非骨水泥型全髋关节置换术中心腔内栓子来源与效应的研究

The origin and effects of embolism in heart during uncemented total hip arthroplasty

目的查找全髋关节置换术（totalhiparthroplasty，THA）心腔内栓子的组织学来源及其生理效应。方法选择30例美国麻醉医师协会（ASA）分级I～Ⅲ级行非骨水泥型全髋置换术的全麻患者，术中采用经食道超声（transesophagealechocardiography，TEE）观察手术开始、磨锉髋臼、植入髋臼假体、股骨锉髓、股骨假体植入和关节复位各时段心腔内栓子的发生率；同时在超声引导下经颈内静脉置管至右心房，当TEE观察到栓子影像时同步采血行病理学检查；行有创血压监测和动脉血气分析，观察各时段循环呼吸系统的变化。结果30例患者心腔内均观察到了微栓影像，栓子从磨锉髋臼开始间断出现直至手术结束。手术开始、磨锉髋臼、植入髋臼假体、股骨锉髓、植入股骨假体和关节复位出现栓子影像分别为0、5、19、30、23、24例，差异有统计学意义（P〈0．05）。有形栓子的检出率分别为0、0、0、47、61、38％，栓子的组织学成分包含脂肪滴和骨碎粒，组织学构成差异有统计学意义（P〈0．05）。心率（HR）、脉氧饱和度（SpO2）、呼末二氧化碳（PⅡCO2）、氧分压（PO2）全程无明显变化，收缩压（SBP）、舒张压（DBP）在股骨假体植入后开始下降（P〈0．05），以关节复位5min后下降幅度最大。结论非骨水泥式THA中心腔内微栓普遍存在。植入髋臼假体、股骨锉髓、股骨假体植入和关节复位是微栓的频发阶段；微栓子的成份中包含了脂肪滴和骨碎粒；术中的微栓常伴有血流动力学改变。

Objective To explore histological origin and effects of the embolism during uncemented total hip arthroplasty （THA）. Methods Thirty patients with ASA grade I -Ⅲ undergoing uncemented total hip arthroplasty under general anesthesia received intraoperative transesophageal echocardiography （TEE） monitoring. The incidence of embolism were observed at various operative stages （beginning of the operation, reaming of the acetabula, insertion of the acetabular prosthesis, reaming of the femur, insertion of the femoral prosthesis, relocation of the hip. Blood from right atria was sampled by central venous catheter each time for histological examination when echogenic speckles were detected. Haemodynamic and blood-gas variables were also measured repeatedly during the operative procedure. Results Ultrasonic image of microembolus were detected in the hearts of all 30 patients, respectively 0,5,19,30,23,24 cases at beginning of operation, acetabular reaming, insertion of the acetabular component, reaming of the femur, insertion of femoral prosthesis and relocation of the hip joint. The incidences differed significantly （P〈0.05）. The percentages of embolism histologically positive at different stages were 0,0,0,47,61,38% respectively. The origin of embohsm included fat drops and bone debris while the ratios were significantly different at different stages （P〈0.05）. HR, SPO2, PO2, PCO2 and PETCO2 varied little throughout the operation. However, systolic blood pressure and diastolic blood pressure markedly decreased after implantation of the femur prosthesis （P〈0.05）,especially at 5 min after relocation of the hip joint. Conclusions Emboli are common during uncemented THA and most frequent at the stages of implantation of the acetabular and femoral component, reaming of the femur and relocation of the hip joint. The histological origin of embolism includes fat drops and bone debris. Intraoperative emboli gives rise to haemodynamic changes.