老年髖部骨折術前健側肢體深靜脈血栓形成的危險因素分析

劉月星 楊朝昕 萬乾

摘要：目的? 探討老年髖部骨折患者術前健側肢體深靜脈血栓（DVT）形成的發生率及相關影響因素。方法? 回顧性分析2018年1月1日～12月31日承德醫學院附屬醫院創傷骨科收治的168例老年髖部骨折患者的臨床資料，術前均行雙下肢靜脈多普勒超聲檢查，根據超聲檢查結果分為DVT組和非DVT組，其中DVT組21例，非DVT組147例;住院期間給予低分子肝素鈣預防抗凝，以性別、年齡、合并內科疾病、受傷至觀察時間、血漿白蛋白、纖維蛋白原為變量，分析患者術前發生DVT的危險因素。結果? 共168例患者在住院期間行下肢靜脈多普勒超聲檢查，其中有147例（87.50%）雙下肢未發生DVT，21例（12.50%）健側肢體發生DVT。在21例健側肢體發生血栓的患者中，有9例（42.86%）僅發生在健側肢體，患側肢體無血栓形成。DVT組受傷等待的時間大于非DVT組（P<0.05）;高血壓、冠心病、糖尿病的患病率高于非DVT組（P<0.05），且在血栓形成高峰期DVT血漿白蛋白明顯低于非DVT組（P<0.05），纖維蛋白原高于非DVT組（P<0.05）。多因素分析結果顯示，受傷平均等待時間、糖尿病、血漿白蛋白、纖維蛋白原是下肢骨折后健側肢體DVT形成的獨立危險因素（P<0.05）。結論? 針對老年髖部骨折患者，盡管給與低分子肝素鈣進行預防，但術前健側肢體深靜脈血栓仍有發生，應該引起臨床醫生的足夠重視，術前均應行雙下肢靜脈多普勒超聲檢查;并且對于手術等待時間長、纖維蛋白原過高、血漿白蛋白過低同時合并糖尿病患者應特別警惕下肢DVT的發生。

關鍵詞：髖部骨折;老年;健側肢體;深靜脈血栓;危險因素

Abstract：Objective? To investigate the incidence and related influencing factors of the formation of deep vein thrombosis （DVT） of the healthy limbs in elderly patients with hip fractures. Methods? The clinical data of 168 elderly patients with hip fractures admitted to the Department of Traumatology and Orthopedics of the Affiliated Hospital of Chengde Medical College from January 1 to December 31， 2018 were retrospectively analyzed. All patients were examined by doppler ultrasonography of the lower extremity vein before surgery. The examination results were divided into DVT group and non-DVT group， including 21 cases in DVT group and 147 cases in non-DVT group; low molecular weight heparin calcium was given to prevent anticoagulation during hospitalization， based on gender， age， medical disease， injury to observation time， plasma white protein and fibrinogen were variables， and the risk factors of patients with DVT before operation were analyzed.Results? A total of 168 patients underwent venous Doppler ultrasonography during hospitalization. Among them， 147 （87.50%） had no DVT in both lower extremities， and 21 （12.50%） had DVT on the contralateral limb. Of the 21 patients with thrombosis on the contralateral limb， 9 （42.86%） occurred only on the contralateral limb， and no thrombosis occurred on the affected limb. The waiting time for injury in the DVT group was longer than that in the non-DVT group（P<0.05）; the prevalence of hypertension， coronary heart disease， and diabetes was higher than that in the non-DVT group（P<0.05）， and DVT plasma albumin was significantly lower at the peak of thrombosis In the non-DVT group（P<0.05）， fibrinogen was higher than that in the non-DVT group（P<0.05）. The results of multivariate analysis showed that the average waiting time for injury， diabetes， plasma albumin， and fibrinogen were independent risk factors for the formation of DVT in the healthy limb after lower limb fracture（P<0.05）.Conclusion? For elderly patients with hip fractures， although low molecular weight heparin calcium is given for prevention， deep vein thrombosis of the healthy limbs still occurs before surgery， and should be paid enough attention by clinicians. Both lower limb vein Doppler should be performed before surgery Ultrasound examination; and for patients with long waiting time for surgery， high fibrinogen， low plasma albumin and diabetic patients with diabetes， special attention should be paid to the occurrence of lower limb DVT.

本研究的不足之處：首先本研究是一個單中心回顧性研究，樣本量較少，研究時限短，仍需要前瞻性、多中心、大樣本研究對結果進行校驗。

總之，由于老年人各項生理功能的減退、髖部骨折后下肢制動、高齡以及內科合并癥的存在等因素導致老年髖部骨折后發生DVT的危險性增高。術前等待時間越長，血漿白蛋白越低、纖維蛋白原越高同時合并糖尿病是健側肢體DVT發生的危險因素。因此，對于老年髖部骨折患者需要內科、麻醉科及骨科醫師通力合作，盡快手術治療是減少下肢DVT發生以及各種并發癥的首要措施。

參考文獻：

[1]孫家元，張英澤.老年髖部骨折圍手術期處理[J].國際骨科學雜志，2013，25（1）：11-14.

[2]Mok C，Hoaglund F，Rogoff S，et al.The incidence of deep vein thrombosis in Hong Kong Chinese after hip surgery for fracture of the proximal femur[J].British Journal of Surgery，1979，66（9）：640-642.

[3]Falckytter Y，Francis CW，Johanson NA，et al.Prevention of VTE in orthopedic surgery patients：Antithrombotic Therapy and Prevention of Thrombosis，9th ed：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines[J].Chest，2012，141（2）：e278S.

[4]孫灝，魏俊強，劉利蕊，等.股骨干骨折患者圍手術期發生下肢深靜脈血栓的特點[J].中國現代醫學雜志，2017，27（18）：93-97.

[5]付亞輝，王鵬飛，王寶輝，等.老年髖部骨折患者圍手術期深靜脈血栓形成的發生規律及血漿D-二聚體的變化特點[J].中華創傷骨科雜志，2016，18（8）：668-672.

[6]安學志，胡文蘭，吳新寶，等.老年髖部骨折術前下肢深靜脈血栓形成臨床特點分析[J].心肺血管病雜志，2018，37（10）：55-58.

[7]中華醫學會外科學分會血管外科學組，李曉強，王深明.深靜脈血栓形成的診斷和治療指南（第二版）[J].中華普通外科雜志，2012，23（1）：235-238.

[8]Wilson D，Cooke EA，Mcnally MA，et al.Altered venous function and deep venous thrombosis following proximal femoral fracture[J].Injury-international Journal of the Care of the Injured，2002，33（1）：33-39.

[9]王寶輝，王鵬飛，付亞輝，等.下肢骨折患者RAPT評分結合D-二聚體監測預防DVT的意義[J].中國骨與關節損傷雜志，2015，30（8）：846-848.

[10]范吉星，李寧，龔曉峰，等.老年髖部骨折術前下肢深靜脈血栓形成的影響因素研究[J].中國矯形外科雜志，2017（25）：2031.

編輯/王朵梅