全膝关节置换术后堆叠模式预防血栓的研究

"Stacked modalities" thromboprophylactic therapy for patients undergoing total knee arthroplasty

背景:全膝关节置换术后下肢深静脉血栓(deep vein thrombosis,DVT)的预防一直是存在争议的话题。机械加压法结合使用抗凝剂的联合预防模式已被证实比仅使用机械加压法或仅使用抗凝剂预防的单一预防模式更为有效,但是早期使用抗凝剂潜在增加术后出血的风险。目的:评估全膝关节置换术后早期使用机械加压法,后续联合使用抗凝剂利伐沙班这一贯序法对预防全膝关节置换术后下肢DVT形成的影响。方法:回顾性研究包括754例接受全膝关节置换术的患者。同步组369例,术后早期同步联合使用机械加压法与利伐沙班进行下肢DVT的预防;贯序组385例,术后早期使用机械加压法,术后48 h后再贯序联合使用利伐沙班进行下肢DVT的预防。比较两组在术后第2日,术后第5周下肢近端和远端DVT的发生率及其术后引流量的多少。结果:研究表明术后第2日、术后第5周贯序组与同步组的下肢近端和下肢远端DVT发生率无统计学差异(P>0.05),2组均未发生肺栓塞(pulmonary embolism,PE)。贯序组的引流量明显少于同步组(P<0.001)。结论:术后早期单独使用机械加压法,术后48 h后再联合使用利伐沙班直至术后第5周这一贯序法预防全膝关节置换术后下肢DVT形成的效果与同步法相当,并能减少术后引流量。该贯序模式被称为"堆叠模式"。

Background： Thromboprophylaxis is a controversial and challenging topic in joint replacement. Mechanical prophylaxis in combination with anticoagulants has been shown to have greater efficacy than single pattern（mechanical prophylaxis or anticoagulants）. But the early use of anticoagulants has the potential to increase the risk of postoperative bleeding.Objective： To evaluate the effect of early mechanical compression combined with delayed rivaroxaban on the deep vein thrombosis（DVT） after total knee arthroplasty（TKA）. Methods： A retrospective cohort study including 369 patients receiving simultaneous combined mechanical and pharmacological thromboprophylaxis and 385 patients receiving early mechanical compression treatment followed by rivaroxaban 48 h after primary TKA was conducted. The incidences of proximal and distal DVT on the second day and at the fifth week after surgery and the volume of postoperative wound drainage were compared between two groups. Results： There were no significant differences in the incidence of proximal or distal DVT between two groups（P〈0.05）. No pulmonary embolism（PE） occurred. The mean volume of wound drainage in the sequential group was significantly less than that in the simultaneous group（P〈0.001）. Conclusions： The sequential therapy（mechanical compression in 48 h after TKA followed by rivaroxaban until the fifth week） has the same antithrombotic effect with simultaneous combined thromboprophylactic therapy. Meanwhile, the volume of drainage can reduce greatly. It is called ＂stacked modality＂ thromboprophylactic therapy for DVT.