李　劍　傅品來　丘青中　黃輝文

廣東省中西醫(yī)結(jié)合醫(yī)院(佛山 528200)

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髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律及深靜脈血栓辨證預防研究*

李劍傅品來丘青中黃輝文

廣東省中西醫(yī)結(jié)合醫(yī)院(佛山 528200)

摘要目的：探討髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律及深靜脈血栓辨證預防研究。方法：選取120例行髖膝關(guān)節(jié)置換圍手術(shù)期患者作為前瞻性調(diào)查對象，隨機分為辨證治療組及西藥對照組，辨證治療組根據(jù)患者的中醫(yī)證型演變規(guī)律，進行深靜脈血栓的辨證預防；西藥對照組采取西醫(yī)治療預防深靜脈血栓。結(jié)果：辨證治療組的深靜脈血栓形成率為3.33%、患肢腫脹率為5.00%，西藥對照組的深靜脈血栓形成率為11.67%、患肢腫脹率為16.67%；兩組數(shù)據(jù)具有顯著性差異(P<0.05)。結(jié)論：髖膝關(guān)節(jié)置換圍手術(shù)期的中醫(yī)證型演變過程中，手術(shù)前期以實證，濕熱下注型為主；術(shù)后初期以虛實證，氣血瘀滯型為主；手術(shù)后期以虛證，脾腎陽虛型為主；根據(jù)患者的中醫(yī)證型演變規(guī)律，進行辨證預防深靜脈血栓形成，可顯著減小深靜脈血栓形成的風險，降低深靜脈血栓形成率及患肢腫脹率，改善患者的預后。

主題詞關(guān)節(jié)成形術(shù), 置換, 髖/中醫(yī)藥療法關(guān)節(jié)成形術(shù), 置換, 膝/中醫(yī)藥療法病因證候靜脈血栓栓塞

深靜脈血栓作為髖膝關(guān)節(jié)置換圍術(shù)期常見的并發(fā)癥之一，目前仍缺乏滿意的防治方法[1-3]。阿司匹林、右旋糖酐類藥物被證實對預防深靜脈血栓形成無確切療效，低分子肝素、華法林在預防深靜脈血栓形成的過程中，可增加出血的風險[4-6]。通過系統(tǒng)科學的觀察總結(jié)髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律，為中醫(yī)藥辨證防治術(shù)后深靜脈血栓的形成，提供臨床依據(jù)。對此，本研究旨在探討髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律及深靜脈血栓辨證預防研究。

臨床資料選取于2014年12月～2015年10月期間，我院治療的120例行髖膝關(guān)節(jié)置換圍手術(shù)期患者作為前瞻性調(diào)查對象，對所有研究對象隨機分為辨證治療組及西藥對照組；辨證治療組60例，其中男28例，女32例；年齡范圍39.5～68.5歲，平均年齡57.8±4.5歲；病因類型：股骨頸骨折9例，股骨頭壞死27例，髖關(guān)節(jié)發(fā)育不良4例,膝關(guān)節(jié)骨性關(guān)節(jié)炎20例。西藥對照組60例，其中男29例，女31例；年齡范圍38.7～69.6歲，平均年齡56.3±4.7歲；病因類型：股骨頸骨折12例，股骨頭壞死27例，髖關(guān)節(jié)發(fā)育不良3例，膝關(guān)節(jié)骨性關(guān)節(jié)炎18例；兩組患者的一般資料無統(tǒng)計學差異(P>0.05)。

治療方法選取120例行髖膝關(guān)節(jié)置換圍手術(shù)期患者作為前瞻性調(diào)查對象，參考經(jīng)典文獻、中醫(yī)體質(zhì)量表、中醫(yī)病證診斷療效標準、中醫(yī)診斷學、中醫(yī)證候辨證規(guī)范，結(jié)合臨床實際情況及征詢專家意見，制定髖膝關(guān)節(jié)置換圍手術(shù)期證候調(diào)查表(術(shù)前1天、術(shù)后第1、3、7、14 天)，收集所有患者的相關(guān)數(shù)據(jù)，運用SPSS17.0 統(tǒng)計軟件進行描述性分析，總結(jié)髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律；對所有研究對象隨機分為辨證治療組及西藥對照組，辨證治療組根據(jù)患者的中醫(yī)證型演變規(guī)律，進行深靜脈血栓的辨證預防；濕熱下注型采取四妙散加味治療，氣血瘀滯型采取活血通脈飲加減治療，脾腎陽虛型采取溫腎陽健脾湯加減治療；西藥對照組采取西醫(yī)治療預防深靜脈血栓，采用低分子肝素抗凝治療、采用尿激酶溶栓治療。

療效標準對比兩組患者的深靜脈血栓形成率及患肢腫脹率，綜合評價深靜脈血栓的預防效果。

治療結(jié)果120例髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)證型演變規(guī)律見表1。

表1　120例髖膝關(guān)節(jié)置換圍手術(shù)期中醫(yī)

注：與其它中醫(yī)證型對比，?P<0.05

兩組患者的深靜脈血栓及患肢腫脹發(fā)生情況對比見表2。

表2　兩組患者的深靜脈血栓及患肢腫脹

討論中醫(yī)學認為，深靜脈血栓屬于 “脈痹”、“腫脹”或“瘀血流注”的范疇，以腫脹、疼痛及靜脈曲張為主要表現(xiàn)[7-9]。本研究對120例行髖膝關(guān)節(jié)置換圍手術(shù)期患者的中醫(yī)證型進行分析，手術(shù)前期以實證的濕熱下注型為主；而術(shù)后第3天，各中醫(yī)證型分布均勻，無顯著差異性；提示病情有所惡化或改善，癥狀體征有所變化，應采取清熱利濕治療。術(shù)后初期以虛實證為主要表現(xiàn)，以氣血瘀滯型為主，體現(xiàn)為氣虛血瘀或氣滯血瘀，提示在治療原則上，應采取理氣活血止痛的標本兼治。術(shù)后期以虛證，脾腎陽虛型為主，提示病情有所好轉(zhuǎn)，應注意病情變化及中醫(yī)體質(zhì)因素，進行辨證治療用藥。現(xiàn)代臨床表明，血液高凝狀態(tài)、靜脈回流減慢及血管內(nèi)皮損傷作為深靜脈血栓形成的獨立危險因素；與中醫(yī)認為深靜脈血栓以濕熱、血瘀阻絡為主要病機的觀點相貼近[10-11]。

在髖膝關(guān)節(jié)置換圍手術(shù)期的中醫(yī)證型演變過程中，以濕熱下注型、氣血瘀滯型及脾腎陽虛型為主，瘀熱互結(jié)作為深靜脈血栓形成的基礎病機，而涼血化瘀、清熱解毒作為髖膝關(guān)節(jié)置換圍手術(shù)期預防深靜脈血栓形成的基礎原則[12-13]。在深靜脈血栓形成的預防治療中，存在氣滯血瘀、濕熱蘊結(jié)及脾腎陽虛等情況，需進一步辨證治療，提高臨床治療的針對性。在本研究中，辨證治療組中，濕熱下注型患者采取四妙散加味治療，旨在清熱利濕、活血消腫；氣血瘀滯型采取活血通脈飲加減治療，旨在活血消腫、化瘀通脈；脾腎陽虛型采取溫腎陽健脾湯加減治療，旨在溫腎健脾、活血利濕[14-15]。研究結(jié)果提示根據(jù)患者的中醫(yī)證型演變規(guī)律，進行辨證預防深靜脈血栓形成，可顯著減小深靜脈血栓形成的風險，降低深靜脈血栓及患肢腫脹率，改善患者的預后。

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(收稿2015-12-16；修回2016-01-08)

Development regularity of traditional Chinese medicine syndrome

and discriminative prevention of perioperative deep venous thrombosis following total hip/knee arthroplasty Guangdong, Chinese and Western Medicine Hospital (Foshan528200)

Li JianFu PinlaiQiu Qingzhonget al

ABSTRACTObjective:To explore the development regularity of traditional Chinese medicine syndrome and discriminative prevention of perioperative deep venous thrombosis following total hip/knee arthroplasty. Methods:A prospective analysis was carried out on 120 perioperative patients following hip/knee arthroplasty.These patients were randomly divided into two groups: the discriminative treatment group and the routine western medicine therapy group. The discriminative prevention of perioperative deep venous thrombosis for patients in the discriminative treatment group was performed according to the development regularity of traditional Chinese medicine syndrome. The patients from the routine western medicine therapy group used western medicine to prevent the deep venous thrombosis. Results: The rate of deep venous thrombosis in the treatment group was 3.33%, the swelling rate was 5%, the rate of deep venous thrombosis in western medicine control group was 11.67%, the affected limb swelling rate was 16.67%; the data of the two groups were significant difference (P< 0.05). Conclusions: During the development process of traditional Chinese medicine syndrome following total hip/knee arthroplasty, the patients before surgery based on excess syndrome and damp-heat pouring downward syndrome. The patients in preliminary stage after operation based on deficiency or excess syndrome, and vital energy and blood choked syndrome. The patients in later stage after operation based on deficiency syndrome and spleen-kidney yang deficiency syndrome. According to the development regularity of traditional Chinese medicine syndrome, discriminative prevention of perioperative deep venous thrombosis following total hip/knee arthroplasty could significantly reduce the incidence and risk of deep venous thrombosis, and decrease the swelling rate of the wounded limb, improving prognosis in patients.

KEY WORDSArthroplasty, replacement, hip/traditional Chinese medicine therapyArthroplasty, replacement, knee/traditional Chinese medicine therapyEtiological factors symptom complex (TCM) Venous thromboembolism

【中圖分類號】R228

【文獻標識碼】A

doi:10.3969/j.issn.1000-7369.2016.05.009

*廣東省佛山市衛(wèi)生和計劃生育局資助醫(yī)學科研課題(2015290)