全膝关节置换术后血清中性粒细胞胞外诱捕网水平同术后深静脉血栓形成之间的关系研究

发布时间：2018-09-18 10:01

【摘要】：第一章全膝关节置换术后血清中性粒细胞胞外诱捕网水平同术后深静脉血栓形成之间的关系研究目的：探讨全膝关节置换术(total knee arthroplasty, TKA)术后中性粒细胞胞外诱捕网水平与下肢深静脉血栓形成(deep vein thrombosis, DVT)之间的关系。方法：本研究收集了2014年5月至2015年7月,在鼓楼医院运动医学与成人重建外科行TKA手术,术后发生下肢DVT的30名患者。病例纳入标准：1,诊断为骨关节炎或类风湿关节炎；2,术后行双下肢静脉造影诊断为下肢DVT。排除标准：1,血液样本或血液指标检测不全者。2,围手术期出现呼吸道感染、发热及手术切口感染者。并随机选取30名TKA术后未形成DVT的患者作为对照组。所有患者均在TKA术后第五天接受双下肢深静脉造影检查有无下肢DVT形成。分别在术前一天,术后第一、第三、第五天留取静脉血样,检测血清中NETs的水平。结果：两组患者,术后第一天血清NETs水平和术前相比都存在明显升高(P0.05)。在术后第三天时两组都开始下降,术后第五天几乎下降到术前水平。此外,术后DVT组,术后第一天和第三天血清NETs的含量都明显高于术后无DVT组(术后第一天,1.598±0.067vs 1.212±0.037,P0.001；术后第三天,1.305±0.044 vs 1.167±0.032,P0.05)。在NETs预测DVT能力的ROC曲线中,术后第一天和术后第三天血清NETs的曲线下面积分别为0.828(95%CI：0.722-0.933,P0.001)和0.677(95% CI：0.541-0.814,P0.05)。当术后第一天的NETs取1.294时,其阳性预测价值为80%,阴性预测价值为80%,敏感性为80%,特异性为80%。Logistic多因素回归分析表明,术后第一天NETs水平是TKA术后DVT发生的独立危险因素(OR=24.08,95% CI:4.94-117.28, P0.01)。结论：TKA术后患者血清NETs水平与术后DVT形成密切相关。第二章综述：人工关节假体置换术后血栓形成的免疫学机制静脉血栓事件包括深静脉血栓和肺栓塞,是人工关节置换术术后最主要的并发症之一,部分患者可以出现血栓后综合症,导致下肢溃疡、坏死及色素沉着,少部分患者甚至出现肺栓塞,威胁生命安全。目前对于深静脉血栓形成机制的理解还局限于过度活化的生理性止血反应和凝血反应,但是依然不能完全解释深静脉血栓形成的全部原因。近些年,不断有研究将静脉血栓形成和免疫学反应相联系,认为免疫系统在血栓形成中具有重要的作用。本文就此进行综述,介绍骨科人工关节置换术后,免疫系统的相关反应在术后下肢深静脉血栓形成中的作用和机制。
[Abstract]:Chapter 1 study on the relationship between the level of serum neutrophil extracellular entrapment net and deep venous thrombosis after total knee arthroplasty objective: to explore the relationship between total knee arthroplasty and neutrophil extracellular entrapment after total knee arthroplasty (total knee arthroplasty, TKA) The relationship between (deep vein thrombosis, DVT) level and deep venous thrombosis of lower extremity. Methods: from May 2014 to July 2015, 30 patients with lower extremity DVT were treated with TKA in the Department of Sports Medicine and Adult Reconstruction surgery in Gulou Hospital. Case inclusion criteria: 1, diagnosed as osteoarthritis or rheumatoid arthritis, followed by two lower extremity venography to diagnose lower extremity DVT. Exclusion standard 1, blood samples or blood indicators were not detected completely. 2. Respiratory tract infection, fever and surgical incision infection occurred in perioperative period. Thirty patients without DVT after TKA were randomly selected as control group. All patients underwent deep venography on the fifth day after TKA. Venous blood samples were collected on the first, third and fifth day before operation, and the serum levels of NETs were measured. Results: the serum NETs level was significantly higher in both groups on the first day after operation than that before operation (P0.05). On the third day after the operation, both groups began to decrease, and on the fifth day after the operation, they almost fell to the preoperative level. In addition, the level of serum NETs in the DVT group on the first and third day after operation was significantly higher than that in the no DVT group (1.598 卤0.067vs 1.212 卤0.037 P0.001 on the first day and 1.305 卤0.044 vs 1.167 卤0.032 P 0.05 on the third day after operation). In the ROC curve of NETs predicting the ability of DVT, the area under the curve of serum NETs on the first day and the third day after operation were 0.828 (95 CI: 0.722-0.933) and 0.677 (95% CI:0.541-0.814,P0.05), respectively. The positive predictive value was 80, the negative predictive value was 80, the sensitivity was 80, and the specificity was 80%.Logistic multivariate regression analysis showed that the NETs level on the first day after operation was an independent risk factor for the occurrence of DVT after TKA (OR=24.08,95% CI:4.94-117.28, P0.01). Conclusion the level of serum NETs is closely related to the formation of postoperative DVT in patients with TKA. Chapter two: the immunological mechanism of thrombosis after artificial joint prosthesis replacement, including deep vein thrombosis and pulmonary embolism, is one of the most important complications after artificial joint replacement. Some patients may develop post-thrombotic syndrome, leading to lower limb ulcers, necrosis and pigmentation, a small number of patients even pulmonary embolism, threatening life. The current understanding of the mechanism of deep venous thrombosis is limited to the hyperactive physiological hemostasis and coagulation reactions, but still can not fully explain the causes of deep venous thrombosis. In recent years, it has been studied that the immune system plays an important role in thrombosis. This article reviews the role and mechanism of immune system response in postoperative deep venous thrombosis of lower extremities after orthopedic arthroplasty.
【学位授予单位】：南京大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.4

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