Vol 21, No 3 (2015)

Cover Page

Clinical studies

Correlation between generalized joint hypermobility and hallux valgus

Kardanov A.A., Karandin A.S., Korolev A.V., Chernous V.N.

Abstract

Purpose: to evaluate correlation between generalized joint hypermobility, forefoot deformities and elasticity of the first ray of the foot. Material and methods. We examined 138 patients with complaints related with deformities at the forefoot level. During this study the medical history was obtained, the elasticity type of the feet was defined and the degree of motion of the medial metatarsal-cuneiform joint was evaluated. Forefoot elasticity was identified by bringing together the heads I and V metatarsal bones with fingers. If convergence occurred with little resistance, those feet were called hyperelastic. The convergence of the heads I and V metatarsal bones of the foot with an average type of elasticity occurred with resistance. It was impossible to converge the heads of I and V metatarsal bones. Due to the results of weight-bearing and non-weight bearing X-ray, analysis of the main radiographic angles of the foot was performed: between I and V metatarsal bones, between the first and second metatarsal bones and between the first metatarsal bone and proximal phalanx of the great toe. Calculation formula of the forefoot flatness index, showing the average ratios of basic radiographic angles of the foot on the x-ray images (weight-bearing and non-weight bearing) was created. An assessment of total joint hypermobility using Beighton scale and evaluation of first ray deformity using DuPont scale were performed. Statistical analysis of obtained data was performed, as a result of which significantly strong correlation between total joint hypermobility, forefoot elasticity and valgus deviation of the great toe were revealed. Results. 11% of the feet were hyperelastic. Calculation of the index of forefoot flatness showed that forefoot flatness wasn’t significant for a rigid foot - 5.6 %, for the feet with an average degree of mobility it was 6.0% and it was expressed for hypemobile feet - 12.3 %. Strong correlation relation between the forefeet mobility degree, the number of points on a DuPont scale and the degree of sagittal mobility of the medial metatarsal-cuneiform joint were revealed. Conclusion. Our study demonstrates that generalized joint hypermobility, horizontal and sagittal first ray mobility and forefoot deformities are directly proportional.
Traumatology and Orthopedics of Russia. 2015;21(3):5-11
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Osteosynthesis of femoral neck fractures: dynamic hip screw (DHS) or mini-invasive Targon FN system?

Dulaev A.K., Tsed A.N., Dzhusoev I.G., Usubaliev K.N.

Abstract

Objectives: to investigate the long-term outcomes of femoral neck fractures that were surgically fixed using various types of extramedullary implants in patients aged 65 years and younger. Material and methods: We analyzed the clinical results of surgical treatment of femoral neck fractures by extramedullary osteosynthesis in 94 patients aged 38 to 65 years old (71 women and 23 men). The patients were divided into 3 groups according to AO/ASIF fracture classification. We used different techniques of osteosynthesis: with DHS or with Targon FN. In all patients the mental status rate SPMSQ), osteoporosis degree (Singh index), general somatic status (WHO scale) were evaluated in the preoperative period. We also evaluated next intraoperative parameters: duration of surgery, blood loss, quality of reduction, long of incision. In a year after surgery we assessed functional results (Harris Hip Score) and analysed postoperative complications. Results: It was found the inverse correlation (r = -0,8) of total preoperative parameters (WHO scale, the Singh index and mental status SPMSQ) and postoperative functional results on Harris Hip Score. With the reliability of p<0.05 the average rate of blood loss and length of skin incision were less in patients operated with Targon FN. In 12 months unsatisfactory results rate on Harris Hip Score was 12.7% in all study groups, great - 22,3%, good - 52.1%, and satisfactory - 12,9%. Complications rate in patients operated with DHS was 17,02%, and in patients operated with Targon FN - 18.1%. Conclusion: Minimally invasive osteosynthesis of femoral neck fractures (type B1 and B2 on AO/ASIF classification) allows to achieve the best results in compare with DHS osteosynthesis. Revealed complications such as screw migration, false joint formation and femoral head avascular necrosis were determined by impaired surgical technique and inadequate reduction.
Traumatology and Orthopedics of Russia. 2015;21(3):12-21
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Gender features of functional state of musculoskeletal system in patients with coxarthrosis

Shchurov V.A., Gaidyshev I.P., Sazonova N.V.

Abstract

Purpose of the study - a comparative quantitative evaluation of regional circulation state, the degree of reducing femoral and leg contractility, as well as gait disorders in male and female patients with coxarthrosis. Material and methods. The patients with stages 1, 2, and 3 coxarthrosis were examined. The mean age of female group was 47±0.7 years, that of male one - 37±1,4 years, the number of observations was 314 and 99 persons, respectively. Arterial blood pressure (ABP), locomotion rate and the increase in heart rate during walking were determined in the patients, as well as walking time parameters, distribution of foot part loading statically and dynamically (DiaSled-Scan complex), the maximum moment of strength of femoral and leg anterior and posterior muscle groups. Linear blood flow rate in magistral arteries was determined by Doppler ultrasonography. Laser Doppler flowmetry of skin anterior surface of the leg middle third, and the dorsal surface of both limb feet (BLF-21 device of Transonic Systems, uSA) was used for capillary blood flow evaluation. Results. More rapid age-related increase in ABP and decrease in capillary blood flow rate in limb skin integuments for Stage 2 and 3 of the disease were observed in female patients above 45 years. As for Stage 3 of the disease in female patients, the maximum load of the foot support (bearing) surface when standing and walking was reduced. Limb muscle strength in female patients is twice lower than that in male patients. As far as the disease progressed, more rapid decrease in the contractility of femoral muscles was noted compared to that of the leg. The compensatory increase in muscle strength of the leg was observed for Stage 1 of the disease and after the performed complex conservative treatment. Walking speed in the patients decreased with their age increasing, and the pulse value of locomotion increased with the disease stage increasing. Conclusion. More frequent involvement of the hip in women may be partially explained by the increase in the relative number of the gender representatives in the older age groups. Hypertension in female patients with coxarthrosis is a compensatory response related to microcirculation aggravation in limb tissues, the dynamometric parameters of femoral muscles in female patients are much lower, and the load of foot support surface is less.
Traumatology and Orthopedics of Russia. 2015;21(3):22-29
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Prolonged blockade of the brachial plexus for the early rehabilitation of children with posttraumatic elbow contractures

Zabolotsky D.V., Koryachkin V.A., Ivanov M.D., Nikitin M.S., Prokopovich E.V., Savenkova A.A.

Abstract

Objective. Improvement of surgical treatment outcomes in children with post-traumatic elbow contractures. Materials and methods. The study is based on the diagnostic findings of 48 children with post-traumatic elbow contractures who were treated at the Turner Scientific and Research Institute for Children’s Orthopedics. All children underwent complex rehabilitation after reconstructive intra-articular surgery to work out passive motions in the elbow using ARTROMOT-E2 device. The patients of the study group started rehabilitation in the first days after reconstructive intra-articular surgery in the background of prolonged blockade of the brachial plexus. In the control group, the rehabilitation was carried out traditionally on the 6th day after surgery without regional anesthesia. The patients of the study group were supplied with Contiplex SU perinural catheters for prolonged blockade of the brachial plexus using ultrasound (Edge SonoSite) and neurostimulation (Stimuplex® HNS12) before surgery. For perioperative blockade of the brachial plexus we used intermittent injection of 0.5% ropivacaine (2 mg / kg). The severity of pain at the stages of rehabilitation was assessed using 10-point grading scale (FPS-R). The range of active and passive motions in the joints was evaluated by measuring the range of motions with a fleximeter. Results. Intermittent injection of ropivacaine before rehabilitation allowed to correct post-traumatic elbow contractures in children in the first days after surgery associated with the minimum subjective pain level and stable hemodynamic parameteres, accompanied with a significant increase of the elbow motion range in comparison with the group of the patients who were not performed regional anesthesia . Conclusion. Prolonged blockade of the brachial plexus in rehabilitation treatment of children with post-traumatic contractures provides appropriate analgesic and myoneural block components from the 1st day after intra-articular reconstructive surgery. Early rehabilitation provides good results of the treatment and reduces rehabilitation period terms.

Traumatology and Orthopedics of Russia. 2015;21(3):30-36
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Theoretical and experimental studies

The effect of water, various incorporations and substitutions on physical and chemical properties of bioapatite and mechanical properties of bone tissue

Avrunin A.S., Denisov-Nikolsky Y.I., Doktorov A.A., Krivosenko Y.S., Samoylenko D.O., Pavlychev A.A., Shubnyakov I.I.

Abstract

Basing on scientific publications and original research the authors specified the effect of incorporation and adsorption of different ions and water molecules on physical, chemical and mechanical properties of bioapatite and determined new directions for investigations of intercrystallite interactions in nanoscale. Inner structure of the apatite crystallites more adaptable to chemical substitutions in comparison with other minerals controls their important characteristics such as a size, solubility, hardness, fragility, formability and thermal stability. The water molecules incorporated in crystallites and adsorbed on their surfaces stabilize them. In case the distances between crystallites become shorter than 10 nm the water molecules adsorbed on their surface play dominant role in bonding between the crystallites. This bond determines the main mechanical properties of bones. We bring forward a suggestion that theoretical model developed on the basis of near edge X-ray spectroscopic studies of bones using the contemporary high brilliant sources of X-ray radiation (synchrotrons and X-ray free electrons lasers) will allow to receive new quantitative data on local electronic and atomic structure (coordination numbers, ionic charges, interatomic distances interatomic and intercrystallite forces) of nanoelements in osseous tissue. The investigation results must bring to construction of new morphologically correct model providing deeper understanding of processes occurring in mineral matrix and mechanical properties of bones.
Traumatology and Orthopedics of Russia. 2015;21(3):37-50
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Results of bone regenerate study after osteosynthesis with bioinert and calcium phosphate-coated bioactive implants in experimental femoral neck fractures (experimental study)

Kazanin K.S., Basov A.V., Shpakovsky M.S., Gribanov N.I., Ardashev I.P., Nikitenko E.V.

Abstract

Objective - to analyze the results of X-ray, cytomorphometric and immunohistochemistry experimental studies of bone regenerates after osteosynthesis with bioinert and calcium phosphate-coated bioactive implants. Material and methods. The study was conducted on experimental femoral neck fractures in rabbit males. Reparative osteogenesis processes were studied in groups of bioinert titanium implant osteosynthesis and calcium phosphate-coated bioactive titanium implant osteosynthesis. The animals were clinically followed-up during the postoperative period. X-ray, cytomorphometric and immunohistochemistry studies of samples extracted from femoral bones were conducted over time on days 1, 7, 14, 30 and 60. The animal experiments were kept and treated according to recommendations of international standards, Helsinki Declaration on animal welfare and approved by the local ethics committee. All surgeries were performed under anesthesia, and all efforts were made to minimize the suffering of the animals. Results. In the animal group without femoral neck fracture osteosynthesis, femoral neck pseudoarthrosis was observed at the end of the experiment. The results of cytomorphometric and immunohistochemistry studies conducted on day 60 of the experiment confirmed that the cellular composition of the bone regenerate in the group of calcium phosphate-coated bioactive titanium implants corresponded to a more mature bone tissue than in the group of bioinert titanium implants. Conclusion. The results of the statistical analysis of cytomorphometric and immunohistochemistry data show that the use of calcium phosphate-coated bioactive titanium implants allows to achieve significantly earlier bone tissue regeneration.
Traumatology and Orthopedics of Russia. 2015;21(3):51-60
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Experience exchange

Features of treatment for posterior impingement in sportsmen and ballet dancers

Kuznetsov I.A., Velichko K.E., Shchepkina E.A.

Abstract

35 posterior ankle arthroscopies for posterior ankle impingement were performed within the period of time between January 2014-April 2015. Radiological investigation and MRI were held preoperatively. The examinations and operations revealed the following findings: os trigonum 21 (60%), posterior lateral fracture 6 (17%), Stieda process 8 (23%). The patients were tested on the scale of AOFAS pre and post-operatively. In comparison with preoperational period all the patients recognized the decrease or full disappearance of pain syndrome as well as functional improvements (AOFAS 59,8 preoperatively to 93,9 2 months postoperatively). The posterior ankle arthroscopy is an efficient and relatively safe method for posterior ankle impingement treatment which works efficiently to eliminate or decrease pain syndrome and helps to recover the function of plantaris.

Traumatology and Orthopedics of Russia. 2015;21(3):61-69
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Analysis of drug prevention of venous thromboembolic complications in hip arthroplasty (review)

Bochanova E.N., Belousov M.A., Bozhkova S.A., Veselova O.F., Golovina N.I., Zdzitovetsky D.E., Lubnin A.M., Shchukin A.A.

Abstract

The retrospective analysis of 131 medical records of patients who underwent surgery for total hip arthroplasty in two large hospitals in Krasnoyarsk in 2013 was made. All patients received anticoagulants for the purpose of thromboprophylaxis. In the structure of these drugs prevails prescriptions anticoagulant with a low risk of bleeding, requiring no laboratory control, such as low molecular weight heparins and direct oral anticoagulants. The assessment of anticoagulant dosing regimens revealed defects related to non-compliance as a single dose and duration of use after discharge from hospital. To eliminate the detected defects is necessary to conduct training seminars, the approval of the local protocol of prevention and formation of the VTEC system audit.

Traumatology and Orthopedics of Russia. 2015;21(3):70-75
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Modern technologies in traumatology and orthopedics

A new algorithm for histopathological diagnosis of periprosthetic infection using CD15 focus score and computer program CD15 Quantifier

Krenn V., Kölbel B., Wienert S., Dimitriadis J., Kendoff D., Gehrke T., Huber M., Frommelt L., Tiemann A., Usbeck S., Atzrodt V., Saeger K., Bozhkova S.A.

Abstract

Introduction. A simple microscopic diagnostic quantification system for neutrophile granulocytes (NG) was developed evaluating a single focal point (CD15 focus score) which enables the detection of bacterial infection in SLIM (synoviallike interface membrane) Additionally a diagnostic algorithm is proposed how to use the CD15 focus score and the quantification software (CD15 Quantifier). Methods. 91 SLIM removed during revision surgery for histopathological diagnosis (hip; n=59 and knee; n=32) underwent histopathological classification according to the SLIM-consensus classification. NG where identified immunohistochemically by means of a CD15-specific monoclonal antibody exhibiting an intense granular cytoplasmic staining pattern. This pattern is different from CD15 expression in macrophages showing a pale and homogenous expression in mononuclear cells. The quantitative evaluation of CD15-positive neutrophils granulocytes (CD15NG) used the principle of maximum focal infiltration (focus) together with an assessment of a single focal point (approximately 0.3 mm2). This immunohistochemical data made it possible to develop CD15 Quantifier software which automatically quantifies CD15NG. Results. SLIM-cases with positive microbiological diagnosis (n=47) have significantly (p<0.001, Mann-Whitney U test) more CD15NG/focal point than cases with negative microbiological diagnosis (n=44). 50 CD15NG/focal point were identified as the optimum threshold when diagnosing infection of periprosthetic joints using the CD15 focus score. If the microbiological findings are used as a ‘gold standard’ the diagnostic sensitivity is 0.83, specificity is 0.864. (PPV: 0.87; NPV: 0.83; accuracy 0.846; AUC: 0.878.) The evaluation findings for the preparations using the CD15 Quantifier (n=31) deviated in an average of 12 cells from the histopathological evaluation findings (CD15focus score). From a cell-count greater 62 CD15 Quantifier needs on average 32 seconds less than the diagnostic pathologist. Conclusion. The CD15 focus score, and the use of the «CD15 Quantifier» software which is thereby made possible, offers an automated procedure which shortens the mentally tiring and time-consuming process of microscopic cell-counting. The proposed diagnostic algorithm (how to use the CD15 focus score and the quantification software, CD15 Quantifier) may contribution towards the standardisation for periprosthetic joint infection and diagnosing bacterial infections in the SLIM.
Traumatology and Orthopedics of Russia. 2015;21(3):76-85
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Case Reports

Pulmonary embolism in a wounded with mine blast injury against the background of anticoagulant prophylaxis (case report)

Nikolaev K.N., Zubritsky V.F., Kapustin S.I., Koltovich A.P., Zakharov R.S.

Abstract

Venous thrombosis and pulmonary embolism in healthy military are rare. Fighting surgical trauma is the trigger of a cascade of defense reactions of the body and the blood coagulation system, leading to stop bleeding. Hemostatic disorders, shifting the equilibrium toward hypercoagulable state, the emergence of the risk factors associated with the injury, lead to uncontrolled thrombosis with subsequent development of venous thromboembolic complications. We present the case of the left pulmonary artery thromboembolism in 41 year old wounded with a gunshot fracture of the right femur, obtained by blowing an unknown explosive device. Medical assistance was provided in three stages of evacuation. In order to stabilize a femur fracture the external fixation device was used. According coagulogram thrombinemia persisted for more than 30 days. Prevention of thrombosis carried LMWH (Clexane), with 9 days after injury. 31 day angiography was performed computer, identified thrombus by 70% ceiling clearance left pulmonary artery; by ultrasound scanning of the veins of the lower limbs was diagnosed asymptomatic thrombosis of the right iliofemoral. Against the background of complex treatment for 67 hours after the injury occurred recanalization. This case shows that the injured limb wound clinical symptoms of the disease symptoms negate venous thrombosis, which becomes the only manifestation of pulmonary embolism. Prevention of venous thromboembolic events, as well as monitoring of its effectiveness, should be carried out at all stages of the evacuation of the wounded and for the entire period of the presence of risk factors for their development.

Traumatology and Orthopedics of Russia. 2015;21(3):86-91
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Reviews

Current trends in local antibacterial therapy of periprosthetic infection and osteomyelitis

Bozhkova S.A., Novokshonova A.A., Konev V.A.

Abstract

The rational use of antibiotics in the treatment of orthopedic infection still presents a significant problem. Local antibiotic delivery systems enable to achieve effective concentrations of drugs in the focus of bone infection without the development of toxicity. It is the important accompaniment to systemic antibiotics in the treatment of periprosthetic infection and osteomyelitis. The data collected through the PubMed and eLIBRARY databases (http://www.ncbi.nlm. nih.gov/pubmed, 1995-2015; http://elibrary.ru, 2005-2015 years) present the information about bone substitutes used for local antibiotic therapy in scientific investigations and in clinical practice. The information is submitted in accordance with the groups of materials: cements based on polymethylmethacrylate, bone grafts, demineralized bone matrix, bioceramics, natural and synthetic polymers, combined antibiotic delivery systems. The majority of these materials have only been studied experimentally and only a limited range of them is registered for use in clinical practice. Informing orthopedic surgeons about current methods of local antibiotic use is the key to the development of a modern integrated approach to the therapy of infectious complications after orthopedic surgery.
Traumatology and Orthopedics of Russia. 2015;21(3):92-107
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Neuroendocrinal regulation of bone metabolism in osteoarthritis of large joints (review)

Lychkova A.E., Shirokova L.Y., Kryukova E.V.

Abstract

The regulation of bone metabolism by adrenergic, cholinergic and endocrine transmitters in osteoarthritis is reviewed. Regulatory effects of α- and β-receptor mechanisms of norepinephrine, M- and N-receptors of acetylcholine, glucocorticosteroids, PTH and peptidergic systems in the bone remodeling process are characterized that can serve as a basis for the development of promising therapies osteoarthritis.

Traumatology and Orthopedics of Russia. 2015;21(3):108-115
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High-resolution ultrasonography in the diagnosis and management of peripheral nerve lesions (review)

Aitemirov S.M., Ninel V.G., Korshunova G.A., Shchanitsyn I.N.

Abstract

The diagnosis of peripheral nerve lesions relies on clinical history, physical examination, electrodiagnostic studies, and radiography. The availability of these methods may be limited, and the costs can be significant. By comparison, ultrasonography is a comfortable, sensitive and economic technology, however, until now it is not widespread in Russia. An increasing number of publications have evaluated the role of ultrasonography in peripheral nerve diseases. The authors explored the clinical applicability of high-resolution ultrasonography in the preoperative and intraoperative management of peripheral nerve lesions.
Traumatology and Orthopedics of Russia. 2015;21(3):116-125
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