人工髋关节置换后深静脉血栓形成影响因素的回顾分析

背景:目前尚缺少严格遵照<中国骨科大手术静脉血栓栓塞症预防指南>进行血栓预防的大宗人工髋关节置换后深静脉血栓栓塞症发生情况的报道.目的:调查人工髋关节置换患者在进行规范预防性抗凝治疗后下肢深静脉血栓的发生情况.方法:纳入2005-01/2010-07于北京协和医院骨科接受人工髋关节置换的患者,对置换后出现下肢深静脉血栓形成者进行回顾性分析,包括高危因素、预防措施、症状特点、治疗方案及转归.结果与结论:共纳入670例人工髋关节置换患者,其中16例发生下肢深静脉血栓,11例为人工股骨头置换患者,5例为单侧全髋关节置换患者.诊断分布为股骨颈骨折14例,股骨头无菌性坏死1例,血友病性关节炎1例.其合并症1~4个,包括高血压、糖尿病、类风湿性关节炎、慢性肾功能不全等.围手术期皆应用规范物理、药物疗法预防下肢深静脉血栓形成.14例表现为下肢肿胀、疼痛;2例以肺栓塞为首发症状.多数预后良好;1例死于与下肢深静脉血栓形成无关的肺部感染,1例抗凝治疗后并发脑出血导致植物生存状态.提示进行规范预防治疗可以降低下肢深静脉血栓形成发生率,但仍不能完全杜绝其发生.髋部骨折、长期卧床、高龄、代谢性内科疾病仍是下肢深静脉血栓形成的高危因素.     

中西药物预防人工髋关节假体置换后下肢深静脉血栓形成

背景：药物治疗和物理疗法对人工髋关节假体置换后下肢深静脉血栓形成的预防和治疗有积极作用。目的：探讨中西药物预防人工髋关节假体置换后下肢深静脉血栓形成的疗效。方法：收集中药和西药预防人工髋关节假体置换后下肢深静脉血栓形成的相关文献,分析不同药物对下肢深静脉血栓的作用机制,比较中药和西药在治疗和预防人工髋关节假体置换后下肢深静脉血栓形成的疗效及安全性。结果与结论：磺达肝癸钠在预防骨科大手术后总深静脉血栓形成的作用大于依诺肝素,利伐沙班在减少关节置换后患者隐性失血量方面优于低分子肝素。中药在人工髋关节假体置换后下肢深静脉血栓形成的预防上选用益气活血和改善血液循环的方法,如活血通脉汤、桃红四物汤等,还有补阳还五汤、佛手通瘀汤、活血通栓饮、加味桃核承气汤等,在下肢深静脉血栓预防和治疗效果方面均较好。中西药的比较研究中发现,中药或中西药联合对预防人工髋关节假体置换后下肢深静脉血栓形成与西药效果相同,且安全性较高。     

人工髋关节置换术后预防下肢深静脉栓塞的护理

目的：探讨预防人工髋关节置换术后下肢深静脉栓塞的有效护理方法。方法：针对下肢深静脉血栓形成的高危因素，采取相应的综合护理措施。结果：本组32例高危患者均未发生下肢深静脉栓塞，治疗效果满意。结论：细致有效的护理是预防下肢深静脉栓塞的关键，对提高患者的生活质量起着非常重要的作用。     

人工膝关节置换术后下肢深静脉血栓形成的原因分析及护理

目的探讨人工膝关节置换术后患者下肢深静脉血栓形成的预防及护理方法。方法对120例行膝关节置换患者,术前全面评估、心理护理及指导;术后给予抗凝药物治疗,指导功能锻炼并配合护理等。结果 120例患者均未发生下肢深静脉血栓。结论通过预防治疗和护理干预,对预防人工膝关节置换术后下肢深静脉血栓的形成效果显著。     

老年单侧全髋关节置换与下肢深静脉血栓形成

背景:下肢深静脉血栓形成是全髋关节置换患者围手术期严重的并发症,其发生率较高.目前尚不清楚原发病对老年全髋关节置换后下肢深静脉血栓形成的影响.目的:观察不同原发病对老年全髋关节置换后下肢深静脉血栓形成的影响.方法:选择单侧全髋关节置换患者147例,年龄64～93岁,根据原发病不同分为2组:骨折组68例,置换前经历了创伤,均为股骨颈骨折患者;骨病组79例,术前未经历过创伤.根据患者生理年龄、置换前社会活动能力、骨质情况、预期寿命等选择全髋假体,其中采用生物学假体5例,混合型假体12例,其他全部采用骨水泥型假体.对术后出现患肢肿胀和/或疼痛,下肢伴有或不伴有Homans征/Neuhofs征阳性的患者常规应用加压超声技术进行超声多谱勒检查.结果与结论:骨折组置换后32例出现患侧肢体肿胀,伴有疼痛者20例,出现Homans征/Neuhofs征15例,经超声多普勒检查证实29例下肢下肢深静脉血栓形成阳性;股骨颈骨折后行全髋关节置换1例,无下肢深静脉血栓形成临床症状,于置换后17 d猝死,尸检证实为伤侧下肢混合型下肢深静脉血栓形成合并肺栓塞;骨病组置换后20例出现患侧肢体肿胀,伴有疼痛者11例,出现Homans征/Neuhofs征9例,经超声多普勒检查证实20例下肢深静脉血栓形成阳性.股骨颈骨折患者比骨病组患者具有更高的血液凝固状态,下肢深静脉血栓形成发生率更高(P＜0.05).提示股骨颈骨折是老年全髋关节置换后下肢深静脉血栓形成发生的高危因素.     

足底泵联合系统护理预防全髋关节置换术后深静脉血栓形成

目的:探讨足底泵联合围手术期系统护理预防全髋关节置换术后深静脉血栓形成的效果。方法:对86例因股骨头无菌性坏死行全髋关节置换的患者行足底泵治疗联合围手术期系统护理。结果:本组86例患者术后未发生下肢深静脉血栓。结论:足底泵治疗联合围手术期系统护理能有效预防全髋关节置换术后深静脉血栓的形成。     

下腔静脉滤器对预防骨折合并下肢深静脉血栓患者肺栓塞的临床分析

目的探讨可回收下腔静脉滤器在骨折合并下肢深静脉血栓形成患者治疗过程中预防肺栓塞的作用。方法 80例骨折合并下肢深静脉血栓形成患者置入可回收下腔静脉滤器后行骨折手术治疗,术后采用抗凝治疗,临床观察有无肺栓塞的症状和体征。结果 80例可回收下腔静脉滤器均一次置入成功,置入滤器12天后回收55例,其中40例滤器上有血栓附着。1例因骨科手术治疗尚未结束错过回收时间窗,余24例作为永久滤器长期置入。随访时间3～6个月,下肢深静脉血栓形成患者的症状、体征缓解,未发生肺栓塞。结论可回收下腔静脉滤器在骨折合并下肢深静脉血栓形成患者治疗过程能有效预防肺栓塞的发生。     

寒区髋关节置换术后下肢深静脉血栓的预防和护理

人工髋关节置换术是治疗股骨颈骨折。股骨头无菌性坏死的方法。但人工髋关节置换的普遍应用，出现了一些并发症。特别是危及生命的深静脉血栓形成继发的肺栓塞．引起了医护人员的警惕．在寒区尤为突出．近年来，我科在整体护理中实施预防优于治疗．在应用抗凝治疗的同时．配合加强早期的下肢功能锻炼的方法．收到了明显的效果。     

全髋关节置换术后早期主动规律锻炼预防深静脉血栓形成——81例（92髋）血栓发生率4．94％

目的：观察全髋关节置换术后早期主动规律的锻炼对预防深静脉血栓形成的有效性。方法：选择2000-02／2004-04中山大学附属第二医院骨科收治的髋关节疾病行全髋关节置换患者81例（92髋）。股骨头无菌性坏死34例，股骨颈骨折29例，骨性关节炎8例，髋关节翻修4例，陈旧性髋关节结核2例，强直性脊柱炎2例，恶性肿瘤2例。生物固定型髋关节66髋，混合型17髋，骨水泥型9髋。术前彩色超声多普勒证实双下肢无深静脉血栓形成，术后早期（2～5h）开始进行主动规律锻炼，行跖趾关节伸屈、双侧距小腿关节伸屈内外翻运动；术后一两天行双距小腿关节环转运动；术后3～7d做距小腿关节环转运动，股四头肌等长收缩运动；术后8—14d在以上的基础上根据个人情况适当加大运动量。同时术后患者不使用任何抗凝药。①术后每日检查有无深静脉血栓形成的相应症状体征并于术后12d行双下肢彩色超声多普勒检查，与术前进行自身对照，观察血栓发生率。②术后不用抗凝药对出血情况的影响。结果：按意向处理分析，81例患者均进入结果分析。①患者术后下肢深静脉血栓发生率：术后深静脉血栓形成发生率为4．94％（4／81）。其中1例于术后4d出现患侧下肢肿胀，经彩超检查发现胭静脉和股浅静脉均出现栓子，3例无症状者均在术后12d复查时发现深静脉血栓形成，分别为胭静脉血栓1例，股浅静脉中段血栓2例。4例中股骨颈骨折骨水泥型全髋关节置换2例，非骨水泥型1例；骨性关节炎混合型全髋关节置换1例。病因为股骨颈骨折病例的深静脉血栓形成发生率为10．34％（3／29），术中应用骨水泥的病例发生率为11．54％（3／26）。②患者术中术后出血量：平均总出血量为（779．6&;#177;207．4）mL。67％（54／81）的患者无需输血。结论：①本文结果表明全髋关节置换术后早期进行主动规律的功能锻炼，其深静脉血栓形成发生率显著低于国内1999年曾有报道的全髋置换术后深静脉血栓形成40％的发生率。②本组术后未用抗凝药降低了出血量等并发症的发生。     

髋关节置换后药物预防深静脉血栓的分组对照

背景:术后深静脉血栓形成是髋关节置换患者围手术期的危险并发症之一,药物治疗是预防血栓形成的有效方法,临床上正逐步规范用药方案,以取得最佳的预防效果。目的:探索置换后预防血栓的规范化治疗措施。方法:回顾分析固原市人民医院骨科2010-01/2011-05接受髋关节置换者110例,应用低分子肝素、磺达肝癸钠、利伐沙班及华法林防治深静脉血栓的临床资料,用药方案根据《中国骨科大手术静脉血栓栓塞症预防指南(2009版)》的要求。将上述临床结果与2007-01/2009-12接受骨科髋关节置换后不规律用药者123例的临床资料比较分析。结果与结论:所有患者均无因注射抗凝药物而产生明显不适症状。两组中均有少量病例在置换后出现不同深静脉血栓临床症状。不规律用药组和规律用药组D-二聚体检测分别有45,29例阳性。不规律用药组与规律用药组的深静脉血栓主要发生在置换后4周内,随着置换后用药时间的延长,血栓发生率出现下降趋势。置换后12周时规律用药组发生血栓人数明显低于不规律用药组(P<0.05)。提示在髋关节置换后规律应用低分子肝素、磺达肝癸钠、利伐沙班及华法林可有效预防深静脉血栓的发生。     

利伐沙班与依诺肝素预防髋关节置换术后下肢深静脉血栓形成的对照研究

目的比较利伐沙班与依诺肝素预防股骨颈骨折人工全髋关节置换术后下肢深静脉血栓形成（DVT）的有效性及安全性。方法选取本院2012年7月至2013年7月收治的105例股骨颈骨折行人工全髋关节置换术的老年患者为研究对象,经患者及家属知情同意用药方案,将以上患者分为利伐沙班组和依诺肝素组。通过观察两组患者术后静脉血栓栓塞症（VTE）的相关临床症状及体征,行血管彩超及 CTA检查诊断统计 DVT和肺栓塞（PE）例数,评价其有效性。统计两组患者出血事件、额外输血率评价其安全性。结果两组患者均没有出现PE,均无出现大出血事件。而DVT的发生率,一般出血事件发生率,额外输血率,两组比较差异均无统计学意义（P ＞0.05）。结论利伐沙班对比依诺肝素,对老年股骨颈骨折患者行人工全髋关节置换术后预防 VTE 发生具有同样良好的效果,并且未增加出血风险。     

医护一体化管理降低人工髋关节置换术患者深静脉血栓发生率的实践

目的：探讨医护一体化管理降低人工髋关节置换术后深静脉血栓（DVT）发生率的成效。方法：成立医护一体化专项管理小组,制定医护一体化管理流程,分析人工髋关节置换术所致深静脉血栓发生原因并提出对策,医护人员共同参与培训学习,明确责任,共同监督、协作、反馈、持续改进。对比分析实施医护一体化管理前后人工髋关节置换术患者DV T的发生率。结果：实施前髋关节置换术患者DVT发生率为42.1%,经两轮持续质量改进,DVT发生率降低至17.3%,实施前后比较差异有统计学意义（P〈0.01）。结论：医护一体化管理可降低人工髋关节置换术患者DVT的发生率,从而提升医疗护理质量。     

Venous thromboembolism associated with hip and knee arthroplasty: current prophylactic practices and outcomes.

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.     

Investment in prolonged thromboprophylaxis with dalteparin improves clinical outcomes after hip replacement

Summary. Clinical guidelines recommend the use of extended out‐of‐hospital thromboprophylaxis in patients who have had major arthroplasty. However, the cost‐effectiveness of prolonging pharmacological thromboprophylaxis into the out‐of‐hospital phase following hip replacement surgery remains the subject of considerable debate. This debate centers on the clinical relevance of the ‘surrogate’ venographic endpoints that have been used in most clinical trials and used to generate some of the cost analyses of thromboprophylaxis. The objective of this study was to estimate, from the payer perspective, the direct medical costs of prolonging the duration of thromboprophylaxis with dalteparin from 1 week to 28–35 days in patients undergoing hip replacement, and to compare these to the costs associated with using ‘standard’ in‐hospital thromboprophylaxis with low‐molecular‐weight heparin (LMWH) or warfarin. To derive ‘best’ estimates for rates of clinically and economically relevant thromboembolism associated with hip replacement surgery (i.e. those that would in reality incur management costs), we used data on the prevalence of both symptomatic and asymptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE). These estimates were used in conjunction with diagnostic‐related groups (DRG) reimbursement rates and a dalteparin cost model, which assumed home‐based self‐administration for prolonged thromboprophylaxis, to calculate overall direct medical costs of prolonged vs. in‐hospital thromboprophylaxis. The management costs of the strategies evaluated were, to the nearest 1000 Euros: 465 000 Euros for in‐hospital prophylaxis with LMWH; 339 000 Euros for in‐hospital prophylaxis with warfarin; and 368 000 Euros for prolonged prophylaxis with dalteparin. For every 1000 patients treated, prolonging thromboprophylaxis with dalteparin from 1 to 4–5 weeks will avoid 30 clinical DVTs and 18 PEs at a saving of 2000 Euros per clinical event. Compared with in‐hospital warfarin, prolonged thromboprophylaxis with dalteparin will avoid 28 DVTs and four PEs at an incremental cost‐effectiveness ratio of 900 Euros per clinical event avoided. We consider that investment in prolonged thromboprophylaxis with dalteparin is justified for the improvement in clinical outcomes produced.     

Venous thromboembolism in pregnancy

The risk of venous thromboembolism is increased during pregnancy. Although the absolute overall risk of deep venous thrombosis (DVT) or pulmonary embolism (PE) in pregnancy is low, clinicians are highly vigilant to the development of this disease in pregnancy because of the severe consequences to both mother and child if this condition is not diagnosed, treated and prevented. Although prompt recognition and diagnosis of DVT or PE is critical to reduce maternal morbidity, diagnosis of both DVT and PE currently relies on data from studies in nonpregnant patients. However, there are some recent studies offering new insights in this area. The development of venous thromboembolism during pregnancy is influenced by inherent patient risk factors, pregnancy-associated risk factors, and the mode and type of delivery. The degree of risk increase from these factors individually and in combination, to warrant routine thromboprophylaxis, weighed against bleeding risks, is not yet defined. With increased use of assisted reproductive techniques to achieve pregnancy, clinicians must also be vigilant to the development of venous thrombosis in early pregnancy, occurring in unusual sites such as the upper extremities.     

Venous thromboembolism in pregnancy

The risk of venous thromboembolism is increased during pregnancy. Although the absolute overall risk of deep venous thrombosis (DVT) or pulmonary embolism (PE) in pregnancy is low, clinicians are highly vigilant to the development of this disease in pregnancy because of the severe consequences to both mother and child if this condition is not diagnosed, treated and prevented. Although prompt recognition and diagnosis of DVT or PE is critical to reduce maternal morbidity, diagnosis of both DVT and PE currently relies on data from studies in nonpregnant patients. However, there are some recent studies offering new insights in this area. The development of venous thromboembolism during pregnancy is influenced by inherent patient risk factors, pregnancy-associated risk factors, and the mode and type of delivery. The degree of risk increase from these factors individually and in combination, to warrant routine thromboprophylaxis, weighed against bleeding risks, is not yet defined. With increased use of assisted reproductive techniques to achieve pregnancy, clinicians must also be vigilant to the development of venous thrombosis in early pregnancy, occurring in unusual sites such as the upper extremities.     

髋关节置换术中预防下肢深静脉血栓形成的护理干预

目的探讨在髋关节置换手术过程中实施护理干预措施对下肢深静脉血栓形成(DVT)的影响。方法选取本院骨科实施髋关节置换手术的66例患者作为研究对象,随机分为对照组和干预组,各33例。手术期间对照组采用常规护理,干预组采用综合性护理干预,在术中对两组患者深静脉血栓的发生率进行比较。结果对照组有3例患者在术中发生了肺栓塞,术后1月内有5例出现了DVT;干预组1例在手术过程中发生了肺栓塞,术后1月内发生DVT 2例,2组比较差异有统计学意义(P0.05)。结论对实施髋关节置换手术的患者进行术中进行综合性护理干预,可以有效降低髋关节置换术患者深静脉血栓的发生率,减少后期康复风险,提高患者的预后质量。     

Venous thromboembolism in the ICU: main characteristics,diagnosis and thromboprophylaxis

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.     

Gamma钉与人工股骨头置换修复老年股骨转子间粉碎性骨折的比较

背景：近年国内外有较多文献报道对比内固定与人工股骨头置换治疗老年股骨转子间骨折的疗效,意见均不统一;并且较多文献内固定治疗包含Richard钉、鹅头钉及动力髋等髓外固定方法,可能导致结论不准确。目的：通过 Gamma钉内固定与人工股骨头置换治疗老年股骨转子间骨折的临床指标的比较,探讨人工股骨头置换治疗股骨转子间骨折的经验,适应证及置换后并发证的处理。 方法：回顾性分析154例80岁以上股骨转子间粉碎性骨折的老年患者;其中98例患者采用Gamma钉内固定治疗,56例患者采用人工股骨头置换治疗,对比分析两组患者手术时间、住院天数、手术中出血量及离床活动时间;末次髋关节功能恢复情况（根据 Harris 评分）和内固定后并发症的发生率;将所得结果进行比较和评估,并进行统计学分析。 结果与结论：Gamma钉组平均随访时间为6.6年;人工股骨头组平均随访时间为5.7年。两组数据在手术时间、住院天数及手术中出血量方面比较,差异无显著性意义（P 〉0.05）,离床活动时间差异有显著性意义（P 0.05）;内固定后并发症：深静脉血栓形成、肺部感染及泌尿系感染方面,差异无显著性意义（P 〉0.05）;内固定后置入物松动断裂或假体松动、下沉、脱位,以及双下肢不等长方面,差异有显著性意义（P 〈0.05）。选用人工股骨头置换治疗老年股骨转子间骨折患者,有助于患者早期离床活动,改善患者部分生活质量;人工股骨头置换后髋关节功能恢复较 Gamma 钉内固定无明显差异;但早中期并发症的发生率较低;出现假体松动、下沉及脱位等严重并发症后,处理较为困难,对患者日常生活影响较大,需严格掌握其手术适应证及手术技巧。