس مدى انثن م قي ة وت أم ، لكل المرضى فى اليوم الأول والثانى من العملي

م ).الجونيوميتر(الحرآة ة الأل وع والجرعة لكل وبالنسبة للعلاج المساعد لإزال ده من حيث الن م توحي د ت فقد إوتم تسجيل لكل المرضى . المرضى .ستهلاك عقار المورفين المساعد لإزالة الألم والذى يؤخذ تحت الجل

وأظهرت النتائج آفاءة آل الطرق فى آل المجموعات فى التحكم فى الألم والتحسن الملحوظ فى درجة انثناء ة صل الرآب ا أظهرت الن .مف ق الإ آم م عن طري سكين الأل ة ت وة طريق ائج أن ق سكنات ت ستمر للم سكاب الم ن

ة ق التخدير الموضعى للعصب الفخذى بطريق م عن طري سكين الأل ة ت ى طريق خارج الأم الجافية تتفوق علة .ثلاثة فى واحد م طريق ذين أجريت له ر فى المرضى ال ة فوجدت ملحوظة أآث ار الجانبي سبة للآث ا بالن أم

سكين الأ ق الإت م عن طري ة ل ارج الأم الجافي سكنات خ ستمر للم سكاب الم ى . ن ات الت رت المجموع ا أظه آمساعد ومشترك د آعامل م ق الجل أجرى لها طريقة تسكين الألم عن طريق التنبيه الكهربى للعصب عن طري

د آع ق الجل ى للعصب عن طري ه الكهرب ة التنبي ا طريق ستخدم به م ي ى ل ا الت وق ملحوظ عن نظيرته ل تف امم وتحسين سكين الأل ى للعصب فى ت ه الكهرب ة التنبي درة طريق مشترك ومساعد، وهذا يوضح مدى آفاءة وق

.ستبدال مفصل الرآبة بمفصل صناعىإحرآة مفصل الرآبة عند المرضى الذين أجريت لهم عملية د أن الإ :الاستنتاج ا بع م م سكين أل ة ت ان لطريق اءة والأم ل من حيث الكف ار الأمث د ختي ة عن العملي

ة إالمرضى الذين تجرى لهم عملية م عن طريق سكين الأل ة ت آخر صناعى هى طريق ة ب ستبدال مفصل الرآبى ه الكهرب ة التنبي التخدير الموضعى للعصب الفخذى بطريقة ثلاثة فى واحد وذلك عندما يستعمل معها طريق

.للعصب عن طريق الجلد