Abstracts journal "Polytrauma" 1/2015

Leading article

HOSPITAL MORTALITY IN POLYTRAUMA AND MAIN DIRECTIONS FOR ITS DECREASE

Agadzhanyan V.V., Kravtsov S.A., Shatalin A.V., Levchenko T.V.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective – to estimate the level and significance of the main factors influencing on the structure of hospital mortality in polytrauma.

Materials and methods. The retrospective analysis included 1,303 case histories of the patients with polytrauma who were treated in the specialized trauma center based on Clinical Center of Miners’ Health Protection from 2005 till 2014. 486 patients were transported from the non-specialized medical facilities. 229 patients died. The mortality was 17.5 %. The clinical morphologic analysis of hospital mortality was performed, and the quality of clinical diagnostics was estimated.

Results. The mean hospital mortality was 17.5 %. The optimal time for transfer of patients with polytrauma to a specialized trauma center is 1^st days from an accident. In case of later transfer the disease prognosis worsens significantly, and mortality increases by 23.6 %, if transfer is performed on day 4. As for acute period of traumatic disease, the mortality was 21.4 %, 24 hour mortality – 10.1 %, with relative increase up to 50.6 % after 10 days. The maximal amount of lethal outcomes (79.4 %) was associated with road traffic accidents.

The greatest hospital mortality was observed in the patients with concurrent dominating injuries (72 %). The second place is related to the patients with dominating spine-spinal cord injury (27.8 %). Virtually the same level of mortality is observed in the patients with dominating traumatic brain, abdominal and thoracic injuries (16.6-17.7 %). The most favorable outcomes are observed in the group of dominating skeletal injury, with mortality of 6.5 %.

The thanatological profile in acute period: shock and blood loss 31 (13.5 %), edema and dislocation of the brain 41 (17.9 %); in the early period: MODS 86 (37.5 %), infectious complications 66 (28.9 %), others 5 (2.1 %).

The defects in the quality of clinical diagnostics were found in 54 (52.9 %) of died patients, including 2 (1.9 %) patients with thanatologically significant characteristics. The greatest amount of diagnostic errors (80.2 %) was observed in acute period of traumatic disease and was associated with the objective causes: extremely severe state of the patients, necessity for resuscitative measures and surgical procedures, and short hospital stay.

Conclusion. In acute period of traumatic disease the mortality decreased up to 21.4 %, with relative increase up to 50.6 % after 10 days because of developed MODS and septic complications. It is necessary to focus on improving the organizational and medical diagnostic measures for polytrauma. The special attention is needed for preventive measures and measures for treating complications of polytrauma.

Key words: hospital mortality; polytrauma; traumatic disease (TD); diagnostic defects; complications.

Information about authors:

Agadzhanyan V.V., MD, PhD, professor, director of Federal Scientific Clinical Center of the Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Kravtsov S.A., MD, PhD, head of center of resuscitation, intensive care and anesthesiology, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Shatalin A.V., MD, PhD, head of resuscitation and intensive care department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Levchenko T.V., head of anatomic pathology department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Kravtsov S.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Federal Scientific Clinical Center of Miners’ Health Protection

Тел.: +7 (384-56) 2-39-99

E-mail: info@gnkc.kuzbass.net

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New medical technologies

USE of microsurgical RECONSTRUCTIVE techniques for treatment of patients with injuries to THE spinAL CORD and ITS MATER

Yakushin O.A., Novokshonov A.V., Agadzhanyan V.V.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective – to ascertain the efficiency of primary restorative and late reconstructive operations in treatment of patients with injuries to the spinal cord and its mater.

Materials and methods. The materials are based on treating 223 patients with spine and spinal cord injury. Surgical treatment for the spinal cord and its mater was realized for 116 (52 %) patients, including 72 patients with primary restorative operations in acute period, and 44 patients with reconstructive operations in late period. Dura mater plastics was carried out in 116 cases, including 8 patients with circular plastics, and 17 patients with spinal cord plastics using combined vascular neural autograft according to Stepanov G.A. (17 patients).

Results. Appropriate volume of primary restorative and late reconstructive operations for spinal cord and dura mater with use of microsurgical technique resulted in improving disordered spinal cord functions, with satisfactory and good outcomes in 82.8 % of the cases.

Conclusion. Microsurgical operations for reconstruction of the spinal cord and its dura mater and pia mater allow providing volume continuality of the spinal cord at the level of its injury.

After an injury to the spinal cord and its mater the normal cerebrospinal fluid circulation is restored only after dura mater plastics. Both in acute and remote periods of spine and spinal cord injury the method of choice for dural sac plastics is venous autograft and artificial dura mater.

Key words: injury to spinal cord and its mater; microsurgical techniques; optical magnification.

Information about authors:

Yakushin O.A., candidate of medical science, traumatologist-orthopedist, neurosurgery department #2, Federal Scientific Clinical Center of the Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Novokshonov A.V., MD, PhD, head of neurosurgery center, Federal Scientific Clinical Center of the Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Agadzhanyan V.V., MD, PhD, professor, director of Federal Scientific Clinical Center of the Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Yakushin O.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7 (384-56) 9-53-58

E-mail: Yakushin-GNKC@rambler.ru

Rеferences:

1. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

2. Gaydar BV, Korolyuk MA, Kropotov SP. Nerve tissue transplantation in spinal cord injuries: possibilities and perspectives. Clinical Medicine and pathophysiology. 1996; (1): 102-114. Russian

3. Lutsik AA, Shevelev IN, Perlmutter OA, Shulev YuA, Konovalov NA, Grin AA. Diagnostics and treatment of acute spine-spinal cord injury (the recommendation protocol). Novokuznetsk, 2006. 36 p. Russian

4. Neurosurgery. European manual of medicine: 2 volumes. Vol. 2. Lumenta CB, editor ; translated from english edited by DA. Gulyaev. Moscow : Panfilov’s Publishing Office ; BINOM. Laboratory of Knowledge Publ., 2013. 360 p. Russian

5. Neurosurgery : the manual for physicians : 2 volumes. Vol. 2: Lectures, workshops, clinical works. Dreval ON, editor. Moscow : Litterra Publ., 2013. 864 p. Russian

6. Agadzhanyan VV, Agalaryan AKh, Ustyantseva IM, Galyatina EA, Dovgal DA, Kravtsov SA, et al. Polytrauma. Treatment of Children. Novosibirsk : Nauka Publ., 2014. 244 p. Russian

7. Stepanov GA. New techniques of reconstructive microsurgery of spinal cord in severe injury. Moscow : SCIENCE-PRESS Publ., 2011. 120 p. Russian

8. Traumatology and orthopedics : manual for doctors : 4 volumes. Vol. 4: Injuries and diseases of pelvis, chest, spine and head. Administration of DTC in traumatology and orthopedics. The principles of experimental studies in traumatology and orthopedics. Kornilov NV, Gryaznukhin EG, editors. Saint Petersburg : Hippocrates, 2006. 624 p. Russian

9. Tyulkin ON, Shchedrenok VV, Anikeev NV, Moguchaya OV. Surgical stage of restorative treatment in late period of spinal cord traumatic disease. Polytrauma. 2011; (3): 43-47. Russian

10. Usikov VD, Vorontsov KE, Kuftov VS, Ershov NI. Short term and long term results of surgical treatment of spinal cord injury at thoracic and lumbar levels. Traumatology and Orthopedics of Russia. 2014; (2): 37-44.

11. Yumashev GS, Kurbanov NM. Reconstructive operations for spine and spinal cord injuries. Tashkent, 1991. 189 p. Russian

12. Yakushin OA, Novokshonov AV, Krashennikova LP, Kubetsky YuE, Glebov PG, Kitiev IB-G. The result of complex treatment of a child with severe spinal cord injury. Polytrauma. 2012; (4): 63-68. Russian

13. Butcher N, Balogh ZJ. The definition of polytrauma: the need international consensus. Injury. 2009; 40 (4): 12-22.

14. Basques BA, Golinvaux NS, Bohl DD, Yacob A, Toy JO, Varthi AG. et al. Use of an operating microscope during spine surgery is associated with minor increases in operating room times and no increased risk of infection. Spine. 2014; 39 (22): 1910-1919.

15. Spine trauma. Surgical techniques. Patel VV. et al., editors. Berlin ; Heidelberg : Springer, 2010. [xiv], 413 p.

TRAUMATIC BRAIN INJURIES IN CHILDREN WITH POLYTRAUMA

Novokshonov A.V., Lastaev T.V.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective ‒ to analyze the treatment of traumatic brain injuries in children with polytrauma in conditions of a specialized trauma center.

Materials and methods. There was a retrospective analysis of traumatic brain injuries in the children who were treated in the specialized trauma center. The materials are based on 106 patients treated during the last 10 years (2003-2013). Among the patients the prevailing group included boys (67.9 %) and the children at the age of 7-14 (60.4 %). Most children were admitted in severe (94.3 %) and extremely severe state (5.7 %). A severe traumatic brain injury presented the main component of polytrauma in 43.6 % of the injured children. At the moment of discharge the outcomes were as indicated below: mild neuropsychic dysfunction ‒ 54.7 %, recovery ‒ 23.5 %, death ‒ 7.5 %.

Results. Depending on outcomes, all patients were distributed into two groups: deceased and survived patients. There were 98 survived patients (92.5 %). Lethal outcomes were in 8 patients (7.3 %). Most patients were transported to the hospital during the time interval not exceeding 3 hours from an injury ‒ 49 (46.2 %). There were 28 surgical interventions. Most patients were operated during 2 hours after admission ‒ 25 (89.3 %). Alongside with surgical treatment the pathogenetic therapy was carried out. Automobile-pedestrian accident was the most common injury mechanism (58.3 %); transport speed-up and decelerating was in 24.5 %. Most children with polytrauma were admitted in severe (94.3 %) and extremely severe state (5.7 %). Different types of depression of consciousness were found in all patients. Evident disorders of consciousness (coma II-III) were found in 48.2 %.

Conclusion. Treatment for children with traumatic brain injuries should be performed in a special medical facility, with possibilities for complex surgical, traumatological and neurosurgical assistance. The prevailing injury mechanisms in children are automobile-pedestrian accidents (58.3 %), transport speed-up or decelerating (24.5 %). A severe traumatic brain injury as the main component of polytrauma was in 43.6 %. The discharge outcomes were mild neuropsychic dysfunction (54.7 %), recovery (23.5 %), and death (7.5 %).

Key words: traumatic brain injury; polytrauma in children.

Information about authors:

Novokshonov A.V., MD, PhD, head of neurosurgery center, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Lastaev T.V., physician of neurosurgery department #2, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Novokshonov A.V., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Federal Scientific Clinical Center of Miners’ Health Protection

Tel: + 7 (384-56) 9-53-58

E-mail: irmaust@gnkc.kuzbass.net

References:

1. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

2. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Novokshonov AV, Agalaryan AKh. Polytrauma. Septic complications. Novosibirsk : Nauka Publ., 2005. 391 p. Russian

3. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

4. Agadzhanyan VV, Novokshonov AV, Yakushin OA. Traumatic brain injury and spinal injuries in children. In: Polytrauma. Treatment of Children. Agadzhanyan VV, editor. Novosibirsk : Nauka Publ., 2014. p. 102-147. Russian

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8. Novokshonov AV, Agadzhanyan VV. Surgical treatment for severe traumatic brain injury in the acute period. Polytrauma. 2008; (3):33-39. Russian

9. Novokshonov AV, Vaneev AV, Fedorov MYu, Elistratov OB, Yakushin ON. A case of active surgical tactics in acute and remote periods of severe traumatic brain injury in a child. Polytrauma. 2008; (4): 42-46. Russian

10. Novokshonov AV, Nikolaev AS, Litvinenko RN, Sel'skova IG, Burzyantseva NS, Vostrikova TA. Generic traumatic brain injury of newborn: diagnosis and treatment. Polytrauma. 2009; (1): 42-49. Russian

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Clinical aspects of surgery

THE FEATURES OF DIAGNOSTICS AND SURGICAL TREATMENT OF DIAPHRAGM INJURIES IN PATIENTS WITH POLYTRAUMA

Agalaryan A.Kh.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Background. Diagnostics and treatment of diaphragm injuries present an unsolved issue in urgent surgery. Such type of an injury is characterized by specific severity of clinical course, difficulties in timely diagnostics, treatment, and high mortality (19.4-28 %).

Objective – to assess incidence, localization of injuries, diagnostics and treatment of diaphragm injuries in patients with polytrauma.

Materials and methods. The retrospective monitoring included 76 case histories of the patients with diaphragm injuries treated at the special traumatology center, which is located on the basis of Clinical Center of Miners’ Health Protection, during 1999-2013. The analysis included demographics (age, gender, injury mechanism) and clinical indicators (ISS, ALV duration, ICU stay, hospital treatment duration, complications, mortality).

Results. Invasive and non-invasive diagnostic techniques were used for diagnostics of diaphragm injuries in the patients with polytrauma. X-ray examination confirmed diaphragm injuries in 8 (10.5 %) patients. According to CT examination, diaphragm injuries were found in 16 (21.1 %) patients on days 2-5 after trauma. Laparoscopic and thoracoscopic examinations confirmed diaphragm injuries in 44 (57.9 %) patients.

Surgical interventions for diaphragm injuries in polytrauma were performed for 36 patients. Laparotomy approach was used for 29 (80.5 %) patients, thoracotomic one – for 7 (19.5 %). The identified defects were treated with interrupted sutures with use of non-absorbable suture material with creation of duplication – 15 (41.7 %) patients. In case of small diaphragmatic defects (up to 5 cm) and impossibility of duplication the suturing was carried out with continuous suture with non-absorbable suturing material – 19 (52.7 %) patients. We used mesh implants for two cases with an injury to the right diaphragm cupula and high risk of inconsistent diaphragm suture.

There were no intrasurgical complications. Systemic complications (acute respiratory distress syndrome and multiple organ insufficiency) were in 39.4 %. The total mortality was 21 % (16 patients). The most common causes of lethal outcome were head injury (39.1 %) and multiple organ insufficiency (47.1 %).

Conclusion. Therefore, diaphragm injuries present 3.7 % in polytrauma composition. Injuries were associated with road traffic accidents in 71 %. Invasive techniques (laparoscopy and thoracoscopy) are most informative for diagnostics of diaphragm injuries (57.9 %). Most commonly, diaphragm injuries were sutured through laparotomy approach (80.5 %). The total mortality was 21 % and was conditioned by decompensated blood loss in early posttraumatic period and late systemic complications.

Key words: polytrauma; diaphragm injury; laparoscopy; thoracoscopy.

Information about author:

Agalaryan A.K., candidate of medical science, head of surgery department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Agalaryan A.K., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Federal Scientific Clinical Center of Miners’ Health Protection

Tel: + 7 (384-56) 9-55-05

E-mail: irmaust@gnkc.kuzbass.net

References:

1. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

2. Goncharuk EV. Treatment of a patient with concomitant injury and diaphragm rupture (a case history). Genius of Orthopedics. 2012; (2): 144-147. Russian

3. Ukhanov AP, Gadzhiev ShA. Use of endovideosurgical technique for diagnostics and treatment of diaphragm injuries. Endoscopic Surgery. 2011; (5): 9-13. Russian

4. Kubachev KG, Kukushkin AV. Diaphragm injuries in open and closed thoracoabdominal injury. Siberian Medical Journal. 2009; 91 (8): 145-149. Russian

5. Maslov VI, Takhtamysh MA. Ligature fixation for floating rib valves in closed chest injury. Surgery. 2007; (3): 39-43. Russian

6. Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in patients with traumatic diaphragmatic injury: A 15-year experience. J. Trauma Acute Care Surg. 2013; 74 (6): 1392-1398.

7. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

8. Ties JS, Peschman JR, Moreno A, Mathiason MA, Kallies KJ, Martin RF, et al. Evolution in the management of traumatic diaphragmatic injuries: A multicenter review. J. Trauma Acute Care Surg. 2014; 76 (4): 1024-1028.

9. Alishikhov AM, Puzanov SYu, Bogdanov DYu. Results of endovideosurgical diagnostics and surgical treatment of thoracoabdominal injury. Surgeon. 2013; (2): 51-60. Russian

THE ROLE OF ENDOTHELIAL DYSFUNCTION IN PATHOGENESIS OF VARICOSE VEINS

Kolobovа O.I., Simonova O.G., Leshchenko V.A.

Diagnostic Center of Altay Region,

Barnaul, Russia

Varicose disease is the most widespread chronic venous disease with complex and insufficiently studied pathogenesis.

Objective ‒ to ascertain the role of endothelial dysfunction in varicose disease pathogenesis using the comparative study of the levels of systemic and regionary mitogenetic factors of the venous wall.

Methods. The study was oriented to investigation of the role of systemic and regionary factors of endothelial injury in the lower limb veins as a part of varicose disease (VD) mechanism in 69 patients, predominantly with C2 and C3 clinical stages of the disease. We examined the values of oxidative-antioxidative status (total oxidative activity, the level of thiobarbiturate reactive products, general antioxidative activity and concentration of superoxide dismutase and catalase in red blood cells). We defined the markers of venous wall dysfunction ‒ endothelial growth factor (VEGF-A), fibroblast growth factor (FGF basic), endotheline-1 in systemic (the cubital vein) and regionary (the great saphenous vein) blood flow. The results were compared to the data of general blood flow in 33 volunteers. Dynamics of the endothelial peptides was investigated in 9 patients receiving Antistax during antioxidative therapy.

Results. The patients with VD showed systemic oxidative stress conditioned by decreasing main intracellular antioxidative enzymes SOD (13 %) and CAT (40 %). At this background the signs of endothelial dysfunction with increasing plasma levels of cytokines VEGF-A and FGF basic were found. The most significant changes were found in the blood from the great saphenous vein, with hyperproduction of endothelial growth factor (169.3 ± 10.2 pg/ml, p < 0.02) during disease formation.

Conclusion. The role of endothelial dysfunction in the lower limb veins was ascertained in varicose disease pathogenesis, the relationship was traced with decreasing adaptation to orthostatic dynamic loads and hypoxia that conditioned the compensatory remodeling and varicose transformation. It was found that antioxidative therapy with Antistax resulted in 1-3 time increase in plasma endothelin-1 and decreasing the clinical signs of the disease.

Key words: varicose disease; oxidative stress; endothelial dysfunction; endothelial growth factor; fibroblast growth factor; endothelin-1; orthostatic phlebohypertension of lower extremities.

Information about authors:

Kolobova O.I., MD, PhD, cardiovascular surgeon, Diagnostic Center of Altay Region, Barnaul, Russia.

Simonova O.G., head of immunology laboratory, Diagnostic Center of Altay Region, Barnaul, Russia.

Leshchenko V.A., candidate of medical science, chief physician, Diagnostic Center of Altay Region, Barnaul, Russia.

Address for correspondence:

Kolobova O.I., Molodyozhnaya St., 30-55, Barnaul, Russia, 656015

Tel: +7 (3852) 62-35-50

E-mail: ogic@yandex.ru

Rеferences:

1. Savel'ev VS. Phlebology. Moscow : Medicine Publ., 2001. p. 438-489. Russian

2. Naoum JJ, Hunter GC. Pathogenesis of Varicose Veins and Implications for Clinical Management. Vascular. 2007; 15: 5: 242-249.

3. Raffetto JD, Khalil R A. Mechanisms of varicose vein formation: valve dysfunction and wall dilation. Phlebology. 2008; 23: 85-98.

4. Somers P, Knaapen M. The Histopathology of Varicose Vein Disease. Angiology. 2006; 57(5): 546-555.

5. Gervaziev VB, Kolobova OI. Features of orthostatic venous hemodynamics of the lower limbs in healthy persons and patients with varicose disease according to duplex scanning data. Angiology and Vascular Surgery. 2003; (3): 47-52. Russian

6. Cai H. Hydrogen peroxide regulation of endothelial function: origins, mechanisms, and consequences. Cardiovasc. Res. 2005; 68(1): 26-36.

7. Wassmann S, Wassmann K, Nickenig G. Modulation of oxidant and antioxidant enzyme expression and function in vascular cells. Hypertension. 2004; 44(4): 381-386.

8. Puddu p, Puddu G.M., Zaca F, Muscari A. Endothelial dysfunction in hypertension. Acta Cardiol. 2000; 55(4): 221-232.

9. Bader M. Molecular Interactions of Vasoactive Systems in Cardiovascular Damage. Journal of Cardiovascular Pharmacology. 2001; 38(Suppl 2): S7-S9.

10. Pfisterer L, König G, Hecker M, Korff T. Pathogenesis of varicose veins - lessons from biomechanics. Vasa. 2014; 43(2): 88-99.

11. Raffetto J, Khalil R. Matrix Metalloproteinases in Venous Tissue Remodeling and Varicose Vein Formation. Current Vascular Pharmacology. 2008; 6(3): 158-172.

12. Szasz Th, Thakali K, Fink G, Watts S. A Comparison of Arteries and Veins in Oxidative Stress. Experimental Biology and Medicine. 2007; 232: 27-37.

13. Bharath V, Kahn SR, Lazo-Langner A. Genetic polymorphisms of vein wall remodeling in chronic venous disease. Blood. 2014; 124(8): 1242-1250.

14. Shevchenko YuL, Stoyko YuM, Zamyatin MN, Gudymovich VG. Endothelial dysfunction in the pathogenesis of venous transformation. Angiology and Vascular Surgery. 2008; (1): 15-19. Russian

Clinical aspects of traumatology and orthopedics

DAMAGE CONTROL ORTHOPEDICS FOR TREATMENT OF SEVERE COMBAT INJURIES TO THE LIMBS

Lerner A.A., Fomenko M.V., Rotem D., Pikkel I., Yulish М., Salamon T.

Ziv Medical Center,

Safed, Israel

High energy trauma causes deep and extensive tissue injuries, which significantly limit possibilities of restorative treatment and the range of medical measures.

Objective – to describe the experience with treating 409 patients who suffered as result of combat actions in Syria.

Materials and methods. Low traumatic techniques for external tubular fixation of fractures allowed stabilizing injured segments of the extremities and achieving the minimal additional injury, without introduction of foreign bodies to an injured region, without limiting surgical approach to an injured extremity.

Results. The simplicity of the technique and the relative short surgery time are important for treatment of patients with multiple injuries and in case of massive admissions. Subsequent final reposition and stable fixation with Ilizarov device provided early mobilization and full axial load.

Conclusion. Minimal invasive staged treatment with external fixation devices and damage control principles allowed saving severely injured extremities and achieving functional restoration even in cases of extensive defects of bone and soft tissues and in critically ill patients.

Key words: damage control; combat injury; open fractures; staged treatment; external fixation of fractures.

Information about authors:

Lerner A.A., professor, director of orthopedics department, Ziv Medical Center, Safed, Israel.

Fomenko M.V., candidate of medical science, MD, Ziv Medical Center, Safed, Israel.

Rotem D., MD, Ziv Medical Center, Safed, Israel.

Pikkel I., MD, Ziv Medical Center, Safed, Israel.

Yulish М., MD, Ziv Medical Center, Safed, Israel.

Salamon T., MD, Ziv Medical Center, Safed, Israel.

Address for correspondence:

Fomenko M.V., Ziv Medical Center, orthopedics department, Safed, Israel, 13100

Tel: 972-50-8434175; 972-4-6828641

E-mail: fomenko_mv@mail.ru

Rеferences:

1. Nechaev EA, Gritsanov AI, Fomin NF, Minnullin IP. Mine-explosive trauma. Saint-Petersburg : Ald Publ., 1994. 488 p. Russian

2. Foglar C, Ibarra M, Miclau T. Gunshot wounds of the forearm. Injury. 1997; 28 (Suppl 3): S8-S22.

3. Has B, Jovanovic S, Wertheimer B, Mikolasevic T, Grdic P. External fixation as a primary and definitive treatment of open limb fractures. Injury. 1995; 26(4): 245-248.

4. Kenwright J. The principles of use of external fixation. Curr. Orthop. 1992; 6: 214-219.

5. Labeeu F, Pasuch M, Toussaint R, Van Erps S. External fixation in war traumatology: report from the Rwandese war. J. Trauma. 1996; 40(Suppl 3): 223-227.

6. Saleh M, Yang L, Sims M. Limb reconstruction after high-energy trauma. Br. Med. Bull. 1999; 55(4): 870-884.

7. Lerner A, Reis D, Soudry M. Severe Injuries to the Limbs: Staged. Treatment. Berlin - Heidelberg : Springer–Verlag, 2007. 235 p.

8. Lerner A, Soudry M. Armed Conflict Injuries to the Extremities: A Treatment Manual. Berlin-Heidelberg : Springer-Verlag, 2007. 407p.

9. Lerner A, Stahl S, Stein H. Hybrid external fixation in high-energy elbow fractures: a modular system with a promising future. J. Trauma. 2000; 49(6): 1017-1022.

10. Norris RI, Kellam JF. Soft-tissue injuries associated with high-energy extremity trauma: principles of management. J. Am. Acad. Orthop. Surg. 1997; 5(1): 37-46.

11. Johnson KD, Cadambi A, Seibert GB. Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J. Trauma. 1985; 25: 375-384.

12. Omer GE Jr. Injuries to nerves of the upper extremity. J. Bone J. Surg. Am. 1974; 56(8): 1615-1624.

13. Buckwalter JA, Grodzinsky AJ. Loading of healing bone, fibrous tissue, and muscle: implications for orthopaedic practice. J. Am. Acad. Orthop. Surg. 1999; 7: 291-299.

14. Ilizarov GA. The transosseous osteosynthesis : theoretical and clinical aspects of the regeneration and growth of tissue. New-York : Springer, 1992. 589 p.

15. Murray CK, Obremskey WT, Hsu JR, Andersen RC, Calhoun JH, Clasper JC, et al. Prevention of infections associated with combat-related extremity injuries. J. Trauma. 2011; 71(Suppl 2): S235-257.

Researches of young scientists

Early surgical restoration of chest structure in patients with polytrauma

Pronskikh Al.A., Shatalin A.V., Agalaryan A.Kh.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective ‒ to evaluate efficiency of early surgical restoration of chest structure using an original fixator under thoracoscopy control in patients with dominating thoracic injury.

Materials and methods. The study included 50 patients with polytrauma and a dominating thoracic injury who were treated in Clinical Center of Miners’ Health Protection during 2012-2014. The patients were distributed into 2 equal groups. The main group received tactics of early surgical treatment for chest structure by means of open reposition and osteosynthesis for multiple and floating rib fractures with original fixing plates under endovideothoracoscopy control. The comparison group received pneumatic fixation using artificial lung ventilation (ALV) combined with positive end-expiratory pressure (PEEP) (10-12 mbr).

Results. The duration of ALV was significantly lower in the main group compared to the comparison group (5.2 ± 1.48 and 12.4 ± 1.5 bed days [b/d] correspondingly, p < 0.05). Also the statistically significant differences were related to hospital treatment duration: 21.7 ± 22.5 b/d in the main group, 31.4 ± 3.6 b/d in the comparison group (p < 0.05). ICU stay was 11.3 ± 2.3 b/d in the main group, and 14.3 ± 1.6 b/d in the comparison group; there were no statistically significant differences between the groups (p > 0.05). The amount of such complications as endobronchitis and pneumonia was 44 % in the main group and 84 % in the comparison group. The mortality was 12 % in the main group and 20 % in the comparison group.

Conclusion. The offered tactics of early surgical restoration of chest structure in patients with polytrauma and a dominating thoracic injury allowed 40 % reduction of pulmonary complications, 2.4 times reducing ALV duration, reduction of ICU stay by 21 %, hospital treatment period ‒ by 32 %, and mortality ‒ by 8 %.

Key words: polytrauma; closed chest injury; floating rib fracture; restoration of chest structure.

Information about authors:

Pronskikh Al.A., traumatologist-orthopedist, department of traumatology and orthopedics #1, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Shatalin A.V., MD, PhD, head of department of resuscitation and intensive care, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Agalaryan A.Kh., candidate of medical science, head of surgery department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Pronskikh Al.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7 (384-56) 9-52-87; +7 (904) 576-99-70

E-mail: Proal_88@mail.ru

References:

1. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

2. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Novokshonov AV, Agalaryan AKh. Polytrauma. Septic complications. Novosibirsk : Nauka Publ., 2005. 391 p. Russian

3. Agalaryan AKh, Krylov YuM, Zakharov AV. A way of prevention of pleural pulmonary complications in chest injuries in patients with polytrauma. In: Multi-profile hospital: problems and solutions : the materials from All-Russian scientific practical conference, Leninsk-Kuznetsky, 4-5^th of September, 2003. Novosibirsk: Publ., 2003. p. 79. Russian

4. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

5. Vagner EA. Surgery of chest injuries. Moscow : Medicine Publ., 1981. 288 p. Russian

6. Zhestkov KG, Barsky BV, Voskresensky OV. Mini-invasive surgery in treatment of floating fractures of ribs. Pacific Medical Journal. 2006; (1): 62-65. Russian

7. Kligunenko EN, Novikov PP, Maystrovsky AI. Et al. The algorithm for intensive care of severe chest injury. Anesthesiology. 2003; (1): 34-43. Russian

8. Pronskikh AlA, Kravtsov SA, Pronskikh AA. Surgical restoration of chest structure in a patient with polytrauma. A case report. Polytrauma. 2014; (2): 65-70. Russian

9. Sapozhnikova MA. The morphology of closed chest and abdominal injury. Moscow : Medicine Publ., 1988. 160 p. Russian

10. Sigal EI, Zhestkov KG, Burmistrov MV, Pikin OV. Thoracoscopic surgery. Moscow, 2012. 352 p. Russian (Сигал Е.И., Жестков К.Г., Бурмистров М.В., Пикин О.В. Торакоскопическая хирургия. М., 2012. 352 с)

11. Surgical diseases : the manual. Fedorov VD, Emelyanov SI, editors. Moscow : MIA Publ., 2005. 480 p. Russian

12. Sharipov IA. Chest injury: problems and solutions. Moscow : Grail Publ., 2003. 328 p. Russian

13. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J. Thorac. Cardiovasc. Surg. 1995; 110 (6): 1676-1680.

14. Bemelman M, Poeze M, Blokhuis TJ, Leenen LPH. Historic overview of treatment techniques for rib fractures and flail chest. Eur. J. Trauma Emerg. Surg. 2010; 36 (5): 407–415.

15. Engel C1, Krieg JC, Madey SM, Long WB, Bottlang M. Operative chest wall fixation with osteosynthesis plates. J. Trauma. 2005; 58 (1): 181-186.

16. Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J. Trauma. 2003; 54 (6): 1058-1063.

17. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur. J. Cardiothorac. Surg. 2003; 23 (3): 374-378.

18. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J. Surg. 2009; 33 (1):14-22.

19. Reber P, Ris HB, Inderbitzi R, Stark B, Nachbur B. Osteosynthesis of

the injured chest wall. Use of the AO (Arbeitsgemeinschaft fur Osteosynthese) technique. Scand J Thorac Cardiovasc Surg. 1993;27:137 142.

20. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. A prospective randomized study of management of severe flail chest patients. J. Trauma. 2002; 52 (4): 727-732.

21. Warren DK, Shukla SJ, Olsen MA, Kollef MH, Hollenbeak CS, Cox MJ, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit. Care Med. 2003; 31 (5): 1312-1317.

Case history

THE FEATURES OF REPLANTATION OF EXTREMITY SEGMENTS IN CHILDREN

Afanasyev L.M., Isaev E.A., Ezhov A.A.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Replantation of ruptured fingers is a significant problem for complexity of realization, graft acceptance, but also for further restoration of segment functioning.

Objective ‒ to estimate the treatment outcomes in a child with detached fingers of the hand after very long term ischemia and with small volume of restored structures.

Materials and methods. The child A., age of 3 years and 4 months, was admitted with diagnosis: “Almost completely traumatic detachment of the fingers 2, 3, 4 of the right hand at the level of fetlock joint, decompensated ischemia of the fingers 2, 3, 4. Complete traumatic disruption of the distal phalanx of the first finger at the level of the head of the phalangeal joint. Open fracture of the base of the proximal phalanx of the 4^th finger of the right hand with displaced fragments”.

13 hours and 30 minutes before admission the child was hit by an axe on the right hand. The duration of ischemia in the segment was 19 hours and 30 minutes. The replantation of the hand fingers was completed successfully.

Results. Replantation of three hand fingers was performed with microsurgical technique. The favorable result was full acceptance of the implanted segment.

Conclusion. In unfavorable mechanism of an injury and continuous ischemia the reparative possibilities of the child’s body extends the indications for replantation realization. Prognosis of functional restoration is optimistic because of more developed adaptive mechanisms and the features of scar formation.

Finger replantation for children is indicated at any age. Their tissues are characterized with persistent viability, and in case of absent perfusion the rehabilitation potential is evident.

Key words: microsurgery; replantation of fingers of the hand in a child.

Information about authors:

Afanasyev L.M., MD, PhD, head of department of traumatology and orthopedics #3, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Isaev E.A., traumatologist-orthopedist, department of traumatology and orthopedics #3, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Ezhov A.A., surgeon, department of traumatology and orthopedics #3, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Afanasyev L.M., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7 (384-56) 2-40-31

E-mail: info@gnkc.kuzbass.net

References:

Afanasyev LM. Surgical tactics for treatment of patients with open concomitant injuries to the upper extremities and their consequences. Dr. med. sci. diss. Leninsk-Kuznetskiy, 1999. 409 p. Russian
Belousov AE, Tkachenko SS. Microsurgery in traumatology. Leningrad : Medicine Publ., 1988. 224 p. Russian
O’Brien BM. Microvascular Reconstructive Surgery. Edinburg : Churchill Livingstone, 1977. 376 p.

А CASE OF CEREBROVASCULAR PATHOLOGY IN A CHILD RESULTING IN EPIDURAL HEMATOMA

Dolzhenko D.A., Bashmakov V.A., Lyutikova N.I., Eremeeva V.I.

Regional Clinical Hospital,

Altay Regional Bureau of Forensic Medicine,

Barnaul, Russia

Intracranial hemorrhage is one of the most common causes of death and disability. A hemorrhage due to a craniocerebral trauma or cerebrovascular disorder is still a difficulty for differential diagnosis in clinical and forensic medicine.

Objective – to present the case of an epidural hematoma due to ruptured arteriovenous malformation in the child, which was mistakenly interpreted as traumatic one.

Materials and methods. The criminal case of infliction to 12-year-old person V. was presented, as well as the expert analysis of medical documentation, case materials and the results of the corpse examination.

Results. According to the data of the deceased child, the expert board found the undiagnosed (while alive) pathology of the cerebral vessels: the arteriovenous malformation in the dura mater in the left parietooccipital region complicated by the rupture and the bleeding with development of the epidural hematoma.

Conclusion. Diagnostic errors were due to rarity of this pathology. However, proper medical attention might allow to suspect a cerebrovascular disorder in the child and to avoid the initiation of criminal proceeding, investigation of the medical care quality and possible child’s death.

Key words: craniocerebral trauma; arteriovenous malformation; cranial epidural hematoma; dura mater.

Information about authors:

Dolzhenko D.A., MD, PhD, professor, neurosurgeon, head of neurosurgery department, Regional Clinical Hospital, Barnaul, Russia.

Bashmakov V.A., forensic medical expert, head of bureau of forensic medicine, Altay Regional Bureau of Forensic Medicine, Barnaul, Russia.

Lyutikova N.I., forensic medical expert, Altay Regional Bureau of Forensic Medicine, Barnaul, Russia.

Eremeeva V.I., neurologist, Regional Clinical Hospital, Barnaul, Russia.

Address for correspondence:

Eremeeva V.I., Lyapidevskogo St., 1, Barnaul, Russia, 656024

Tel: +7 (3852) 68-98-35

E-mail: eremeeva.vi@yandex.ru

References:

1. Neurology : national guidelines. Gusev EI, Konovalov AN, Skvortsova VI, Gekht AB, eds. Moscow : GEOTAR-Media Publ., 2009. 1040 p. Russian

2. Likhterman LB. Neurology of traumatic brain injury. Moscow : Medical Publ., 2009. 385 p. Russian

3. Kornienko VN, Pronin IN. Diagnostic neuroradiology. Moscow: Medical Publ., 2009. 463 p. Russian

4. Gandhi D, Chen J, Pearl M, Huang J,Gemmete JJ, Kathuria S. Intracranial Dural Arteriovenous Fistulas: Classification, Imaging Findings, and Treatment. Am. J. Neuroradiol. 2012; 33: 1007–1013.

5. Krylov VV, Dmitriev AYu. The risk factors of surgical treatment at patients suffered from cerebral arteriovenous malformations combined with intracerebral hematomas. Russian Journal of Neurosurgery. 2012; (3): 26-33. Russian

6. Iliescu BD, Ioan BG, Zetu I, Astărăstoae V. Non-traumatic spontaneous acute epidural hematoma - case report. Romanian Journal of Legal Medicine. 2009; 17(2): 11-114.

7. Wani A, Ramzan A, Kirmani A, Bhatt R, Latoo R, Iqbal T, et al. Spontaneous Extradural Hematoma Caused by Dural Hemangioma: Case Report. Journal of Neurological Sciences. 2011; 28(1): 116-119.

8. Zheng XU, Chao Y. Spontaneous intracranial extradural hematoma: Case report and literature review. J. Neurology India. 2009; 57(3): 324-326.

Discussions

UNRESOLVED QUESTIONS OF SURGICAL PROCESSING OF WOUNDS.WHETHER BURN WOUND REQUIRES SEPARATE TERMINOLOGY?

Torgunakov A.P.

Kemerovo State Medical Academy,

Kemerovo, Russia

Different directions of the doctrine about wounds developed independently and without coordination with other directions that finally led to multiple conditional terms, infinite attempts of introduction of new terms with their different interpretation, isolation of different medical surgical specialties from each other in terms of this problem, and complexity of perception of a problem by students.

Objective ‒ to gradate the terminology and to simplify its practical application for treatment of wounds of any origin.

Materials and methods. The analysis of the literature data about surgical processing of wounds, the private experience of the teacher of surgical chair and the head of the surgical clinic.

Results. The new concept of the problem of surgical processing of wounds was developed. According to the problem, there are four stages of wound process in relation to morphological criteria of inflammation which are in correspondence with clinical forms of wounds (aseptic and infected, inflamed, purulent [purulent necrotizing], granulating). It is supposed that the name of surgical preparation should include a clinical form of a wound, but without the following terms: primary, secondary, early, late wound, because a form of a wound better determines prescription of these terms. The main independent measures for wound treatment are surgical preparation, dressing, amputation and necrotomy. The elements of the main measures are granulation dissection, necrectomy, wound dissection, wound coverage, autodermoplastics, suturing, draining, wound debridement.

Conclusion. The stated concept relieves of numerous terms, simplifies understanding of the problem by doctors and students. The approaches are expedient for using in practical activity of doctors of all surgical specialties.

Key words: surgical processing of a wound; terminology.

Information about author:

Torgunakov A.P., MD, PhD, professor, had of general surgery chair, Kemerovo State Medical Academy, Kemerovo, Russia.

Address for correspondence:

Torgunakov A.P., Oktyabrsky prospect, 82-402, Kemerovo, Russia, 650065

Tel: + 7 (384-2) 53-15-96

E-mail: aptorgunakov@rambler.ru

References:

Eryukhin IA, Rozhkov AS, Shlyapnikov SA, Rybkin AK. Wound infection. Bulletin of Surgery by the name of I.I. Grekov. 1992; (9–10): 206–215. Russian
Korzh AA. About the problem of wound surgical preparation. Bulletin of Surgery by the name of I.I. Grekov. 1991; (3): 101–102. Russian
Kuzin MI. Wounds and wound infection. Kuzin MI, Kostyuchenok BM, editors. Moscow : Medicine Publ., 1990. 592 p. Russian
Kuzmin KP. What one mean by primary surgical preparation? Orthopedics, Traumatology and Prosthetics. 1982; (1): 65–68. Russian
Lytkin MI, Zubarev PN. Wound surgical preparation. Bulletin of Surgery by the name of I.I. Grekov. 1990; (5): 3–8. Russian
Smirnov SV, Borisov VS. Surn injury in surgical practice. In: 80 lectures. Savelyev VS, editor. Moscow : Literature Publ., 2008. p. 865–875. Russian
Tkachenko SS. Surgical preparation of wounds – the problem of the integral body. Bulletin of Surgery by the name of I.I. Grekov. 1992; (9–10): 261–264. Russian
Torgunakov AP. What one mean by primary surgical preparation of wounds? Orthopedics, Traumatology and Prosthetics. 1983; (5): 57–58. Russian
Torgunakov AP. The unsolved issues of wound surgical preparation. Polytrauma. 2011; (3): 94–98. Russian
Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62939 wounds. Surg. Clin. North. Am. 1980. 60(1): 27–40.

Reviews

RADIAL DIAGNOSTICS OF OSTEOPOROSIS – CURRENT STATE OF THE PROBLEM

Zakharov I.S.

Kemerovo State Medical Academy,

Kemerovo, Russia

Objective – to review the literature devoted to the methods of bone densitometry. The article presents the results of Russian and foreign researches.

Conclusion. The leading place for osteoporosis diagnostics is related to the methods based on determining the level of bone mineral density (dual energy X-ray absorptiometry and densitometry conducted by means of quantitative computed tomography). The method of quantitative ultrasound, according to most authors, should have the character of a screening test. Special attention should be paid to the creation of population databases of indicators of bone mineral density, taking into account regional differences. In its turn, the developed standards allow improving the quality of osteoporosis diagnostics.

Key words: osteoporosis; bone mineral density; dual energy X-ray absorptiometry; quantitative computed tomography; bone ultrasound.

Information about author:

Zakharov I.S., candidate of medical science, docent, chair of obstetrics and gynecology #1, Kemerovo State Medical Academy, Kemerovo, Russia.

Address for correspondence:

Zakharov I.S., Voroshilova St., 22a, Kemerovo, Russia, 650029

Tel: +7 (3842) 46-51-62.

E-mail: isza@mail.ru

References:

Abdrakhmanova ZhS. Bone densitometry and computed tomography for evaluating thresholds of mineral density of the vertebral bodies as a risk factor of fractures. Cand. med. sci. abstracts diss. Tomsk, 2006. Russian.
ACR–SPR–SSR practice parameter for the performance of quantitative computed tomography (QCT) bone densitometry. PRACTICE GUIDELINE. 2013; Resolution No. 32. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/QCT.pdf Res. 32 – 2013, Amended 2014 (Res. 39).
Bansal SC, Khandelwal N, Rai DV, Sen R, Bhadada SK, Sharma KA, et al. Comparison between the QCT and the DEXA scanners in the evaluation of BMD in the lumbar spine. Journal of Clinical and Diagnostic Research. 2011; 5 (4): 694-699.
Bauer JS, Virmani S, Mueller DK. Quantitative CT to assess BMD as a diagnostic tool for osteoporosis and related fractures. Medica Mundi 2010; 54 (2): 31-37.
Beloselsky NI. Osteoporosis of the spine (the complex radial diagnostics). Dr. med. sci. abstracts diss. Yaroslavl, 2000. 36 p. Russian.
Bauer DC, Glüer CC, Cauley JA, Vogt TM, Ensrud KE, Genant HK, et al. Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women. Archiv Int. Med. 1997; 157 (24): 629-634.
Chechurin RE, Akhmetov AS, Rubin MP. Comparative evaluation of X-ray densitometry of skeleton and ultrasonic densitometry of the calcaneus. Osteoporosis and Osteopathy. 1999; (4): 7-10. Russian.
Churilov SL. Quantitative computed tomography in diagnosing and monitoring the treatment of osteopenia and osteoporosis in patients with rheumatic diseases. Cand. med. sci. abstracts diss. St. Petersburg, 2007. 24 p. Russian.
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Duppe HR, Gardsell P, Nilsson B, Johnell O. A single bone density measurement can predict fractures over 25 years. Calcif. Tissue Int. 1997; 60: 171–174.
Dyachkova GV, Reutov AI, Eydlina EM, Stepanov RV, Kovaleva AV. Possibilities and benefits of quantitative computed tomography in detection of osteoporosis of the spine. Radiology Practitioner. 2006; (4): 32-36. Russian.
Glüer CC1, Eastell R, Reid DM, Felsenberg D, Roux C, Barkmann R, et al. Association of five quantitative ultrasound devices and bone densitometry with osteoporotic vertebral fractures in a population-based sample: the OPUS Study. J. Bone Miner. Res. 2004; 19 (5): 782–793.
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Hui SL1, Gao S, Zhou XH, Johnston CC Jr, Lu Y, Glüer CC, et al. Universal standardization of bone density measurements: a method with optimal properties for calibration among several instruments. J. Bone Miner Res. 1997; (12): 1463–1470.
Kotelnikov GP, Bulgakova SV. Osteoporosis : a guide. Moscow : GEOTAR-Media Publ., 2010. 512 p. Russian.
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