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。     

全髋关节置换术后深静脉血栓形成

目的：探讨全髋关节置换术后下肢深静脉血栓形成（DVT）的发生情况及预防治疗措施。方法：对220例（244髋）全髋关节置换患者围手术期皮下注射低分子肝素来预防治疗下肢深静脉血栓形成。术后第7天行彩色多普勒超声检查。结果：58例发生下肢深静脉血栓，其中远端血栓33例，近端血栓14例，全静脉血栓11例，DVT发生率26．4％，未发生1例肺栓塞。结论：围手术期低分子肝素应用可降低全髋关节置换术后DVT发生率，且安全可靠。     

藏族人群关节置换术后下肢深静脉血栓发生的时间分布

[目的]探讨藏族人群在全髋关节置换(THA)和全膝关节置换(TKA)术后下肢深静脉血栓(DVT)的发生率及时间分布特点。[方法]回顾分析2017年3月～2018年3月于本院行全髋关节置换术、全膝关节置换术的藏族患者临床资料,其中THA 70例,TKA 167例。所有患者均于术前、术后第1、3、7、14 d常规行双下肢静脉彩超检查,常规使用抗纤溶药,术后常规抗凝。记录THA、TKA术后第1、3、7、14 d DVT的发生例数,计算血栓发生率,统计血栓新发生率最高的时间点,并比较THA、TKA组间的差异。[结果] THA组术后DVT共15例,发生率为21.43%;TKA组术后DVT共51例,发生率为30.54%。TKA术后血栓发生率较THA高,差异有统计学意义(P0.001)。THA、TKA术后血栓发生的高峰均在术后第1 d,而TKA术后DVT发生的高峰可延至术后第7 d。THA术后第1、3、7、14 d发生的血栓占总血栓数的比例分别为73.33%、6.67%、6.67%、13.33%;TKA术后第1、3、7、14 d发生的血栓占血栓总数的比例分别为43.14%、19.61%、25.49%、11.76%。两组均未发现症状性DVT和PE病例。[结论]藏族人群关节置换术后DVT的发生率偏高,DVT发生的高峰均在术后第1 d。     

髋膝关节置换术前预测深静脉血栓形成的多因素分析

[目的]通过对髋、膝关节置换术前患者的相关危险因素的分析,个体化预测其术后下肢深静脉血栓形成(deepveinthrombosis,DVT)的可能性.[方法]2006年4月～2011年11月共309例(髋关节病变113人、膝关节病变196人)接受髋、膝关节置换术的无DVT的患者被纳入研究.所有患者在围术期均接受正规的物理及药物预防血栓治疗.术后第3～10d根据患者病情复查双下肢深静脉彩超了解是否形成血栓.最后,通过术后DVT组与非DVT组的各种术前危险因素的对比分析,提出术前预测术后DVT的公式.[结果]309名患者中术后发生DVT者82例,其中髋关节12例,膝关节70例;单关节置换术后38例,双关节同时置换术后44例.通过判别分析,发现年龄、谷草转氨酶、肌酐、一次手术关节数量、凝血酶原时间和D-二聚体定量与髋、膝关节置换术后DVT的相关性较强,并得出函数预测公式.所有患者平均随访3.5年(4～71个月),均未发生症状性肺栓塞,也未发生明确的肝素类药物副作用.[结论]即使在围术期正规抗凝治疗的前提下,髋、膝关节置换术后DVT的发生率仍然较高.术前如开展个体化预测,能提示对高危人群给予更积极、合理的干预,从而减少术后DVT相关的并发症.     

藏族人群关节置换术后下肢深静脉血栓发生率及解剖分布

[目的]探讨藏族人群全髋关节置换(THA)和全膝关节置换(TKA)术后下肢深静脉血栓(DVT)的发生率及其解剖分布特点。[方法]纳入2017年3月～2018年3月行全髋、全膝关节置换术的237例藏族患者,其中THA 70例,TKA 167例。所有患者于术前、术后第1、3、7、14 d常规行双下肢静脉彩超检查,术中、术后常规使用氨甲环酸,术后常规抗凝。统计分析术后DVT的发生率、类型及其解剖分布情况。[结果]术后下肢静脉DVT发生率THA组为15/70 (21.43%),包括1例中央型,14例周围型;TKA组为51/167 (30.54%),包括49例周围型、2例混合型;两组差异有统计学意义(P0.05)。THA术后血栓:13例为孤立性,包括12例小腿肌间静脉血栓、1例腘静脉血栓;1例肌间静脉及胫后静脉血栓;1例肌间静脉及腓静脉血栓。TKA术后血栓:41例为孤立性(39例肌间静脉血栓、1例胫后静脉血栓、1例大隐静脉血栓);4例肌间静脉及胫后静脉血栓;1例腓静脉及胫后静脉血栓;1例肌间静脉及腓静脉血栓;1例肌间静脉及腘静脉血栓;1例肌间静脉及皮下静脉血栓;1例肌间静脉、腓静脉及胫后静脉血栓;1例肌间静脉、腓静脉、胫后静脉及腘静脉血栓。TKA术后DVT的发生率高于THA, THA组以孤立性静脉血栓为主,TKA组更容易同时累及多支静脉,差异有统计学意义(P0.05)。两组均未发现症状性DVT和PE病例。[结论]藏族人群在全髋关节置换术和全膝关节置换术后下肢DVT的发生率偏高,两者发生率及其解剖分布存在差异。     

人工髋膝关节置换术后症状性静脉血栓栓塞性疾病的危险因素分析

[目的]分析人工髋、膝关节置换术后症状性静脉血栓栓塞性疾病(venous thromboembolism,VTE)发生的危险因素。[方法]2013年5月~2013年12月行人工髋、膝关节置换术患者602例,这些患者在术后出现下肢疼痛、肿胀、周径发生改变、Homans征阳性时行双下肢深静脉彩超(ultrasonography,USG)检查是否发生下肢深静脉血栓(deep vein thrombosis,DVT),同时记录入组患者肺栓塞(pulmonary embolism,PE)事件的发生,分析患者年龄、性别、BMI、手术类型、单双侧、糖尿病史、术前血糖、术前胆固醇、术前甘油三酯、术前D-dimer等与症状性VTE发生风险的相关性。[结果]人工髋、膝关节置换术后共发生症状性VTE 19例(3.16%),其中远端DVT 18例(3.00%),近端DVT 4例(0.66%),PE 2例(0.33%)。症状性VTE患者的平均年龄为(66.74±9.04)岁,显著高于其余患者人群(OR=1.065;95%CI=1.001~1.133;P=0.047)。[结论]症状性VTE是人工髋、膝关节置换术后不容忽视的问题,尽管进行常规的预防,其发生率仍不低。年龄是人工髋、膝关节置换术后发生症状性VTE的危险因素。对于年龄大的患者,应进行及时有效的VTE预防措施。     

人工关节置换术后间歇充气压力泵使用时间对下肢深静脉血栓形成的影响

目的探讨人工关节置换术后间歇充气压力泵(intermittent pneumatic compression,IPC)使用时间对下肢深静脉血栓形成(deep vein thrombosis,DVT)的影响。方法将2018年10月—2019年2月拟行单侧人工全髋、膝关节置换术并符合选择标准的94例患者纳入研究,按照随机数字表法随机分为对照组(47例)及试验组(47例)。两组患者性别、年龄、手术部位及手术原因比较,差异均无统计学意义(P0.05)。两组术后返回病房即开始IPC治疗,其中试验组使用至手术当天晚上9点,对照组至术后第1天早上8点。记录并比较两组患者以下指标:血红蛋白、血小板计数、D-二聚体水平,住院时间、治疗费用、患者使用IPC满意度;血栓弹力图检测,包括凝血形成时间(K值)、凝固角(α角)、反应时间(R值)、血栓最大振幅(MA值);疼痛视觉模拟评分(VAS);手术前后小腿周径差值;匹兹堡睡眠评估量表评估患者睡眠情况;彩色超声多普勒检查下肢DVT情况。结果试验组及对照组患者术前D-二聚体及血栓弹力图K值差异有统计学意义(P0.05),术后差异无统计学意义(P0.05);两组手术前后血红蛋白、血小板计数及其他血栓弹力图指标比较,差异均无统计学意义(P0.05)。两组患者术前及术后各时间点VAS评分比较,术后各时间点小腿周径差值比较,差异均无统计学意义(P0.05)。试验组术后第1天睡眠评分明显低于对照组(t=2.107,P=0.038)。两组患者住院时间及治疗费用比较,差异均无统计学意义(P0.05)。术后试验组发生下肢DVT 1例(2.1%)、肌间静脉血栓3例(6.4%)、感染1例(2.1%),对照组分别为2例(4.3%)、4例(8.5%)、0例(0),差异均无统计学意义(P0.05)。IPC治疗结束后,试验组患者使用IPC满意率为89.4%(42/47),高于对照组的70.2%(33/47),但差异无统计学意义(χ2=0.097,P=0.104)。结论人工关节置换术后短时间应用IPC,不会增加疼痛及小腿肿胀程度,可有效预防下肢DVT,改善患者睡眠情况,有利于术侧肢体康复。     

人工关节置换术后并发深静脉血栓形成的危险因素评估

[目的]探讨全髋和全膝关节置换术后下肢深静脉血栓(deep venous thrombosis,DVT)形成的相关危险因素。[方法]选取2010年1月~2014年12月在本院行人工髋膝关节置换术的患者536例进行DVT的回顾性分析。选择性别、年龄、体重指数、凝血指标、吸烟史、麻醉方式、手术时长、合并慢性病史等22项与人工关节置换术后DVT形成的可能相关因素进行统计分析。[结果]216例人工膝关节置换术后发生DVT 23例,320例人工髋关节置换术患者术后发生DVT 22例,进行单因素分析表明:年龄、性别、体重指数、D-D、心肌梗死病史、深静脉血栓史是关节置换术后DVT发生的危险因素(P0.05),多因素logistic回归分析表明:年龄、深静脉血栓史使术后发生DVT的风险分别增加到1.058、6.283。[结论]年龄、性别、体重指数、D-D、心肌梗死病史、深静脉血栓史等的患者发生DVT的风险较高。尤其是高龄、深静脉血栓史与术后DVT发生密切相关,需要引起临床医生的重视。     

低分子肝素预防髋膝关节术后下肢深静脉血栓形成

目的 评价低分子肝素预防髋、膝关节术后深静脉血栓形成（DVT）的疗效和安全性。方法 1997年4月－1998年10月选择接受髋、膝周围手术的患者46例均为40岁以上,3个月内无血栓栓塞性疾病史、无凝血功能障碍,术前经彩色多普勒超声法筛查,双下肢无DVT,随机分成两组。预防组应用低分子肝素（速避凝）预防DVT,对照组不采用任何预防措施。术后第4－7天行患侧静脉造影,了解深静脉血栓的发生情况。结果 对照组中8例发生DVT,占34．8％;预防组中1例发生DVT,占4．3％。经统计学处理有显著性差异（P＜0．05）。两组均未发生明显的出血并发症。结论 低分子肝素能安全、有效地预防髋膝关节术后深静脉血栓形成。     

中西药预防下肢深静脉血栓形成血液流变学对比

[目的]通过血液流变学研究,探讨中药血塞通注射液预防下肢深静脉血栓形成的疗效确切性及其安全性。[方法]选择行全髋关节置换术符合研究标准的76例患者,随机分为中药试验组(37例)和西药对照组(39例),均采用相同的基本预防措施和物理预防措施。试验组采用中药血塞通注射液,对照组采用西药低分子量肝素钙针剂,对手术后可能发生的深静脉血栓(DVT)进行预防。比较两组术后DVT发生率及其血液流变学指标变化。[结果]两组76例患者共发生DVT 18例,中药组发生DVT 8例,发生率21.62%;西药组发生10例,发生率25.64%。经统计学检验,DVT发生率差异无统计学意义。两组间术后7d时红细胞变形指数比较差异有统计学意义(P<0.05),其余血液流变学指标变化与对照组相比无统计学意义(P>0.05)。[结论]单独应用中药血塞通注射液预防髋关节置换术后DVT可获得与西药低分子量肝素钙近似的疗效与安全性。     

Late occurring clinical deep vein thrombosis in joint-operated patients

In a prospective study of 4,840 patients, we determined the annual incidence of clinical deep vein thrombosis (DVT) in mobilized, discharged orthopedic-operated "high-risk" patients (hip replacement surgery, knee replacement surgery, nailed hip fracture) and assumed "low-risk" patients (diagnostic knee arthroscopy). In addition, the time from the operation to the time when the patients were readmitted with clinically suspected DVT and the distribution of radiologically-confirmed DVT were recorded. Thromboprophylaxis was routinely given for about 10 days to the high-risk groups during the hospital stay but not to patients undergoing knee arthroscopy. During 9 years, the annual incidence of DVT following major procedures was 2.1% (95% CI 1.6-2.6) vs. 0.6% (95% CI 0.2-1.1) after diagnostic knee arthroscopy. Symptoms appeared, on average, 27 (3-150) days after total hip replacement surgery, 36 (3-150) days after nailed hip fracture, 17 (6-30) days after total knee replacement and 1 (1-6) day after knee arthroscopy. In hip-operated patients, 50% of the DVT's were found in the proximal veins vs. 40% following knee arthroplasty.     

Late occurring clinical deep vein thrombosis in joint-operated patients

In a prospective study of 4,840 patients, we determined the annual incidence of clinical deep vein thrombosis (DVT) in mobilized, discharged orthopedic-operated "high-risk" patients (hip replacement surgery, knee replacement surgery, nailed hip fracture) and assumed "low-risk" patients (diagnostic knee arthroscopy). In addition, the time from the operation to the time when the patients were readmitted with clinically suspected DVT and the distribution of radiologically-confirmed DVT were recorded. Thromboprophylaxis was routinely given for about 10 days to the high-risk groups during the hospital stay but not to patients undergoing knee arthroscopy. During 9 years, the annual incidence of DVT following major procedures was 2.1% (95% CI 1.6-2.6) vs. 0.6% (95% CI 0.2-1.1) after diagnostic knee arthroscopy. Symptoms appeared, on average, 27 (3-150) days after total hip replacement surgery, 36 (3-150) days after nailed hip fracture, 17 (6-30) days after total knee replacement and 1 (1-6) day after knee arthroscopy. In hip-operated patients, 50% of the DVTs were found in the proximal veins vs. 40% following knee arthroplasty.     

Late occurring clinical deep vein thrombosis in joint-operated patients

In a prospective study of 4,840 patients, we determined the annual incidence of clinical deep vein thrombosis (DVT) in mobilized, discharged orthopedic-operated "high-risk" patients (hip replacement surgery, knee replacement surgery, nailed hip fracture) and assumed "low-risk" patients (diagnostic knee arthroscopy). In addition, the time from the operation to the time when the patients were readmitted with clinically suspected DVT and the distribution of radiologically-confirmed DVT were recorded. Thromboprophylaxis was routinely given for about 10 days to the high-risk groups during the hospital stay but not to patients undergoing knee arthroscopy. During 9 years, the annual incidence of DVT following major procedures was 2.1% (95% CI 1.6-2.6) vs. 0.6% (95% CI 0.2-1.1) after diagnostic knee arthroscopy. Symptoms appeared, on average, 27 (3-150) days after total hip replacement surgery, 36 (3-150) days after nailed hip fracture, 17 (6-30) days after total knee replacement and 1 (1-6) day after knee arthroscopy. In hip-operated patients, 50% of the DVT's were found in the proximal veins vs. 40% following knee arthroplasty.     

磺达肝癸钠预防髋膝关节置换术后下肢深静脉血栓形成

目的：探讨磺达肝癸钠预防髋、膝关节置换术后下肢深静脉血栓形成的有效性和安全性。方法：选择89例连续的行人工髋、膝关节置换手术患者,随机分为对照组45例：给予肢体气压泵预防深静脉血栓;磺达肝癸钠组44例：给予磺达肝癸钠联合肢体气压泵预防。术后观察比较血小板、凝血功能指标变化情况及深静脉血栓形成。结果：两组患者总失血量、血小板、凝血酶原时间及活动度与活化部分凝血酶时间变化比较均无统计学差异（P＞0.05）;磺达肝癸钠组无1例发生深静脉血栓,对照组16例深静脉血栓形成（χ2=19.073,P＜0.01）。结论：使用磺达肝癸钠预防髋、膝关节置换术后深静脉血栓形成对凝血功能、血小板无明显影响,是安全有效的。     

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.     

Intermittent pneumatic compression versus coumadin. Prevention of deep vein thrombosis in lower-extremity total joint arthroplasty

One hundred forty-nine consecutive patients requiring lower extremity total joint arthroplasty were randomized to either coumadin (52 patients) or intermittent pneumatic compression (48 patients) as prophylaxis against deep vein thrombosis (DVT). Forty-nine patients were excluded. When fully ambulatory, the presence or absence of DVT was diagnosed by ascending venography (90% of patients), nuclear venography, venous dopplers, or impedence plethysmography. The two groups were similar in average age (64 years), indication for arthroplasty (pain because of arthritis in 90%), gender (98% male), and average number of risk factors (2.4). Twenty-five percent of patients on coumadin and 25% of patients on intermittent pneumatic compression (IPC) developed DVT. IPC was more effective than coumadin following primary total hip arthroplasties (THAs) (16% versus 24% incidence DVT); coumadin was more effective than IPC following primary total knee arthroplasties (TKAs) (19% versus 32% incidence of DVT). DVT developed in 36% of patients following revision arthroplasty. Seventy-five percent of all thrombi were proximal. Both IPC and coumadin were found to be safe; there was no increased perioperative bleeding in the coumadin group. Of three postoperative deaths, one was possibly due to pulmonary embolism (PE).     

磺达肝癸钠联合足底静脉泵预防髋、膝关节置换术后下肢深静脉血栓形成

目的探讨磺达肝癸钠联合足底静脉泵预防髋、膝关节置换患者术后下肢深静脉血栓形成的有效性和安全性。方法根据入选标准选择133例连续的行人工髋、膝关节置换手术患者,随机分为三组：低分子肝素组45例、磺达肝癸钠组43例、磺达肝癸钠＋足底静脉泵组44例．分别给予低分子肝素、磺达肝癸钠、磺达肝癸钠联合足底静脉泵预防深静脉血栓。结果三组患者总失血量、血小板、凝血酶原时间及活动度与活化部分凝血酶时间变化比较均无统计学差异（P〉0．05）;低分子肝素组、磺达肝癸钠组患者术后下肢DVT发生率分别为11．11％（5／45）、9．30％（4／43）,差异无统计学意义（x2=0．078,P〉0．05）,磺达肝癸钠＋足底静脉泵组无1例发生深静脉血栓,与前两组比较均有统计学差异（X2=4．29,P=0．038;）（X^2=5．18,P=0．023）。结论使用磺达肝癸钠预防髋、膝关节置换术后DVT的形成是安全有效的,联合足底静脉泵能够提高预防效果,比单独药物预防更加有效。     

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.