扩髓对髓内压和肺部脂肪栓塞的影响

The Effect of Reaming on Intramedullary Pressure and Pulmonary Fat Embolization

目的 扩髓是髓内钉内固定手术的常用步骤, 由于可能引起肺部脂肪栓塞综合征而受到争议。尽管已知扩髓可使髓内压升高, 但髓内压升高和肺部脂肪栓塞之间的关系以及肺部脂肪栓子的来源仍不清楚。作者用山羊制作动物模型,研究扩髓对髓内压和肺部脂肪栓塞的影响。方法 在实验组进行扩髓手术,而对照组只进行软组织切开术,然后测量髓内压及用薄层层析和气相色谱检测法分析骨髓和肺部组织的脂肪成分。结果 在第一次扩髓时,髓内压升高最明显(532 m mHg)。对照组的肺组织没有脂肪栓塞,但全部实验组均有脂肪栓塞,而且栓塞的程度与髓内压的累积量成正比(r= 0-87,P=0-005)。骨髓脂肪的主要成分是甘油三酯,其含量最高的脂肪酸是油酸(18∶1,n- 9) 。在肺部脂肪检测中,实验组的甘油三酯明显升高(对照组0-10 mg/g,实验组0-45 mg/g,P=0-036),其中包括硬脂酸(18∶0)(对照组0-03 mg/g,实验组0-13 mg/g,P= 0-021)和油酸(18∶1,n- 9)( 对照组0-03 mg/g,实验组0-18 mg/g,P= 0-020)。结论 本研究显示:肺部的脂肪栓子来源于骨髓脂肪,而且过度急速的扩髓可使髓内压升高,从而引起严重的肺部脂肪栓塞。

Objective To investigate the reaming effect on intramedullary pressure and pulmonary fat embolization in goats model Methods Intramedullary reaming was carried out in the experiment group, and soft tissue was dissected in the control group The changes of intramedullary pressure were measured The composition of bone marrow fat and pulmonary lipids were analyzed using the combination of thin layer chromatography and gas chromatography Results The intramedullary pressure increased significantly during the first reaming procedure with peak value of 532 mmHg in average Pulmonary fat emboli were found in all of experiment group The severity of pulmonary fat embolization correlated with the accumulated intramedullary pressure (r=0 87, P=0 005) From the analysis of lipids, triglycerides were the most abundant lipid in bone marrow Its major fatty acid was oleic acid (18∶1,n-9) Whereas, higher value of pulmonary triglyceride was found in the experiment group (cont 0 10 mg/g, exp 0 45 mg/g,P= 0 036), and their major fatty acids were stearic acid (18∶0)(cont 0 03 mg/g, exp 0 13 mg/g,P= 0 021) and oleic acid (18∶1,n-9)(cont 0 03 mg/g, exp 0 18 mg/g,P= 0 020) Conclusion This study revealed that pulmonary embolic materials were originated from bone marrow lipids and excessive reaming led to the rise of intramedullary pressure which in turns caused severe pulmonary fat embolization