老年股骨粗隆间骨折患者术后深静脉血栓形成的临床研究及防治策略

Deep vein thrombosis among old patients with intertrochanteric fracture: clinical research and prevention strategies

目的探讨老年股骨粗隆间骨折患者术后深静脉血栓形成的原因以及预防、治疗策略。方法 2008年6月至2014年12月,回顾性分析65岁以上老年股骨粗隆间骨折的患者共341例。经过筛选后,307例患者纳入统计,其中男125例,女182例;平均年龄71.3岁（65~95岁）。采用改良Evans分型：Ⅰ型96例,Ⅱ型117例,Ⅲ型52例,Ⅳ型32例,Ⅴ型10例。其中115例采用髓外固定钢板（动力髋或动力髁螺钉）,192例采用髓内钉固定（股骨近端防旋髓内钉）。纳入研究范围的患者均在术后12~24 h内开始使用低分子肝素预防深静脉血栓,术后使用均在7~10 d范围内,所有患者术后均复查双下肢血管彩超。统计患者病史是否合并有高血压、糖尿病、卒中后遗症,是否行骨牵引,卧床时间长短等可能是导致患者深静脉血栓形成的相关因素。先进行单因素卡方检验,筛选与患者深静脉血栓的形成具有显著统计学关系的因素后再进行多因素非条件Logistic分析,寻找导致老年股骨粗隆间骨折患者术后深静脉血栓形成的高危因素。结果术后彩超证实共并发深静脉血栓51例（16.61%）,发生于近端（股、髂静脉血栓）患者11例（中央型,3.58%）,发生于腘静脉远端血栓患者34例（周围型,11.07%）,混合型6例（1.95%）。17例中央型及混合型静脉血栓患者使用尿激酶溶栓后症状均缓解,无一例发生肺栓塞。单因素卡方检验统计显示患者的性别、术前是否行胫骨结节骨牵引与深静脉血栓的形成无明显统计学关系,而术前卧床时间长短、是否伴有心脑血管病、高脂血症、糖尿病、术中牵拉患肢程度、粗隆间骨折的分型、患者依从性高低等与深静脉血栓的形成显著相关（P〈0.05）。根据这些有显著差异的因素进行的多因素非条件Logistic分析结果显示患者术前卧床时间长短、粗隆间骨折的分型、术中患肢的牵拉程度、陈旧性脑梗死是并发深静脉血栓的高危因素,OR值分别为5.343、3.552、5.774、3.872,P值依次为0.014、0.372、0.011、0.312,患者依从性是并发深静脉血栓的保护因素,OR值为0.445,P值为0.034。结论老年患者股骨粗隆间骨折术后深静脉血栓发生概率高,减少患者卧床时间,避免术中反复牵引以及术后正确的功能锻炼可以降低深静脉血栓的发生概率,有利于患者的康复。

Objective To investigate the causes, prevention and treatment strategies of deep vein thrombosis among elderly patients with the intertrochanteric fracture. Methods From June 2008 to December 2014, 341 cases over 65 years old patients of intertrochanteric fracture were analyzed with the method of retrospective analysis. After screening, 307 cases were included in the statistics, 125 cases male, 182 cases female; average age was 71.3 years（65 to 95 years）. All patients were classified by modified Evans：Ⅰtype 96 cases, Ⅱ type 117 cases, Ⅲ type 52 cases, Ⅳ type 32 cases, Ⅴ type in 10 cases. 115 cases used extramedullary fixation plate and 192 cases were intramedullary nailing. The patients included in the study were started using low molecular weight heparin to prevent deep vein thrombosis, within 12-24 hours and last for 7-10 days after surgery. All patients were reviewed lower limbs vascular ultrasound. Results Postoperative ultrasound confirmed a total of 51 cases complicated with deep vein thrombosis（16.61%）, occurred in the proximal in 11 patients（3.58%）, 34 patients in distal popliteal vein（11.07%）, mixed type in 6 cases（1.95%）. The symptoms of 17 cases central and mixed venous thrombosis after thrombolysis were alleviated with urokinase, no case of pulmonary embolism. The statistics of univariate chi-square test showed that the patient＇s gender, preoperative tibial tuberosity skeletal traction were no significant relationship with deep vein thrombosis. The length of time in bed, cardiovascular disease, hyperlipidemia, diabetes, the extent of intraoperative traction, intertrochanteric fracture type were significantly associated with deep vein thrombosis（P〈0.05）. Multivariate unconditional Logistic regression analysis showed that preoperative length of time in bed, intertrochanteric fracture type, degree of intraoperative limb traction, old cerebral infarction were high risk factors with deep vein thrombosis, OR values were 5.343, 3.552, 5.774, 3.872. The level of patient compliance was a protective factor complicated with deep vein thrombosis, OR value of 0.445. Conclusion The incidence of deep vein thrombosis in elderly patients with intertrochanteric fracture is high postoperative. Reducing time in bed, to avoid repeated traction and proper functional exercise postoperative can reduce the incidence of deep vein thrombosis and is conducive to the rehabilitation of patients.