| Background:The formation of deep vein thrombosis(DVT)after total knee arthroplasty(TKA)is a hot topic in the field of joint replacement today,and is also one of the important factors for perioperative death and unexpected death in hospital.Currently,according to the Guidelines for the prevention of venous thromboembolism after major orthopedic surgery in China,TKA anticoagulation is mostly initiated within12-24 hours after surgery.However,the risk of bleeding complications caused by early postoperative anticoagulation is also high in clinical practice.Rheumatoid arthritis(RA)is a chronic systemic autoimmune disease,mainly including joint lesions.The main clinical manifestations are swelling and pain of the joint caused by synovial diseases,followed by cartilage destruction and joint space narrowing.In the late stage,severe bone destruction and absorption lead to joint stiffness,deformity and dysfunction.In China,the number of patients requiring TKA surgery due to severe RA has accounted for the second place of all TKA surgeries.RA,as an autoimmune disease with the characteristics of chronic inflammation,has beenproved to promote blood coagulation,affect anticoagulation pathway and inhibit fibrinolysis,so as to make the blood in a state of high coagulation,and also lead to vascular endothelial dysfunction.In the treatment of RA patients,the application of non-steroidal anti-inflammatory drugs and glucocorticoids is more common.There is extensive and clear evidence that Coxib and glucocorticoids are both risk factors for thrombosis and vte.RA patients have severe knee joint lesions,more soft tissues and bone tissues need to be removed during surgery,larger tissue wounds,and more blood oozing in the early postoperative period.Therefore,compared with patients with osteoarthritis(OA),patients with rheumatoid arthritis(RA)have more complex blood coagulation status,higher blood loss in the early postoperative period and higher risk of postoperative deep vein thrombosis.Therefore,more sophisticated postoperative anticoagulation management is needed.Starting from the above perspective,this study further refined the 12-24 hour interval recommended by the guidelines,and took 3 time points of this interval for research by referring to domestic and foreign literatures.Low molecular heparin(low moleculer weight heparin,LMWH)due to the anticoagulant effect,low cost,without the advantages of routine surveillance hematology,widely clinical use.The purpose of this study was to explore the anticoagulant timing of postoperative application of LMWH in patients with TKA due to RA,so as to provide theoretical basis for the selection of perioperative anticoagulant scheme for patients with RA.Objective:Studies comparing RA patients TKA surgery in different time to start subcutaneous injection of low molecular heparin(LMWH)on patients with postoperative wound,allogeneic blood transfusion amount,drain and lower extremity deep vein thrombosis(DVT)occurs,the influence of such indicators on patients with rheumatoid arthritis(RA)after knee replacement of anticoagulant drugs low molecular heparin(LMWH)on the use of time.It provides a theoretical basis for the selection of anticoagulation scheme in perioperative period for patients with rheumatoid arthritis.Methods:Prospective,randomized,controlled studies were conducted.From October2016 to February 2019,60 patients with total knee surface replacement(TKA)in the department of osteoarthritis(RA)of henan provincial people's hospital were selected,20 patients in each group.Patients were randomly assigned in order of hospitalization.There were 14 males and 46 females,aged 43-65 years,with an average age of 53.28 years.Patients were randomly divided into three groups,and subcutaneous injection of LMWH 4000 U was started at 12 h,18h and 24 h after surgery,followed by injection once a day for 2 week.There was no significant difference in age and body weight between the three groups.Patients in the 12 h group,18 h group and 24 h group were observed and recorded respectively :(1)wound drainage volume within 48 hours after surgery;(2)record the number and amount of blood transfusion of each group after the operation;(3)record the hemoglobin level before and 5 days after the operation;(4)all patients underwent color doppler ultrasonography of lower limb blood vessels before and 5 days after surgery to determine the presence of lower limb DVT.(5)whether subcutaneous ecchymosis appeared in the affected limb on the 5th day after surgery and the area of ecchymosis was recorded.No other drugs that may affect blood clotting were used in each group.The same analgesics and antibiotics were used postoperatively,and the postoperative functional exercise was consistent in each group.Results:(1)wound-drainage volume increased significantly between the 12 h group and the 18 h group and the 24 h group,and there was a statistical difference between the two groups(P < 0.05),while there was no statistical difference between the 18 h group and the 24 h group(P > 0.05).(2)the amount of postoperative blood transfusion and the number of blood transfusion were significantly increased in the12 h group,the 18 h group and the 24 h group,and the difference between the two groups was statistically significant(P < 0.05),while there was no statisticallysignificant difference between the 18 h group and the 24 h group(P > 0.05).(3)12 h,18 h,24 h group and three groups of patients with preoperative hemoglobin is no statistical difference between groups,12 h group compared with 18 h,24 h two groups of postoperative significantly lower hemoglobin,a comparison between groups were statistically significant(P < 0.05),the comparison between 18 h and 24 h group had no statistical difference(P > 0.05);(4)color doppler ultrasonography of the blood vessels of both lower limbs showed that all the patients had no lethal DVT formation.In the 12 h group,1 cases of lower limb intramuscular venous thrombosis were found;in the 18 h group,2 cases of lower limb intramuscular venous thrombosis were found;in the 24 h group,5 cases of lower limb intramuscular venous thrombosis were found.(5)in the 12 h group,4 cases of subcutaneous petechiae occurred in the lower limbs of the surgical side,among which one case had a large area of petechiae,and the area of petechiae expanded to about 4% of the body surface area by the third day after the operation.The use of LMWH was suspended urgently,and DVT was continued to be prevented by physical methods.2 cases and 1 case of subcutaneous ecchymosis occurred in the 18 h and 24 h groups respectively,but the area was small(less than 1% of the body surface area).LMWH was continued to be used according to the original treatment plan,and no significant expansion of the ecchymosis area was observed after discharge.Conclusion:1.The risk of postoperative blood loss and subcutaneous hemorrhage increased when anticoagulation was initiated at 12 h after surgery,compared with that at 18 h and 24 h.2.Anticoagulation was initiated 24 h after TKA in RA patients,although it could effectively prevent the generation of DVT.However,compared with starting anticoagulation 18 hours after surgery,it has no obvious advantage in reducing postoperative blood loss,but increases the possibility of lower limb intramuscular vein thrombosis.3.In this study,starting anticoagulation at 18 h was superior to starting anticoagulation at 12 h and 24 h after TKA in RA patients. |
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