目的 通过观察首次及二次全膝关节置换术术后早期认知功能及炎性细胞因子的变化，探讨二次全膝关节置换手术对老年患者术后早期认知功能的影响。方法 择期行全膝关节置换术患者96例，年龄≥65岁，美国麻醉医师协会（American Society of Anesthesiologists, ASA）分级Ⅰ或Ⅱ级，按手术次数分为一次手术组和二次手术组，每组48例。采用简易精神状态检查量表（mini-mental state examination , MMSE）于术前及术后1d、3d、5d、7d进行认知功能评估。本研究以术后MMSE评分较术前降低大于或等于一个标准差则判定为术后认知功能障碍（postoperative cognitive dysfunction , POCD）。根据术后是否发生POCD分为POCD组和NPOCD组。于麻醉诱导前、术后24h抽取外周静脉血，应用酶联免疫吸附法（enzyme-linked immunosorbent assay , ELISA）测定IL-1、IL-6和IL-10的浓度。结果 二次手术组患者术后3d、5d POCD的发生率（56.3%、10.4% ）显著高于一次手术组（25.0%、2.1%），（P<0.05）。与NPOCD组相比，POCD组术后IL-6的水平较术前明显增加，术后IL-10的水平较术前明显降低，差异有统计学意义（P<0.05）。与术前比较，一次手术组和二次手术组POCD患者术后24h IL-6的水平明显增加（P<0.05）、IL-10的水平明显降低（P<0.05）；与一次手术组POCD患者比较，二次手术组POCD患者术后24h IL-6的水平明显升高（P<0.05）、 IL-10的水平明显降低（P<0.05）。结论 二次全膝关节置换术老年患者术后早期POCD发生率增加，可能与血液中IL-6浓度升高及IL-10浓度降低有关。
Objective To investigate the effects of second total knee replacement on early postoperative cognitive function in elderly patients by comparing the changes of postoperative cognitive function and inflammatory cytokines between first and second elective total knee replacement. Method We included 96 ASA I or Ⅱ patients aged ≥65 years performed total knee replacement under general anesthesia. According to the number of operations they were divided into the first operation group and the second operation group (n = 48). Patients were given cognitive function assessment preoperatively and 1d, 3d, 5d, 7d postoperatively using the Mini-Mental State Examination (MMSE). Postoperative cognitive dysfunction (POCD) was defined by MMSE score decreased ≥2 compared with preoperative level. Patients were divided into POCD or NPOCD group according to the occurrence of POCD. The blood samples were reserved before anesthesia induction and 24h after surgery for detecting the concentrations of IL-1, IL-6, and IL-10 by enzyme-linked immunosorbent assay (ELISA). Results The incidences of POCD in second group on 3d and 5d postoperatively (56.3% and 10.4%) were significantly higher than those of first group (25.0% and 2.1%) (P <0.01). Compared with NPOCD group, the concentration of IL-6 at 24h after operation was higher significantly than it's preoperative level and the concentration of IL-10 at 24h after operation was lower significantly than it's preoperative level (P<0.05) in POCD group. Compared with preoperative level, the concentration of IL-6 was increased significantly and the concentration of IL-10 was decreased significantly (P<0.05) at 24h after operation in patients with POCD of two groups. Compared to patients with POCD in the first operation group, the concentration of IL-6 was increased significantly and the concentration of IL-10 was significantly decreased (P<0.05) at 24h after surgery in patients of POCD in the second operation group. Conclusion The incidence of POCD early after the second operation of total knee replacement in elderly patients shows higher than rate after the first operation, which may be related to the concentration of IL-6 increased and the concentration of IL-10 decreased.
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