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0КИНЕТИЧЕСКИЕ ПАРАМЕТРЫ ОСТЕОСЦИНТИГРАФИИ ПРИ ПРОТЕЗИРОВАНИИ ТАЗОБЕДРЕННЫХ И КОЛЕННЫХ СУСТАВОВ У ЛИКВИДАТОРОВ АВАРИИ НА ЧЕРНОБЫЛЬСКОЙ АТОМНОЙ СТАНЦИИ
Король П.А.
доктор медицинских наук, заведующий отделением радионуклидной диагностики Киевской городской клинической больницы № 12, Киев, Украина
Ткаченко М.Н.
доктор медицинских наук, профессор, заведующий кафедры радиологии и радиационной медицины Национального медицинского университета имени А.А. Богомольца, Киев, Украина
KINETIC PARAMETERS OF BONE SCINTIGRAPHY FOR RELACEMENT OF HIP AND KNEE JOINTS IN LIQUIDATORS OF ACCIDENT AT THE CHERNOBYL NUCLEAR POWER PLANT
Korol P.
doctor of medical science, head of department of nuclear medicine of Kiev Clinical City
Hospital # 12, Kiev, Ukraine Tkachenko M.
doctor of medical science, professor, head of the department of radiology of Bohomolets National Medical
University, Kiev, Ukraine
Аннотация
Цель работы - определить диагностическую роль трехфазовой остеосцинтиграфии (3-ф ОСГ) в раннем прогнозировании параэндопротезных осложнений тазобедренных и коленных суставов у ликвидаторов аварии на Чернобыльской атомной электростанции. Методом 3-ф ОСГ были исследованы радио-нуклидные кинетические параметры включения и распределения радиофармпрепарата (РФП) в пораженных суставах у 75 мужчин. Установлено, что расчет количественных показателей кинетики РФП на разных стадиях 3-ф ОСГ позволил определить достоверные различия в метаболических изменениях очаговых поражений в суставных структурах, что является оптимизирующим фактором дифференциально-диагностических возможностей радионуклидного метода исследования пациентов при эндопротезировании тазобедренных и коленных суставов. Кинетика остеотропного РФП в очагах фиксации пораженных суставов при инфекционных и воспалительных процессах характеризуется достоверным преобладанием ретенции и удельного накопления индикатора в ранней и отсроченной статической фазой 3-ф ОСГ по сравнению с очагами фиксации РФП при деформирующих остеоартрозах (p < 0,05), что коррелирует с различиями в деструктивно-репаративных процессах в них.
Abstract
The objective of the work to determine the diagnostic role of the three-phase bone scintigraphy (3-F BS) in the early prediction of paraendoprosthetic complications of the hip and knee joints of the participants in clean-up workers. The 3-F BS method were investigated the radionuclide kinetic parameters of the inclusion and distribution of radiopharmaceuticals (RF) in damaged joints in the 75 male clean-up workers. It was established that calculating the quantitative indices of kinetics of the drug at various stages of the 3-F BS allowed determining statistically significant differences in metabolic changes in focal lesions in articular structures. Thus, the differential diagnostic capabilities of the radionuclide method of examination of patients with arthroplasty of the hip and knee joints are elevated. The kinetics of osteotropic RF in the foci of fixing the damaged hip and knee joints in the infectious and inflammatory processes is characterized by the predominance of retention and specific accumulation of the drug in the early static phase and the delayed static phase of the 3-F BS compared with the centers of fixation of RF in deforming osteoarthrosis (p < 0,05), which correlates with the differences in destructive - reparative processes in them.
Ключевые слова: остеосцинтиграфия, эндопротезирование, тазобедренный и коленный суставы, радиофармацевтический препарат.
Keywords: bone scintigraphy, arthroplasty, hip and knee joints, radiopharmaceuticals.
Introduction. In recent decades, the issue of morbidity on the degenerative-degenerative pathology of the hip and knee joints of clean-up workers has been acutely relevant [3, 4]. This is due, firstly, to the intensification of the static load on the joints, and secondly, with the negative effect of ionizing radiation on the bone and cartilage apparatus, as well as the deterioration of the demographic situation in Ukraine and an increase in the proportion of persons of retirement age who make up the main massif patients with lesions of the hip and knee joints [1, 3].
Total arthroplasty is a revolution in the treatment of degenerative-dystrophic diseases and traumas of the hip and knee joints. Due to this method of treatment, patients quickly restore their ability to work and return to full-fledged life [8]. Arthroplasty of hip and knee joints with their pathological instability is an actual leading method of orthopedic correction, which can significantly improve the quality of life [9]. Intensive development of arthroplasty of hip joints, along with the high rehabilitation potential of this operation, is ac-
The scientific heritage No 18 (18),2017 companied by an increase in the number of cases of severe infection in the field of surgical intervention, which, according to domestic and foreign authors, ranges from 0.3% to 1% at the primary arthroplasty bath, and more 4% - with a revision [5, 10]. Treatment of infectious complications after these operations is a long process that requires the use of expensive medicines and materials [7].
The issue of treating patients who developed a paraendoprosthetic complication after the hip and knee arthroplasty is still a topical issue for discussions among specialists. Previously, it was completely unacceptable to implant the endoprosthesis in the affected area [3]. However, the development of understanding of the septic process associated with implants, as well as the progress in surgical technique, made possible a successful arthroplasty in these conditions. Most surgeons agree that removal of the components of the en-doprosthesis and thorough surgical treatment of the wound are an important step in the treatment of the patient [9, 10]. However, as to which of the instrumental methods is most effective in early diagnosis of acute paraendoprosthetic complications during arthroplasty of the hip and knee joints, there is still no consen-sus.The aim of this work is to determine the diagnostic role of 3-F BS in the early prediction of paraendopros-thetic complications of the hip and knee joints of cleanup workers.
Material and methods. The main group is represented by 75 clean-up workers with lesions of hip and knee joints of different genesis, males aged from 17 to 85 years old. The average age of the examined patients was 57.2 ± 12.4. The total number of control group was 42 patients aged 25 to 73 years old, mean age 58.3 ± 9.3. The control group was presented by patients who
Radionuclide parameters of inclusion and distribution of radiopharmaceuticals in pathological centers were calculated in each group of patients:
• F - Specific maximum accumulation of RF in the area of 3-F BS.
• P - relative accumulation ratio in the area of 3 -F
BS.
• A - asymmetry of accumulation of RF during 3-F BS in pathological center and symmetric intact site.
• Parameters of the quasi-linear approximation of the phase of the equilibrium concentration of the angiographic curve (a - angular coefficient; b - initial ordinate).
• FE - area under the angiographic curve.
• Ir - retention index (%).
The results of research carried out during this work were statistically processed. To process the received data, the statistical software package of IBM SPSS Statistics Base v.22 was used.
had no complaints and clinical symptoms that were characteristic of lesions of the hip and knee joints
For all patients, 3-F BS was performed according to the standard protocol [2, 6]:
• Stage I - angiographic phase (AF); was performed immediately after intravenous bolus injection of 600-800 MBq of 99mTc-methylenediophosphonate (99mTc-MDP);
• Stage II - Early static phase (ESF); was performed in a static mode immediately after the AF collection, the collection of information for 120 s;
• Stage III - deferred static phase (DSF); was carried out in 2 - 4 years after the introduction of ESF, was performed in static mode.
After receiving the images and performing standard computer diagnostic information processing operations, they performed a visual assessment of the investigated areas. The sites were localized mainly in the projections of the structures of the articular complexes of the hip and knee joints, as well as in the projection of the proximal regions of the femur and tibia. The shape, size and intensity of the visualization of the plots varied widely. The nature of each of the cells was clearly determined by the results of clinical and instrumental studies (anamnesis, objective status, laboratory data) and radiation (X-ray, computer tomography (CT), ultrasound (US), magnetic resonance imaging (MRI)) methods confirmed by repeated scintigraphic examinations. In order to analyze the information, all foci are divided into groups that are arranged in order of increasing the intensity of bone injury, aggressiveness of pathological changes: 1st group - avascular necrosis; 2nd group - deforming osteoarthrosis; 3rd group - posttraumatic osteoarthrosis; 4th group - rheumatoid arthritis. Distribution of patients with primary diagnosis is
Results and discussion.
According to the results of analysis of radionu-clide indices AF, ESF and DSF, the patterns of fixation of RF in dynamics in pathological cells of articular structures of different nature were revealed. Thus, increasing the intensity of blood flow in deforming osteoarthritis, post-traumatic processes and rheumatoid arthritis in the AF indicated an intensification of arterial blood supply to such centers due to active inflammation, the influence of an infectious agent or increased osteolytic activity. Integral perfusion of sites with de-generative-dystrophic changes and osteonecrosis exceeded the control group's parameters due to hypere-mia, tissue edema and the influence of inflammatory mediators; in the foci of rheumatoid arthritis - the blood filling of the tissues was significantly higher due to increased vascular permeability, due to the action of infectious agents, activation of factors of resorption and synthesis of mineral components, angiogenesis.
presented in the table. 1
Groups of patients Absolute number %
Deforming osteoarthrosis 24 32,0
Avascular necrosis 16 21,3
Revmatoid arthritis 20 26,7
Post-traumatic osteoarthrosis 15 20.0
Total: 75 100,0
The washing of RF from different sites by nature also had its own distinctive features - so, the avascular areas behaved similarly to normal bone tissue without delaying the drug. The retention of RF was increased in post-traumatic osteoarthrosis and rheumatoid arthritis, indicating a high extractive ability of such areas. The asymmetry of fixation of RF in the pathological areas and the symmetric intact site was also higher for the 3rd and 4th groups of centers, which was indicative of the more intensive drug delay in them.
In order to determine the reliability of the differences in the obtained kinetic parameters for cells of different nature, the correlation of statistical probability of their difference in the groups of investigated centers was analyzed. Each parameter was compared to that of the same group. According to the results of the statistical analysis, it should be noted that the avascular areas differed significantly from the centers in the case of deforming and post-traumatic arthrosis only on the basis of indexes of retention and asymmetry of fixation in the DSF; in the AF there were no significant differences for these groups of centers. The parameters of angiograms of arthritic centers also did not differ significantly from other areas, except for rheumatoid arthritis sites. FE for the 4th group significantly exceeded the indicators of the control, 1st and 2nd groups of centers (p <0,05); in post-traumatic osteoarthrosis, this indicator, despite the high average, did not differ significantly from other areas, with the exception of the control group. The coefficient of relative accumulation of RF in the AF also had a significant difference for rheumatoid arthritis compared with the control group, 1 and 2 groups of areas (p <0.05). For the 4th and all other groups, the values of specific accumulation of RF in ESF (p <0,05)
and DSF (p <0,05) significantly differed significantly. It was also important to determine the retention index, which had credible differences in the centers of deforming and post-traumatic osteoarthrosis, rheumatoid arthritis (p <0.05).
The asymmetry of the accumulation of RF in the pathological center and the symmetric intact section in the AFF significantly differed in all groups except for the 3rd and 4th groups of lesions. This indicator in the AF was statistically significantly higher for rheumatoid arthritis, and in the ESF, the rates in the groups were not statistically different. In general, the largest number of significantly different indicators in all three phases was observed between centers in rheumatoid arthritis and sites with aseptic necrosis and deforming osteoar-throsis, while static phases were more informative.
The parameters of the AF had significant differences only in the groups with the most different metabolic processes - in aseptic centers and foci at rheumatoid arthritis. Summing up the obtained results, we can conclude that the calculation of quantitative indicators of kinetics of the RF at different stages of the 3-F BS allowed determining statistically significant differences in metabolic changes in focal lesions in the articular structures. Thus, the differential diagnostic capabilities of the radionuclide method of examination of patients with arthroplasty of the hip and knee joints are elevated.
According to the results of the analysis of kinetic indices of 3-F BS, a radionuclide model "dual timepoint imaging" has been developed for the dynamics of inclusion and distribution of radiopharmaceuticals for septic and aseptic disease of joints (Fig. 1).
Figure 1. Radionuclide model "dual time-point imaging" dynamics of inclusion and distribution of radiopharmaceuticals for septic and aseptic disease of joints
According to this model, in the early static phase of the 3-F BS - there is a gradual increase in the percentage of inclusion and distribution of RF in degenerative and degenerative and infectious-inflammatory foci. Increasing the accumulation of the indicator in inflammatory foci and areas of deforming osteoarthrosis
is due to an increase in the blood flow in the AF, indicating an intensification of arterial blood supply to such centers, due to active inflammation, the influence of an infectious agent or increased osteoblastic activity.
The most revealing was the analysis of the parameters of the delayed static phase of the 3-F BS - a day after the introduction of RF. According to the analysis,
in case of deforming osteoarthrosis there was a rapid elimination of the radiological indicator from the pathological focus, due to the active washing of the RF, due to the decrease in blood supply to the tissues of the site - a retention "failure".
It should be noted that in the foci of rheumatoid arthritis, on the contrary, there was a gradual increase in the percentage of accumulation of the indicator in the hearth due to the intensification of integral perfusion of these sites, due to increased vascular permeability, due to the action of infectious agents, activation of factors of resorption and synthesis of mineral components, and angiogenesis.
Thus, based on the results of the estimation of the kinetic parameters of the 3-F BS of the early and delayed static phases, by the analysis of the "activity-time" curves of the radionuclide model "dual time point imaging" - in patients with an aseptic process, it is possible to conduct an arthroplasty without the risk of paraendoprosthetic complications. While in the diagnosis of the septic process (according to the microbiological verification), an exponential growth of the curve of the radionuclide model "activity-time" is observed in the affected joint region. In patients of this group, in order to prevent the occurrence of implant-associated complications, it is appropriate to conduct a course of antibiotic treatment, according to the sensitivity of the pathogen to the antibiotics, without the arthroplasty at this stage.
Conclusions. The growth of arterial inflow and integral perfusion indices at 3-F BS of clean-up workers - at the centers of hyperfixation of RF in infectious-inflammatory processes, due to the intensification of os-teoblastic activity and angiogenesis in them, in comparison with degenerative-dystrophic areas of fixation of RF. The kinetics of osteotropic RF in the areas of fixing the damaged hip and knee joints in the infectious and inflammatory processes is characterized by the predominance of retention and specific accumulation of the drug in the early static phase and the delayed static phase of the 3-F BS compared with the centers of fixation of RF in deforming osteoarthroses, which correlates with the differences in destructive- reparative processes in them. The practical application of the dual time point imaging radionuclide model facilitates the early detection of paraendoprosthetic complications in the postoperative period, reducing the number of revi-sional arthroplasty and reducing the period of rehabilitation and restoration measures after arthroplasty of clean-up workers.
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