李　剑　傅品来　丘青中　黄辉文

广东省中西医结合医院(佛山 528200)



髋膝关节置换围手术期中医证型演变规律及深静脉血栓辨证预防研究*

李剑傅品来丘青中黄辉文

广东省中西医结合医院(佛山 528200)

摘要目的：探讨髋膝关节置换围手术期中医证型演变规律及深静脉血栓辨证预防研究。方法：选取120例行髋膝关节置换围手术期患者作为前瞻性调查对象，随机分为辨证治疗组及西药对照组，辨证治疗组根据患者的中医证型演变规律，进行深静脉血栓的辨证预防；西药对照组采取西医治疗预防深静脉血栓。结果：辨证治疗组的深静脉血栓形成率为3.33%、患肢肿胀率为5.00%，西药对照组的深静脉血栓形成率为11.67%、患肢肿胀率为16.67%；两组数据具有显著性差异(P<0.05)。结论：髋膝关节置换围手术期的中医证型演变过程中，手术前期以实证，湿热下注型为主；术后初期以虚实证，气血瘀滞型为主；手术后期以虚证，脾肾阳虚型为主；根据患者的中医证型演变规律，进行辨证预防深静脉血栓形成，可显著减小深静脉血栓形成的风险，降低深静脉血栓形成率及患肢肿胀率，改善患者的预后。

主题词关节成形术, 置换, 髋/中医药疗法关节成形术, 置换, 膝/中医药疗法病因证候静脉血栓栓塞

深静脉血栓作为髋膝关节置换围术期常见的并发症之一，目前仍缺乏满意的防治方法[1-3]。阿司匹林、右旋糖酐类药物被证实对预防深静脉血栓形成无确切疗效，低分子肝素、华法林在预防深静脉血栓形成的过程中，可增加出血的风险[4-6]。通过系统科学的观察总结髋膝关节置换围手术期中医证型演变规律，为中医药辨证防治术后深静脉血栓的形成，提供临床依据。对此，本研究旨在探讨髋膝关节置换围手术期中医证型演变规律及深静脉血栓辨证预防研究。

临床资料选取于2014年12月～2015年10月期间，我院治疗的120例行髋膝关节置换围手术期患者作为前瞻性调查对象，对所有研究对象随机分为辨证治疗组及西药对照组；辨证治疗组60例，其中男28例，女32例；年龄范围39.5～68.5岁，平均年龄57.8±4.5岁；病因类型：股骨颈骨折9例，股骨头坏死27例，髋关节发育不良4例,膝关节骨性关节炎20例。西药对照组60例，其中男29例，女31例；年龄范围38.7～69.6岁，平均年龄56.3±4.7岁；病因类型：股骨颈骨折12例，股骨头坏死27例，髋关节发育不良3例，膝关节骨性关节炎18例；两组患者的一般资料无统计学差异(P>0.05)。

治疗方法选取120例行髋膝关节置换围手术期患者作为前瞻性调查对象，参考经典文献、中医体质量表、中医病证诊断疗效标准、中医诊断学、中医证候辨证规范，结合临床实际情况及征询专家意见，制定髋膝关节置换围手术期证候调查表(术前1天、术后第1、3、7、14 天)，收集所有患者的相关数据，运用SPSS17.0 统计软件进行描述性分析，总结髋膝关节置换围手术期中医证型演变规律；对所有研究对象随机分为辨证治疗组及西药对照组，辨证治疗组根据患者的中医证型演变规律，进行深静脉血栓的辨证预防；湿热下注型采取四妙散加味治疗，气血瘀滞型采取活血通脉饮加减治疗，脾肾阳虚型采取温肾阳健脾汤加减治疗；西药对照组采取西医治疗预防深静脉血栓，采用低分子肝素抗凝治疗、采用尿激酶溶栓治疗。

疗效标准对比两组患者的深静脉血栓形成率及患肢肿胀率，综合评价深静脉血栓的预防效果。

治疗结果120例髋膝关节置换围手术期中医证型演变规律见表1。

表1　120例髋膝关节置换围手术期中医

注：与其它中医证型对比，∆P<0.05

两组患者的深静脉血栓及患肢肿胀发生情况对比见表2。

表2　两组患者的深静脉血栓及患肢肿胀

讨论中医学认为，深静脉血栓属于 “脉痹”、“肿胀”或“瘀血流注”的范畴，以肿胀、疼痛及静脉曲张为主要表现[7-9]。本研究对120例行髋膝关节置换围手术期患者的中医证型进行分析，手术前期以实证的湿热下注型为主；而术后第3天，各中医证型分布均匀，无显著差异性；提示病情有所恶化或改善，症状体征有所变化，应采取清热利湿治疗。术后初期以虚实证为主要表现，以气血瘀滞型为主，体现为气虚血瘀或气滞血瘀，提示在治疗原则上，应采取理气活血止痛的标本兼治。术后期以虚证，脾肾阳虚型为主，提示病情有所好转，应注意病情变化及中医体质因素，进行辨证治疗用药。现代临床表明，血液高凝状态、静脉回流减慢及血管内皮损伤作为深静脉血栓形成的独立危险因素；与中医认为深静脉血栓以湿热、血瘀阻络为主要病机的观点相贴近[10-11]。

在髋膝关节置换围手术期的中医证型演变过程中，以湿热下注型、气血瘀滞型及脾肾阳虚型为主，瘀热互结作为深静脉血栓形成的基础病机，而凉血化瘀、清热解毒作为髋膝关节置换围手术期预防深静脉血栓形成的基础原则[12-13]。在深静脉血栓形成的预防治疗中，存在气滞血瘀、湿热蕴结及脾肾阳虚等情况，需进一步辨证治疗，提高临床治疗的针对性。在本研究中，辨证治疗组中，湿热下注型患者采取四妙散加味治疗，旨在清热利湿、活血消肿；气血瘀滞型采取活血通脉饮加减治疗，旨在活血消肿、化瘀通脉；脾肾阳虚型采取温肾阳健脾汤加减治疗，旨在温肾健脾、活血利湿[14-15]。研究结果提示根据患者的中医证型演变规律，进行辨证预防深静脉血栓形成，可显著减小深静脉血栓形成的风险，降低深静脉血栓及患肢肿胀率，改善患者的预后。

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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

【中图分类号】R228

【文献标识码】A

doi:10.3969/j.issn.1000-7369.2016.05.009

*广东省佛山市卫生和计划生育局资助医学科研课题(2015290)