Hall Jeremy A, McKee Michael D, Vicente Milena R, Morison Zachary A, Dehghan Niloofar, Schemitsch Christine E, Kreder Hans J, Petrisor Brad, Schemitsch Emil H
*Department of Surgery, Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON; †Department of Surgery, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; and ‡Department of Surgery, Division of Orthopaedic Surgery, Hamilton General Hospital, Hamilton, ON.
J Orthop Trauma. 2017 Apr;31(4):200-204. doi: 10.1097/BOT.0000000000000744.
We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures.
Prospective randomized clinical trial.
Multi-centered trial, level I trauma centers.
PATIENTS/PARTICIPANTS: All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group.
Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli.
Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative.
There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2).
This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
我们试图确定在股骨干骨折行髓内钉固定时，与标准扩髓（SR）相比，使用扩髓-冲洗-吸引器（RIA）装置是否能减少脂肪栓子的数量。
前瞻性随机临床试验。
多中心试验，I级创伤中心。
患者/参与者：所有因孤立性股骨干骨折就诊于参与机构且适合行顺行髓内钉固定的符合条件患者。共纳入31例患者：9例因经食管超声心动图（TEE）记录存在技术困难而被排除。因此，该研究包括22例患者：11例随机分为SR组，11例随机分为RIA组。
使用标准扩髓器或RIA装置对股骨干骨折行顺行髓内钉固定。所有患者术中均持续使用TEE监测，以评估右心房的栓子事件。使用桡动脉置管监测血气及栓子的潜在全身影响。
通过TEE测量栓子的持续时间、大小和严重程度。手术过程分为6个不同阶段：术前、复位、导丝置入、扩髓、髓内钉置入和术后。
术前、骨折复位、导丝置入或术后，RIA组和SR组之间的栓子情况无显著差异。采用标准化评分系统测量，RIA组在扩髓期间（SR 5.30 [标准差；1.81] vs. RIA 4.05 [标准差；2.19]，P = 0.005）和髓内钉置入期间（SR 5.09 [标准差；1.74] vs. RIA 4.25 [标准差；1.89]，P = 0.03）的总栓子评分有适度降低。我们无法将这种降低与任何生理参数（平均动脉压、呼气末二氧化碳分压、氧饱和度、pH值、动脉血氧分压和动脉血二氧化碳分压）的改善相关联。
本研究表明，在手术过程的扩髓和髓内钉置入阶段，栓子碎片有适度减少。我们无法将其与生理参数的任何变化相关联。
治疗性II级。有关证据水平的完整描述，请参阅作者指南。
