Heim D, Regazzoni P, Tsakiris D A, Aebi T, Schlegel U, Marbet G A, Perren S M
Department of Surgery, Bezirksspital, Frutigen, Switzerland.
J Trauma. 1995 Jun;38(6):899-906. doi: 10.1097/00005373-199506000-00013.
Pulmonary embolism in reamed femoral nailing has been reported and discussed over recent years. Does an unreamed nailing technique with a solid nail prevent this rare but serious complication of intramedullary fixation? In an animal model in rabbits, we studied the pathophysiologic impact on pulmonary function and the impact on hemostasis of reamed and unreamed nailing of intact femora and tibiae, and of femoral fracture in relation to intramedullary pressure. No statistical difference of PaO2, PaCO2, and PCO2et was found in the femur whether a reamed or unreamed procedure was performed. Two of six animals with unreamed femoral nailing, one of six animal with reamed femoral nailing, and one of five animals with a femoral fracture fulfilled four of four or three of four criteria for embolization (increase of the difference of PaCO2 and PCO2et, decrease of PaO2, increase of blast cells in central-venous blood and bone marrow/fat in histologic section of the lungs and bone). Tibial nailing did not alter pulmonary function in either group. Intramedullary pressure was increased in all animals with perioperative impairment of pulmonary function (375 to 676 mbar). Analysis of the hemostatic results showed a significant difference of platelet activation in reamed versus unreamed nailing of the femur 1 hour after nailing (p < 0.01) and a significant decrease of fibrinogen and antithrombin III (p < 0.001/p < 0.01) in reamed femoral nailing. We conclude that unreamed nailing of the femur with a solid rod may also cause bone marrow embolization with alteration of pulmonary function as long as an important increase of the intramedullary pressure is generated during the nailing procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
近年来，已有关于扩髓股骨髓内钉固定术中发生肺栓塞的报道及讨论。使用实心钉的非扩髓钉技术能否预防这种罕见但严重的髓内固定并发症呢？在兔动物模型中，我们研究了完整股骨和胫骨的扩髓与非扩髓髓内钉固定以及股骨骨折与髓内压力相关的情况对肺功能的病理生理影响和对止血的影响。无论进行扩髓还是非扩髓操作，股骨组的动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）和呼气末二氧化碳分压（PCO2et）均无统计学差异。非扩髓股骨髓内钉固定的6只动物中有2只、扩髓股骨髓内钉固定的6只动物中有1只以及股骨骨折的5只动物中有1只符合栓塞的四项标准中的四项或三项（PaCO2与PCO2et差值增加、PaO2降低、中心静脉血中胚细胞增加以及肺和骨组织学切片中肺内有骨髓/脂肪）。胫骨钉固定两组中肺功能均未改变。所有围手术期肺功能受损的动物髓内压力均升高（375至676毫巴）。止血结果分析显示，钉固定1小时后，股骨扩髓与非扩髓髓内钉固定的血小板活化存在显著差异（p < 0.01），扩髓股骨髓内钉固定的纤维蛋白原和抗凝血酶III显著降低（p < 0.001/p < 0.01）。我们得出结论，只要在钉固定过程中产生重要的髓内压力升高，使用实心棒对股骨进行非扩髓钉固定也可能导致骨髓栓塞并伴有肺功能改变。（摘要截选至250词）
