Pape Hans-Christoph, Zelle Boris A, Hildebrand Frank, Giannoudis Peter V, Krettek Christian, van Griensven Martijn
Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
J Bone Joint Surg Am. 2005 Nov;87(11):2515-22. doi: 10.2106/JBJS.D.02024.
Reaming of the femoral canal has been demonstrated to introduce intramedullary contents into the circulation with subsequent pulmonary embolization. The aim of this study was to investigate whether this effect can be minimized by use of a reamer system that provides simultaneous irrigation and aspiration of intramedullary contents.
A unilateral lung contusion was created and intramedullary femoral nailing was subsequently performed in eighteen female skeletally mature Merino sheep. The animals were divided into three groups, of six animals each, to receive one of three types of treatment: reamed femoral nailing; reaming, irrigation, and aspiration; and unreamed femoral nailing. Blood samples were obtained and a bronchoalveolar lavage was performed at baseline, immediately after creation of the lung contusion, immediately after intramedullary nailing, and at four hours after surgery. Pulmonary permeability, polymorphonuclear leukocyte activity, and systemic hemostatic response were measured. Lung specimens were obtained for histological evaluation.
At baseline and immediately after creation of the lung contusion, endothelial permeability was comparable among the three groups. At four hours postoperatively, pulmonary permeability was significantly higher in the group treated with reamed femoral nailing (urea/protein ratio; 256.7) than in the group treated with reaming, irrigation, and aspiration (urea/protein ratio, 91.5) and the group treated with unreamed femoral nailing (urea/protein, 110.64) (p < 0.05). The stimulatory capacity of the polymorphonuclear leukocytes was significantly decreased (p < 0.05) only in the group treated with reamed femoral nailing; the other two groups had no significant decrease postoperatively (p > 0.05). The D-dimer level at four hours postoperatively was significantly higher in the group treated with reamed femoral nailing than it was in the other two groups (p < 0.05). Histological examination showed that the grades of edema and polymorphonuclear leukocyte diapedesis were also highest in the group treated with reamed femoral nailing.
It appears that, in the presence of a unilateral pulmonary injury, the systemic effects of intramedullary reaming of an intact femur can be minimized with use of a modified reamer design that simultaneously irrigates the canal and removes debris. Additional clinical validation of this reaming system is necessary.
已证实扩髓股骨髓腔会将髓内物质带入循环系统，继而引发肺栓塞。本研究的目的是调查使用一种能同时冲洗和抽吸髓内物质的扩髓系统是否可将这种影响降至最低。
对18只骨骼成熟的雌性美利奴绵羊造成单侧肺挫伤，随后进行股骨髓内钉固定术。将动物分为三组，每组6只，分别接受三种治疗方式之一：扩髓股骨髓内钉固定术；扩髓、冲洗和抽吸；非扩髓股骨髓内钉固定术。在基线、造成肺挫伤后即刻、髓内钉固定术后即刻以及术后4小时采集血样并进行支气管肺泡灌洗。测量肺通透性、多形核白细胞活性和全身止血反应。获取肺标本进行组织学评估。
在基线和造成肺挫伤后即刻，三组的内皮通透性相当。术后4小时，扩髓股骨髓内钉固定术治疗组的肺通透性（尿素/蛋白比值；256.7）显著高于扩髓、冲洗和抽吸治疗组（尿素/蛋白比值，91.5）和非扩髓股骨髓内钉固定术治疗组（尿素/蛋白，110.64）（p < 0.05）。仅扩髓股骨髓内钉固定术治疗组的多形核白细胞刺激能力显著降低（p < 0.05）；其他两组术后无显著降低（p > 0.05）。扩髓股骨髓内钉固定术治疗组术后4小时的D - 二聚体水平显著高于其他两组（p < 0.05）。组织学检查显示，扩髓股骨髓内钉固定术治疗组的水肿和多形核白细胞渗出程度也最高。
在存在单侧肺损伤的情况下，使用改良的扩髓设计同时冲洗髓腔并清除碎屑，似乎可将完整股骨扩髓的全身影响降至最低。该扩髓系统还需要更多的临床验证。
