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。     

彩超检测在预防人工关节置换术后下肢深静脉血栓形成的应用

目的 探讨彩色多普勒超声监测抗凝及早期锻炼预防人工关节置换术后下肢深静脉血栓形成(DVT)的应用价值.方法 对接受人工髋、膝关节置换术患者199例予术前、术后进行双下肢深静脉彩色多普勒超声检测,为术后抗凝及早期锻炼提供依据,并对检出下肢深静脉血栓阳性患者及时进行溶栓等处理,追踪观察治疗效果.结果 149例接受全髋关节置...     

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。     

髋臼骨折术后下肢深静脉血栓形成的多因素分析

目的 分析影响髋臼骨折术后下肢深静脉血栓形成(DVT)的危险因素.方法 对102髋臼骨折术后DVT发生情况进行分析.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,并对11项临床因素与人工关节置换术后DVT形成的相关性进行分析.结果 髋臼骨折术后发生DVT有18例,DVT发生率为17.65%(18/102).经Logistic多因素回归分析,与DVT相关的因素有6个,其中年龄、肥胖、静脉曲张及手术方式使术后发生DVT的风险分别增加到4.075、7.803、46.176和4.251倍(P＜0.05);硬膜外麻醉和踝泵练习使术后发生DVT的风险减少到0.121和0.114倍(P＜0.01).结论 年龄和肥胖是人工关节术后发生DVT的危险因素,而硬膜外麻醉和踝泵练习则是术后发生DVT的保护因素.髋臼骨折术后无症状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.     

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。     

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.     

低分子肝素预防髋、膝关节手术后下肢深静脉血栓形成的多中心研究

目的 探讨国人髋、膝关节手术后下肢深静脉血栓（deepvenous thrombosis，DVT）的发生率及应用低分子肝素预防DVT的有效性和安全性。方法 根据入选标准选择120例髋、膝关节手术患者，分别在北京、上海、广州三个中心参加该项研究，观察组和对照组分别为68例和52例。观察组中男30例，其中全髋关节置换术19例，全膝关节置换术2例，动力髋螺钉（DHS）9例；女38例，其中全髋关节置换术17例，全膝关节置换术17例，DHS4例。对照组中男21例，其中全髋关节置换术19例，全膝关节置换术1例，DHS1例；女31例，其中全髋关节置换术15例，全膝关节置换术15例，DHS1例。结果 除观察组与对照组女性全髋关节置换术患者术中、术后失血量差异有统计学意义（P〈0．05）外，其余出血量差异均无统计学意义（P〉0．05）。手术前后血红蛋白、血小板、凝血酶原时间及活动度与活化部分凝血活酶时间变化差异均无统计学意义（P〉0．05）。两组患者术后下肢DVT发生率差异有统计学意义（P〈0．05）。观察组总的不良反应发生率为8．8％（6.68）。结论 低分子肝素可以有效预防髋、膝关节置换术后DVT的发生，同时对于已发生的DVT有良好的治疗效果，不良反应发生率低。     

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。     

抗凝并早期被动活动预防膝关节置换后深静脉血栓

目的：寻找人工膝关节置换术后下肢深静脉血栓形成（Deep Venous Thrombosis,DVT）的最佳预防方案,评价围手术期抗凝并早期持续被动活动（Continuous Passive Motion,CPM）对人工膝关节置换术后深静脉血栓形成的预防作用。方法：2002年1月～2005年12月对接受人工膝关节置换术者280例（均为单侧关节置换）根据围手术期处理方法的不同,采用分层随机化的方法前瞻性地分成空白对照组（对照组,n=70）、单纯抗凝组（抗凝组,n=70）、单纯早期被动活动组（CPM组,n=70）和抗凝＋CPM锻炼治疗组（观察组,n=70）。手术后第4天观察各组患者下肢的肿胀情况,并行术侧下肢彩色多普勒血管检查,诊断DVT。统计各组中DVT的发生率,采用SPSS11．0统计分析软件进行统计学分析。结果：抗凝组术后DVT发生率25．7％,CPM组30．0％,观察组12．9％,对照组45．7％,经统计学检验,观察组术后DVT发生率明显低于其它各组（P〈0．05）。结论：围手术期抗凝并早期被动活动对人工膝关节置换术后深静脉血栓形成具有明显的预防作用。     

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。     

Changes in LPIA D-dimer levels after total hip or knee arthroplasty relevant to deep-vein thrombosis diagnosed by bilateral ascending venography

 The purpose of the current retrospective study was to determine the most sensitive and specific cutoff value of plasma D-dimer level associated with deep-vein thrombosis (DVT) after total hip (THA) or knee (TKA) joint arthroplasty. Diagnosis of DVT was determined by bilateral ascending venography pre- and postoperatively. Plasma D-dimer levels were measured by a latex photometric immunoassay system (LPIA) preoperatively and postoperatively on days 1, 3, 7, 10, 14, and 21. Postoperative DVT diagnosed by venography was found in 22 patients (40.1%) after THA and in 18 patients (64.3%) after TKA. Plasma D-dimer levels were significantly higher (P < 0.01) in patients with DVT than in those without DVT on days 1, 7, and 10 after THA, but only on day 7 after TKA. Statistical analysis confirmed that a cutoff value of 10.0 μg/ml for D-dimer on day 7 was most sensitive (THA, 95.5%; TKA, 94.4%) and most specific (THA, 96.9%; TKA, 90.0%) in the diagnosis of DVT after THA as well as TKA. It was concluded that over 10 μg/ml of LPIA D-dimer on postoperative day 7 appears to be an indication of the occurrence of DVT after THA and TKA. Received: December 10, 2001 / Accepted: March 18, 2002     

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.     

Postthrombotic syndrome after asymptomatic deep vein thrombosis following total knee and hip arthroplasty

Lower extremity deep vein thrombosis (DVT) is relatively common after total knee arthroplasty (TKA) and total hip arthroplasty (THA). In this study, we sought to identify whether post-thrombotic syndrome is a significant risk in patients with asymptomatic DVT after TKA and THA. Included in the study were 186 patients (203 lower extremities) who had undergone routine lower extremity venography after TKA or THA between 1989 and 1993. Patients were contacted a minimum of 7 years after surgery. Postoperative varicose veins occurred in 8% of limbs without DVT compared with 12% of limbs with DVT. Hyperpigmentation occurred in 13% of limbs without DVT and in 16% and 18% of limbs with proximal and distal DVT, respectively. Swelling occurred in 6% of limbs without DVT, in 8% of limbs with proximal DVT, and in 12% of limbs with distal DVT. None of these differences was statistically significant, and there were no differences for proximal versus distal DVT. There was no significant increase in risk for postthrombotic syndrome after asymptomatic proximal or distal DVT after TKA or THA.     

对全髋与全膝关节置换术后LMWH应用时机的初步研究

目的 探讨全髋与全膝关节置换术后应用低分子肝素(LMWH)预防深静脉血栓(DVT)的时机.方法 158例全髋与全膝关节置换者中髋关节置换(THA)81例、全膝关节置换(TKA)77例.观察术后不同时机使用LMWH对术后引流量、DVT发生率的影响.结果 THA术后开始使用LMWH组引流量与术后72 h组差异具有统计学意义(P=0.000),而TKA术后组与术后72 h组差异无统计学意义(P=0.552).在THA和TKA中,术后组与术后72 h组DVT发生率差异均有统计学意义(P=0.000).结论 THA术后LMWH的最佳应用时机是术后72 h,但术后即应用LMWH则是TKA术后预防DVT的最佳时机.     

膝髋关节置换术围手术期血浆D-二聚体动态监测及临床意义

目的探讨膝、髋关节置换（TKA、THA）围手术期患者血浆D-二聚体动态变化规律并对其进行比较。方法采用免疫比浊法于术前、术后1、3、7、14d测定61例TKA、THA患者围手术期血浆D-二聚体水平,其中男15例,女46例;年龄33～82岁,平均（63.62±10.75）岁。TKA手术36例,其中单侧TKA手术25例,19例使用止血带、6例不使用止血带;双侧同期TKA11例,均使用止血带。单侧THA手术25例。术前、术后7d下肢彩超检查有无深静脉血栓形成。结果术前所有患者均未发现DVT,术后有1例单侧TKA发现右胫后静脉深静脉血栓,发生率1.6%。测得患者术前、术后第1、3、7、14第测得的D-二聚体值分别为（0.39±0.41）、（2.18±1.72）、（0.85±0.39）、（1.32±0.85）、（1.38±0.97）μg/ml,其差异具有统计学意义（F=21.873,P〈0.05）。术后第1天达最高峰。单侧TKA组与单侧THA组比较差异有统计学意义（F=4.216,P〈0.05）,其中术后第1天单侧TKA组明显高于单侧THA组（t=2.251,P〈0.05）;单侧TKA组与双侧TKA组比较差异有统计学意义（F=5.944,P〈0.05）,其中术后第7、14天单侧TKA组均明显低于双侧TKA组（t=2.832,P〈0.05;t=3.110,P〈0.05）;单侧TKA止血带组与非止血带组比较差异无统计学意义（F=2.125,P〉0.05）。结论 TKA、THA术后血浆D-二聚体水平均升高;TKA术后血浆D-二聚体水平明显高于THA。双膝同期TKA术后D-二聚体水平高于单侧TKA。     

关节置换术后下肢深静脉血栓形成的解剖分布

目的 探讨初次全膝关节置换术和全髋关节置换术后下肢深静脉血栓形成的解剖分布特点.方法 回顾性分析2007年6月至2012年5月接受初次全膝关节置换术或全髋关节置换术后经下肢静脉造影诊断为下肢深静脉血栓形成的272例患者的病例资料,全膝关节置换组110例,全髋关节置换组162例.观察静脉造影中两种术式术后下肢深静脉血栓形成的部位及其差异.结果 全膝关节置换组中,中心型血栓10例、周围型血栓94例、混合型血栓6例;全髋关节置换术组中,中心型血栓3例、周围型血栓140例、混合型血栓19例.两组血栓类型的差异有统计学意义(x2=9.996,P=0.007).全膝关节置换术和全髋关节置换术后血栓最易累及部位依次为肌间静脉193例(71.0％,193/272)、胫后静脉98例(36.0％,98/272)、腓静脉85例(31.3％,85/272)、胫前静脉24例(8.8％,24/272)、腘静脉24例(8.8％,24/272)、髂股静脉20例(7.4％,20/272).周围型血栓中,全膝关节置换组比全髋关节置换组更容易累及多支静脉,两组差异有统计学意义(x2=14.712,P=0.000).在孤立性血栓中,无胫前静脉血栓形成.在多支静脉血栓中,两组均以累及胫后静脉、腓静脉、肌间静脉血栓中的两支或三支常见.结论 全膝关节置换术和全髋关节置换术后下肢深静脉血栓形成的解剖分布不同.     

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty

Background and purpose Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization.

Patients and methods 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS).

Results The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9).

Interpretation The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.