切换至 "中华医学电子期刊资源库"

中华关节外科杂志(电子版) ›› 2019, Vol. 13 ›› Issue (01) : 78 -85. doi: 10.3877/cma.j.issn.1674-134X.2019.01.015

所属专题: 文献

荟萃研究

全膝关节置换术后静脉血栓栓塞症危险因素的Meta分析
曾敬1, 赵洪普1,(), 杨展翔1, 张静云1, 郑兆宽1, 吴宝杰1   
  1. 1. 510150 广州医科大学附属第三医院骨科
  • 收稿日期:2018-07-17 出版日期:2019-02-01
  • 通信作者: 赵洪普

Meta-analysis on risk factors for venous thromboembolism after total knee arthroplasty

Jing Zeng1, Hongpu Zhao1,(), Zhanxiang Yang1, Jingyun Zhang1, Zhaokuan Zheng1, Baojie Wu1   

  1. 1. Department of Orthopedics, The third affiliated hospital of guangzhou medical university, Guangzhou 510150, China
  • Received:2018-07-17 Published:2019-02-01
  • Corresponding author: Hongpu Zhao
  • About author:
    Corresponding author: Zhao Hongpu, Email:
引用本文:

曾敬, 赵洪普, 杨展翔, 张静云, 郑兆宽, 吴宝杰. 全膝关节置换术后静脉血栓栓塞症危险因素的Meta分析[J/OL]. 中华关节外科杂志(电子版), 2019, 13(01): 78-85.

Jing Zeng, Hongpu Zhao, Zhanxiang Yang, Jingyun Zhang, Zhaokuan Zheng, Baojie Wu. Meta-analysis on risk factors for venous thromboembolism after total knee arthroplasty[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2019, 13(01): 78-85.

目的

通过Meta分析总结全膝关节置换术后静脉血栓栓塞症的危险因素,为临床识别和预防全膝关节置换术后静脉血栓栓塞症提供循证医学的根据。

方法

检索PUBMED、EMBASE、Cochrane library、中国知网(CKNI)等数据库建库至2018年6月关于全膝关节置换术后发生静脉血栓栓塞症的临床研究。排除研究对象为非成人的文献及结局指标与静脉血栓不相关的文献。由2位研究者独立进行资料提取和质量评估,采用RevMan 5.3软件进行Meta分析。

结果

最终共纳入23篇文献,累计病例775 294例,其中10 325例静脉血栓,平均发生率(18.29±0.23)%。Meta分析结果显示,年龄≥ 70岁[OR =0.92,95%CI(0.87,0.97),I2 =33%,P =0.0030]、年龄≥ 80岁[OR =0.85,95%CI(0.76,0.96),I2 =68%,P =0.0090]、术中止血带的使用[OR=2.14,95%CI(1.36,3.38),I2 =0%,P =0.0010]是全膝关节置换术后发生静脉血栓栓塞症的危险因素,差异有统计学意义(P < 0.05)。女性[OR =0.95,95%CI(0.85,1.05),I2 =59%,P =0.32]、尼格罗人种[OR=0.40, 95%CI(0.11,1.48),I2=99%, P=0.1700]、高血压[OR=1.46,95%CI(0.87,2.45),I2 =91%,P =0.1500]、糖尿病[OR =1.11,95%CI(0.90,1.37),I2 =68%,P =0.3300]、类风湿性关节炎[OR =0.78,95%CI(0.38,1.56),I2 =89%,P =0.4800]、翻修[OR =1.14,95%CI(0.18,7.25),I2 =88%,P =0.8900]、下肢静脉曲张[OR =1.30,95%CI(0.83,2.04),I2 =29%,P =0.2500]、肿瘤[OR =1.11,95%CI(0.32,3.92),I2 =91%,P =0.8700]、心脏疾病[OR =1.19,95%CI(0.37,2.89),I2 =98%,P =0.9600]、肝肾疾病[OR =1.19,95%CI(0.84,1.67),I2 =0%,P =0.3200]不是全膝关节置换术后发生静脉血栓栓塞症的危险因素,差异无统计学意义(P > 0.05)。

结论

年龄≥ 70岁、年龄≥ 80岁、术中止血带的使用是全膝关节置换术后发生静脉血栓栓塞症的高危险因素,临床医护人员应更加关注以上相关危险因素,以预防全膝关节置换术后静脉血栓栓塞症的发生。

Objective

To systematically analyze the risk factors associated with venous thromboembolism(VTE) after total knee arthroplasty(TKA) and to provide evidence for prevention of VTE after TKA through meta-analysis.

Methods

Potential clinical studies were identified by searching PUBMED, EMBASE, Cochrane library, China National Knowledge Infrastructure (CNKI) and other databases from the start time of the data bases to June 2018. The literatures which were irrelevant to adult, and the literatures in those without general population of VTE and non-VTE groups, were all excluded. Two authors independently extracted data and assessed the methodological quality. RevMan analyses(RevMan 5.3.5)were used to analyze the data.

Results

Twenty-three studies were finally selected. The total number of patients included in this review were 775 294, whereas 10 325 patients developed VTE after TKA. The averaged VTE rate was (18.29±0.23)%. Factors found to be associated with VTE after TKA included age≥70[OR=0.92, 95%CI(0.87, 0.97), I2=33%, P<0.05], age≥80[OR=0.85, 95%CI(0.76, 0.96), I2=68%, P<0.05], and the use of tourniquet during the surgery[OR=2.14, 95%CI(1.36, 3.38), I2=0%, P<0.05]. No significant association was found in female[OR=0.95, 95%CI(0.85, 1.05), I2=59%, P>0.05], Negroids[OR=0.40, 95%CI(0.11, 1.48), I2=99%, P>0.05], hypertension[OR=1.46, 95%CI(0.87, 2.45), I2=91%, P>0.05], diabetes[OR=1.11, 95%CI(0.90, 1.37), I2=68%, P>0.05], rheumatoid arthritis[OR=0.78, 95%CI(0.38, 1.56), I2=89%, P>0.05], revision TKA[OR=1.14, 95%CI(0.18, 7.25), I2=88%, P>0.05], varicose veins in lower extremities[OR=1.30, 95%CI(0.83, 2.04), I2=29%, P>0.05], tumors[OR=1.11, 95%CI(0.32, 3.92), I2=91%, P>0.05], heart disease[OR=1.19, 95%CI(0.37, 2.89), I2=98%, P>0.05], and liver and kidney disease[OR=1.19, 95%CI(0.84, 1.67), I2=0%, P>0.05].

Conclusion

In this review, risk factors associated with VTE after TKA include age≥70 and 80 years, the use of tourniquet during the surgery; surgeons should be pay close attention to the patients involved with the these factors to prevent VTE after TKA.

表1 纳入文献的基本特征
文献 国家 研究类型 质量评分 例数 随访时间 术式 诊断方法  风险因素
Owens等[5]2018 美国 多中心前瞻性队列研究 6 96 230 30 d TKA 未注明 种族
Wakabayashi等[6]2017 日本 单一中心回顾性队列研究 7 322 未注明 TKA 超声多普勒 性别、年龄、大手术史、高血压、类风湿、翻修、心脏疾病、高血脂、糖尿病、子宫肌瘤、结缔组织疾病、肿瘤
Tay等[7]2016 新加坡 单一中心回顾性病例对照研究 7 894 1年 TKA 超声多普勒 性别、年龄、身体质量指数、合并疾病数、高脂血症病史
Mori等[8] 2016 日本 单一中心前瞻性随机对照研究 RCT 103 7 d TKA 超声多普勒 有无止血带
Izumi等[9]2015 日本 多中心前瞻性队列研究 6 1 288 10~28 d TKA 超声多普勒 类风湿性关节炎、骨关节炎
Rostom等[10]2014 加拿大 单一中心回顾性队列研究 6 115 627 7 d TKA,THA 超声多普勒 年龄,高血压
BinAbd等[11]2014 新加坡 单一中心回顾性队列研究 6 531 未注明 TKA 未注明 止血带时间
Yeager等[12]2014 美国 单一中心前瞻性队列研究 5 428 未注明 TKA,THA 螺旋CT扫描 单双侧
Wupk等[13]2014 中国台湾 单一中心回顾性队列研究 6 52 566 28 d THA,TKA 未注明 年龄、性别、全/半关节、翻修、早期VTE病史、心脏衰竭、中风、短暂性脑缺血发作、糖尿病、高血压、静脉曲张
Adams等[14]2013 美国 多中心回顾性队列研究 7 40 491 1年 TKA 未注明 身体质量指数
Dua等[15]2012 美国 单一中心回顾性病例对照研究 5 51 859 90 d TKA,THA 未注明 静脉曲张的既往史或手术史
Pedersen等[16]2011 丹麦 多中心回顾性病例对照研究 5 37 223 90 d TKA 未注明 性别、年龄层次、类风湿、骨关节炎、合并疾病、血栓病史、糖尿病、肿瘤、心脏疾病、肝肾疾病、全半膝手术、单双侧、麻醉方式、手术时间、住院时间
Baser等[17]2011 美国 单一中心回顾性队列研究 5 115 627 1年 TKA,THA 未注明 种族,年龄,高血压,肿瘤,性别,肾脏疾病
Baser等[1]2010 美国 单一中心回顾性队列研究 5 118 086 2年 TKA,THA 未注明 种族,年龄,高血压,肿瘤,性别,肾脏疾病
Niki,等[18]2010 日本 单一中心回顾性队列研究 7 407 90 d TKA 超声多普勒 类风湿、骨关节炎
Kapoor等[19]2010 美国 多中心回顾性病例对照研究 4 223 600 未注明 TKA,THA 未注明 性别、年龄分层、双侧性、冠状动脉疾病、充血性心力衰竭、慢性阻塞性肺病、糖尿病和脑血管疾病
Xu等[20]2008 中国 单一中心回顾性病例对照研究 4 40 13 d TKA,THA 超声多普勒 止血带、骨水泥、类风湿、骨关节炎
Ricardo等[21]2008 西班牙 单一中心回顾性病例对照研究 4 58 037 未注明 TKA,THA 未注明 年龄、性别、住院时间、糖尿病、慢性肺疾病、慢性心力衰竭、高血压、缺血性心脏疾病、肿瘤、脑梗塞
Fukuda等[22]2007 美国 单一中心前瞻性随机对照研究 RCT 48 5 d TKA 超声多普勒 有无止血带
Chotanaphuti等[23]2007 泰国 单一中心回顾性队列研究 4 100 7~10 d TKA 静脉造影 性别、年龄分层、翻修、手术部位、体重、心脏疾病、肿瘤、静脉曲张、高血压、糖尿病、类风湿性关节炎、痛风、激素、类固醇、甲状腺功能、血液病
Wauke等[24]2002 日本 单一中心前瞻性随机对照研究 RCT 37 21 d TKA 超声多普勒 有无止血带
Fujita等[25]2000 日本 单一中心前瞻性队列研究 6 138 6~29 d TKA,THA 超声多普勒 年龄、身体质量指数、骨关节炎、类风湿性关节炎、单双侧
Harvey等[26]1997 加拿大 单一中心前瞻性随机对照研究 RCT 78 14 d TKA 超声多普勒 有无止血带
表2 风险因素的Meta分析结果
表3 REFE计算结果比较
图1 年龄≥70岁与TKA(全膝关节置换术)术后VTE(静脉血栓栓塞症)关系森林图
图2 年龄≥80岁与TKA(全膝关节置换术)术后VTE(静脉血栓栓塞症)关系森林图
图3 术中使用止血带与TKA(全膝关节置换术)术后VTE(静脉血栓栓塞症)关系森林图
[1]
Baser O, Supina D, Sengupta N, et al. Impact of postoperative venous thromboembolism on Medicare recipients undergoing total hip replacement or total knee replacement surgery[J]. Am J Health Syst Pharm, 2010, 67(17): 1438-1445.
[2]
Vekeman F, Lamori JC, Laliberte F, et al. Risks and cost burden of venous thromboembolism and bleeding for patients undergoing total hip or knee replacement in a managed-care population[J]. J Med Econ, 2011, 14(3): 324-334.
[3]
吕厚山,徐斌.人工关节置换术后下肢深静脉血栓形成[J].中华骨科杂志,1999,19(3):155-160.
[4]
Piovella F, Wang CJ, Lu H, et al. Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography[J]. J Thromb Haemost, 2005, 3(12): 2664-2670.
[5]
Owens JM, Bedard NA, Dowdle SB, et al. Venous thromboembolism following total knee arthroplasty: does race matter?[J]. J Arthroplasty, 2018, 33(7, S): S239-S243.
[6]
Wakabayashi H, Hasegawa M, Kato S, et al. Clinical analysis of preoperative deep vein thrombosis risk factors in patients undergoing primary total knee arthroplasty [J]. Ann Rheum Dis, 2016, 75(2): 965.
[7]
Tay K. Bin Abd Razak HR, Tan AH.Obesity and venous thromboembolism in total knee arthroplasty patients in an Asian population[J]. J Arthroplasty, 2016, 31(12): 2880-2883.
[8]
Mori N, Kimura S, Onodera T, et al. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: a prospective, randomized study[J]. Knee, 2016, 23(5): 887-889.
[9]
Izumi M, Migita K, Nakamura M, et al. Risk of venous thromboembolism after total knee arthroplasty in patients with rheumatoid arthritis[J]. J Rheumatology, 2015, 42(6): 928-934.
[10]
Rostom M, Beechinor MD, Mills A, et al. Risk factors associated with venous thromboembolic disease in orthopaedic surgery patients: a retrospective case control study for quality analysis(oral presentation)[J]. Can J Hosp Pharm, 2014, 67(1): 83.
[11]
Bin Abd Razak HR, Tan HC. The use of pneumatic tourniquets is safe in asians undergoing total knee arthroplasty without anticoagulation[J]. Knee, 2014, 21(1): 176-179.
[12]
Yeager AM, Ruel AV, Westrich GH. Are bilateral total joint arthroplasty patients at a higher risk of developing pulmonary embolism following total hip and knee surgery?[J]. J Arthroplasty, 2014, 29(5): 900-902.
[13]
Wu PK, Chen CF, Chung LH, et al. Population-based epidemiology of postoperative venous thromboembolism in Taiwanese patients receiving hip or knee arthroplasty without pharmacological thromboprophylaxis[J]. Thromb Res, 2014, 133(5): 719-724.
[14]
Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009[J]. J Bone Joint Surg Am, 2013, 95A(6): 481-487.
[15]
Dua A, Neiva S, Sutherland A. Does previous varicose vein surgery alter deep vein thrombosis risk after lower limb arthroplasty?[J]. Orthop Surg, 2012, 4(4): 222-226.
[16]
Pedersen AB, Mehnert F, Johnsen SP, et al. Venous thromboembolism in patients having knee replacement and receiving thromboprophylaxis a Danish population-based follow-up study[J]. J Bone Joint Surg Am, 2011, 93A(14): 1281-1287.
[17]
Baser O, Supina D, Sengupta N, et al. Clinical and cost outcomes of venous thromboembolism in Medicare patients undergoing total hip replacement or total knee replacement surgery[J]. Curr Med Res Opin, 2011, 27(2): 423-429.
[18]
Niki Y, Matsumoto H, Hakozaki A, et al. Rheumatoid arthritis: a risk factor for deep venous thrombosis after total knee arthroplasty? Comparative study with osteoarthritis[J]. J Orthop Sci, 2010, 15(1): 57-63.
[19]
Kapoor A, Labonte AJ, Winter MR, et al. Risk of venous thromboembolism after total hip and knee replacement in older adults with comorbidity and co-occurring comorbidities in the Nationwide Inpatient Sample (2003-2006)[J/OL]. BMC Geriatr, 2010, 10: 63.doi:10.1186/1471-2318-10-63
[20]
Xu B, Xu HG. Analyse of the risk factors of dvt after lower extremity surgery[J]. China J Orthop Trauma, 2008, 21(11): 855-857.
[21]
Guijarro R, Montes J, San Roman C, et al. Venous thromboembolism and bleeding after total knee and hip arthroplasty findings from the Spanish National Discharge Database[J]. Thromb Haemost, 2011, 105(4): 610-615.
[22]
Fukuda A, Hasegawa M, Kato K, et al. Effect of tourniquet application on deep vein thrombosis after total knee arthroplasty[J]. Arch Orthop Trauma Surg, 2007, 127(8): 671-675.
[23]
Chotanaphuti T, Ongnamthip P, Songpatanasil T, et al. Risk factors of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) at Phramongkutklao Hospital[J]. J Med Assoc Thai, 2007, 90(3): 485-491.
[24]
Wauke K, Nagashima M, Kato N, et al. Comparative study between thromboembolism and total knee arthroplasty with or without tourniquet in rheumatoid arthritis patients[J]. Arch Orthop Trauma Surg, 2002, 122(8): 442-446.
[25]
Fujita S, Hirota S, Oda T, et al. Deep venous thrombosis after total hip or total knee arthroplasty in patients in japan [J]. Clin Orthop Relat Res, 2000, 375: 168-174.
[26]
Harvey EJ, Leclerc J, Brooks CE, et al. Effect of tourniquet use on blood loss and incidence of deep vein thrombosis in total knee arthroplasty[J]. J Arthroplasty, 1997, 12(3): 291-296.
[27]
邱贵兴.中国骨科大手术静脉血栓栓塞症预防指南[J/CD].中华关节外科杂志(电子版),2009,3(3):380-383.
[28]
姚尧,陈东阳,徐志宏,等.人工全膝关节置换术后下肢深静脉血栓的特点与预防[J/CD].中华关节外科杂志(电子版),2015,9(6):789-792.
[29]
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[J]. Br J Surg, 2011, 98(10): 1356-1364.
[30]
Zhou XD, Qian WK, Li J, et al. Who are at risk for thromboembolism after arthroplasty? A systematic review and meta-analysis[J]. Thromb Res, 2013, 132(5): 531-536.
[31]
Zhang J, Chen Z, Zheng J, et al. Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis[J]. Arch Orthop Trauma Surg, 2015, 135(6): 759-772.
[32]
Hill J, Treasure T, Guideline DG. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: summary of NICE guidance[J]. Br Med J, 2007, 334(762): 1053-1054.
[33]
Montagnana M, Favaloro EJ, Franchini MA, et al. The role of ethnicity, age and gender in venous thromboembolism[J]. J Thromb Thrombolysis, 2010, 29(4): 489-496.
[34]
White RH, Keenan CR. Effects of race and ethnicity on the incidence of venous thromboembolism[J]. Thromb Res, 2009, 123(4): S11-S17.
[35]
Abdel-Salam A, Eyres KS. Effects of tourniquet during total knee arthroplasty. A prospective randomised study[J]. J Bone Joint Surg Br, 1995, 77(2): 250-253.
[36]
Mori N, Kimura S, Onodera T, et al. Use of a pneumatic tourniquet in total knee arthroplasty increases the risk of distal deep vein thrombosis: a prospective, randomized study [J/]. 2016, 23(5):887-889.
[37]
Jiang FZ, Zhong HM, Hong YC, et al. Use of a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials[J]. J Orthop Sci, 2015, 20(1): 110-123.
[38]
Yi SX, Tan JX, Chen C, et al. The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis[J]. Arch Orthop Trauma Surg, 2014, 134(10): 1469-1476.
[1] 明昊, 肖迎聪, 巨艳, 宋宏萍. 乳腺癌风险预测模型的研究现状[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(05): 287-291.
[2] 罗文斌, 韩玮. 胰腺癌患者首次化疗后中重度骨髓抑制的相关危险因素分析及预测模型构建[J/OL]. 中华普通外科学文献(电子版), 2024, 18(05): 357-362.
[3] 贺斌, 马晋峰. 胃癌脾门淋巴结转移危险因素[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 694-699.
[4] 林凯, 潘勇, 赵高平, 杨春. 造口还纳术后切口疝的危险因素分析与预防策略[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 634-638.
[5] 杨闯, 马雪. 腹壁疝术后感染的危险因素分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 693-696.
[6] 周艳, 李盈, 周小兵, 程发辉, 何恒正. 不同类型补片联合Nissen 胃底折叠术修补食管裂孔疝的疗效及复发潜在危险因素[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 528-533.
[7] 马振威, 宋润夫, 王兵. ERCP胆道内支架与骑跨十二指肠乳头支架置入治疗不可切除肝门部胆管癌疗效的Meta分析[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 807-812.
[8] 张伟伟, 陈启, 翁和语, 黄亮. 随机森林模型预测T1 期结直肠癌淋巴结转移的初步研究[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(05): 389-393.
[9] 王芳, 刘达, 左智炜, 盛金平, 陈庭进, 蒋锐. 定量CT与双能X线骨密度仪对骨质疏松诊断效能比较的Meta分析[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 363-371.
[10] 于洁, 金小红, 顾艳楣, 王慧, 葛杨杨, 李燕. 癌症相关静脉血栓栓塞症患者疾病体验与需求的质性研究[J/OL]. 中华临床医师杂志(电子版), 2024, 18(08): 739-744.
[11] 颜世锐, 熊辉. 感染性心内膜炎合并急性肾损伤患者的危险因素探索及死亡风险预测[J/OL]. 中华临床医师杂志(电子版), 2024, 18(07): 618-624.
[12] 周倩妹, 王宪娥, 徐筱, 老慧琳, 赵欣悦, 胡菁颖. 多元化系统护理对老年人群牙周健康指标影响的系统评价[J/OL]. 中华临床医师杂志(电子版), 2024, 18(05): 500-506.
[13] 李文哲, 王毅, 崔建, 郑启航, 王靖彦, 于湘友. 新疆维吾尔自治区重症患者急性肾功能异常的危险因素分析[J/OL]. 中华卫生应急电子杂志, 2024, 10(05): 269-276.
[14] 刘志超, 胡风云, 温春丽. 山西省脑卒中危险因素与地域的相关性分析[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 424-433.
[15] 曹亚丽, 高雨萌, 张英谦, 李博, 杜军保, 金红芳. 儿童坐位不耐受的临床进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 510-515.
阅读次数
全文


摘要