RU2506592C1 - Method for choosing surgical approach to patients with peri-implantation inflammation of greater joints - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to a method for choosing a surgical approach to the patients with a peri-implantation inflammation of greater joints. Substance of the method consists in analysing the material sampled from a lesion, namely fistula secretion or peri-prosthetic punctatue a drop of which is applied on a slide, dried and subject to cytological screening by optical microscopy. If observing fibroblast and fibrocyte cells in the number of 1-3 in each visual field, osteoblast cells in the number of 1-2 in scarce visual fields and synoviocyte cells grouped in 3-10 cells in the analysed material, a revision endoprosthesis replacement is chosen, while the presence of fibroblast, fibrocyte and osteoblast cells in the number of 1-2 in scarce visual fields, isolated dystrophic synoviocytes in the number of 1-2 in scarce visual fields, as well as osteoblast cells in the number of 1-3 in the preparation, a resection arthroplasty is chosen.

EFFECT: using the method enables providing higher reliability and accuracy of choosing the surgical approach to the patients with the peri-implantation inflammation of the greater joints.

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Description

The invention relates to medicine, namely to laboratory research and surgical treatment of patients with peri-implant inflammation.

In everyday clinical practice, the diagnosis of periprosthetic and peri-implant infection is based on the presence of leukocytosis in the peripheral blood, an increase in ESR, an increase in the proteins of the acute phase of inflammation, and data from a microbiological study of puncture of the hip and knee joints.

In the presence of obvious inflammation in the area of the alleged surgical intervention, the prognosis of the further development of the infection requires a dynamic microbiological study.

However, the listed research methods do not reflect the peculiarities of the local inflammatory reaction in the hip joint, and also do not allow us to judge the level of local infection resistance.

To characterize the features of the local inflammatory reaction, information is needed on the quantitative and qualitative composition of the inflammatory cells in the focus of infection, as well as on the prevalence of the local inflammatory process.

A known method for predicting periprosthetic infection, which consists in an express study of histological preparations obtained during surgery. In this method, tissue sections from the lesion are exposed to low temperature, after which polymorphonuclear leukocytes are counted (Feldman DS, Lonner JH, Desai P., Zuckerman JD, published in J Bone Joint Surg Am. 1995; 77A: 1807-1813. ) If five polymorphonuclear leukocytes are detected during a histological examination in five fields of view, the results are interpreted as positive, less than 5 - negative.

The disadvantage of this method is the complexity both in the preparation of material for histological examination and in the study itself. In addition, statistical studies showed that the method has a low sensitivity of 70%, specificity of 87%, accuracy of 82%.

Closest to the proposed is a method of choosing the tactics of surgical treatment of patients with peri-implant inflammation in the area of large joints, including the study of material selected from the lesion, (Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop Relat Res. 2002 Aug; (401): 230-8).

In this method, a microscopic examination of a sample of natively frozen paraarticular tissue obtained during revision arthroplasty is performed. Moreover, when more than 10 neutrophils are detected in the field of view of a sample, the infectious nature of the complication is judged.

The disadvantage of this method is the possibility of using it only in the study of surgical material, which does not allow to determine the tactics of surgical treatment in the preoperative period. The known method allows to determine the infectious nature of the complication, however, it does not allow to evaluate the activity of the inflammatory process, which is necessary for an individual choice of treatment tactics.

Statistical analysis showed that the sensitivity and specificity of the method of microscopy of frozen native histological preparations for the study of the activity of the inflammatory process with revision hip arthroplasty is 45% and 92%, respectively, and for the knee joint - 100% and 96%, respectively.

The objective of the invention is to conduct reliable diagnosis through the use of a cytological research method that allows you to track the features of proliferation, differentiation, destruction of paraarticular tissue elements during endoprosthetics of large joints, which makes it possible to obtain objective data on the features of local inflammation at the stage of preoperative planning of a particular patient.

To solve this problem, in the method of choosing the tactics of surgical treatment of patients with peri-implant inflammation in the area of large joints, including the study of material taken from the lesion, it was proposed to use a sample of material removed from the fistula or punctate from the periprosthetic region, a drop of which is applied to a glass slide, dry and conduct a cytological examination under light microscopy and in the presence of fibroblasts and fibrocyte cells in the studied material, 1-3 in each field of view, 1-2 theoblasts in the rare fields of vision and synoviocytes located in groups of 3-10 cells choose revision arthroplasty, and in the presence of fibroblast cells, fibrocytes, osteoblasts 1-2 in the rare fields of view, scattered synoviocytes with dystrophic changes of 1 -2 in rare fields of view, as well as osteoclast cells of 1-3 in the drug, choose resection arthroplasty.

On figa, b, c - cytogram of the patient (example 1)

Figure 2 a, b, c, d - cytogram of the patient (example 2)

The implementation of the method is shown in specific examples.

Example 1

The patient Miftyakhova T.I., 58 years old No. IB 11350-s (2012). The main diagnosis: Instability of the endoprosthesis of the left hip joint with a combined defect and fracture of the bottom of the acetabulum, a combined defect in the proximal femur.

A study of the proposed method. Punctate was selected from the periprosthetic region. A drop of punctate was placed on a fat-free glass slide, dried, stained with azure-eosin according to the Pappenheim method, and the prepared cytological material was examined under a light microscope. As a result of the study, fibroblasts and 1-2 fibrocytes in each field of view were detected in the cytogram (Fig. 1a), osteoblasts of single in rare fields of vision (Fig. 1b), synoviocytes located in groups of 3-5 cells (Fig. 1c). Thus, the predominance of fibroblastic differential cells and synoviocytes in paraarticular tissue indicates reparative processes.

07/02/2012, the patient performed the removal of the endoprosthesis of the left hip joint, bone xenoplasty of the pelvic bone defect, revision endoprosthesis replacement.

Example 2

Patient Litvinova G.N., 61 years old. No. IB 23106-s (2011).

The main diagnosis: Deep suppuration with destabilization of the endoprosthesis of the right hip joint with cement fixation, fistulous form. Stage 2 by Coventry-Fitgerald-Tsakayama classification.

From the anamnesis: Regarding a fracture of the neck of the right femur in the Central City Hospital Ramenskoye in 2008, osteosynthesis was performed. In March 2011, at the Federal State Medical Research Center named after N.I. Pirogov was performed by TEP with a De-Puy cemented prosthesis for an overgrown fracture of the neck of the right hip joint. In May 2011, a fistula formed in the area of the postoperative scar. In the preoperative period, a study was performed on the proposed method. In this case, a drop of punctate taken from the fistula was placed on a fat-free glass slide, dried, stained with azure-eosin according to the Pappenheim method, and the prepared cytological material was examined under a light microscope. The result of the study showed the presence in the cytogram of 1-2 in rare fields of vision of fibroblasts and fibrocytes (Fig.2a) and osteoblasts (Fig.2b), as well as scattered synoviocytes with dystrophic changes of 1-2 in rare fields of vision (Fig.2c) , the presence of osteoclasts up to 3 in the drug (Fig.2g). The presence in the cytological material of a small number of fibroblastic differential cells, dystrophic changes in synoviocytes, the presence of osteoclasts indicates destructive processes in soft tissues and bone resorption.

12/01/2011, the patient performed resection arthroplasty.

Using this method allows you to track the features of proliferation, differentiation, destruction of the elements of paraarticular tissue during arthroplasty of large joints. The cellular composition adequately reflects the state of the process occurring in the field of surgical intervention. Material for the study is obtained by puncture of the periprosthetic area, and smears prepared from a separated fistula are also examined. The study is carried out once, before surgery. The revealed morphological characters, in the presence of which the tactics of surgical treatment are chosen in the cytological material, are substantiated by the authors' studies (36 patients were studied). The results of the study are confirmed by clinical and radiological data.

Claims (1)

A method for choosing the tactics of surgical treatment of patients with peri-implant inflammation in the area of large joints, including the study of material taken from the lesion, characterized in that the material used is a sample separated from the fistula or punctate from the periprosthetic region, a drop of which is applied to a glass slide, dried and conduct a cytological study under light microscopy and in the presence of fibroblasts and fibrocytes cells in the studied material, 1-3 in each field of view, osteoblasts 1-2 in revision endoprosthetics are selected in the visual fields and synoviocytes located in groups of 3-10 cells, and in the presence of fibroblast cells, fibrocytes, osteoblasts 1-2 in rare fields of vision, scattered synoviocytes with dystrophic changes of 1-2 in rare fields of vision , as well as osteoclast cells of 1-3 in the drug, select resection arthroplasty.

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