单侧全膝关节置换术后下肢肌间静脉血栓形成因素分析及预防

Factors for and prevention of muscular calf vein thrombosis after unilateral total knee arthroplasty

目的调查单侧人工全膝关节置换术(TKA)后肌间静脉血栓形成(MCVT)的相关危险因素及预防。方法回顾性分析2018年1月至2020年10月期间郑州大学第一附属医院骨科收治的551例患者资料。男187例,女364例;年龄32~90岁,平均64.6岁;左膝234例,右膝317例。根据术后第7天是否出现下肢MCVT将其分为MCVT组(n=77)和非MCVT组(n=474)。记录患者的基线资料和术中止血带时间、失血量以及术后凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(FIB)、D-二聚体、血小板计数(PLT)、卧床时间、膝关节功能评分表(KSS)评分、红细胞沉降率(ESR)下降时间、C-反应蛋白(CRP)下降时间等,分析筛选血栓形成的危险因素。结果MCVT组和非MCVT组在年龄[(66.8±7.0)、(64.2±9.6)岁]、体质指数[(28.7±2.2)、(25.0±2.4)kg/m^(2)]、吸烟史(20/57、41/433)、糖尿病(56/21、172/302)、原发性高血压(45/32、174/300)、冠状动脉硬化性心脏病(50/27、204/270)、高脂血症(33/44,149/325)、静脉曲张(50/27、166/308)、止血带时间[(97.9±22.6)、83.1±10.6)min]、术中失血量[(73.2±40.6)、(62.4±11.5)mL]、PT[(10.7±0.8)、(11.9±1.0)s]、TT[(15.2±1.3)、(17.2±2.4)s]、FIB[(3.7±0.8)、(3.2±0.5)g/L]、D-二聚体[(1.1±1.0)、(0.8±0.3)μg/L]、PLT[(233.4±68.5)、(178.5±27.8)10^(9)/L]、卧床时间[(17.3±2.6)、(14.6±3.8)h]、KSS评分[(3.32±0.7)、(3.61±0.56)分]、ESR下降时间[(2.90±0.74)、(1.55±0.64)d]和CRP下降时间[(3.49±0.50)、(1.40±0.50)d],组间比较差异均有统计学意义(P<0.05)。多因素logistic回归分析结果表明:高龄(95%CI:0.890~1.112,P=0.034)、高体重指数(95%CI:1.012~1.214,P=0.046)、合并糖尿病(95%CI:1.002~2.590,P=0.020)、D-二聚体(95%CI:1.239~10.292,P=0.001)和术后PLT(95%CI:1.012~1.112,P=0.014)是术后血栓发生的独立危险因素,术后减少卧床时间(95%CI:1.009~1.469,P=0.040)是保护性因素。结论高龄、高体重指数、合并糖尿病、D-二聚体和术后PLT是术后血栓发生的独立危险因素,对具有这些特征的患者应警惕MCVT,临床医生应指导患者术后减少卧床时间,早期下地活动以预防MCVT。

Objective To investigate the factors for and prevention of muscular calf vein thrombosis(MCVT)after unilateral total knee arthroplasty(TKA).Methods Between January 2018 and October 2020,551 patients were admitted to Department of Orthopedics,The First Affiliated Hospital to Zhengzhou University for unilateral TKA.They were 187 males and 364 females,aged from 32 to 90 years(average,64.6 years)and with 234 left and 317 right knees affected.They were assigned into a MCVT group(n=77)and a non-MCVT group(n=474)according to whether or not MCVT had happened at 7 days after operation.Recorded were the patients’baseline information,tourniquet time,intraoperative blood loss,postoperative prothrombin time(PT),postoperative thrombin time(TT),postoperative fibrinogen(FIB),D-dimer,platelet count(PLT),postoperative bed time,knee society score(KSS),erythrocyte sedimentation rate(ESR)fall time,and C-reactive protein(CRP)fall time so as to analyze the risk factors for MCVT.Results There were significant differences between the 2 groups in age[(66.8±7.0)versus(64.2±9.6)years],body mass index(BMI)[(28.7±2.2)versus(25.0±2.4)kg/m^(2)],smoking(20/57 versus 41/433),diabetes(56/21 versus 172/302),primary hypertension(45/32 versus 174/300),coronary heart disease(50/27 versus204/270),hyperlipidemia(33/44 versus 149/325),varicosity(50/27 versus 166/308),tourniquet time[(97.9±22.6)versus(83.1±10.6)min],intraoperative blood loss[(73.2±40.6)versus(62.4±11.5)mL],postoperative PT[(10.7±0.8)versus(11.9±1.0)s],TT[(15.2±1.3)versus(17.2±2.4)s],FIB[(3.7±0.8)versus(3.2±0.5)g/L],D-dimer[(1.1±1.0)versus(0.8±0.3)μg/L],PLT[(233.4±68.5)versus(178.5±27.8)10^(9)/L],postoperative bed time[(17.3±2.6)versus(14.6±3.8)h],KSS[(3.32±0.7)versus(3.61±0.56)points],ESR fall time[(2.90±0.74)versus(1.55±0.64)d]and CRP fall time[(2.90±0.74)versus(1.55±0.64)d](all P<0.05).Multivariate logistic regression analysis showed that old age(95%CI:0.890 to 1.112,P=0.034),high BMI(95%CI:1.012 to 1.214,P=0.046),diabetes(95%CI:1.002 to 2.590,P=0.020),D-dimer(95%CI:1.239 to 10.292,P=0.001)and postoperative PLT(95%CI:1.012 to 1.112,P=0.014)were independent risk factors for MCVT.Reduced postoperative bed time(95%CI:1.009 to 1.469,P=0.040)was a protective factor.Conclusions As old age,high BMI,diabetes,and high postoperative levels of D-dimer and PLT may be independent risk factors for MCVT,patients with such characteristics should be alert to MCVT.Early ambulation should be encouraged in patients after unilateral TKA to reduce postoperative bed time for prevention of the disease.