低分子肝素预防人工髋、膝关节置换术后下肢深静脉血栓形成的研究

目的 对比观察采用低分子有直素预防人工髋、膝置换术（ＴＨＲ、ＴＫＲ）后下肢深静脉血栓形成（ＤＶＴ）的临床效果。方法 将１９９７掉１１月－１９９９年３月行人工髋膝置换术的患者随机分为未用药组和用药组,其中未用药组共４７例患者,６２例关节置换,未预防性使用低分子肝素抗凝;用药组共３１例患者,３６例关节置换（１９膝,１７髋）,围手术期给予低分子肝素预防治疗。两组患者均于术后行下肢静脉造影检查。结果 用药     

利伐沙班预防全膝关节置换术后静脉血栓栓塞症的临床研究

目的探讨利伐沙班和那曲肝素在预防人工膝关节表面置换术（TKA）术后静脉血栓栓塞症（VTE）的疗效和抗凝并发症方面的差异。方法接受初始单侧膝关节表面置换手术的骨关节炎患者75例,随机分为利伐沙班组（n=50）和那曲肝素组（n=25）。监测术后1、3、5 d血常规并记录异体血输血率和输血量,测量术前和术后1、3和5 d大腿周径,了解肢体肿胀程度。观察切口愈合情况,记录切口并发症。同时,根据肢体肿胀程度查下肢血管超声诊断或排除VTE。结果利伐沙班组发生1例股深静脉血栓（2.00%）,那曲肝素组无VTE发生,VTE发生率无组间统计学差异（P〉0.05）。两组均无大出血事件发生。利伐沙班组5例发生小出血事件,那曲肝素组为2例,小出血事件发生率无组间统计学差异（P〉0.05）。利伐沙班组2例切口乙级愈合,那曲肝素组全部甲级愈合,切口感染率无组间统计学差异（P〉0.05）。利伐沙班异体输血率54.00%,输血量（286.00±302.38）ml,相对那曲肝素组无统计学差异（P〉0.05）。利伐沙班组与那曲肝素组患者术后大腿周径变化总体无组间统计学差异（P〉0.05）。结论本组数据显示利伐沙班预防TKA术后VTE的疗效和出血并发症与那曲肝素大致相当。     

A prospective comparison of warfarin to aspirin for thromboprophylaxis in total hip and total knee arthroplasty

Current orthopedic practice requires consideration of contradictory recommendations regarding pulmonary embolism (PE) prevention among patients undergoing total hip arthroplasty (THA) and knee joint arthroplasty (TKA). A total of 696 consecutive patients underwent elective THA or TKA. Two hundred eighty-one patients received PE risk stratification per American Academy of Orthopaedic Surgeons guidelines. Of these patients, 152 standard-risk patients received aspirin, and 129 elevated-risk patients received warfarin. The comparator group of 415 patients received American College of Chest Physicians-recommended warfarin without PE risk stratification. Primary study outcomes were symptomatic PE, deep venous thrombosis, major bleeding, and death. The rate of symptomatic PE and venous thromboembolism among standard-risk group patients receiving aspirin was greater than the comparator group (4.6% vs 0.7% and 7.9% vs 1.2%, respectively). Most events (16/18) occurred among patients undergoing TKA. Patients with total joint arthroplasty at standard risk for PE receiving aspirin had a higher rate of symptomatic PE and venous thromboembolism than did patients receiving anticoagulation.     

Postoperative management after total hip and knee arthroplasty

Despite major advances in the field of total joint arthroplasty, a standardized postoperative management protocol currently does not exist following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A survey was mailed to the active members of the American Association of Hip and Knee Surgeons to investigate issues such as postoperative rehabilitation and activity restriction. The information derived from this survey provides the total joint surgeon with a compilation and consensus of responses that can serve as the foundation for a standardized postoperative protocol for THA and TKA surgery.     

Nonsurgical complications after total hip and knee arthroplasty

Postoperative medical complications after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may occur in patients of any age. However, percentage of adverse events increases with increasing patient age and can cause significant morbidity and even mortality. It is important that the orthopedist identify risk factors and symptoms and be knowledgeable in the treatment of nonsurgical postoperative complications. Nonsurgical complications after THA and TKA include pulmonary embolism, fat embolism syndrome, pneumonia, myocardial infarction, postoperative delirium, cerebrovascular accident, urinary retention, urinary tract infections, and deep vein thrombosis.     

New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty

Patients undergoing total hip arthroplasty(THA)are at high risk for developing venous thromboembolism and,therefore,require short term prophylaxis with antithrombotic agents.Recently,target specific oral anticoagulants(TSOA)including the direct thrombin inhibitor,dabigatran,and the factorⅩa inhibitors rivaroxaban,apixaban,and edoxaban have been approved for THA thrombopropylaxis in various countries.The TSOAs provide a rapid acting,oral alternative to parenteral agents including low-molecular weight heparins(LMWH)and fondaparinux;and compared to warfarin,they do not require routine laboratory monitoring and possess much fewer drug-drug interactions.Based on phaseⅢclinical studies,TSOAs have established themselvesas an effective and safe option for thromboprophylaxis after THA compared to LMWH,particularly enoxaparin,but require additional evaluation in specific populations such as the renally impaired or elderly.The ability to monitor and reverse these TSOAs in the case of bleeding complications or suspected sub-or supra-therapeutic anticoagulation is of importance,but remains investigational.This review will focus on the drug-specific characteristics,efficacy,safety,and economic impact of the TSOAs for thromboprophylaxis following THA,as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal.     

Reinfusion drains after primary total hip and total knee arthroplasty

The purposes of this study were to evaluate the efficacy of intraoperative surgeon-elected reinfusion drain placement and to determine whether drainage at 90 minutes is useful in predicting the need for a reinfusion drain. In the standard drain hip arthroplasty group, 6 of 30 patients (20%) received a reinfusion, similar to the 11 of 41 patients (27%) in the reinfusion drain group. In the total knee arthroplasty group, 38 of 45 patients (84%) in the standard group had reinfusion, similar to the 23 of 27 patients (85%) in the reinfusion drain group. The surgeon could not predict intraoperatively which patients would need a subsequent reinfusion drain. However, in more than 94% of the cases, one could know by 90 minutes postoperatively whether a reinfusion would be necessary. We believe that a drain that can be converted to a reinfusion drain in the recovery room would be the most cost-effective drain system.     

Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression

After total hip (THR) or knee replacement (TKR), there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin (LMWH). In a prospective, randomised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR. We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings. Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression. In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6% (40% after TKR, 14% after THR). This difference was significant (p < 0.0001). In the early post-operative phase after THR and TKR, combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings.     

Duplex ultrasonography after total hip or knee arthroplasty

We prospectively studied all patients admitted for total hip (THR) or knee (TKR) arthroplasty from July 2000 to February 2001. No pharmacological anticoagulation was given. All patients received a standardized postoperative rehabilitation regimen. Forty-six patients with known risk factors for deep vein thrombosis (DVT) were excluded. Eighty patients were studied (22 THR, 58 TKR; 55 women, 25 men). Mean age was 68 (30-90) years. Duplex ultrasonography on both lower limbs was performed on days 5-7 postoperatively. Location and extent of any thrombus were documented. In patients with distal DVT, a follow-up scan was done on days 10-14. If proximal propagation was observed, patients received full anticoagulation. If no propagation was detected, the distal thrombus was considered stable and clinical observation was continued. In the THR group, 1/22 and in the TKR group 9/58 were found to have distal DVT. All were asymptomatic. On follow-up scanning, none showed proximal propagation. All patients were followed up for at least 18 months, and none showed postthrombotic symptoms. Isolated distal DVT in "low-risk" Chinese patients after THR or TKR is not uncommon. Clinically they are usually "silent." If routine perioperative pharmacologic antithrombotic prophylaxis is not practiced, monitoring with duplex ultrasonography may need to be considered.     

Portable compression device and low-molecular-weight heparin compared with low-molecular-weight heparin for thromboprophylaxis after total joint arthroplasty

This preliminary prospective study to determine the rate of deep venous thrombosis (DVT) examined 277 patients undergoing total knee or total hip arthroplasty (TKA or THA) who were randomized to use a portable, continuous enhanced circulation therapy (CECT) compression device and low-molecular-weight heparin (LMWH) or to receive LMWH alone. Patients were screened for DVT using duplex ultrasound at hospital discharge and followed clinically for 3 months. In TKA, 5 DVTs (6.6%) occurred in the CECT + LMWH group compared with one pulmonary embolism and 14 DVTs (19.5%) in the LMWH group (P = .018). In THA, 1 DVT (1.5%) occurred in the CECT + LMWH group and 2 DVTs (3.4%) occurred in the LMWH group. This preliminary study demonstrated significant reduction in rate of DVT after TKA when the CECT device was combined with LMWH.     

Current methods of thromboprophylaxis in total hip arthroplasty]

The paper presents a review of methods of thromboprophylaxis, with regard given to both pharmacological and physiotherapeutic means in patients who underwent a total hip replacement procedure. Routine procedure should involve proper assertion of indications for surgical treatment, appropriate preoperative planning, surgery carried out in conduction anaesthesia, in the shortest possible time and as atraumatically as possible. Several weeks' of pharmacological treatment involving use of low molecular weight heparins in unison with mechanical means e.g. elastic stockings should follow surgical intervention. Quick mobilization of the patient following the surgical procedure along with intensive physiotherapy results in a decrease of the risk of thrombosis. In order to increase the efficiency of thromboprophylaxis different preventive methods should be applied simultaneously.     

Outpatient total hip and knee arthroplasty

As a result of the introduction of fast-track programs, the length of hospital stay after arthroplasty has decreased to a point where some patients meet the discharge criteria on the day of surgery. In several studies, well-established fast-track centers have demonstrated the feasibility of outpatient procedures in selected patients. However, in literature the term “outpatient” is sometimes also used for patients who spend one or more nights in hospital. We therefore propose to use “outpatient” solely for patients who are discharged to their own home on the day of surgery and do not have an overnight stay at either the hospital or another non-home facility. Also, several challenges need to be overcome before this becomes an established procedure. The combination of preoperative high-dose steroids and multimodal opioid-sparing analgesia has enhanced patient recovery after arthroplasty, but efforts to control undesirable pathophysiological responses will be a prerequisite to improve the success rate of an outpatient setting. Also, care must be taken to avoid extra activities or investments solely to enable discharge on the day of surgery. Further cost analyses will have to be performed to establish the true financial benefit of outpatient treatment.     

低分子肝素和利伐沙班在髋膝关节置换中的应用

下肢深静脉栓塞是髋膝关节置换术后常见并发症,危险性大。目前对临床应用广泛的低分子肝素的有效性及安全性存在一定的争议,对其不良反应研究报道较少。大规模临床试验显示,逐渐应用于临床的利伐沙班作为一种新型口服抗凝药,具有较好的疗效及安全性。该文就低分子肝素和利伐沙班在预防髋膝关节置换术后下肢深静脉栓塞形成中的作用作一简要综述。     

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。     

Outcomes of total hip and knee arthroplasty after cardiac transplantation

The outcomes of 18 primary or revision total hip (THA) and knee arthroplasties (TKA) in 9 patients with cardiac transplants were reviewed. Primary total joint arthroplasties were performed for osteonecrosis (5 hips) or osteoarthritis (5 hips, 4 knees). There were no infections in any of these patients. Final Harris Hip Scores were 71.8 for patients with osteonecrosis and 88.6 for osteoarthritis. Eight of 10 hips were pain-free at final follow-up. Two of the 10 primary THAs required late revision at 7 and 10 years after the index arthroplasty. One patient (2 hips and 1 knee) had chronic bilateral lower extremity pain. Total knee arthroplasty range of motion averaged from 7.5° to 118°. Average final Knee Society function score was 79, and objective score was 88. One of 4 patients with primary TKA required a manipulation under anesthesia. No reoperations were required in this group. Overall, patients with heart transplantations on immunosuppression had generally good pain relief after THA and TKA. There were no infections in this small cohort; however, there were many complications.