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2. Venous Thromboembolism

VENOUS THROMBOEMBOLISM

Oleh Dr H Subagyo SpB - SpOT

 Venous thromboembolism (VTE) terjadi karena pembentukan bekuan darah yang tersumbat di dalam vena, membatasi aliran darah yang melewati vena.Hal ini paling sering terlihat pada vena profunda pada tungkai bawah, femoral atau pelvis (deep vein thrombosis, DVT).Terkadang, bagian dari bekuan lepas, berjalan melewati sistem vena, dan tersangkut pada bagian tubuh lainnya.Ketika bekuan tersebut tersumbat di paru-paru (pulmonary embolism, PE), dapat menjadi fatal.Di seluruh dunia, VTE menimbulkan angka morbiditas, angka mortalitas serta angka pengeluaran yang tinggi.

Di Amerika Serikat, insiden dari VTE yang pertama kali sekitar 120 dari 100.000 orang per tahun. Insiden ini sangat bervariasi tergantung dari usia dan jenis kelamin penderita. Pada anak-anak umur 14 tahun atau lebih muda, insidennya adalah 1 dari 100.000 orang per tahun, dan pada dewasa umur 85 tahun keatas, hampir 1000 dari 100.000 orang pertahunnya.

Angka ini lebih tinggi pada wanita pada usia subur dan juga pada laki-laki dengan usia 50 tahun ke atas. Hampir sepertiga dari penduduk yang mempunyai riwayat VTE, dapat terjadi kejadian VTE yang kedua pada 10 tahun kedepan.

Angka mortalitas keseluruhan dari VTE adalah 30% dalam tiga bulan di setiap kejadian. Suddent death terjadi hampir 25% pada pasien PE, dengan hampir 40% kematian terjadi dalam tiga bulan.

Di United Kingdom, pulmonary embolism kedua dengan DVT pada pasien rawat inap menyebabkan antara 25.000 sampai 32.000 kematian setiap tahunnya. Sekitar 10% dari semua pasien yang meninggal di rumah sakit, PE merupakan penyebab yang mendadak. Angka ini lebih dari total kombinasi kematian dengan kanker payudara, AIDS, dan kecelakaan lalul lintas. Kurang dari 1 diantara 10 orang PE yang fatal didiagnosis sebelum kematian.Tidak dapat disangkal bahwa VTE merupakan penyakit yang tenang dan sulit untuk diketahui tetapi sangat bisa untuk dicegah.

 

 

Gambar Venous Thromboembolism

 

 VII.1 Pathogenesis

 

VTE berkembang sebagai hasil dari beberapa faktor yang bersamaan pada waktu operasi.Faktor-faktor yang mempengaruhi thrombosis vena – statis, kerusakan vascular, dan hiperkoagulabilitas – yang digambarkan oleh trias Virchow’s.Dipercaya bahwa operasi besar pada ortopedi, merusak bone marrow, impaksi oleh semen tulang, statis selama prosedur operasi, pencetus kuat dari terbentuknya thrombin secara local dan sistemik dan aktivitas yang menyebabkan terjadinya formasi thrombus pada bagian yang dioperasi atau bagian lain yang resisten (locus minoris resistentia).

Bagian dari sisa-sisa sumsum tulang dan agregat sel dapat menyebabkan keadaan klinis yang parah selama dan segera sesudah operasi, yang mungkin terjadi pada beberapa organ seperti paru-paru, otak dan miokardium. Thrombin berhubungan dengan proses penyembuhan inflamasi dan dapat menempatkan pasien tertentu pada risiko terjadinya tromboemboli vena dan arteri untuk waktu yang lama setelah operasi. Kondisi klinis yang menyebabkan statisnya aliran darah, kerusakan pembuluh darah, atau meningkatkan kecenderungan menuju koagulabilitas, dapat mempengaruhi terjadinya VTE.

 

Table 1 Inherent disorders that predispose to venous thromboembolism

  • Antiphospholipid syndrome
    • Primer, tanpa penyakit autoimun lainnya seperti SLE
    • Sekunder dengan SLE dengan LA (dengan aCL)
    • Sekunder dengan SLE tanpa LA (dengan aCL)
    • Sekunder, dengan penyakit autoimun lainnya atau dikarenakan obat
    • Myeloproliferative disorders – termasuk polisitemia vera, pada daasarnya thrombositosis
    • Hiperhomositenemia – kadar plasma homositein puasa diatas 40 μmol/L pada wanita; 18 μmol/L pada laki-laki
    • Defisiensi antithrombin – Heterozygotic
    • Defisiensi Protein C  – Heterozygotic
    • Defisiensi Protein S  – Heterozygotic
    • Mutasi Factor V Leiden – Heterozygotic
    • Mutasi Factor II  – Heterozygotic
    • Mutasi Factor V or II  – Homozygotic
    • Riwayat venous thromboembolism sebelumnya
      • Proximal saphenous/superficial vein thrombosis
      • Proximal with or without distal deep-vein thrombosis
      • Hanya distal deep vein thrombosis
      • Pulmonary embolism
      • Additional risk caused by clinical idiopathic VTE event
      • Riwayat keuarga adanya venous thromboembolism – pada keluarga pertama, orang tua atau saudara kandung.

 

aCL: anticardiolipin antibodies; LA: lupus anticoagulant; SD: standard deviation; SLE: systemic lupus erythematosus.

 

 

Table 2 faktor risiko umum yang mempengaruhi venous

  • Karakteristik umum pasien
    • Jenis kelamin – laki-laki
    • Umur >40 tahun (risiko meningkat dengan bertambahnya usia, maksimum pada usia lebih dari 70 tahun)
    • Golognan darah / goloongan Non- O
    • Obesitas / BMI > 30 kg/m2
    • Perokok
    • Terapi kontrasepsi oral dengan kombinasi esterogen / progesteron
    • Terapi hormone replacement therapy combined estrogen/ progesterone
    • Menggunakan obat spesifik – dengan protective effects seperti statins, aspirin
    • Kondisi klinis saat ini (kurang dari 3 bulan)
      • Menjalani operasi besar (3 bulan), lebih jika terdapat komplikasi yang berhubugan dengan operasi
      • Myocardial infarction – dalam 3 bulan terahir
      • Ischemic stroke dalam 3 bulan terakhir, mengabaikan paralisis
      • Perjalanan panjang – lebih dari 6 jam
      • Dehidrasi – dehidrasi berat dengan kehilangan berat badab 10%
      • Hematokrit yang meningkat >45% untuk wanita; >50% untuk laki-laki
      • Hyperviscosity ‡ – meningkatnya viscositas darah
      • Kondisi klinis kronik
        • Keganasan
          • Risiko bertambah dengan meningkatnya stage
          • Risiko lebih tinggipada kanker metastatis
          • Risiko bertambah jika terdapat tipe spesifik yaitu pancreatik, gastrointestinal, ovarian, prostatik, pulmonary, malignant glioma (dibanding dengan buka keganasan)
          • Radioterapi
          • Chemotherapy
          • Hormonal therapy
  • Gagal jantung / kelainan jantung (semakin tinggi staging NYHA, semakin tinggi risikonya)
  • Chronic respiratory disease – chronic obstructive pulmonary disease atau emphysema
  • Nephrotic syndrome – sindroma dari proteinuria, hypoalbuminemia dari
  • Kesakitan yang parah dan akut
    • Dengan rawat inap
    • Systemic sepsis (septicemia)
  • Immobilisasi
    • Terkurung dalam tempat tidur atau kursi roda  >3 hari
    • Paralisis tungkai bawah (hemiplegia/paraplegia/ neurological disease)
  • Inflammatory bowel disease – Crohn’s disease dan ulcerative colitis
  • Venous insufficiency
    • Varicose veins, penonjolan vena superficial pada waktu berdiri
    • Pembengkakan tungkai bawah, tidak nyaman
    • Ulcerasi
  • Penyakit arteri pada tungkai bawah – intermittent claudication
  • Diabetes – termasuk kedua tipe 1 dan 2 dari setiap etiologi
  • Meningkatnya tingkat trigliserid
  • Menurunnya tingkat HDL

Normal relative serum viscosity ranges from 1.4–1.8 units; symptoms usually are not seen at viscosities of less than 4 units, and the hyperviscosity syndrome typically requires

a viscosity greater than 4 units; ASA: acetyl salicylic acid; BMI: body mass index; NYHA: New York Heart Association; HDL: High Density Lipoprotein

 

 VII.2 Diagnosis

Diagnosis awal penting untuk mencegah morbiditas dan mortalitas yang berhubungan dengan VTE.Pemeriksaan fisik dan penilaian kemungkinan yang detail memberikan informasi yang berguna untuk kemungkinan antara DVT dan PE.

 

VII.2.1 Peraturan kemungkinan klinis pada pasien non-bedah

Berdasarkan penilaian kemungkinan pre-test dari VTE, DVT dan PE, ditetapkan keputusan untuk keadan klinis, seperti peraturan kemungkinan Wells, yang sering digunakan.Peraturan ini kombinasi dari berbagai komponen yaitu anamnesa, pemeriksaan dan invetigasi, dan menyederhanakan prosedur diagnostik, meningkatkan akurasi klinis dan mengurangi biaya keseluruhan dari investigasi yang dibutuhkan. Peraturan Wells member hasil yang lebih baik pada pasien yang lebih muda tanpa co-morbiditas atau dengan riwayat VTE, pada pasien yang lebih tua dan pasien dengan co-morbiditas, pemeriksa menyarankan untuk mempercayakan pada pertimbangan pemeriksaan.

 

VII.2.2 D-dimer assay

Sensivitas tinggi D-dimer assay untuk VTE bisa dilakukan pada pasien dengan probabilitas pre-test untuk DVT atau  PE yang rendah, seperti yang dijelaskan dengan peraturan prediski Wells. D-dimmer assay yang negative merupakan indikasi dari probabilitas VTE yang rendah. Enzyme-linked immunosorbent assay (ELISA), rapid ELISA kuantitatif, dan penentuan D-dimmer turbidimetric sebelumnya merupakan D-dimmer assay sesivitas tinggi yang digunakan saat ini untuk mendukung diagnosis dari VTE. D-dimmer assay negative dengan sensitivitas 96% dari 100% indikasi dari kemungkinan kecil dari VTE.

Hal ini menurunkan kebutuhan untuk pemeriksaan radiologi. D-dimmer adalah hasil degradasi fibrin, dibentuk ketika cross-linked fibrin dalam bekuan darah terdegradasi. Tingkat D-dimmer dalam darah meningkat pada VTE yang akut.Akan tetapi ini adalah marker yang non-spesifik, sejak tingkat D-dimmer juga meningkat pada kondisi non-trombotik seperti pada operasi besar, perdarahan, trauma, kehamilan, atau kanker.

 

VII.2.3 Ultrasound

Pada pasien non-bedah dengan pretest probabilitas tingkat menengah sampai tingkat tinggi dari DVT dengan peraturan Wells, ultrasound membantu dalam diagnosis thrombosis yang simtomatik pada vena proksimal dari tungkai bawah.Sejak ultrasound kurang sensitive pada pasien yang asimtomatik atau mempunyai DVT yang terbatas pada tungkai bawah, tidak bisa digunakan peraturan DVT pada pasien ini.Jika ada kecurigaan DVT pada betis dan hasil dari ultrasound adalah negative, ultrasound ulang atau venografi dengankontras dapat disarankan. Venografi dengan kontras adalah test yang menentukan keluarnya peraturan DVT.

 

VII.2.4 Diagnosis radiologi

Jika hasil pre-test probabilita dari pulmonary embolism adalah intermediet sampai tinggi, pasien disarankan untuk melakukan pemeriksaan diagnostik radiologi. Radiologi ini meliputi ventilation-perfusion (V/Q) scans, multi detector helical computed axial tomography (CT), dan/ atau pulmonary angiography. Saat ini disarankan bahwa CT scan saja tidak cukup sensitive untuk mendeteksi pulmonary embolism pad pasien yang mempunyai pre-test probabilitas yang tinggi pada pulmonary embolism. Saat CT scannegative, direkomendasikan dilakukan pemeriksaan radiologi yang selanjutnya. Yaitu single atau rangkaian penilaian ultrasound pada ekstremitas bawah atau pulmonary angiography.

 

 VII.3  Penyebab penyakit dan rekurensi

 

Deep vein thrombosis biasanya terjadi pada satu tungkai, tetapi tidak selalu.Pada pasien non-bedah, gejala klasik seringkali tidak jelas, progresif, dan “sensasi tarikan” yang mengganggu pada betis bawah.Setelah itu perasaan ini menjadi lebih berat dan disertai dengan rasa panas, bengkak, dan eritem.Mungkin bisa mnimbulkan nyeri di sepanjang daerah vena yang terlibat dan vena mungkin teraba.Bisa terjadi meningkatnya turgor kulit dan distensi dari vena superficial.Kolateral vena dapat menjadi mencolok.Tanda Homan’s (nyeri yang berhubungan dengan pergerakan dorsofleksi dari sendi ankle) mungkin juga ditemukan.

Pada kasus yang tidak biasa dari thrombosis adalah vena iliaca, femoral, atau politeal, arus balik vena yang dapat dikompromikan, dapat menyebabkan iskemik.Daerah dibawah vena yang tersumbat dapat berwarna biru, bengkak, dan sakit.Hal ini mengarah seperti phlegmasia cerulea dolens. Dengan meningkatnya bekuan dan pembengkakan, vena sama halnya dengan arteri, keduanya bisa terganggua dan meyebabkan kepucatan, phlegmasia cerulea dolens, yang dapat menyebabkan gangrene dan bisa mengarah ke amputasi.

Komplikasi DVT yang sering dan serius adalah pulmonary embolism.Hal ini terjadi ketika bekuan di vena tungkai terlepas dan berjalan menuju ke paru-paru.bekuan bisa sebagian atau seluruhnya menghambat arteri di dalam paru-paru dan menyebabkan nyeri dada atau rasa tidak nyaman, nafas pendek yang tidak bisa dijelaskan, nafas yang cepat pada saat istirahat, batuk darah tiba-tiba, dan detak jantung yang cepat. Embolus yang besar dapat menyebabkan terhambatnya pembuluh darah ke kedua paru-paru dan berakibat fatal; hal ini adalah penyebab yang sering dari kematian mendadak yang tidak terduga.

 

VII.4 Penanganan dari Venous thromboembolism

 

VII.4.1 Pencegahan

Profilaxis rata-rata dari VTE sedikit rendah di seluruh dunia.Profilaxis dari VTE, normalnya menggunakan heparin, atau low-molecular-weight heparin (LMWH), dipakai secara luas untuk pasien dengan risiko operasi tetapi kurang sering pada pasien medis yang berisiko. The Epidemiologic International Day untuk penelitian Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) merupakan survey cross-sectional multinational yang menunjukkan bahwa hanya 58,5% dari pasien bedah dan 39,5% dari pasien medis menerima profilaxis untuk VTE. Spencer et al, menemukan bahwa beberapa VTE didiagnosis dalam 3 bulan setelah perawatan daripada yang sedang menjalani perawatan. Hingga kini, rumah sakit yang rutin menggunakan profilaxis dapat mengurangi insiden dari pasien yang terkena VTE.Profilaxis untuk VTE harus dilanjutkan diluar rumah sakit untuk mencegah perkembangan mengarah ke DVT dan gejala DVT.

 

VII.4.2 Farmakologi dan mekanisme intervensi

Umumnya unfractioned heparin (UFH) dan LMWH efektif untuk mencegah terjadinya VTE.Heparin dan warfarin dipercaya menjadi nilai yang lebih rendah.Meskipun terdapat bukti yang kuat bahwa aspirin mencegah arterial thrombosis, ini berperan dalam mencegah venous thrombosis diragukan.Selain pendekatan farmakologi, kompresi fisik pada vena, mobilisasi awal, dan pencegahan dehidrasi dapat juga menjalankan peran sebagai pencegahan VTE, tetapi intervensi mekanik tidak berarti mngganti profilaxis kimia.

 

VII.4.3 Profilaxis

Pilihan antikoagulan profilaxis kini membuat sulit bagi dokter maupun pasien. Tantangan yang dihadapi termasuk:

  • Membutuhkan pemberian parenteral
  • Mengganggu pasien
  • Interaksi makanan dan obat
  • Sempitnya terapi
  • Meningkatkan risiko perdarahan
  • Risiko serius lainnya

 

Beberapa perbedaan langkah pada kaskade koagulasi dapat ditargetkan pada pencarian obat yang baru yang dapat ideal untuk venous thromboprophylaxis. Strategi profilaxis VTE yang ideal dapat mempunyai karakteristik sebagai berikut:

  • Pemberian oral
  • Dapat mengurangi VTE
  • Tidak membutuhkan monitoring koagulasi.

 

VII.4.4 Pengobatan

Tujuan dari terapi dari VTE adalah untuk membantu thrombolysis, mencegah thrombus berkepanjangan dan PE, dan mengurangi insiden dari berulangnya VTE dan PPS.Tujuan tambahan adalah untuk mencapai pilihan terapi yang menyebabkan minimalnya efek samping dan gangguan pasien.

 

 VII4.4.1 Anticoagulation

Antikoagulasi adalah andalan dari pengobatan VTE. Terapi antikoagulasi untuk PE dan DVT tanpa komplikasi menggunakan obat antikoagulasi yang sama. pengobatan pertama untul VTE adalah dengan heparin untuk lima sampai sepuluh hari. Digunakan secara oral antikoagulan untuk minimum tiga bulan.Terapi rawat jalan dengan LMWH telah diganti dengan pengobatan rawat inap dengan intravena UFH seperti yang paling sering digunakan sebagai obat antikoagulan.

Beberapa penelitian menegaskan bahwa LMWH fixeddose subkutan yang tidak dimonitor paling kurang efektif dan aman sebagai dosis biasa UFH iv untuk mengobati pasien dengan VTE. Dalam penelitian pasien dalam LMWH mempunyai episode yang lebih sedikit perdarahan besar dan juga secara signifikan mengurangi mortalitas selama 3 sampai 6 bulan dalam follow up, dibanding dengan UFH. Monitoring laboratorium yang kontinu tidak diperlukan.Untuk sebagian besar pasien, pasien rawat jalan dengan terapi LMWH sc aman dan efektif.

 

Meskipun pasien dengan risiko tinggi komplikasi perdarahan, pengobatan awal dengan iv UFH dapat digunakan karena mempunyai waktu paruh yang pendek dan kemungkinan untuk membalikkan efek antikoagulan dengan protamine sulfat. Pengobatan jangka panjang dengan terapi UFH dapat dihubungkan dengan komplikasi seperti heparin induce trombositopenia dan osteoporosis. Komplikasi ini lebih jarang dibanding LMWH.Obat lainnya adalah hirudin, lepirudin dan derivate coumarin (warfarin) lebih jarang dipakai untuk antikoagulan awal.

Durasi dari antikoagulasi tergantung dari setiap pasien.Umur, pribadi, dan riwayat keluarga dari VTE, dan adanya co-morbiditas dan faktor risiko harus perhitungkan sebelum menetukan panjangnya terapi antikoagulasi. Obat yang paling sering digunakan untuk antikoagulasi jangka panjang adalah Vitamin K antagonis oral  dalam kelas coumarin, seperti warfarin.

 

 VII.5 Review tentang Dabigatran Etexilate®

 

VII.5.1 Latar belakang

Lebih dari lima decade, vitamin K antagonis warfarin sudah menjadi standart koagulan oral jangka panjang yang dipakai secara klinis. Meskipun efektif, obat ini masih banyak kekurangan.Beberapa dari faktor yang mempengaruhi keefektifan warfarin dalam thromboprophylaxis meliputi perbedaan genetic saat metabolism, asupan vitamin K, konsumsi alcohol, dan meminum obat bersama-sama dengan obat. Dosis sehari-hari warfarin dapat bervariasi secara luas, dari kurang dari 1 sampai lebih dari 20 mg/hari, berdasarkan pemeliharaan pasien dalam batas target International Normalized Ratio (INR). Dengan demikian pengawasan ketat dan perbaikan dosis sangat dibutuhkan.Warfarin juga merupakan reaksi onset yang lambat.Ketika antikoagulasi cepat dibutuhkan, pasien mendapat terapi antrithrombin parenteral bersamaan dengan heparin.Panjang waktu paruh dari warfarin, yang dikombinasi dengan waktu paruh dari vitamin K berdasarkan faktor pembekuan, juga berkontribusi pada onset reaksi yang lambat.Obat antikoagulan alternative juga dibutuhkan diberikan secara oral.

Obat antikoagulan oral baru Pradaxa® memberikan harapan. Penelitian menunjukkan bahwa obat ini mempunyai onset dan offset reaksi yang cepat dan menunjukkan antikoagulan yang dapat diprediksi, mengurangi kebutuhan untuk memonitor koagulasi. Obat ini tidak menunjukkan adanya interaksi dengan makanan dan potensial untuk berinteraksi dengan obat lain juga dipertimbangkan rendah.

Setelah persetujuan dari EMEA pertemuan ilmuwan (CHMP), dabigatran etexilate diluncurkan dengan nama dagang Pradaxa® di negara-negara Europe pada tahun 2008, dan sekarang dipasarkan di di seluruh negara anggota Europe. Obat ini diindikasikan untuk mencegah terajdinya venous thromboembolism pada pasien yang telah menjalani operasi THR/TKR. Obat ini juga dipasarkan di Kanada dengan nama dagang Pradax®.

 

 

VII.5.2 Mekanisme aksi

Interaksi antara beberapa faktor pro- dan antikoagulan mempertahankan keseimbangan antara hemostasis dan thrombosis yang normal.Ketika terdapat luka pada dinding dari pembuluh darah, faktor jaringan dan unsur pokok subendothelial lainnya dikeluarkan.Faktor jaringan berinteraksi dengan faktor VII aktif untuk membentuk thrombin.Thrombin merubah fibrinogen ke fibrin dan merupakan pemeran utama dalam formasi thrombus.

 

 

 

Thrombin juga mengaktifkan faktor XI, faktor V dan faktor VIII.Hal ini mengakselerasi produksi molekul thrombin tambahan.Sebagai tambahan, thrombin mempercepat aktivasi platelet.Bekuan darah berikatan dengan thrombin lalu mengaktifkan kaskade koagulasi.Dengan demikian thrombin memegang peranan penting pada tiga fase dari inisiasi kaskade koagulasi, perkembangan dan pembentukan bekuan darah. Oleh karena itu thrombin adalah target tepat untuk menginhibisi terbentuknya kaskade bekuan darah. Sebagian besar antikoagulan natural seperti anti-thrombin dan sistem protein C berperan melawan produksi maupun aksi dari thrombin.

Dabigatran etexilate merupakan inovatif kelas terbaru dari antikoagulan, yang mengarah sebagai direct thrombin inhibitors (DTIs), dimana mengikat secara langsung dan reversible pada thrombin dan menghambat proses pembekuan. Dabigatran etexilate secara spesifik dan selektif menghambat ikatan fibrin amupun thrombin bebas dengan mengikat sisi aktif dan mencegah konversi dari fibrinogen ke fibrin.Dengan demikian menghambat perkembangan dari thrombus.

Molekul thrombin mempunyai tiga sisi dimana inhibitor thrombin dapat bekerja: exosite 1, exocsite 2, dan site A aktif. Exosite 1 adalah tempat melekatnya fibrin, sedangkan exosite 2 adalah tempat heparin melekat.Heparin secara tidak langsung menghambat thrombin dengan mengkatalisasi fungsi dari anti-thrombin.Heparin menginduksi perubahan konformasi antithrombin, dimana kemudian secara permanen mengikat sisi aktif dari thrombin dan menghambatnya.

 

Seperti direct thrombin inhibitor (DTI), dabigatran adalah bentuk anti-thrombin tidak terikat dan secara langsung mengikat dengan sisi aktif dari molekul thrombin dengan interaksi hidrofobik. Ketika DTI bivalent dapat berikatan dengan exosite 1 dan sisi aktif, DTI univalent, seperti dabigatran, mengikat hanya sisi yang aktif. Secara langsung memblok thrombin, dabigatran memblok konversidari fibrinogen ke fibrin, aktivasi platelet, dan regulasi dari faktor V,VIII dan IX.

Dalam perbedaan yang lain, DTI dapat bereaksi pada keduanya (larutan) sama baiknya ikatan fibrin thrombin, ketika heparin complex antithrombin tidak dapat berinteraksi dengan ikatan fibrin thrombin, seperti dalam bekuan darah. Reaksi dari dabigatran adalah reversible.Dabigatran etexilate memisahkan dari thrombin, meninggalkan sebagian kecil, secara enzimatik mengaktifkan thrombin untuk hemostasis normal.

 

 

 

 

BAB VIII

KESIMPULAN

 

Sendi lutut merupakan persendian yang paling besar pada tubuh manusia. Sendi ini terletak  pada  kaki  yaitu  antara  tungkai atas dan tungkai bawah. Pada dasarnya sendi lutut ini terdiri dari dua articulatio condylaris diantara condylus femoris medialis dan lateralis dan condylus tibiae yang terkait dan sebuah sendi pelana , diantara patella dan fascies patellaris femoris. Gerakan yang dapat dilakukan oleh sendi lutut yaitu gerakan fleksi , ekstensi dan sedikit rotatio.

Fungsi dari sendi lutut ini adalah untuk mengatur pergerakan dari kaki, dan untuk menggerakkan kaki ini diperlukan koordinasi berikut ini :

  • Otot- otot yang membantu menggerakkan sendi.
  • Capsul sendi yang berfungsi untuk melindungi bagian tulang yang bersendi supaya jangan lepas bila bergerak.
  • Adanya permukaan tulang yang dengan bentuk tertentu yang mengatur luasnya gerakan.
  • Adanya cairan dalam rongga sendi yang berfungsi untuk mengurangi gesekan antara tulang – tulang rawan pada permukaan sendi.
  • Ligamentum - ligamentum yang ada di sekitar sendi lutut yang merupakan penghubung kedua buah tulang yang bersendi sehingga tulang menjadi kuat untuk melakukan gerakan-gerakan tubuh.

Total knee arthrosplasty modern terdiri dari pengangkatan penyakit permukaan articular dari lutut yang diikuti dengan melapisi kembali dengan komponen metal dan polietilen prostetik. Indikasi utama untuk total knee arthroplasty adalah untuk mengurangi rasa nyeri yang berhubungan dengan arthritits di lutut pada pasien yang gagal dengan terapi non operatif.

Evaluasi pra operasi yang hati-hati harus dilakukan untuk menentukan diagnosa yang tepat, mengidentifikasi kebutuhan untuk operasi, membantu perencanaan operasi dan mencegah komplikasi pada periode perioperatif.Management postoperatif ini meliputi profilaxis melawan infeksi, vena tromboemboli dan terapi fisik yang paling cocok agar mendapatkan pergerakan lutut yang paling baik dan rehabilitasi yang aman yang dapat dipraktekkan.

MIS Quad-Sparing TKA meredakan sakit lutut dan memungkinkan beberapa pasien untuk pulih dan kembali pada pekerjaan dan kegiatan sehari-hari lebih cepat daripada mereka melakukan operasi knee replacement tradisional.Ketika cartilago pada satu bagian lutut mengalami kerusakan, ahli bedah mungkin dapat mengganti hanya bagian yang rusak dari sendi tersebut.Prosedur ini disebut partial atau unicompartmental atau unicondylar knee replacement.

Dipercaya bahwa operasi besar pada ortopedi, merusak bone marrow, impaksi oleh semen tulang, statis selama prosedur operasi, pencetus kuat dari terbentuknya thrombin secara local dan sistemik dan aktivitas yang menyebabkan terjadinya formasi thrombus pada bagian yang dioperasi atau bagian lain yang resisten (locus minoris resistentia).Obat antikoagulan oral baru Pradaxa® memberikan harapan. Penelitian menunjukkan bahwa obat ini mempunyai onset dan offset reaksi yang cepat dan menunjukkan antikoagulan yang dapat diprediksi, mengurangi kebutuhan untuk memonitor koagulasi. Obat ini diindikasikan untuk mencegah terajdinya venous thromboembolism pada pasien yang telah menjalani operasi THR/TKR.

 

DAFTAR PUSTAKA

 

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