RU2480767C1 - Method for prediction of delayed bone consolidation accompanying extrafocal osteosynthesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for the purpose of the prediction of the delayed bone consolidation accompanying extrafocal osteosynthesis, preoperative blood CD3+ lymphocytes and CD 19+ lymphocytes are counted, and then the CD3+ lymphocytes/CD 19+ lymphocytes index is calculated. If the relation is more than 6.6 units, the postoperative delayed bone consolidation is predicted, and the value being 6.6 units and less enables predicting the normal clinical course of osteogenesis.

EFFECT: use of this method allows for the preoperative prediction of the bone consolidation pattern.

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Description

The invention relates to medicine, namely to clinical laboratory diagnostics and can be used in traumatology and orthopedics.

The method of extrafocal transosseous osteosynthesis is a comprehensive treatment system for orthopedic and traumatological patients, consisting of numerous and highly effective methods that can radically change the principles of restoration of injuries and diseases of different segments of the musculoskeletal system, for example, the spine, lower jaw, and long tubular bones (Devyatov A.A. Transosseous osteosynthesis .-- Chisinau: Shtinitsa, 1990 .-- 320 p.). The method is unique in that it allows you to significantly speed up the rehabilitation of the patient and, as a result, reduce material costs for treatment. In a number of cases, when using this technology, as in the treatment of damage to bone tissue in general, complications occur during transosseous osteosynthesis, which lead to a significant increase in the duration of inpatient treatment. One of these complications is the delayed consolidation of bone tissue (Berdyugina OV Immunological monitoring of delayed osteogenesis [Text] / OV Berdyugina // Medical immunology. - 2008. - T. 10. No. 4-5. - P.371 -378). The appearance of such a complication calls into question the feasibility of using the widely established recovery method.

The X-ray and morphological methods currently used to assess the nature of osteogenesis do not allow predicting the course of bone tissue consolidation and assessing the state of bone regenerate during its formation (up to 1 month after surgery) (Reinberg S.A. X-ray diagnosis of bone and joint diseases .-- M .: Medgiz, 1955. - 306 p.). Clinical and laboratory studies (general blood analysis, determination of the main biochemical constants, electrolytes) reflect the state of the functional systems of the body that are not related to bone tissue, which also does not allow us to evaluate the dynamics of osteogenesis. At the same time, the problem of early diagnosis and prediction of delayed consolidation remains very relevant today. Recent studies show that among the large number of laboratory parameters currently used, immunological tests are the most informative, which can be used to assess the nature of bone consolidation in extra focal transosseous osteosynthesis. It was also established that a violation of immunological reactivity becomes one of the reasons for changing the nature of osteogenesis and delayed formation of bone tissue (Matchin A.A., Smolyagin A.I., Lebedyantsev V.V. Indices of natural immunity in patients with fractures of the lower jaw // Dentistry. - 1985. - No. 3. - P.40-42).

There is a method of evaluating bone tissue regeneration during bone elongation (A.S. No. 1800364, IPC G01N 33/48), according to which the number of monocytes and lymphocytes in the patient’s peripheral blood before surgery and before the start of distraction, these indicators are compared with a decrease and increase the first and second indicators relative to the initial level, the regeneration of the impaired is evaluated, and if these indicators change in different directions relative to each other or one of the indicators, while maintaining the other at the initial level, the regenerator is evaluated nation not broken.

However, this method has several disadvantages. In particular, when using this method, information on delayed consolidation can be obtained only before the start of distraction, that is, 2 weeks after the operation. Secondly, for prediction, it is necessary to conduct repeated blood tests, which is traumatic for the patient and increases the risk of infection with blood components for the researcher. Thirdly, the result obtained allows predicting delayed consolidation only during distraction osteogenesis, while in some cases treatment is also carried out under conditions of stable osteosynthesis.

Closest to the proposed is a method for predicting delayed consolidation of bone tissue from an article by O. Berdyugina (O. Berdyugina. Immunological monitoring of bone tissue regeneration disorders [Text] / O. V. Berdyugina // Traumatology and Orthopedics of Russia. - 2006. - No. 3 (41). - P. 62-67). According to the criteria specified in the article on pages 64-65 in Table 2, it is known that at 3 days after surgery, with a value of CD3 + 45% or less, delayed consolidation of bone tissue is predicted with extra focal osteosynthesis, and with a value of CD3 + 46.0 -70.0% predict a normal course of bone consolidation; when the CD19 + value is 10% for 4 days or less, delayed consolidation of bone tissue is predicted, and with a value of 5.0-12.0%, normal course of bone consolidation is predicted. The disadvantage of this method is postoperative forecasting, which can no longer significantly affect the result of treatment, as well as change the tactics of patient management to achieve the best treatment result.

The technical result - preoperative prediction of the nature of the consolidation of bone tissue in the treatment of external fixation device is solved as follows.

Before surgery of any type of transosseous osteosynthesis, the number of CD3 + and CD19 + lymphocytes is determined, the index of the ratio of the number of CD3 + lymphocytes to CD19 + lymphocytes is calculated, and with a value of this ratio of more than 6.6 units, delayed consolidation of bone tissue in the postoperative period is predicted, and with a value of 6.6 units or less predict the normal course of osteogenesis.

The prognostic criterion is selected by the authors based on the Bayesian theory, which characterizes a phased optimal choice of the value of the laboratory indicator, which allows attributing a patient with a different nature of bone consolidation to the corresponding group of patients. The studies were conducted in 274 patients with injuries of the musculoskeletal system, 136 of them - with fractures of the lower jaw before and after stable osteosynthesis in conditions of fixation by an external fixation device (of which delayed consolidation was noted in 17 patients), 27 - with the restoration of long tubular bones using the Ilizarov method (of which delayed consolidation was observed in 11 patients), 111 patients with spinal fractures during osteosynthesis with an external fixation device (of which delayed consolidation was noted in 16 patients).

Of the 54 studied determinable and calculated immunological parameters, since they, according to some authors, are the most informative, the one that best allows to evaluate the nature of osteogenesis at the preoperative stage was chosen. The determination coefficient on the training sample was 92.7%, the recognition accuracy on a test sample independent of this study (118 people) was 93.2%.

Compared with the prototype, the proposed method allows to predict delayed consolidation of bone tissue before surgery, which makes it possible to prescribe medication (drugs that improve local and systemic blood flow, the creation of calcium depot, etc.) in a timely manner (even before surgery) to reduce the risk of delayed consolidation , and also makes it possible to prevent its occurrence. In addition, prediction at the preoperative stage allows, based on the data obtained, to change treatment tactics and use, for example, bone or intraosseous fixation of skeleton segments, which will improve the outcome of treatment and reduce the length of patient’s hospitalization.

The method of immunological blood testing was tested in the laboratory department of the State Healthcare Institution "Sverdlovsk Regional Clinical Hospital No. 1" in the treatment of patients with injuries and diseases of the facial skeleton, long bones and in the intensive care and neurosurgery department of the State Regional Healthcare Institution "Sverdlovsk Regional Clinical Psychoneurological Hospital for Veterans war ”in the treatment of patients with injuries and diseases of the spine. The method is as follows.

The determination of the number of CD3 + and CD19 + lymphocytes is carried out by the standard immunocytochemical method (Totolyan A.A. Standardization of immunophenotyping methods for human blood cells and bone marrow [Text]: Part 1. Pre-analytical stage: Part 2. Indirect immunofluorescence method / A.A. Totolyan, I. A. Baldueva, L.N. Bunova [et al.] // Clinical laboratory diagnostics. - M .: Medicine, 2001. - No. 8. - P.31-38) or using any type of flow cytofluorimeter (for example , FC-500 from Beckman Coulter) and monoclonal antibody panels of the same manufacturer, followed by calculation with ratios of CD45 + CD3 + to CD45 + CD19 + cells. With a value of this ratio of more than 6.6 units, delayed consolidation of bone tissue in the postoperative period is predicted, and with a value of 6.6 units or less, the normal course of osteogenesis is predicted. The technique of staining cells with fluorescent dyes followed by lysis of red blood cells takes no more than 1 hour, identification on the device no more than 5-10 minutes, which allows predicting osteogenesis disturbance at the preoperative observation stage as soon as possible.

Table COMPARISON OF FORECAST FOR PROTOTYPE AND SUGGESTED METHOD No. history
disease Laboratory data Forecast
prototype Forecast
by the proposed method Expert
conclusion Patient F. (IS No. 30247) prototype 3 days Ds: fracture CD3 + lymphocytes - 52% lower 10 days normal jaws CD19 + lymphocytes - 7% by the proposed method normal normal before surgery CD3 + / CD19 + - 5 units. Coalescence occurred 23 days after osteosynthesis Patient A. (IS No. 92893) prototype 3 days Ds: CD3 + lymphocytes - 41% comminuted 10 days slow motion fracture L 4 CD19 + lymphocytes - 2% vertebra by the proposed method slow motion slow motion before surgery CD3 + / CD19 + - 7.2 units Fusion occurred 8 months after osteosynthesis Patient M. (IS No. 28510) prototype 3 days Ds: CD3 + lymphocytes - 10% immature 10 days slow motion fracture CD19 + lymphocytes - 3% lower by the proposed method jaws before surgery normal normal CD3 + / CD19 + - 4.3 units Coalescence occurred 24 days after osteosynthesis Patient K. (IS No. 17381) prototype 3 days Ds: CD3 + lymphocytes - 67% immature 10 days normal fracture CD19 + lymphocytes - 9% lower jaw by the proposed method slow motion slow motion before surgery CD3 + / CD19 + - 6.9 units. Coalescence occurred 36 days after osteosynthesis Patient P. (IS No. 18259) Ds: prototype 3 days chronic CD3 + lymphocytes - 49% osteomyelitis 10 days normal right CD19 + lymphocytes - 7% tibia by the proposed method normal normal before surgery fistulous CD3 + / CD19 + - 6.1 units the form Coalescence occurred 68 days after osteosynthesis

The coincidence of the forecast and the result: according to the prototype - 84.3%, according to the method - 92.7%.

As can be seen from the table, the reliability of forecasting increases. Based on the essence of the method, there are no obstacles to its use in predicting delayed consolidation of bone tissue during extrafocal osteosynthesis of other segments of the musculoskeletal system (pelvis, hand, thigh, shoulder, forearm).

Claims (1)

A method for predicting delayed consolidation of bone tissue during extrafocal osteosynthesis, including a laboratory blood test to determine the number of CD3 + -H CD19 + lymphocytes, characterized in that it is carried out before surgery and the index of the ratio of the number of CD3 + lymphocytes to CD19 + lymphocytes is determined and if the ratio is more than 6.6 units predict a delayed consolidation of bone tissue in the postoperative period, and with a value of 6.6 units or less, the normal course of osteogenesis is predicted.