摘要
目的探讨对于多发骨折的患者，行股骨干内固定手术的时机与术后机体炎性变化及临床结果间的关系。方法进行前瞻性非随机队列研究。按入选标准选取2005年4月至2007年8月78例患者。分为多发骨折伴有股骨干开放骨折组26例（A组）、多发骨折伴股骨干闭合骨折组23例（B组）、单纯股骨干闭合骨折组29例（C组）。A组实施伤害控制骨科学（damage control orthopaedics，DCO）处理行分期手术，B、C组均早期行骨折确定性内固定术（〈24h）。各组患者术前、术后血液IL-6、TNF-α浓度作为炎性反应水平的指标，PaO2／FiO2、总胆红素、肌酐等项目作为了解各器官功能损害的指标，并统计各组术后并发症的发生率。对各组患者术前、术后炎性反应程度的变化以及多器官功能损害情况和术后并发症率进行比较分析。结果A组二期术后IL-6平均升高了59ng／L，TNF-α平均升高了85ng／L，而B组分别平均升高了154ng／L和250ng／L，两组之间IL-6、TNF-α升高的值均有显著差异（P〈0．01）。A组一期术后、C组术后IL-6、TNF-α平均升高的程度也均明显小于B组（P〈0．01）。相应的，B组术后中出现PaO2／FiO2〈250mmHg（1mmHg=0．133kPa）的比例、总胆红素出现异常的比例、肌酐出现异常的比例均大于A组两期手术术后（P〈0．05），在人工通气时间、ICU时间、正性体液平衡时期上也均高于A组二期术后（P〈0．01）。与A组一期手术比较，B组术后人工通气时间略高（P〈0．05），而ICU时间、正性体液平衡时期无明显差异（P〉0．05）。C组术后在以上各个项目上也均小于B组（P〈0．01）。术后统计栓塞和MODS的发生率，A组（11．5％）与B组（13．0％）比较无明显差异，但均高于C组（P〈0．01）。结论多发骨折股骨干早期髓内钉固定，可引起机体炎性反应的显著变化，并引起各器官亚临床的改变，而晚期手术引起的上述改变较小。因此，选择多发骨折早期股骨干髓内钉固定手术时机仍需要谨慎。
Objective To investigate the relationship between the operation time of femur shaft fracture with post-operation system inflammation changes and clinical outcomes for those multiple fractures. Methods This investigation was designed as a prospective, nonrandomized cohort study. From April 2005 to August 2007, all 78 hospitalized patients were divided into 3 groups by an inclusion criteria ： multiple fractures with opened fracture of femur shaft （ group A, n = 26 ） , multiple fractures with closed fracture of femur shaft （ group B, n = 23 ） , single closed fracture of femur shaft （ group C, n = 29 ）. In the group A, damage control orthopaedics （DCO） procedure were performed. In the group B and C, all the femur shaft fractures were performed intramedullary nail fixation early （ 〈 24 h ）. From serially sampled venous blood, inflammatory reaction index were estimated by measured the concentration of IL-6, TNF-α surround the operation, and the conditions of multiple organs were estimated by assayed PaO2/FiO2, total bilirubin （TBIL）, creatinine （Cr） levels, the postoperation complication rates were analyzed among each groups. The extent of inflammation changes, multiple organs damage conditions and postoperation complication rates were compared and analyzed among the 3 groups. Results In the group A, the median increase values of IL-6 ,TNF-α after the secondary surgery were 59 ng/L and 85 ng/L, whereas they were 154 ng/L and 250 ng/L respectively in the group B, there was a significant difference between the 2 groups （ P 〈 0. 01 ）. In addition, the median increase values of IL-6, TNF-α after the first surgery in group A and in group C were both significantly less than group B （ P 〈 0. 01 ）. Correspondly, the abnormal rates of PaO2/ FiO2, TBIL, Cr levels occurred in the group B were all greater than group A after the 2 surgery procedures （P 〈 0. 05 ） , and in the aspects of average ventilation days, ICU staying days, duration of positive fluid balance （ input/output 〉 500 ml/24 h） , the group B were all greater than group A after the second surgery （ P 〈 0. 01 ）. Compared with group A after the first surgery, group B showed a longer average ventilation days, but it had no significant difference in average ICU stay days and duration of positive fluid balance. In addition, for group C, all the aspects above were less than group B （P 〈 0. 01 ）. Concerned with the complications after surgery in each groups, fat embolism and MODS rate between group A and B had no significant diference （ 11.5% vs 13. 0%, P 〉 0. 05 ）, but higher than which of group C （ P 〈 0. 01 ）. Conclusions The early intramedullary nail fixation of femur shaft fracture in multiple fractures may lead to a significant system inflammation changes, and may develop the subclinical changes of multiple organs. However, these changes are less in those surgery procedures later performed, namely intramedullary nail fixation of femur shaft fracture in multiple fractures as a primary definitive treatment has a potential risk, and should be carefully evaluated.
出处
《中华外科杂志》
CAS
CSCD
北大核心
2008年第13期961-965,共5页
Chinese Journal of Surgery
关键词
股骨骨折
受体
白细胞介素6
多发骨折
炎性反应
伤害控制骨科学
Femoral fractures
Receptors,interleukin-6
Multiple fractures
Inflammation
Damage control orthopaedics
作者简介
通讯作者：孙天胜，Email：suntiansheng-@163．com
