Catheter-directed thrombolysis for iliofemoral deep venous thrombosis improves health-related quality of life

PURPOSE: Treatment designed to eliminate thrombus in patients with iliofemoral deep venous thrombosis (DVT) is theoretically attractive; however, its benefits, compared with those of anticoagulation, have not been definitively demonstrated. Although not previously analyzed, an effective measure of treatment success is likely to be the assessment of health-related quality of life (HRQOL). This study evaluated whether catheter-directed thrombolysis for iliofemoral DVT is associated with improved HRQOL, compared with standard anticoagulation, and whether HRQOL outcome in the thrombolysis group is related to lytic success. METHODS: An 80-item self-administered HRQOL questionnaire was developed. It contained the Health Utilities Index, Short Form-12, and disease-targeted scales, including health distress, stigma, health interference, physical functioning, and symptoms (eg, leg swelling, pain, ulcers). The HRQOL questionnaire was confirmed to be reliable and valid by means of psychometric testing. Questionnaires were administered to 98 retrospectively identified patients who had had iliofemoral DVT treated at least 6 months earlier. Sixty-eight patients who were identified through a DVT registry were treated with catheter-directed thrombolysis with urokinase (UK), and 30 patients who were identified by means of a medical record review were treated with anticoagulation alone. The treatment decision was made by the attending physician, and all patients were candidates for both thrombolysis and anticoagulation. RESULTS: Most patients were women (61%), white (95%), married (65%), and had a mean interval since initial DVT of 16 months. The group treated with UK was younger (53 +/- 17 years) than the group treated with heparin (61 +/- 6 years; P =.039). After treatment, patients treated with UK reported better overall physical functioning (P =.046), less stigma (P =.033), less health distress (P =.022), and fewer post-thrombotic symptoms (P =. 006), compared with the patients treated with anticoagulation alone. Within the UK group, phlebographically successful lysis correlated with improved HRQOL (P =.038). Patients classified as lytic failures had similar outcomes to patients treated with heparin. CONCLUSION: Patients with iliofemoral DVT treated with catheter-directed thrombolysis have better functioning and well-being, compared with patients treated with anticoagulation alone. Successful lysis was directly correlated with improved HRQOL, with patients who were classified as lytic failures having similar outcomes to patients treated with heparin. These data support the need for a future randomized trial, which should include an HRQOL measure as part of the outcome analysis.     

Early diagnosis of deep vein thrombosis in female patients who undergo total knee arthroplasty with measurement of P-selectin activation

BACKGROUND: Deep vein thrombosis (DVT) remains a leading cause of postoperative morbidity and mortality in patients who undergo total knee arthroplasty (TKA). Although patients with previous thrombotic episodes are inherently at a higher risk for subsequent episodes of DVT, it remains difficult to predict such an occurrence and to make a diagnosis in early stages. One potentially useful assay that can be used in the determination of changes of coagulation among patients who undergo arthroplasty is platelet activation. The goal of this study was to establish a predictive value for DVT with measurement of P-selectin levels that could help in planning appropriate perioperative management strategies for patients at high risk for DVT. METHODS: A total of 52 patients who underwent TKA with general anesthesia underwent contrast venography on the 5th postoperative day. Platelet activation before and after operation was measured with platelet surface expression of P-selectin with flow cytometry in these two groups of patients for TKA. None of the patients underwent any anticoagulation therapy. RESULTS: Nineteen of the 52 patients for TKA showed radiologic evidence of DVT, whereas 33 patients for TKA had no radiologic signs of DVT. There was no difference in platelet activation at baseline, which was 1 hour before induction of anesthesia, between the two groups (P >.05) as measured with P-selectin assays. Differences were noted between the two groups on the 5th day after operation, wherein P-selectin was expressed in only 2.72% +/- 0.9% (mean +/- standard deviation) of platelets in patients for TKA with healthy venogram results. This differed significantly from platelets in patients for TKA with DVT, who had P-selectin expression of 6.56% +/- 3.1% (mean +/- standard deviation; P <.01). Sensitivity for the diagnosis of DVT with P-selectin assay was calculated to be 74%, and specificity was found to be 94%. CONCLUSION: The findings showed that radiologically confirmed DVT in patients for TKA surgery with general anesthesia is associated with an elevated number of activated platelets. Perioperative assessment of P-selectin may predict the early onset of DVT in patients who undergo high risk surgical procedures like TKA. This laboratory assay may help prevent the occurrence of the fatal events caused by DVT with use of early therapeutic intervention, such as heparinization.     

Deep vein thrombosis outcome and the level of oral anticoagulation therapy.

OBJECTIVE: The purpose of this study was to assess the rate of deep vein thrombosis (DVT) resolution and DVT outcomes as functions of the level of oral anticoagulation therapy achieved with warfarin. METHODS: In 33 consecutive patients, a series of 35 limbs with acute symptomatic DVT was followed throughout 1 year of anticoagulation therapy. All the patients underwent 5 days of intravenous unfractionated sodium heparin therapy that was adjusted in dose to prolong the activated thromboplastin time to 2.0 to 2.5 times the control. In addition, warfarin was administered for a period of 6 months, with a target international normalized ratio (INR) between 2.0 and 3.0. All the patients underwent venous duplex scanning and physical examination at the time of diagnosis and at 1 week, 1 month, 3 months, 6 months, and 1 year. RESULTS: At the end of the 1-year study period, the rate of complete DVT resolution was 68%. The median INR values in patients with complete DVT resolution were significantly higher than those of patients with incomplete DVT resolution after 1, 3, and 6 months of treatment with warfarin. In addition, the proportion of patients with INR values below therapeutic range was significantly higher in patients with incomplete DVT resolution than in patients with complete DVT resolution after 1, 3, and 6 months of treatment with warfarin. The presence of occlusive thrombi was associated with incomplete DVT resolution. Of the patients with occlusive thrombi, 62% had chronic venous insufficiency symptoms develop, whereas only 11% of the patients with nonocclusive thrombi (P =.003) had these symptoms develop. CONCLUSION: Despite 6 months of oral anticoagulant therapy, almost one third of thrombi did not resolve completely. The INR values were significantly higher in those patients with complete DVT resolution. These results suggest that the maintenance of an INR level between 2.0 and 3.0 throughout oral anticoagulation therapy will minimize the rate of incomplete DVT resolution.     

初次全膝关节置换术后隐性失血的影响因素研究

目的 探讨初次全膝关节置换术(TKA)术后隐性失血的相关影响因素.方法 回顾性分析2007年10月至2009年8月接受初次TKA的422例患者,男性60例,女性362例;年龄18～84岁,平均65.7岁.根据Ward和Gross的方法 计算隐性失血量.分析性别、年龄、体质量指数(BMI)、单双侧手术、下肢深静脉血栓、术后抗凝方式、止血带使用时间、假体类型等对术后隐性失血的影响.结果 接受单膝TKA与一期双膝TKA的患者术后隐性失血量分别为(1284±207)ml和(2248±504)ml,差异有统计学意义(P=0.000).单因素分析显示:BMI、止血带使用时间、假体类型及抗凝方式与TKA术后隐性失血有关.多元线性回归分析结果 表明,TKA术后隐性失血的影响因素包括BMI、止血带使用时间及假体类型.结论 BMI、一期双膝关节置换、止血带使用时间及假体类型是TKA术后隐性失血量的影响因素,而性别、年龄、诊断、下肢深静脉血栓及抗凝方式对术后隐性失血形成的影响不大.

Abstract：

Objective To investigate the relative factors for hidden blood loss (HBL) after primary total knee arthroplasty (TKA). Methods A retrospective study of 422 consecutive patients who underwent primary TKA between October 2007 and August 2009 was carried on. There were 60 male and 362 female patients with a mean age of 65. 7 years. The HBL was calculated according to Gross formula. The effect of patient gender, age, body mass index (BMI) , pre-operative diagnosis, unilateral or simultaneous bilateral TKA, tourniquet time, type of prosthesis, postoperative anticoagulation method and deep vein thrombosis (DVT) on the postoperative HBL were analyzed. Results The HBL in patients underwent unilateral TKA was significantly lower than that in those underwent simultaneous bilateral TKA [(1284 ± 207) ml vs. (2248 ±504) ml, P = 0. 000] . Unvaried analysis showed that the HBL were associated with BMI, tourniquet time, prosthesis type and postoperative anticoagulation method. Multivariate linear regression analysis showed that the impact factors of postoperative HBL include BMI, tourniquet time and prosthesis type. Conclusions BMI, bilateral simultaneous TKA, tourniquet time and intercondylar open prosthesis impact the HBL after primary TKA. However, the influence of gender, age, diagnosis, postoperative anticoagulation method and DVT on the HBL are not significant.     

Prophylactic and therapeutic inferior vena cava filters to prevent pulmonary emboli in trauma patients

HYPOTHESIS: Insertion of inferior vena cava filters (IVCFs) can prophylactically reduce pulmonary embolism (PE) in trauma patients. DESIGN: Retrospective review. SETTING: Urban, level I trauma center. PATIENTS: Two hundred blunt trauma patients undergoing IVCF placement. INTERVENTIONS: In 122 patients who had already been diagnosed as having deep vein thrombosis (DVT) (112 patients) and/or PE (22 patients), the insertion of the IVCF was considered "therapeutic." In 78 patients who had no evidence of DVT or PE but who were considered to be at high risk for a PE, the IVCF was considered "prophylactic." MAIN OUTCOME MEASURES: Incidence of PE and related mortality and morbidity in therapeutic vs prophylactic IVCFs. RESULTS: The number of prophylactic IVCFs inserted increased significantly from only 4% (3/68 cases) from 1991 through 1996, up to 57% (75/132 cases) from 1997 to June 2001. Although the mean +/- SD age (51 +/- 20 years vs 41 +/- 15 years; P<.001) was higher in the therapeutic group, there was no difference in the mean +/- SD Injury Severity Scores (20 +/- 12 vs 21 +/- 11). Therapeutic filters were placed much later after injury (mean +/- SD time, 11 +/- 7 vs 3 +/- 2 days; P<.001). The mortality rate was 11% (13/122 patients) in patients having a therapeutic IVCF, as compared with only 3% (2/78 patients) in those placed prophylactically (P =.07). None of the patients who had placement of a prophylactic IVCF developed subsequent PE. The incidence of PE decreased in all blunt trauma patients from 0.29% before 1997 to 0.15% after January 1, 1997, when 57% of the IVCF inserted were prophylactic (P =.06). CONCLUSIONS: Prophylactic IVCFs should be inserted within 48 hours of injury in specific trauma patients at high risk for PE and with contraindications to anticoagulation.     

影响人工关节置换术后下肢深静脉血栓形成的临床风险因素分析

目的 分析影响人工关节置换术后下肢深静脉血栓形成（DVT）的临床风险因素。方法对2004年4月至8月95例128个人工髋、膝关节置换术术后DVT发生情况进行分析。其中男性27例,女性68例,平均年龄60岁（23～78岁）。人工髋关节置换术（THA）43例48髋,人工膝关节置换术（TKA）52例80膝。术前及术后7～10d均用彩色多普勒检查双下肢深静脉血流通畅情况及DVT的发生。对19项临床因素与人工关节置换术后DVT形成的相关性进行了分析。结果术后发生DVT的患者有45人,DVT发生率为47．4％（45／95）,其中无症状DVT患者占57．8％（26／45）。经logistic多因素回归分析,与DVT相关的因素有4个,其中女性、肥胖及骨水泥的使用使术后发生DVT的风险分别增加到10．008、3．094、8．887倍（P〈0．05）;类风湿关节炎的诊断使术后发生DVT的可能性减少到0．194倍（P〈0．05）。结论女性、肥胖及骨水泥的使用是人工关节术后发生DVT的危险因素,而类风湿关节炎（RA）则是减少术后发生DVT的保护因素;关节置换术后无症状DVT的大量存在,提示我们术后最好常规行双下肢彩色多普勒或造影检查,一旦有DVT发生,及时治疗,防止发生致命性肺栓塞。     

Deep vein thrombosis after aneurysm surgery

In a prospective study of 100 consecutive patients who underwent operations for intracranial aneurysms, the incidence of deep vein thrombosis (DVT) was 14%. The diagnosis was based on contrast venography, which was carried out in any patient who showed clinical symptoms and signs of DVT. In the presence of DVT the patient was placed on bed rest and intravenous plus peroral anticoagulation was begun. No complications thought to be related to anticoagulation were observed. A programme of postoperative prophylaxis is suggested for a selected group of aneurysm patients with a high risk for thromboembolic disease.     

Quantitative index for deciding whether to administer preventive anticoagulant therapy in osteoarthritis patients undergoing total knee arthroplasty

Background

The 2008 American Academy of Orthopedic Surgeons recommended that surgeons assess the relative risks of venous thromboembolism and bleeding in patients undergoing total knee arthroplasty (TKA). In this situation, a quantitative index is required for deciding whether to administer preventive anticoagulant therapy for deep venous thrombosis (DVT). In this study, we investigated the risk factors for DVT after TKA.

Methods

We included 102 patients (122 knees) who underwent primary TKA for osteoarthritis of the knee between October 2007 and March 2010. DVT was evaluated using lower limb venous ultrasonography. Cutoff values for individual risk factors were determined using a receiver-operating characteristic analysis, and the patients were grouped according to the cutoff values; the odds ratios (95 % CI) were also investigated. The Wilcoxon signed-rank test and χ ² test were also used.

Results

DVT was positive in 25 knees (20.5 %). Three risk factors for DVT after TKA were identified: age 76 years or older, preoperative maximum soleus vein (MAX-SV) diameter of 6.0 mm or greater, and preoperative D-dimer value of 1.1 μg/dl or higher. The incidence of DVT was significantly higher in the group with two or more risk factors than in the group with one or no risk factors (p = 0.0001).

Conclusions

Development of postoperative DVT correlated significantly with the presence of the following risk factors: age 76 years or older, preoperative MAX-SV diameter of 6.0 mm or greater, and a preoperative D-dimer value of 1.1 μg/dl or higher. Considering the risk–benefit ratio, avoiding preventive anticoagulant therapy following TKA can be an option for patients with osteoarthritis with one or no risk factors.     

多模式预防措施对老年关节置换术后静脉血栓栓塞症发生及转归的影响

目的分析采用多模式血栓预防措施后,老年初次髋、膝关节置换术后静脉血栓栓塞症（VTE）的发生和转归情况。 方法回顾性收集2015年1月至2017年6月行初次单侧髋、膝关节置换的老年患者375例（年龄≥60岁）,所有患者均接受抗凝药物、足底小腿静脉气压泵、加强踝泵和早期下地等康复预防以及减少围手术期脱水等多模式血栓预防措施,术后采用彩色多普勒超声检查双侧下肢深静脉血栓（DVT）的发生情况,对有症状患者行肺动脉CT造影排查肺动脉栓塞（PE）。 结果共349名患者获完整随访,随访率92.5%。随访期间无症状性PE,DVT共38例,总发生率为10.9%,均为远端DVT。手术同侧DVT 38例,双侧3例。症状性DVT共27例（27/38,71.1%）,无症状性DVT 11例（11/38,29.0%）。单纯腓肠肌间静脉血栓29例,单条小腿静脉血栓3例,混合静脉血栓6例。接受不同手术方式的患者DVT发生率差别有统计学意义（χ²=0.000,P<0.001）,其中接受全膝关节置换手术患者DVT的发生率为16.3%,显著高于单髁关节置换手术组的4.7%。单纯腓肠肌间静脉血栓未予药物治疗,其他DVT口服利伐沙班抗凝治疗4 w。术后8 w,有26例（26/38,68.4%）血栓完全消融,12例（12/38,31.6%）血栓未完全消融,但所有DVT相关临床表现均消失,无残留血栓后遗症,且无血栓进展或新发PE。 结论采取多模式预防措施后,老年关节置换术后VTE发生率低,且均为远端DVT,经观察或短程抗凝治疗,症状消失并无后遗症。     

全膝关节置换术后间歇充气压力装置使用开始时间研究

目的探讨全膝关节置换术患者术后早期使用间歇充气压力装置预防下肢深静脉血栓的效果及安全性。方法将91例行单侧全膝关节置换手术患者随机分为早期组44例、晚期组47例,术后两组均行常规抗凝治疗及护理;早期组术后返回病房当天行间歇充气压力装置治疗2h,以后每天2次,每次2h;晚期组术后1d开始行间歇充气压力装置治疗,频次与时间同早期组。结果两组出血量及术后各时段VAS评分比较,差异无统计学意义(均P0.05);早期组未发生DVT,晚期组4例(8.51%)发生DVT;早期组术后3d大腿肿胀程度显著轻于晚期组,术后3d、14d膝关节活动度显著大于晚期组(均P0.01)。结论全膝关节置换术后早期应用间歇充气压力装置辅助治疗,不会增加出血量及疼痛;可有效预防下肢深静脉血栓形成,减轻术肢肿胀及改善膝关节活动,有利于术侧肢体康复。     

DVT Prophylaxis After TKA: Routine Anticoagulation Vs Risk Screening Approach — A Randomized Study

The American College of Chest Physicians (ACCP) recommended routine anticoagulation for thromboprophylaxis in patients undergoing lower limb arthroplasty. We compared results of routine anticoagulation Vs risk stratified approach for Deep Venous Thrombosis (DVT) prophylaxis after TKA in terms of symptomatic DVT and wound complications. Nine hundred TKAs done in 673 patients were randomized after DVT risk screening to routine anticoagulation (n = 450) or to risk stratification (n = 450) and selective anticoagulation. 194 patients in the risk screening group received only Aspirin. Primary outcome was symptomatic DVT and wound complication. This randomized study showed that the symptomatic DVT rates after TKA were similar whether patients were routinely anticoagulated or selectively anticoagulated after risk screening. However there was a significantly higher incidence of wound complications (P < 0.014) after routine anticoagulation.     

成人膝部骨肿瘤术后下肢深静脉血栓形成的临床危险因素分析

目的探讨影响成人膝部骨肿瘤术后下肢深静脉血栓（DVT）形成的危险因素及统计DVT的发生率。方法对2011年2月至2012年1月75例成人膝部骨肿瘤患者术后DVT发生情况进行分析。75例患者均未采取任何药物抗凝措施。男45例,女30例,平均年龄（35.55±16.75）岁。其中,良性肿瘤39例,恶性肿瘤36例;26例行肿瘤刮除植骨（或未植骨）内固定术,49例行肿瘤切除肿瘤型膝关节置换术（或膝关节假体翻修术）。术前及术后14d均采用彩色多普勒超声检查双下肢深静脉血流通畅情况及DVT的发生。对15项临床因素与膝部手术后DVT形成的相关性进行分析。结果术后发生DVT的患者为21例,总发生率为28%（21/75）。经Logistic多因素回归分析,DVT形成的危险因素有2个：年龄≥40岁、术前存在深静脉返流。两者使术后DVT形成的风险分别增加到13.337、13.538倍（P〈0.05）。结论年龄≥40岁和术前存在下肢深静脉返流是成人膝部骨肿瘤术后DVT发生的独立危险因素。肿瘤本身因素、是否采取过抗肿瘤治疗（化疗及放疗）、手术方式、是否使用骨水泥或异体骨等因素与DVT的形成无显著相关性。术前行下肢静脉彩色多普勒超声检查意义重大;应对年龄≥40岁或术前存在深静脉返流的患者积极采取药物抗凝措施以预防DVT的形成。     

体重指数及年龄对人工关节置换术后下肢深静脉血栓形成的影响

目的探讨体重指数及年龄对人工关节置换术后下肢深静脉血栓形成(deepveinthrombosis,DVT)的影响。方法采用病例对照研究,分析2004年4月～2004年8月符合纳入条件行髋、膝人工关节置换术的95例患者的临床资料。其中男27例,女68例。年龄23～78岁,平均60岁。体重指数(bodymassindex,BMI)14.34～40.39kg/m2,平均25.88kg/m2。人工髋关节置换43例48髋,人工膝关节置换52例80膝。患者按WHOBMI标准分层,即:非肥胖BMI≤25.00kg/m2、超重BMI25.01～27.00kg/m2、肥胖BMI27.01～30.00kg/m2、病理性肥胖BMI>30.00kg/m2,以及按年龄分为≤40岁、41～60岁、61～70岁、>70岁4层,研究其与关节置换术后DVT的相关性。患者术前及术后7～10d均行低分子肝素抗凝预防术后DVT,并于术后7～10d采用彩色多普勒检查双下肢深静脉血流通畅情况及DVT发生率。结果术后45例患者发生DVT,发生率为47.4%,近端DVT发生率为3.2%。DVT组BMI为27.50±3.18kg/m2,高于无DVT组(24.42±4.51kg/m2),差异有统计学意义(P<0.05);分层后,BMI>25kg/m2的患者发生DVT的风险是BMI≤25kg/m2患者的2.24倍(P<0.05);BMI按WHO标准进行分层后,超重、肥胖及病理性肥胖的患者发生DVT的风险分别是非肥胖患者的7.04、4.80及9.60倍,差异均有统计学意义(P<0.05),肥胖患者发生DVT的风险比其他两层患者低,而病理性肥胖患者发生DVT的风险最高。DVT组年龄为65.24±6.98岁,高于无DVT组(54.84±15.11岁),差异有统计学意义(P<0.05)。41～60岁、61～70岁及>70岁组患者发生DVT的风险分别是年龄≤40岁患者的24.0、38.2及24.4倍,差异均有统计学意义(P<0.05)。结论肥胖(BMI>25kg/m2)及高龄(年龄>40岁)是影响人工关节置换术后DVT形成的高危因素,其中61～70岁的患者发生DVT的风险最高。肥胖、高龄患者行人工关节置换术时应予足够预防性抗凝治疗,术后严密观察双下肢情况,必要时行超声或静脉造影检查,防止发生致命性肺栓塞。     

Incidence of clinically significant venous thromboembolic events in Asian patients undergoing total knee arthroplasty without anticoagulation

This study aimed to evaluate the incidence of clinically significant venous thromboembolic events (VTE) in Asian patients undergoing total knee arthroplasty (TKA) without anticoagulation. All patients who underwent TKA by a single surgeon from 2006 to 2010 in Singapore General Hospital were reviewed. Only symptomatic patients were referred for ultrasonography. Of the 531 patients reviewed, 3 patients developed symptoms of deep vein thrombosis with subsequent ultrasonographic confirmation, whereas 1 patient developed fatal pulmonary embolism without any clinical or radiologic evidence of deep vein thrombosis. Hence, the incidence of clinically significant VTE was 0.75%. Given the low incidence of clinically significant VTE, there is a need to review the current practice of routine chemoprophylaxis in Asian patients undergoing TKA.     

Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty

Introduction There is a great deal of controversy about the effect of tourniquets on development of deep vein thrombosis (DVT) after total knee arthroplasty (TKA). Patients and methods We investigated the incidence of postoperative DVT after TKA with or without the use of a tourniquet. The patients were 48 consecutive patients undergoing primary ipsilateral cemented TKA for osteoarthritis. Group A (21 patients) underwent the operation without a tourniquet, and Group B (27 patients) underwent the operation with a tourniquet. Ultrasonography to assess DVT was performed before and after the operation. Results Group B had less intraoperative and total blood loss than Group A. Postoperative DVT was detected in 81.3% of all cases, and symptomatic pulmonary embolism occurred in 1.7%. Most of DVT was found in the calf vein. There was no significant difference in the incidence of postoperative DVT between the two groups. Conclusion We conclude that the use of a tourniquet is beneficial, because it decreases perioperative blood loss and does not increase the risk of DVT. The incidence of DVT after TKA is considerably high with or without use of a tourniquet. Therefore, prevention and early detection of DVT are important for prevention of fatal pulmonary thromboembolism.     

抗凝治疗对低风险组下肢骨折患者深静脉血栓形成的影响

目的研究静脉血栓形成危险度评分量表(RAPT)评分≤5分的低风险组下肢骨折患者下肢深静脉血栓形成(DVT)发生率及预防性应用抗凝药物的安全性和必要性。方法回顾性分析自2014-09—2016-10诊治的348例RAPT评分≤5分的低风险组下肢骨折患者的临床资料,根据是否应用抗凝药物分为抗凝组和对照组,抗凝组每日皮下注射低分子肝素钙(4 100 IU qd),术前12 h停药,术后12 h伤口无明显出血,拔除引流管时再次给药,对照组则不应用抗凝药物,2组均给予足底静脉泵物理治疗;术后2、30 d行双下肢静脉彩色多普勒超声检查,根据超声检查结果统计血栓发生率、分布及转归情况。结果术后发生DVT 17例(4.89%),抗凝组7例,对照组10例。术后2组DVT发生率比较差异无统计学意义(χ~2=0.753,P=0.385);2组术后在DVT分布、累及肢体和静脉差异均无统计学意义(χ~2=0.843,P=0.656;χ~2=2.205,P=0.364;χ~2=0.957,P=0.916)。所有患者获得30 d随访,2例仍存在远端肌间静脉血栓,但无临床症状;复查超声显示血栓未向近端蔓延,均未出现致死性肺栓塞(PE)。结论低风险组下肢骨折患者术后DVT发生率较低,给予基本预防和物理预防即可,临床上应结合RAPT评分充分评估患者并发VTE的危险程度,避免盲目进行抗凝治疗。     

A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty

Deep venous thrombosis (DVT) is common in total knee arthroplasty (TKA). Because of the rarity of the most serious outcomes, most randomized controlled trials lack the power to analyze these outcomes. A meta-analysis was performed for agents used in DVT prophylaxis in TKA employing a Medline literature search. Study inclusion criteria were randomized controlled trials comparing prophylactic agents in elective TKA with mandatory screening for DVT by venography. Fourteen studies (3,482 patients) met inclusion criteria. For total DVT, all agents except dextran and aspirin protected significantly better than placebo (P < .0001). For proximal DVT rates, low-molecular-weight heparin was significantly better than warfarin (P = .0002). There was a trend that aspirin was better than warfarin (P = .0106). No significant difference was found for symptomatic pulmonary embolism, fatal pulmonary embolism, major hemorrhage, or total mortality.     

Anticoagulation with enoxaparin versus intravenous unfractionated heparin in postoperative vascular surgery patients

BACKGROUND: The use of postoperative anticoagulation is not uncommon for patients undergoing vascular procedures, whether for adjunctive therapy to the surgical procedure or for resumption of preoperative anticoagulation. We investigated whether low-molecular-weight heparin, specifically enoxaparin, was an effective replacement for intravenous heparin during the postoperative period until achievement of a therapeutic international normalized ratio, together with the impact on postoperative length of stay. METHODS: We retrospectively examined 330 patients who received either traditional intravenous unfractionated heparin with adjusted-dose warfarin daily (n = 169) or subcutaneous low-molecular-weight heparin, specifically enoxaparin 1 mg/kg every 12 hours, with adjusted-dose warfarin daily (n = 161). Safety was defined as incidence of bleeding, hematoma, stroke, expiration, thrombocytopenia, return to surgery for graft thrombosis or hematoma, and readmission within 30 days for hematoma or thrombosis. RESULTS: For all procedures, regardless of type of anticoagulation treatment, there was no difference in the incidence of postoperative complications, except for the increased incidence of return to surgery for graft thrombosis (P =.02), failing graft (P =.0004), and debridement (P =.01) in patients who received unfractionated heparin. For all procedures combined, the average postoperative length of stay was shortened by 2 days with use of low-molecular-weight heparin (P =.0001). CONCLUSIONS: In this series, use of enoxaparin appears to be safe and effective for vascular postoperative anticoagulation. At the same time, its use can significantly reduce the average postoperative length of stay for patients undergoing vascular procedures. Further prospective data are needed before this protocol can be accepted as an alternative for postoperative anticoagulation in this set of patients.     

Deep venous thrombosis after total hip or knee arthroplasty in a "low-risk" Chinese population

Scarcely any information has been published on deep vein thrombosis (DVT) in Chinese patients after total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, generally, no prophylaxis is given to patients who do not have conventional high-risk factors because they are believed to be at "low risk." We performed a prospective study on 80 such "low risk" patients undergoing THA or TKA (58 TKA and 22 THA) without prophylaxis and performed duplex ultrasonography on both lower limbs 6 to 8 days after surgery. A total of 22 patients (27.5%) showed ultrasonographic evidence of DVT. Eighteen (31%) TKAs and 4 (18.1%) THAs were complicated by DVT. Three patients showed bilateral involvement, all of whom underwent TKA. Two patients had symptomatic pulmonary embolism. The sensitivity and positive predictive value of the clinical examination was 27.2% and 31.6%, respectively. This study showed that patients who are labeled "low risk" for DVT actually had a significant risk and suggests that the current practice of providing prophylaxis to only patients deemed at "high risk" should be revised.