股骨干骨折扩髓钉固定对血浆细胞因子水平的影响

Impact of reamed femoral intramedullary nailing on the serum concentrations of cytokines

目的探讨股骨干骨折早期扩髓与不扩髓髓内钉固定对血浆细胞因子水平的影响。方法46例股骨干骨折(创伤严重程度评分ISS≤16分别在伤后8～24h内采用扩髓(RFN)和不扩髓髓内钉(UFN)固定,在手术开始前至术后72h内6个不同时间点采集静脉血,采用双抗体夹心ELISA法测定血浆TNF-α、IL-6、IL-10的活性。结果两组中各细胞因子表现出同样的升高趋势;TNF-α在术后1h升高达峰值,术后6h降至正常;IL-6与IL-10均在术后1h开始升高,6h达峰值,两者分别在术后24h和72h降至正常水平;两组间比较,不同时间之间有显著差异,时间和细胞因子水平之间存在交互效应,但两组之间无显著差异。临床观察,两组间均无切口感染和肺部感染等发生。结论扩髓后髓内钉固定和不扩髓相比,机体产生较大的应激反应,对围手术期不同时间段细胞因子水平有一定影响;但在ISS<16时,扩髓激发的炎症反应为一正常有序的炎症反应,不会导致失控的级联反应,不增加术后并发症。

Objective To evaluate the impact of reamed femoral intramedullary nailing on the cytokines concentrations of serum in the treatment of fracture of shaft of femur. Methods 46 cases of femoral shaft fractures whose Injury Severity Score (ISS) was under 16 were divided into 2 groups prospectively. The fractures were fixed with either reamed or unreamed intramedullary nailing from 8 to 24 hours after trauma. From the time before operation till 72 hours after the operation, venous blood samples were taken at 6 consecutive time points. Serum concentrations of tumor necrosis factor alpha (TNF α), interleukin (IL) 6 and IL 10 were measured by an enzyme linked immunosorbent assays (ELISA). Results The 3 kinds of cytokines presented similar trend of changes perioperatively in the 2 groups. TNF αrose and reached the peak 1h postoperatively (PO) and decreased to baseline at 6 h PO. IL 6 and IL 10 began to increase at 1h PO, went up to the highest level at 6h PO and declined to normal 24h and 72h PO respectively. Comparison between the 2 groups showed that there was significant difference at different time points. There were crossover effects between the time points and the cytokines concentrations of serum, but there was no difference between the 2 factors in the 2 groups. No incision or pulmonary infection or other complications was found during the clinical observation period. Conclusions Reamed femoral intramedullary nailing produces a greater systemic stress response and leads to elevation of serum cytokines concentrations perioperatively compared with unreamed technique. When the ISS is under 16, however, the inflammatory response induced by reaming is mild and self limited and will not lead to uncontrollable cascade reaction of cytokines. The complication rate will not be increased with the application of reaming procedure.