中华外科杂志
中華外科雜誌
중화외과잡지
CHINESE JOURNAL OF SURGERY
2008年
13期
961-965
,共5页
孙天胜%陈晓斌%刘智%马舟涌%张建政
孫天勝%陳曉斌%劉智%馬舟湧%張建政
손천성%진효빈%류지%마주용%장건정
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
股骨骨摺%受體,白細胞介素6%多髮骨摺%炎性反應%傷害控製骨科學
고골골절%수체,백세포개소6%다발골절%염성반응%상해공제골과학
Femoral fractures%Receptors,interleukin-6%Multiple fractures%Inflammation%Damage control orthopaedics
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(＜24 h).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59 ng/L,TNF-α平均升高了85 ng/L,而B组分别平均升高了154 ng/L和250 ng/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＜250 mm Hg(1 mm Hg=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.
目的 探討對于多髮骨摺的患者,行股骨榦內固定手術的時機與術後機體炎性變化及臨床結果間的關繫.方法 進行前瞻性非隨機隊列研究.按入選標準選取2005年4月至2007年8月78例患者.分為多髮骨摺伴有股骨榦開放骨摺組26例(A組)、多髮骨摺伴股骨榦閉閤骨摺組23例(B組)、單純股骨榦閉閤骨摺組29例(C組).A組實施傷害控製骨科學(damage control orthopaedics,DCO)處理行分期手術,B、C組均早期行骨摺確定性內固定術(＜24 h).各組患者術前、術後血液IL-6、TNF-α濃度作為炎性反應水平的指標,PaO2/FiO2、總膽紅素、肌酐等項目作為瞭解各器官功能損害的指標,併統計各組術後併髮癥的髮生率.對各組患者術前、術後炎性反應程度的變化以及多器官功能損害情況和術後併髮癥率進行比較分析.結果 A組二期術後IL-6平均升高瞭59 ng/L,TNF-α平均升高瞭85 ng/L,而B組分彆平均升高瞭154 ng/L和250 ng/L,兩組之間IL-6、TNF-α升高的值均有顯著差異(P＜0.01).A組一期術後、C組術後IL-6、TNF-α平均升高的程度也均明顯小于B組(P＜0.01).相應的,B組術後中齣現PaO2/FiO2＜250 mm Hg(1 mm Hg=0.133kPa)的比例、總膽紅素齣現異常的比例、肌酐齣現異常的比例均大于A組兩期手術術後(P＜0.05),在人工通氣時間、ICU時間、正性體液平衡時期上也均高于A組二期術後(P＜0.01).與A組一期手術比較,B組術後人工通氣時間略高(P＜0.05),而ICU時間、正性體液平衡時期無明顯差異(P＞0.05).C組術後在以上各箇項目上也均小于B組(P＜0.01).術後統計栓塞和MODS的髮生率,A組(11.5%)與B組(13.0%)比較無明顯差異,但均高于C組(P＜0.01).結論 多髮骨摺股骨榦早期髓內釘固定,可引起機體炎性反應的顯著變化,併引起各器官亞臨床的改變,而晚期手術引起的上述改變較小.因此,選擇多髮骨摺早期股骨榦髓內釘固定手術時機仍需要謹慎.
목적 탐토대우다발골절적환자,행고골간내고정수술적시궤여술후궤체염성변화급림상결과간적관계.방법 진행전첨성비수궤대렬연구.안입선표준선취2005년4월지2007년8월78례환자.분위다발골절반유고골간개방골절조26례(A조)、다발골절반고골간폐합골절조23례(B조)、단순고골간폐합골절조29례(C조).A조실시상해공제골과학(damage control orthopaedics,DCO)처리행분기수술,B、C조균조기행골절학정성내고정술(＜24 h).각조환자술전、술후혈액IL-6、TNF-α농도작위염성반응수평적지표,PaO2/FiO2、총담홍소、기항등항목작위료해각기관공능손해적지표,병통계각조술후병발증적발생솔.대각조환자술전、술후염성반응정도적변화이급다기관공능손해정황화술후병발증솔진행비교분석.결과 A조이기술후IL-6평균승고료59 ng/L,TNF-α평균승고료85 ng/L,이B조분별평균승고료154 ng/L화250 ng/L,량조지간IL-6、TNF-α승고적치균유현저차이(P＜0.01).A조일기술후、C조술후IL-6、TNF-α평균승고적정도야균명현소우B조(P＜0.01).상응적,B조술후중출현PaO2/FiO2＜250 mm Hg(1 mm Hg=0.133kPa)적비례、총담홍소출현이상적비례、기항출현이상적비례균대우A조량기수술술후(P＜0.05),재인공통기시간、ICU시간、정성체액평형시기상야균고우A조이기술후(P＜0.01).여A조일기수술비교,B조술후인공통기시간략고(P＜0.05),이ICU시간、정성체액평형시기무명현차이(P＞0.05).C조술후재이상각개항목상야균소우B조(P＜0.01).술후통계전새화MODS적발생솔,A조(11.5%)여B조(13.0%)비교무명현차이,단균고우C조(P＜0.01).결론 다발골절고골간조기수내정고정,가인기궤체염성반응적현저변화,병인기각기관아림상적개변,이만기수술인기적상술개변교소.인차,선택다발골절조기고골간수내정고정수술시궤잉수요근신.
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 cohoa 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.
