Tiansheng Sun, Xiaobin Chen, Zhi Liu, Xiaowei Wang, Guang Liu, Liren Zhang
Institute of Orthopaedics, Chinese PLA, Beijing Army General Hospital, Beijing, China.
J Trauma. 2009 Dec;67(6):1402-11. doi: 10.1097/TA.0b013e3181a7462d.
The maximum score of a single anatomic system, the Injury Severity Score, may not reflect the overall damage inflicted by bilateral femoral fractures and justify the strategy of damage control orthopedics (DCO). It is necessary to investigate effects of various therapeutic procedures on such fractures with or without shock to facilitate correct decision making on DCO.
A model of bilateral femoral fractures was made in 36 of 48 male New Zealand White rabbits. A model of bilateral femoral shaft fractures associated with shock was made. After resuscitation, a reamed intramedullary nailing fixation was performed in the first group (IM group), and an external fixation device applied in the second group (EF group), and the fractures in the third group (control group) were supported with splints only. They were divided into four groups: shock with IM nailing (shock-IM), shock with external fixation (shock-EF), shock with conservative method (shock-Cons), and intramedullary nailing without shock (nonshock-IM). Vital signs and inflammatory reactions were recorded. Thirty-six hours after the therapeutic procedures in four groups, the animals were killed for histologic evaluation.
The changes of vital signs were most significant in shock-IM group (p < 0.05). The exaggerated levels of interleukin-6, Interleukin-10, and tumor necrosis factor alpha concentrations demonstrated a significant difference between all the groups-shock-IM and other groups (p < 0.05). As to histologic appearances, the statistical difference varies from organ to organ. There is highly significant difference when the IM group is compared with the other two groups as far as lungs are concerned. As to the liver, there is only significant difference between the IM group and the control group. In terms of kidney and heart, there is no significant difference cross the groups. As to histologic appearances, there is highly significant difference in lungs between shock-IM group and other three groups. There is significant difference in liver between the shock-IM group and the shock-Cons group (p < 0.05). Kidneys and heart were less affected cross the groups.
In this study, an early reamed intramedullary nailing fixation procedure resulted in more adverse effects on system stress, inflammatory response, and multiple organs. The injuries also cause histologic damages to lungs and liver. Therefore, early reamed intramedullary nailing fixation may pose a potential risk of developing complications and adopting the DCO strategy may be more preferable. Shock and IM combined cause most severe damages, followed by IM without shock, shock plus EF, and shock plus conservative procedure in that order. If IM must be used for some reasons, it is desirable be delayed until shock has been fully controlled and vasculorespiratory stability restored.
单一解剖系统的最高评分即损伤严重度评分，可能无法反映双侧股骨骨折所造成的整体损伤情况，也无法证明损伤控制骨科（DCO）策略的合理性。有必要研究各种治疗方法对伴有或不伴有休克的此类骨折的影响，以利于在DCO方面做出正确决策。
在48只雄性新西兰白兔中，对36只制作双侧股骨骨折模型。制作双侧股骨干骨折合并休克的模型。复苏后，第一组（髓内钉组）行扩髓髓内钉固定，第二组（外固定组）应用外固定装置，第三组（对照组）仅用夹板固定骨折部位。将它们分为四组：休克合并髓内钉固定组（休克-髓内钉组）、休克合并外固定组（休克-外固定组）、休克合并保守治疗组（休克-保守组）和无休克髓内钉固定组（非休克-髓内钉组）。记录生命体征和炎症反应。四组治疗措施实施36小时后，处死动物进行组织学评估。
休克-髓内钉组生命体征变化最为显著（p<0.05）。白细胞介素-6、白细胞介素-10和肿瘤坏死因子α浓度的升高水平表明，休克-髓内钉组与其他所有组之间存在显著差异（p<0.05）。至于组织学表现，不同器官的统计学差异各不相同。就肺部而言，髓内钉组与其他两组相比有高度显著差异。就肝脏而言，髓内钉组与对照组之间仅有显著差异。就肾脏和心脏而言，各组之间无显著差异。至于组织学表现，休克-髓内钉组与其他三组在肺部有高度显著差异。休克-髓内钉组与休克-保守组在肝脏方面有显著差异（p<0.05）。各组中肾脏和心脏受影响较小。
在本研究中，早期扩髓髓内钉固定手术对系统应激、炎症反应和多个器官产生了更多不良影响。这些损伤也对肺和肝脏造成了组织学损害。因此，早期扩髓髓内钉固定可能存在发生并发症的潜在风险，采用DCO策略可能更为可取。休克与髓内钉固定联合造成的损害最严重，其次依次为无休克髓内钉固定、休克加外固定和休克加保守治疗。如果因某些原因必须使用髓内钉固定，最好延迟至休克得到充分控制且血管呼吸稳定性恢复后进行。
