全髋关节成形术后静脉血栓栓塞性疾病预防治疗

静脉血栓栓塞性疾病(VTE)是全髋关节成形术后常见的并发症,以深静脉血栓和肺栓塞更具有潜在的致命危险,已引起临床医生高度关注.药物和机械性方法是预防治疗VTE的有效手段.药物预防治疗的同时也带来一定的出血风险,且使用时需经实验室检查监测;机械性措施可避免这些问题,但病人无法在出院后继续使用,可作为药物预防治疗的辅助措施.未来有望以基因测定为基础进行风险评估,以制定个性化的预防治疗方案.     

Deep venous thrombosis in total hip arthroplasty.

Deep venous thrombosis (DVT) is the most common complication of total hip arthroplasty. This article discusses the pathogenesis and diagnosis of DVT and recommends prophylaxis and treatment options.     

综合预防全髋关节置换术后深静脉血栓形成的发生

目的总结预防全髋关节置换术（THA）后深静脉血栓形成（DVT）的经验。方法对2010年2-8月共43例（48髋）患者行THA,通过仔细操作、患肢抬高和主动锻炼、药物（磺达肝癸钠）等综合措施预防下肢DVT,随访血管彩色多普勒超声,对比术前、术后1周、术后3个月的结果,观察伤口情况。结果43例患者中仅l例术后1周血管彩色多普勒发现小腿肌间静脉血栓形成,但无症状。2例伤口周围出现明显瘀斑,1例伤口渗出,停用磺达肝癸钠后渗出消失,伤口愈合良好。结论通过综合预防措施,可以减少THA术后DVT的发生率。     

Atypical pseudotumour after metal-on-polyethylene total hip arthroplasty causing deep venous thrombosis

We describe a patient who developed a mass extending into the pelvis, five years after a metal-on-polyethylene total hip arthroplasty (THA). The histological pattern of perivascular lymphocytic infiltrate and fibrinoid necrosis was more in keeping with a metal-on-metal bearing failure. The pseudotumour compressed the femoral vein causing a deep venous thrombosis.     

Deep venous thrombosis after mini-posterior total hip arthroplasty in Japanese patients

We conducted a retrospective study of the occurrence of deep venous thrombosis (DVT) following mini-posterior total hip arthroplasty (THA) in Japanese patients. From May 2004 to December 2009 mini-posterior THA was performed on 1659 cases, of whom 603 cases didn't receive anticoagulants (Group 1), 547 cases received 2.5 mg percutaneous injection of fondaparinux (a factor Xa inhibitor) daily for 7 days starting the day after surgery (Group 2), and 509 cases received 2000 IU percutaneous injection of enoxaparin (low-molecular-weight heparin) twice daily for 7 days starting the day after surgery (Group 3). The baseline characteristics were very similar in each group. All patients started walking the day after surgery, were advised to wear graduated compression stockings for six weeks after the operation, and used a foot pump for 3 hours a day postoperatively for several days. A week after surgery Duplex ultrasound with colour-flow Doppler imaging of the lower extremities was performed. The occurrence of DVT was significantly different between Groups 1, 2, and 3 (p<0.001): 57 cases (9.5%), 4 cases (0.7%), and 0 cases (0%), respectively. No patients of any group had clinically detected pulmonary emboli. In this study we showed that adding anticoagulants with foot pumps further reduced the incidence of DVT, which seldom occurs following less invasive mini-posterior THA combined with early mobilisation, foot pumps, and anticoagulants.     

Late deep venous thrombosis and delayed weightbearing after total hip arthroplasty

One hundred ninety-nine patients who underwent primary total hip arthroplasty and used in hospital pneumatic compression stockings and aspirin as thromboembolic prophylaxis were screened for deep venous thrombosis using duplex ultrasonography on the fourth postoperative day. Of the initial 98 patients, 21 underwent noncemented arthroplasty, maintained touchdown weightbearing for 6 weeks after surgery, and then began progressive partial weightbearing. Of the subsequent 101 patients, 28 underwent noncemented arthroplasty and began progressive weightbearing immediately after surgery. All other patients underwent hybrid arthroplasty and began weightbearing to tolerance immediately after surgery. After duplex screening examination, patients with proximal deep venous thrombosis were given anticoagulation therapy, and patients with negative study results were observed clinically. The relative risk of proximal deep venous thrombosis after noncemented arthroplasty using delayed weightbearing was compared with that after noncemented arthroplasty using immediate progressive weightbearing. Of patients with noncemented arthroplasty, the prevalence of proximal deep venous thrombosis was significantly lower in those using progressive weightbearing immediately after surgery (none) than in those using delayed weightbearing rehabilitation (19%). This study showed that patients undergoing noncemented total hip arthroplasty with delayed weightbearing rehabilitation risk greater potential for deep venous thrombosis after hospital discharge. This study suggests consideration for continued thromboembolic prophylaxis or routine deep venous thrombosis surveillance, or both measures, after hospital discharge, unless more rapid progression of weightbearing is allowed.     

Prophylaxis of heterotopic ossification after total hip arthroplasty

We performed a randomized, prospective study on the prophylaxis of heterotopic ossification (HO) after total hip arthroplasty (THR), comparing indomethacin and the selective COX-2 inhibitor meloxicam. From the day after surgery, 272 patients were treated with 7.5 mg meloxicam, 15 mg meloxicam, or 2 × 50 mg indomethacin a day, for 14 days. After 6 months, radiographs of patients treated with 7.5 mg meloxicam showed that HO had occurred in one third. This treatment was therefore stopped after 26 patients have been assigned to this group. According to the intention-to-treat principle, patients given 15 mg meloxicam developed HO in 25% (20% Brooker grade I,4% grade II and 1 % grade III) and those given indomethacin in 10% (7% Brooker grade I,1% grade II and 2% grade III), a statistically significant difference.     

Deep venous thrombosis after total hip or total knee arthroplasty in patients in Japan

A single center, prospective, epidemiologic study was conducted to estimate the incidence of deep venous thrombosis detected by venography in patients in Japan undergoing total hip arthroplasty or total knee arthroplasty without prophylactic anticoagulant therapy. Venograms of 164 patients who had total hip arthroplasty and 138 patients who had total knee arthroplasty were evaluated. The incidences of deep venous thrombosis were 22.6% in patients who had total hip arthroplasty and 48.6% in those who had total knee arthroplasty. The incidences of proximal deep venous thrombosis were 9.8% in patients who had total hip arthroplasty and 14.5% in those who had total knee arthroplasty. Statistical analysis revealed that the type of operation influenced the development of deep venous thrombosis. Patients who had total knee arthroplasty were 3.2 times more likely to have deep venous thrombosis develop than were patients who had total hip arthroplasty. Body mass index and age were identified as statistically significant risk factors.     

Upper extremity deep venous thrombosis leading to pulmonary embolism after total hip arthroplasty

Upper extremity deep venous thrombosis most commonly occurs secondary to the presence of subclavian central venous catheters. Of all upper extremity deep venous thromboses, 12% may cause pulmonary embolism; however, pulmonary embolism from a so-called primary thrombosis is uncommon. We report an unusual case of pulmonary embolism after primary deep venous thrombosis in the down arm after total hip arthroplasty.     

Simple,hybrid deep venous thrombosis/pulmonary embolus prophylaxis after total hip arthroplasty

A 7.1% deep venous thrombosis rate followed total hip arthroplasty in 56 patients using a hybrid prophylactic regimen against deep venous thrombosis and pulmonary embolus. There were no bleeding complications, no symptomatic pulmonary emboli, and no unexplained deaths. The regimen consisted of an initial loading dose of warfarin, usually 10 mg, the night of surgery followed by 2.5 mg/day for 3 weeks, with dosage adjustments only in cases of over-anticoagulation. This regimen was combined with elevated sling suspension of the operative leg, bilateral pedal intermittent pneumatic compression devices, and early mobilization. This prophylactic regimen is simple, inexpensive, efficacious, and compatible with an early hospital discharge.     

Factor V Leiden and the risk of proximal venous thrombosis after total hip arthroplasty

Deep vein thrombosis (DVT) remains a major cause of morbidity in patients undergoing total hip arthroplasty (THA). Despite postoperative DVT prophylaxis, 20–50% of THA patients still develop DVT. Currently, there is no accurate way of predicting which patients will develop DVT despite standard prophylaxis. The presence of factor V Leiden is the most common cause of inherited DVT risk. It has been postulated that patients who have factor V Leiden and are subjected to thrombogenic stressors such as THA would have an increased risk of thrombosis. The factor V Leiden genotype of 36 patients who developed proximal DVT after surgery and 45 control patients who had THA but did not develop DVT was determined. All patients had had prophylaxis against thrombosis using intermittent pneumatic compression alone or in combination with warfarin or aspirin. Surveillance for proximal DVT was performed on all patients prior to discharge by duplex ultrasound. The 2 groups were similar in age, sex, and type of operation. Three of 36 study patients who had developed DVT (8%) and 2 of 45 control patients who had not developed DVT (4%) were heterozygotes for factor V Leiden; these prevalences were not statistically different. Heterozygosity for factor V Leiden is not associated with DVT prophylaxis failure in patients undergoing THA.     

Long-term clinical observations and venous functional abnormalities after asymptomatic venous thrombosis following total hip or knee arthroplasty

The long-term clinical and physiological sequelae of venographically diagnosed, asymptomatic postoperative venous thrombosis were studied in a group of 51 patients following total hip or total knee arthroplasty. After a mean follow-up period of 49.7 months, the patients were recalled for interview, physical examination, air plethysmography (APG), and photoplethysmography (PPG). At the time of follow-up examination, legs with prior postoperative venous thrombosis were not more likely to have clinical findings of deep venous insufficiency than legs with a negative venogram. Abnormal venous emptying, as measured by APG, was significantly correlated (p less than 0.005) with postoperative venous thrombosis and was found in patients with both proximal and calf vein thrombi, but was not clearly associated with symptoms. There was, however, a significant correlation (p less than 0.0005) between clinical findings of venous insufficiency and incompetent valves, as reflected by rapid refilling time after exercise shown by PPG. The findings indicate that asymptomatic postoperative venous thrombosis involving calf or proximal veins can lead to abnormal vein function, but is not closely correlated with later development of symptoms. These observations also suggest that symptomatic venous insufficiency is more closely associated with calf vein valve incompetence than with proximal vein obstruction.     

The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty

The purpose of this study was to investigate the effectiveness of intermittent pneumatic compression of the plantar venous plexus with the newly developed arteriovenous impulse system. Seventy-four patients about to undergo primary unilateral total hip arthroplasty for osteoarthrosis, all receiving a standard thrombosis prophylaxis regime of thigh-length anti-embolic stockings, 5,000 IU heparin delivered subcutaneously twice daily, and 400 mg hydroxychloroquine sulfate delivered twice daily, were entered in a prospective trial. The patients were allocated at random to also receive the arteriovenous impulse system on the foot of the operated side. On approximately postoperative day 12 bilateral ascending venography was performed. There were 44 patients in the nonpumped group and 30 patients in the pumped group. The incidence of deep venous thrombosis was 6.6% in the pumped group and 27.27% in the non-pumped group. The incidence of thrombosis was significantly lower in the pumped group (P<.025). The authors conclude that chemical prophylaxis plus the use of the mechanical, pneumatic, and arteriovenous impulse system reduces the incidence of thromboembolic complications further than chemical prophylaxis alone.     

利伐沙班与低分子量肝素在初次全髋关节置换术后深静脉血栓形成防治中的比较研究

目的 通过比较利伐沙班与低分子量肝素(LMWH)在初次全髋关节置换(THA)术后下肢深静脉血栓形成(DVT)防治中的作用,评估利伐沙班的有效性、安全性以及其足疗程应用防治血栓的必要性. 方法 对2008年1月至2010年4月收治的136例单侧初次行THA患者进行回顾性分析,根据术后预防DVT使用药物不同分为利伐沙班组和LMWH组,每组各68例.利伐沙班组男28例,女40例;平均(61.6±10.7)岁,体质量平均(63.9±11.2) kg.LMWH组男31例,女37例;平均(60.3±12.4)岁,体质量平均(65.5±9.8) kg.两组患者治疗前一般资料差异无统计学意义,具有可比性.LMWH组术后应用时间为1周,利伐沙班组术后应用时间分别为2周38例,5周30例.比较分析两组患者应用药物前、后血红蛋白、血小板、凝血功能情况,以及症状DVT发生率、轻微和严重出血事件发生率. 结果 两组患者手术前、后血红蛋白、血小板、凝血功能、轻微和严重出血事件发生率比较差异均无统计学意义(P＞ 0.05),LMWH组症状DVT发生率为7.4％,利伐沙班组为0,两组比较差异有统计学意义(P＜0.05). 结论 与LMWH比较,初次THA术后DVT防治中利伐沙班更安全、有效,足疗程抗凝十分必要.     

利伐沙班预防全髋关节置换术后深静脉血栓的临床效果

目的 评价利伐沙班预防全髋关节置换术后深静脉血栓（DVT）的临床效果.方法 将312例行全髋关节置换术的患者随机分为对照组（皮下注射低分子肝素钙,n=156）和实验组（口服利伐沙班,n=156）.检测术前及术后14 d的凝血指标,B超检查评价DVT的发生情况.观察术后肺栓塞、严重器官出血及切口大血肿等并发症,记录术后24 h内切口引流量.结果两组术后14 d的凝血指标与术前比较差异无统计学意义（P〉0.05）,术后14 d两组间比较差异亦无统计学意义（P〉0.05）.实验组的DVT发生率低于对照组（P〈0.05）.两组均未出现肺栓塞、严重器官出血及切口大血肿;术后24 h两组引流量比较差异无统计学意义（P〉0.05）.结论利伐沙班可以有效预防全髋关节置换术后DVT的发生,抗凝效果显著优于低分子肝素钙,且不增加潜在的出血风险.     

A venous foot pump reduces thrombosis after total hip replacement.

In a prospective, randomised controlled trial, the efficacy of the A-V Impulse System in the prevention of deep-vein thrombosis was investigated in 84 patients who had undergone total hip replacement. The incidence of venographically proven, and clinically significant postoperative deep-vein thrombosis was 40% in the control group and 5% in the treatment group (p less than 0.001). No adverse reactions were recorded.     

阿司匹林预防髋关节置换术后深静脉血栓形成

目的评价阿司匹林用于髋关节置换术后深静脉血栓预防的疗效与安全性。 方法前瞻性纳入60岁以上髋关节置换术患者,排除凝血异常者,共124例,对研究者设盲,按抗凝药物不同以随机数字表分为4组,分别为对照组、阿司匹林组、序贯治疗组、联合治疗组,每组31例,比较术后5周深静脉血栓、出血事件发生率,比较各组药物费用。计量资料比较采用单因素方差分析,计数资料采用卡方检验。 结果术后5周总深静脉血栓发生率为3.2%,各组间深静脉血栓发生率相当,差异没有统计学意义(χ²＝2.067,P>0.05),各组未发生严重出血事件,阿司匹林组抗凝药物费用显著低于其他3组(t＝16.472,P<0.001)。 结论阿司匹林单独用于髋关节置换术后深静脉血栓预防安全有效。