髋膝关节置换术后的深静脉血栓形成

髋膝关节置换术后的深静脉血栓形成(deep venous thrombosis,DVT)是指在各种因素作用下导致纤维蛋白、红细胞以及不等量的血小板和白细胞在静脉内形成凝块的过程。是髋膝关节置换术后最常见的并发症。由于起病隐匿，常常难以诊断。血栓脱落引起肺栓塞(pulmonary thromboembolism,PTE)是DVT常见和严重的并发症，常可导致死亡。     

人工全髋关节置换术后下肢深静脉血栓形成的多因素分析

目的:分析影响人工全髋关节置换术(THA)后下肢深静脉血栓形成(DVT)的危险因素。方法:对98例(112个关节)人工全髋置换术术后DVT发生情况进行分析。其中男55例,女43例;平均年龄59.12岁(41～81岁)。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17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DVT41例,DVT发生率为41.84%(41/98),其中无症状DVT患者占58.54%(24/41)。经Logistic多因素回归分析,与DVT相关的因素有5个,其中年龄、肥胖及肢体延长大于2cm使术后发生DVT的风险分别增加到1.952、3.349及7.376倍(P<0.05);硬膜外麻醉和踝泵练习使术后发生DVT的可能性减少到原来的0.132和0.265(P<0.01)。结论:年龄、肥胖及肢体延长大于2cm是人工关节置换术后发生DVT的危险因素,而硬膜外麻醉和踝泵练习是减少术后发生DVT的保护因素。关节置换术后无症状DVT的大量存在,提示术后最好常规行双下肢彩色多普勒检查,一旦有DVT发生,及时治疗,防止发生致命性肺栓塞。     

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。     

髋、膝关节矫形术和髋部骨折内固定术后病人下肢深静脉血栓形成的危险因素

目的 分析髋、膝关节矫形术和髋部骨折内固定术后病人下肢深静脉血栓形成(DVT)的危险因素.方法 2004年至2005年接受髋、膝关节矫形术和髋部骨折内固定术的病人147例,年龄33～92岁.术后2周行双侧下肢静脉Duplex彩色超声检查,观察DVT形成的情况,根据是否形成DVT,分为非DVT组和DVT组.记录围术期有关病人、手术和麻醉方面的临床资料.结果 术后下肢DVT发生率42.2%,而近端DVT发生率2.7%.与非DVT组相比,DVT组麻黄碱使用率及其用量增加,麻醉时间延长,术后1 d白细胞计数及术后最高白细胞计数明显升高(P＜0.05);logistic回归分析结果显示,上述因素与下肢DVT有关(P＜0.05).结论 髋、膝关节矫形和髋部骨折内固定术后病人下肢DVT的危险因素为麻醉时间＞3 h、使用麻黄碱及术后白细胞计数明显升高.     

基于改良Caprini风险评估模型预测人工全膝关节置换术后深静脉血栓形成风险的确证性

目的:探讨改良Caprini风险评估模型(modified Caprini risk assessment model,Caprini MRAM)预测人工全膝关节置换术(total knee arthroplasty,TKA)患者术后深静脉血栓形成(deep venous thrombosis,DVT)风险的有效性.方...     

阿司匹林预防全髋或全膝置换术后深静脉血栓形成的循证医学进展

目的探讨阿司匹林预防全髋置换术（THA）或全膝置换术（TKA）后深静脉血栓形成（DVT）的循证医学研究证据。 方法检索英国国家医疗服务体系（National Health Service,NHS）数据库、研究转化临床实践（Turning Research into practice,TRIP）医学数据库、系统性评价Cochrane数据库、OVID、Web of science、MEDLINE以及EMBASE数据库2004年1月至2017年9月发表的关于阿司匹林预防THA或TKA术后DVT的随机对照研究（RCT）文章,评价临床疗效主要转归结果是任何形式的DVT,次要转归结果是伤口并发症（伤口延迟渗出、感染）。 结果共纳入14篇文章,其中5篇I级研究证据的文章,9篇Ⅲ级研究证据;证据级别高的1篇RCT文章研究结果显示：阿司匹林与低分子肝素相比,TKA术后DVT发生率差异无统计学意义;目前支持阿司匹林相较低分子肝素、华法林或者达比加群酯对THA或TKA术后DVT预防效果要差的证据尚不充分;与阿司匹林相比,利伐沙班可以使得TKA或THA术后的无症状DVT发生率下降,但是否能够预防有症状的DVT,目前证据尚且不足;与阿司匹林相比,THA或TKA术后使用达比加群酯和利伐沙班伤口并发症要更高。 结论目前临床研究证据表明,除了当前的利伐沙班及低分子肝素抗凝药物外,阿司匹林也许能成为THA或TKA术后DVT预防的另一选择。     

人工全髋关节置换术后下肢深静脉血栓形成的危险因素分析

[目的]分析人工全髋关节置换术后下肢深静脉血栓形成的临床危险因素.[方法]纳入2007年2～7月48名患者51例全髋置换手术病例,术前和术后第7 d进行双下肢血管彩超检查,分析15项临床因素与术后下肢深静脉血栓(DVT)的发生有无相关性.[结果]经双下肢血管彩超检查,51例手术有17例发现DVT,全部为小腿肌间静脉血栓,DVT发生率33.3%;DVT患者中无症状者占47.1%(8/17);多因素Logistic回归分析表明:年龄≥65岁,输血总量大和血清甘油三脂水平(TG)高是全髋关节置换术后DVT发生的重要危险因素,其OR(Odd Ratio)值分别为:116.597、1.01和37.249(P＜0.05).[结论]女性,年龄大,肥胖,血清甘油三脂和胆固醇升高,"O"型血、输血总量大,患糖尿病和高血压的患者发生DVT的风险高(relative risk,RR＞1);年龄≥65岁、输血总量大和血清甘油三脂水平高是人工全髋关节置换术后并发DVT的危险因素;术后应控制输血量,需要大量输血者采取少量多次输血;下肢肌间静脉血栓的发生应该引起临床医师和B超医师的注意.     

止血带对全膝关节置换术后深静脉血栓形成的影响

目的 探讨止血带对全膝关节置换术后深静脉血栓形成的影响.方法 采用随机对照研究,将连续入院的拟行初次全膝关节置换的80例患者随机分为两组:一组使用止血带(止血带组,40例),一组不使用止血带(非止血带组,40例).全部采用后十字韧带替代型骨水泥固定人工膝关节(Smith-Nephew),手术由同一组医生完成.比较两组患者围手术期失血量、深静脉血栓和肺动脉栓塞发生率、术中栓子面积百分率%Ae(即总栓子面积占右心房面积的百分率).术前及术后第1～10天行彩色多普勒超声检查,观察双下肢深静脉血栓的发生;术中使用经食道超声心动图监测右心房,评估止血带释放后的%Ae.结果 止血带组患者术中失血最小于非止血带组患者,但两组患者围手术期总失血量比较差异无统计学意义.止血带组患者和非止血带组患者深静脉血栓发生率比较无统计学差异,两组均未发生肺动脉栓塞.止血带组患者%Ae在释放止血带后的1 min达到高峰;非止血带组患者%Ae仅在扩髓和植入假体时出现高峰,然后缓慢下降;止血带组患者%Ae在释放止血带后大于非止血带组患者.结论 止血带的使用对全膝关节置换术围手术期总失血量并无明显影响,不增加深静脉血栓和肺栓塞的发生风险.     

下肢术后深静脉血栓形成的风险因素分析

目的：研究骨科下肢术后深静脉血栓的发生率并进行风险因素分析。方法：1999年11月至2002年5月未行预防性抗凝治疗的下肢手术患者136例，男78例，女58例；年龄16-82岁，平均49．5岁。术前行双下肢超声多普勒检查排除深静脉血栓，术后行双侧上行性静脉造影检查，并分析可能相关的风险因素。结果：关节置换术后发生深静脉血栓共24例，其中全髋置换术后10例，全膝置换术后14例。骨性关节炎、类风湿性关节炎、股骨头无菌性坏死及股骨颈骨折术后发生深静脉血栓分别为9、6、7和12例。结论：研究发现高龄、深静脉血栓既往史、合并心血管疾病、糖尿病及骨水泥、止血带的使用对深静脉血栓的形成都有较大影响。     

髋、膝关节矫形术和髋部骨折内固定术后病人下肢深静脉血栓形成的危险因素

Objective To determine the factors contributing to the development of deep vein thrombosis (DVT) in the lower extremity in patients after hip or knee arthroplasty and hip fracture internal fixation.Methods One hundred and forty-seven consecutive patients receiving hip or knee arthroplasty and hip fracture internal fixation from 2004 to 2005 were included in this study. Their age ranged from 33 to 92 years. Duplex color ultrasonic inspection was performed on veins of the bilateral lower extremities before operation and 2 weeks after operation for detection of DVT. The patients were divided into a DVT group and a DVT-free group based on the development of DVT after operation. Detailed perioperative clinical information about the patients, surgery and anesthesia was collected.Results Lower extremity DVT was found in 42.2% of the patients after operation, while the incidence of proximal DVT was 2.7%. Compared with the DVT-free group, the usage rate and dosage of ephedrine increased significantly, the duration of anesthesia was significantly longer, and the white blood cell count (WBC) on the 1st postoperative day and the highest WBC count were significantly higher in the DVT group(P＜0.05). Logistic regression analysis indicated that the above factors were closely related to DVT.Conclusion Duration of anesthesia ＞ 3 h, ephedrine administration and a marked increase in WBC count after operation are the risk factors for DVT in the lower extremities in patients after hip or knee arthroplasty and hip fracture internal fixation.     

OCM入路微创小切口全髋关节置换术后的深静脉血栓发生率

背景：OCM入路微创小切口全髋关节置换术（THA）创伤小、恢复快,理论上可降低DVT的发生率,但目前尚缺乏术后早期影像学检查判定DVT发生率的确切报道。目的：对行OCM入路微创小切口的全髋关节置换患者进行术后常规深静脉造影检查,以明确其深静脉血栓发生率并指导临床血栓预防。方法：行单侧OCM入路微创小切口THA患者27例,男13例,女14例;年龄28-90岁,平均（63.4±16.4）岁;BMI为21.2-29.8 kg/m2,平均（24.9±2.42）kg/m2;其中股骨头坏死9例,股骨颈骨折7例,发育性髋关节发育不良（DDH）6例,髋关节骨关节炎3例,强直性脊柱炎2例。术后行利伐沙班及气压泵治疗。评估手术时间、手术切口长度、肢体长度差异、术后下地行走时间、术后VAS评分（术后1、3 d）、术中和术后出血情况、术中和术后输血情况。股骨颈骨折患者术前及所有患者术后3-5d行双下肢深静脉造影,以明确DVT发生情况。结果：手术切口长8-10 cm,平均（8.5±0.6）cm;手术时间为65-125 min,平均（82±13）min;术中出血量为100-350 ml,平均（225±72）ml;术后引流量为120-905 ml,平均（457±218）ml,共4例患者输血。所有患者术后当天即可进行主动屈髋锻炼,双下肢长度差异均〈1 cm,术后1、3 d的VAS评分分别为0-6分,平均（2.5±1.4）分和0-4分,平均（1.9±1.2）分,所有患者术后2-3 d即可站立或行走。术前7例股骨颈骨折患者中2例发现患侧下肢DVT,术后深静脉造影检查仍提示同侧DVT,其余25例患者术后仅1例股骨颈骨折患者提示健侧腓肠肌静脉丛血栓形成。结论：采用OCM微创小切口手术入路THA可明显降低DVT的发生率。     

Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty

We evaluated a total of 473 knees (264 patients) to determine the prevalence of deep vein thrombosis and pulmonary embolism (PE) in those who were not given thromboprophylaxis after total knee arthroplasty (TKA). Deep vein thrombosis was diagnosed by roentgenographic venography, and PE was diagnosed by perfusion lung scanning. In patients with bilateral TKA, 47 (11%) of 418 venograms showed positive findings for thrombi, whereas in patients with unilateral TKA, 11 (20%) of 55 venograms showed positive findings for thrombi (P = .758). No patient had symptoms of PE, and findings for the perfusion lung scans were negative in all patients. We neither treat our patients for deep vein thrombosis and PE prophylactically nor therapeutically unless patient has a symptomatic PE.     

Preoperative risk factors for deep vein thrombosis in knee osteoarthritis patients undergoing total knee arthroplasty

BackgroundTo analyze the risk factors for preoperative deep vein thrombosis (DVT) in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA).MethodsIn this retrospective study, a total of 584 knee OA patients undergoing TKA were enrolled. General information, medical records and preoperative laboratory examination results of the patients were collected. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. Univariate and multivariate logistic regression were used to identify independent risk factors for preoperative DVT in knee OA patients undergoing TKA.ResultsThe incidence of DVT before TKA was 6.85% (40 cases). The increase of ESR (Erythrocyte Sedimentation Rate), platelet crit, IL-6 (Interleukin-6), and PCT (Procalcitonin) were associated with the development of DVT before TKA. Factors as coronary heart disease (CHD), diabetes mellitus (DM), Chronic Kidney Disease (CKD), NLR (ratio of neutrophils to lymphocytes), lower limb venous blood stasis, the time from onset to admission, RBC, PLT were identified by multivariate logistic regression to be the independent risk factors for preoperative DVT in knee OA patients undergoing TKA.ConclusionsDM, CKD, CHD, increased in ESR, IL-6 and PCT, blood stasis of the lower extremities, increased in PLT, platelet crit and the time from onset to admission, decreased in RBC, were high risk factors for preoperative DVT in knee OA patients undergoing TKA.     

Recent Korean perspective of deep vein thrombosis after total knee arthroplasty

This prospective study was performed on 311 consecutive knees in 227 patients for total knee arthroplasty. The aim was to assess the recent incidence of deep vein thrombosis (DVT) after total knee arthroplasty without chemoprophylaxis in Koreans, the efficacy of plasma d-dimer levels as a screening test, and the associated risk factors. Deep vein thrombosis was found in 79 knees (26.60%). There were 9 cases (3.03%) of proximal DVT, 70 cases (23.57%) of distal DVT, and no symptomatic pulmonary embolism. Although this cohort had limited number of patients by a single surgeon, there is still low incidence of proximal DVT in Koreans with rare pulmonary embolism occurrence compared with those of the Western. High postoperative d-dimer levels were correlative, but no appropriate cutoff value was found. Obesity was a significant associated risk factor.     

速碧林预防下肢人工关节置换术后深静脉栓塞的应用

目的评价低分子肝素-速碧林预防下肢人工关节置换术后并发深静脉栓塞(DVT)的临床疗效和安全性。方法136例人工关节置换病例(102例髋关节，34例膝关节)，随机分人实验组和对照组，术后实验组使用速碧林，对照组不使用任何抗凝剂，1周后行下肢深静脉造影。有DVT临床症状者尽早行静脉造影并予以治疗。结果实验组2例出现血红蛋白持续降低，需要持续输血维持而剔除出组，余66例DVT发生率为13．6％；对照组68例病例DVT发生率为42．6％。而在出血或其他不良反应方面，两组间无明显差异。结论术后预防性使用低分子肝素-速碧林对降低下肢人工关节置换术后DVT形成有效并且安全。     

全膝关节置换术后下肢深静脉血栓发生的时间分布

[目的]研究全膝关节置换(total knee arthroplasty,TKA)术后,在气压泵和利伐沙班双重预防下,下肢深静脉血栓(deep venous thrombosis,DVT)发生的时间分布。[方法]于术前,术后第1、2、3 d晨分别进行下肢血管B超检查,于术后第3 d下午行下肢深静脉造影检查;术后当晚开始给予利伐沙班口服(15 mg,1次/d);术后第1 d开始应用双侧间歇性充气加压装置进行血栓预防(1 h/d);术后当晚及第1 d开始有专门康复医师指导患者行关节活动训练。[结果]健侧、术侧DVT的总发生率分别为6.25%、13.75%。健侧肢体术前、术后当日,术后第1、2、3 d发生的血栓数为1(发生率1.25%,占总血栓数20%)、3(3.75%,60%)、1(1.25%,20%)、0(0%,0%)、0(0%,0%);术侧肢体术前,术后当日,术后第1、2、3 d发生的血栓数为0(0%,0%)、9(11.25%,81.8%)、1(1.25%,9.09%)、1(1.25%,9.09%)、0(0%,0%)。[结论]TKA术后,在气压泵和利伐沙班的双重预防下,患者术后当日新发DVT占总数的比例最高(健侧60%、术侧81.8%),而术后第1、2、3 d新发例数则迅速下降,占比重较低。因此DVT的预防需要加强且应从术中开始实行。     

Epidemiology and risk factors for perioperative mortality after total hip and knee arthroplasty

The perioperative mortality of total knee and hip arthroplasties (TKA, THA) remains a major concern among health care providers and their patients. The increase in utilization of TKA and THA makes it imperative to be aware of factors that are associated with this unfortunate event. Therefore we analyzed the Nationwide Inpatient Sample data from 1998 to 2008 and compared admissions with perioperative mortality to those that survived their hospitalization. An estimated total of 4,438,213 TKA and 2,182,121 THA procedures were performed in the United States between 1998 and 2008. The average mortality rate for TKA was 0.13% and 0.18% for THA, or 0.34 and 0.44 events per 1,000 inpatient days, respectively. Independent risk factors for in‐hospital mortality were advanced age, male gender, ethnic minority background, emergency admission as well as a number of comorbidities and complications. Furthermore, we demonstrated that the timing of death occurred earlier after TKA when compared to THA, with 50% of fatalities occurring by day 4 versus day 6 of the hospitalization, respectively. This study provides nationally representative information on risk factors for and timing of perioperative mortality after TKA and THA. Our data can be used to assess the risk for perioperative mortality and to develop targeted intervention to decrease such risk. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1811–1821, 2012