Thrombosis prediction within short time after total knee arthroplasty: dynamic monitoring of D-Dimer and fibrin degradation products

doi:10.3969/j.issn.2095-4344.2015.17.007

Abstract

Abstract:

BACKGROUND: Deep vein thrombosis after total knee arthroplasty has attracted increasing attention in recent years, but how to detect deep vein thrombosis in the early time in clinical practice remains unclear. Whether it is necessary to perform type-B ultrasonic or other invasive examination in lower limbs has become a hot issue.

OBJECTIVE: To explore the significance of D-Dimer and fibrin degradation products in the prediction of deep vein thrombosis after total knee arthroplasty.

METHODS: 56 patients received total knee arthroplasty were collected from Department of Orthopedics, The 306^th Hospital of Chinese PLA, between December 2012 and February 2014. The D-Dimer and fibrin degradation products were dynamically monitored before operation and at 1, 3, 5, 7, 10 days post-operation. All the patients received type-B ultrasonic examination in double lower limbs at 10 days post-operation, and divided into thrombus group and non-thrombus group. The D-Dimer and fibrin degradation products in the two groups were compared.

RESULTS AND CONCLUSION: Deep vein thrombosis was found in 13 cases by ultrasonic-B postoperation, D-Dimer and fibrin degradation products showed no significant difference between the two groups at 1 week after operation (P > 0.05), but the difference was significant at 10 days (P < 0.01). D-Dimer and fibrin degradation products index should be monitored dynamically for at least 10 days after operation, which is helpful for the early diagnosis of thrombosis.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: Arthroplasty, Replacement, Knee, Fibrin Degradation Product, Venous Thrombosis

CLC Number:

R318

Yuan Wei, Ma Hua-song, Wang Xiao-ping, Chen Zhi-ming, Lu Ming, Xu Qi-ming, Ren Dong-yun. Thrombosis prediction within short time after total knee arthroplasty: dynamic monitoring of D-Dimer and fibrin degradation products[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(17): 2661-2666.

Figures/Tables 5

2.6 典型病例男性患者，70岁，主因右膝关节疼痛5年余，加重半年入院。根据症状、体征及影像学检查，右膝骨关节炎诊断明确。行右膝人工膝关节置换。置换前D-D二聚体为190 μg/L，纤维蛋白降解产物为1.41 μg/L；置换后第1，3，5，7，10天的D-D二聚体水平分别为18 153，1 058，983，1 073，882 μg/L；纤维蛋白降解产物水平分别为144，7.8，7.2，7.23，6.9 μg/L。置换后10 d患者行下肢血管B超未见血栓，无不良事件发生，见图2。 2.7 不良事件置换后2例患者出现并发症。其中1例患者置换后出现术侧肢体膝关节周围、小腿及足踝严重肿胀，皮肤软组织张力高，伴较多张力性水泡，分析原因，可能与置换后伤口引流管引流不畅，积血渗入到组织间隙有关，另外，该患者形体较瘦，小腿肌肉容积及脂肪均少，可容纳渗血空间小，另外，亦不除外该患者术区内有小动脉活动性出血，致使置换后患肢肿胀严重。对这位患者，置换后发现肿胀严重后即停抗凝药，查下肢血管B超见下肢静脉回流缓慢，但未见血栓，嘱其减少下床，卧床并抬高患肢，行0°-45° CPM功能锻炼，张力性水泡予以穿刺引流后定期消毒创面，预防感染。约1周后，患者肢体肿胀情况明显减轻，开始加大屈膝功能锻炼角度，伤口延期拆线，未出现伤口开裂情况，愈合良好。另1例患者置换后1周后开始出现术侧肢体小腿外侧、小腿后方、大腿外侧及膝前伤口周围大片皮下淤血，淤血颜色较深，范围较广，但未发现全身其他部位异常出血，给予患者停抗凝药，嘱其加强双下肢肌肉按摩，物理预防下肢深静脉血栓，之后患者行下肢血管B超未见血栓，患膝屈伸功能恢复良好，伤口愈合良好。"

References

[1]Kanchanabat B,Stapanavatr W,Meknavin S,et al.Systematic review and meta-analysis on the rate of postoperative venous thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis.Br J Surg. 2011;98(10): 1356-1364.
[2]Lieberman JR,Geerts WH.Prevention of venous thromboembolism after total hip and knee arthroplasty. J Bone Joint Surg(Am). 1994;76:1239-1250.
[3]邱贵兴,戴尅戎,杨庆铭,等.预防骨科大手术后深静脉血栓形成的专家建议-深静脉血栓形成预防座谈会纪要[J].中华骨科杂志, 2005,25(10):636-640．
[4]中华医学会骨科学分会.中国骨科大手术静脉血栓栓塞症预防指南[J].中华骨科杂志,2009,29(6):602-604.
[5]Ahir S P, Blunn G W, Haider H,et al.Evaluation of a testing method for the fatigue performance of total knee tibial trays. J Biomech. 1999;32:1049-1057.
[6]Tomaso V,Francesco M,Dario G,et al.Contact stresses and fatigue life in a knee prosthesis:comparison between in vitro measurements and computational simulations. J Biomech. 2004;37:45-53.
[7]赵艳,王禹.人工膝关节的生物摩擦学特点[J].中国组织工程研究与临床康复,2010,14(22):4090-4092.
[8]童培健.人工关节材料的生物相容性及其改进[J].中国组织工程研究与临床康复,2009,13(13):2401.
[9]朱金国.人工关节材料的研究进展与骨科临床应用[J].中国组织工程研究与临床康复,2008,12(19):3697-3700.
[10]Schat KR,Evans R,Newman JH.How much blood is really lost in total knee arthroplasty?correct blood loss management should take hidden loss into account. Knee. 2000;7(3): 151-155.
[11]李想,董纪元,陈继营,等.人工全膝关节置换术中止血带应用方法的效果比较[J].军医进修学院学报,2011,32(6):609-610.
[12]曹学伟,杨伟毅,梁比记,等.不同止血带使用方法对TKA围手术期失血量影响的临床研究[J].中国骨与关节外科,2011,4(6): 456-459.
[13]Stucinskas J,Tarasevicius S,Cebatorius A,et al.Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis:a prospective, randomized, trial. Int Orthop. 2009;33(5):1275-1278.
[14]Shen PC,Jou I,Lin YT,et al.Comparison between 4-hour clamping drainage and nonclamping drainage after total knee arthroplasty.J arthroplasty. 2005;20(7):909-913.
[15]Tai TW,Yang CY,Jou JM,et al.Temporary drainage clamping after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2010;25(8):1240-1245.
[16]Huang ZY,Ma J,Pei F,et al.Meta-analysis of temporary versus no clamping in TKA.Orthopedics. 2013;36(7):543-550.
[17]徐昭宁,杨旭,田少奇,等.滑膜切除对全膝关节置换术术后失血及功能恢复的影响[J].中华临床医师杂志(电子版),2013,7(4): 1553-1556.
[18]Seo JG,Moon YW,Park SH,et al.The comparative efficacies of intra-articular and IV tranexamic acid for reducing blood loss during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2013;8:1869-1874.
[19]Irwin A,Khan SK,Jameson SS,et al.Oral versus intravenous tranexamic acid in enhanced-recovery primary total hip and knee replacement:results of 3000 procedures. Bone Joint J. 2013;11:1556-1561.
[20]Abdel-Salam A,Eyres KS.Effects of tourniquet during total knee arthroplasty.A prospective randomized study. J Bone Joint Surg(Br).1995;77(2):250-253.
[21]Tetro AM,Rudan JF.The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg. 2001;44(1): 33-38.
[22]Tai TW,Chang CW,Lai KA,et al.Effects of tourniquet use on blood loss and soft-tissue damage in total knee arthroplasty:a randomized controlled trial. J Bone Joint Surg(Am). 2012; 94(24):2209-2215.
[23]Olivecrona C,Ponzer S,Hamberg P,et al.Lower tourniquet cuff pressure reduces postoperative wound complications after total knee arthroplasty:a randomized controlled study of 164 patients. J Bone Joint Surg(Am). 2012;94(24): 2216-2221.
[24]Mittal R,Ko V,Adie S,et al.Tourniquet application only during cement fixation in total knee arthroplasty : a double-blind , randomized controlled trial. ANZ J Surg, 2012;82(6):428-433.
[25]刘秀娥,杨林花,王宏伟,等.急性白血病患者弥散性血管内凝血的实验室检测及意义[J].血栓与止血学,2002,8(2):60-62.
[26]Kruskal JB,Commerflord PJ,Frank JJ,et al.Fibrin and fibrino-gen-related antigen in Patients with stable and unstable coronary artery disease. N EngI Med. 1987;317: 1361-1365.
[27]熊立凡,王鸿利.D一二聚体与静脉血栓症诊断-循证实验诊断学举例[J].诊断学理论与实践,2005,4(1):75-79.
[28]Papalambros E,Sigala F,Travlou A,et al.P-selectin and antibodies against heparin-Platelet Tactor 4 in patients with venous or arterial deseases after a 7-day heparin treatment. Am Coll Srug. 2004;199(1):69.
[29]中华医学会呼吸病学分会．肺血栓栓塞症的诊断与治疗指南[J].中华结核和呼吸杂志,2001,24(5):259-264.
[30]Kenneth OC. Richard Mreen.The anatomy of deep venous thrombosisof the lower extremity. J Vasc Surg. 2000;31(5)：895.