Optimization of Methods for Treating Acute Hematogenous and Various Forms of Chronic Osteomyelitis Using High-Intensity Laser Radiation

The dissertation is dedicated to the development and scientific substantiation of a new minimally invasive method for the treatment of acute hematogenous and various forms of chronic osteomyelitis using high-intensity laser radiation of the infrared range. The research includes clinical and experimental components in which the parameters of laser osteoperforation, its effect on microcirculation, tissue oxygenation, bacterial colonization, and reparative osteogenesis are studied. A method of gentle percutaneous laser osteoperforation has been developed that allows normalization of intramedullary pressure, reduction of bacterial colonization levels, and stimulation of bone tissue regeneration. The proposed method makes it possible to improve early and late treatment outcomes and reduce the rates of complications and recurrences.

Treatment of purulent surgical infection remains relevant, which is determined by both medical and socio-economic aspects. Despite the successes in private branches of surgery, the development of antibiotic therapy and achievements in immunology, purulent complications are still observed in almost 30% of surgical patients (Dronov A.F. et al., 1998; Grenev M.V., 1998; Amirslanov Yu.A. et al., 1998; Payne J.T., 2001). Osteomyelitis refers to one of the most important sections of surgical infection, and its treatment is considered one of the most difficult problems of surgery. According to WHO data, osteomyelitis accounts for up to 6.5-7% in the general structure of diseases of the musculoskeletal system (Struchkov V.I., 1987; Lyssov A.B., 1992; Privalov V.A. et al., 1998; Akzhigitov G.N. et al., 1998; Abaev Yu.K. et al., 2005; Evrard J., 1983; Privalov V.A. et al., 1998; Lappa A.V. et al., 1998). Developments on complex therapy of osteomyelitis using modern physical methods of impact are reflected in many dissertations (Amirslanov Yu.A. et al., 1998; Svetlakov A.L., 2000; Kutin A.A., 2000; Dolganova T.I. et al., 2001; Amirslanov Yu.A. et al., 2006; Bensman V.M., 2006; Vinogradov V.G., 2006; Gritsai N.P., 2006; Hustak J., 1988; Barbos Pinheiro A.L. et al., 2003; Garavello I. et al., 2004; Payne J.T., 2001). However, despite the modern level of purulent osteology, the variety of conservative and operative treatment methods, and the availability of powerful modern antibacterial agents, fatal outcomes are still observed in the treatment of acute hematogenous osteomyelitis, averaging up to 1.4% according to observations of specialized clinics. The frequency of transition of acute hematogenous osteomyelitis to chronic ranges from 5.5% to 40%. Postoperative wound infection after sequestrectomy is observed in 15.6% to 42% (Akzhigitov G.N., Yudin Ya.B., 1998; Kutin A.A., Mosienko N.N., 2000; Ceballos A. et al., 1997). All of the above compels researchers to continue searching for more effective treatment methods. Amirslanov Yu.A., Svetukhin A.M., 1998; Kutin A.A. et al., 2000; Dolganova T.N. et al., 2001; Niccoli-Filho W., 2001. In connection with this, the development of new surgical methods appears important. It is known that treatment outcomes are influenced by: organism resistance, character of microflora, local conditions of infection development, cause of osteomyelitis, patient age, localization of the process, disturbances of microcirculation arising in both acute and various forms of chronic process, therefore their study in various forms of osteomyelitis remains relevant (Dolganova T.I. et al., 2001; Taylor C.R., Lawson J.P., 1986; Barbos Pinheiro A.L. et al., 2003; Garavello I. et al., 2004; Kuboki Y. et al., 2003). In recent years, the method of gentle decompressive osteoperforation with a drill or Kirschner wire for decompression of the marrow canal combined with drainage of parosteal spaces has been applied in the treatment of acute hematogenous osteomyelitis. This method made it possible to reduce the frequency of transition of the acute process to chronic, but at the same time the osteoperforation process itself remains traumatic (Privalov V.A. et al., 1998; Svetlakov A.I., 1998). Sequestrectomy in chronic forms of osteomyelitis was and remains the main operation with varying finishing components. Adequate methods for eliminating the residual bone cavity are still being sought, and antiseptic methods of impact on this cavity are being actively developed. Significant progress has been made in the operative treatment of post-traumatic osteomyelitis due to the introduction of compression-distraction methods of osteosynthesis, bone tissue transplantation, and transplantation of complex flaps on vascular pedicles. But so far this has not affected the results of osteomyelitis treatment in wide practice (Dolganova T.N. et al., 1996; Dolganova T.N. et al., 2001; Amirslanov Yu.A. et al., 2006; Bensman V.M., 2006; Vinogradov V.G., 2006; Gritsai N.P., 2006). Disease recurrences remain at the level of 3-33% (Kutin A.A. et al., 2000). Long-term course of osteomyelitis with frequent exacerbations is complicated by amyloidosis of internal organs in almost one-third of patients (Lomachenko I.N., 1996; Korovin S.A. et al., 2000; Kutin A.A. et al., 2000; Sina W., 1973). More than 10% of patients who have had acute hematogenous osteomyelitis become disabled. In regional medical institutions, osteomyelitis is detected in 10.3% to 51% during treatment of open fractures. Mortality from sepsis in patients with acute osteomyelitis and during exacerbation of chronic reaches 8.9% (Akzhigitov G.N. et al., 1998). There are practically no studies dedicated to early diagnosis of acute hematogenous osteomyelitis, minimally invasive methods of treatment of acute and chronic osteomyelitis. The effect of high-intensity laser radiation of the infrared range on the morphological picture and course of the osteomyelitic process has been insufficiently studied (Abushkin I.A. et al., 1998; Privalov V.A. et al., 2001). There are only isolated works on this plan, but they have not found wide practical application. Existing methods for stimulating reparative processes in bone tissue are not always effective, therefore the search for new methods and means contributing to the creation of conditions for optimal healing of bone tissue, increasing the intensity of osteogenesis and reducing the duration of bone repair is ongoing (Bashkatova N.A., 2000; Kochetkov S.B. et al., 2002; Petrenko P.A., 2004; Tsulina E.P. et al., 2004; Amirslanov Yu.A. et al., 2006; Bensman V.M., 2006; Gritsai N.P., 2006). Given the contradictory nature of the literature data, the high frequency of chronicization after application of traditional treatment methods, frequent disability of patients, the lack of unity of views on the choice of early diagnostic methods and the rational volume of operative treatment, both for acute and various forms of chronic osteomyelitis, in-depth study of this problem is relevant. Thus, the development of new methods of operative treatment of osteomyelitis and the study of factors influencing the outcome of surgery is a promising problem. Research goal: To develop, scientifically substantiate, and implement in clinical practice a new minimally invasive method for treating acute hematogenous and various forms of chronic osteomyelitis using high-energy laser radiation of the infrared range to improve anatomo-functional treatment outcomes. Research tasks: 1. To study the late results of treatment of acute hematogenous and various forms of chronic osteomyelitis using traditional methods. 2. To develop parameters of laser radiation and techniques of gentle percutaneous laser osteoperforation in the treatment of acute and various forms of chronic osteomyelitis. 3. To study by cytomorphological research the effect of laser osteoperforation on the dynamics of the wound process. 4. To study the character of changes in the bacterial landscape during traditional treatment and after application of laser radiation. 5. To study the effect of laser osteoperforation on the state of microcirculation and oxygenation of soft tissues in various forms of osteomyelitis. 6. To study the character of morphological changes in bone tissue after laser osteoperforation in patients with chronic forms of osteomyelitis. 7. To substantiate the effect of high-intensity laser radiation of the infrared range in the mode of gentle osteoperforation on reparative osteogenesis in experiment and clinical practice. 8. To study early and late treatment results and prove the advantages of the proposed method of treating acute hematogenous and various forms of chronic osteomyelitis over traditional operations. Propositions for defense: 1. Percutaneous laser osteoperforation is a minimally invasive and effective method for treating acute hematogenous and various forms of chronic osteomyelitis. 2. The use of high-intensity laser radiation in the treatment of acute and various forms of chronic osteomyelitis or its combination with traditional operations allows improving early and late treatment results for this category of patients. 3. Laser osteoperforation contributes to the rapid and effective reduction of intramedullary pressure and the level of bacterial colonization of bone tissue, ensuring the elimination of the main etiopathogenetic mechanism of acute hematogenous osteomyelitis in children. 4. High-intensity laser radiation of the infrared range in the mode of gentle laser perforation of bone rapidly and effectively normalizes microcirculation, accompanied by improved tissue oxygenation and stimulation of reparative processes in the affected limb segment. 5. Laser osteoperforation in acute hematogenous and various forms of chronic osteomyelitis contributes to the stimulation of osteogenesis, early and rapid restoration (repair) of bone tissue. Scientific novelty of the research: A new minimally invasive method for treating acute hematogenous and various forms of chronic osteomyelitis using high-intensity laser radiation of the infrared range through closed percutaneous laser osteoperforation has been developed. Adequate parameters of laser radiation for gentle closed laser osteoperforation depending on the form and stage of osteomyelitis have been determined: impulse-periodic mode of infrared laser radiation with power from 10 to 30 W and exposure from 3 to 10 seconds. It has been proven that under the developed modes, deep thermal damage to soft tissues and bones does not occur, and the formed osteoperforation openings serve as drainage systems leading to normalization of intramedullary pressure, which positively affects the restoration of microcirculation and oxygenation in tissues of the affected limb segment. Moreover, laser radiation, by virtue of its biophysical effect, possessing a powerful sanitizing action on bone marrow and surrounding tissues, contributes to the rapid reduction of the pathological concentration of shed microorganisms. It has been established that laser osteoperforation reliably shortens the time for the transition of the inflammatory phase to the regeneration phase. Based on the developed laser osteoperforation, a new minimally invasive and simple-to-execute method of surgical treatment of bone and osseous-articular panaritium has been proposed. Application of this method made it possible to substantially improve anatomo-functional treatment results. It has been proven that gentle percutaneous laser osteoperforation in the proposed modes stimulates reparative osteogenesis both in animal experiment and in clinical application in patients. It has been established that in response to laser action in tissues of the affected limb segment, the volumetric velocity of capillary blood flow and tissue oxygenation improve, which stimulates tissue repair processes. It has been proven that laser osteoperforation contributes to the shortening of the exudative phase of inflammation in the pathological focus and rapid transition to a productive phase with formation of fully developed granulation tissue. Mature lamellar bone is already formed within 6 months after laser exposure. The proposed new method of laser osteoperforation made it possible to reduce the complication rate in children with acute hematogenous osteomyelitis from 11.4% to 4.3%, and in chronic osteomyelitis from 15.5% to 3.1%. It allows substantially increasing the duration of the relapse-free period in patients with chronic forms of osteomyelitis, thereby reducing the recurrence rate. Implementation of research results in practice: The developed method has been implemented in the practical work of departments of purulent surgery, pediatric surgery, traumatology, and orthopedics of MUZ "City Clinical Hospital No.1", the clinic of Chelyabinsk State Medical Academy, MUZ "City Clinical Hospital No.9" of Chelyabinsk, and the district hospital of Nyagan (Khanty-Mansi Autonomous Okrug). The new data and research results are used in the educational process of the Department of General Surgery of the State Educational Institution of Higher Professional Education "Chelyabinsk State Medical Academy". Russian Federation Patents have been obtained: 1. "Method of diagnosis of acute hematogenous osteomyelitis by means of transcutaneous oximetry" No. 2124723 dated 02.25.1997; 2. "Method of treatment of chronic osteomyelitis", No. 2209595 dated 05.15.2001; 3. "Method of surgical treatment of bone and osseous-articular panaritium", No. 2235522 dated 01.14.2003; 4. "Method of stimulation of osteogenesis in animals and humans" No. 2255700 dated 07.07.2003. Presentation of research results: The dissertation materials were reported and discussed at the regional surgeons' society of Chelyabinsk Oblast (Chelyabinsk, 1999, 2001, 2004), at the 3rd Russian Interregional Conference of Surgeons dedicated to the 60th anniversary of the Chelyabinsk Medical Academy "New Technologies and Fundamental Research in Medicine" (Chelyabinsk, 2002), at the 5th All-Russian Conference "New Technologies in Surgery" (Ufa, 2001), at the 8th International Congress of the European Medical Laser Association "Laser, 2001" (EMLA) and the 1st Russian Congress of the Medical Laser Association (RMLA) (Moscow, 2001), at the 4th All-Russian Scientific and Practical Conference "Engineering in Medicine" (Chelyabinsk, 2004), at the international scientific and practical conference dedicated to the 75th anniversary of UGAVM "Actual Problems of Veterinary Surgery" (Troitsk, 2004), at annual international SPIE conferences in Sweden, USA, and Germany (Stockholm, 1998; San Jose, 2000; Munich, 2005), at All-Russian conferences of surgeons "Semiconductor and Fiber Lasers in Medicine" (St. Petersburg, 2004, 2006), at the 4th inter-regional conference of surgeons "Actual Questions of Purulent Surgery" (Buguruslan, 2004). Based on the dissertation materials, 42 works have been published, including 3 abroad, 12 in central publications, of which 9 in publications recommended by the Higher Attestation Commission. The results of the work were awarded the first prize of the Chelyabinsk Oblast Government in the "Innovations 2004" competition. Volume and structure of the dissertation: The dissertation is presented on 313 pages of typed text, consists of an introduction, 8 chapters, conclusions, practical recommendations, and a bibliography including 216 domestic and 181 foreign sources, illustrated with 71 figures and 95 tables.