Vol 22, No 2 (2016)

CLINICAL STUDIES

RECONSTRUCTIVE MICROSURGERY IN THE TREATMENT OF SURFACE FORMS OF CALCANEal OSTEOMYELITIS

Tsybul’ E.S., Rodomanova L.A.

Abstract

One of the most common complications associated with the treatment of calcaneus fracturesis, a necrosis of the edges of the surgical wound and as a result – chronic nonhealing ulcers of the heel region and osteomyelitis of the calcaneus. In the structure of skeletal lesions osteomyelitic chronic osteomyelitis of the calcaneus occurs in 3.1–14.8% of cases, and in relation to the bones of the foot – up to 51%. At the same time after open fractures of the total incidence of deep infection from soft tissue even higher than that for the surface (12.2% vs. 9.6%). The traditional approach to the treatment of osteomyelitis of the calcaneus is often accompanied by poor performance with recurrent osteomyelitis process and high
subsequent disability of working age.

Objective: to identify opportunities and assess the effectiveness of the use of reconstructive microsurgery techniques in the treatment of patients with superficial forms of osteomyelitis of the calcaneus, accompanied by the presence of soft tissue defect.

Materials and мethods.The results of treatment of 28 patients with superficial forms of osteomyelitis of the calcaneus, which in the period from 2006 to 2013 in RNIITO them. R.R.Vredena were performed reconstructive plastic surgery using microsurgical techniques. Defects covering tissues were located on the sole (20) and back-side surfaces (8) of the calcaneus. Scope of interventions included the radical surgical treatment of osteomyelitis focus, marginal resection of the affected heel bone and tissue replacement of defect cover flap with axial blood supply.

Results. With the localization of the defect cover tissues to non-reference surface of the heel region was carried out free plastic ray skin-fascial flap (9 cases). When the location of the defect on the plantar surface of the heel region favored medial plantar flap (10 cases). However, the presence of scarring and damage to the medial plantar artery was performed two-step replacement of defect prefabrikovannym flap medial arch of the foot (9 cases). Complications were observed in 7% of cases (2 patients) in 1 patient who had undergone plastic free radial flap in 1 case – after replacing a defect medial plantar flap. In both cases they were associated with impaired blood supply to the flap and ended necrosis of transplanted grafts. In the remaining cases (93%) failed to achieve full engraftment. Long-term results were followed up in 78,5% (n = 22) of patients in the period from 1 to 8 years after the end of treatment. In four cases, the plantar surface of the calcaneus formed edge wound defects, require additional surgical treatment. on the AOFAS scale results averaged 85 points, that, given the severity of the disease, regarded as a good result.

Conclusions. The use of microsurgical techniques for the treatment of patients with superficial forms of osteomyelitis of the calcaneus, including the presence of soft tissue defect, achieves sustained remission osteomyelitic process and restore support ability of the injured limb. Thus the support surface for the replacement of the heel region is expedient to use grafts comprising the plantar surface of the foot skin.

Traumatology and Orthopedics of Russia. 2016;22(2):7-14
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Knee joint gait function in patients with ACL rupture before and after the surgery

Akhpashev A.A., Zagorodniy N.V., Kanaev A.S., Kaurkin S.N., Skvortsov D.V.

Abstract

Materials and methods. The authors studied gait biomechanics in respect of time, velocity and dynamics in 34 patients with verified ACL rupture including 11 patients (first group) before the surgery and 23 patients (second group) after the surgery. Patients of the first group were followed in the period from 1 week up to 6 years (mean – 18 months), of the second group – from 1.5 months up to 5.5 years (mean – 13 months). Patients of the second group underwent standard arthroscopic ACL reconstruction with semitendinous and gracillis tendon autograft. Biomechanical gait examination was performed using strap down inertial motion sensors that register rotation angles in space. The authors measured time phases of gait cycle, movements in hip and knee joints in three mutually perpendicular planes as well as walking shock load.

Results. Time phases of gait cycle in both groups demonstrated normal values both on healthy and affected limbs. Movements in hip and knee joints were within the normal range, no reliable differences in the analogous indices for each limb were reported. Shock load in walking was registered within 1.6 g, symmetrical on both sides; shock load dynamics was absent in the group of patients after the surgery. Study results did not identify functional disorders during random flat surface waking that would be specific for ACL lesion as compared to normal values and to intact limb. However, a certain tendency was observed towards an increase of flexion-extension movement range in the knees following ACL reconstruction. The reported differences were not credible.

Conclusion. The authors did not observe any specific functional knee joint instability during normal activities in the first group of patients with ACL rupture. On the one hand, that means that ACL lesion does not manifest in such circumstances, on the other - knee joint instability does not progress during flat surface walking at a random pace. The obtained results give certain ground to reconsider the concept of “knee joint instability”.

Traumatology and Orthopedics of Russia. 2016;22(2):15-24
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ANALYSIS OF FAILURES AND COMPLICATIONS FOLLOWING TREATMENT OF DIAPHYSEAL FOREARM FRACTURES IN CHILDREN USING FLEXIBLE INTRAMEDULLARY NAILING

Korobeinikov A.A., Popkov D.A.

Abstract

Introduction. Currently flexible intramedullary nailing (FIN) is the method of choice for treatment of diaphyseal forearm fractures in children.

Purpose of the study: to perform a quantitative and qualitative analysis of failures and complications encountered in treatment of children with diaphyseal forearm fractures using FIN fixation.

Materials and methods. The study included 55 consecutive continuous cases of diaphyseal forearm fractures in children operated by FIN fixation from October 2011 till October 2014. Follow up period covered timeframe from admission until implant removal but no less than 6 months. The authors studied age, gender, fracture pattern, surgical technique features, length of hospital stay, frequency of outpatient examinations, healing period, x-ray data and all complications.

Results. Complications during treatment were reported in 10 patients. Two patients demonstrated two complications. In two cases a surgical procedure was required to address the complications. Early postoperative complications were observed in two cases (neuropathy of superficial branch of radial nerve). In other cases patients developed complications at outpatient stage starting one to six months after the surgery which did not impact the final outcome.

Conclusion. Despite various complications observed following FIN fixation of diaphyseal forearm fractures in children, their severity and frequency had no impact on the final outcome in the authors’ case series. Majority of issues were related to violations in surgical technique and adverse fracture pattern.

Traumatology and Orthopedics of Russia. 2016;22(2):25-33
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THEORETICAL AND EXPERIMENTAL STUDIES

TIBIAL LANDMARKS IN ACL ANATOMIC REPAIR

Demesсhenko M.V., Malanin D.A., Suchilin I.A., Cherezov L.L.

Abstract

Purpose: to identify anatomical landmarks on tibial articular surface to serve as reference in preparing tibial canal with respect to the center of ACL footprint during single bundle arthroscopic repair.

Materials and methods. Twelve frozen knee joint specimens and 68 unpaired macerated human tibia were studied using anatomical, morphometric, statistical methods as well as graphic simulation.

Results. Center of the tibial ACL footprint was located 13,1±1,7 mm anteriorly from posterior border of intercondylar eminence, at 1/3 of the distance along the line connecting apexes of internal and external tubercles and 6,1±0,5 mm anteriorly along the perpendicular raised to this point.

Conclusion. Internal and external tubercles, as well as posterior border of intercondylar eminence can be considered as anatomical references to determine the center of the tibial ACL footprint and to prepare bone canals for anatomic ligament repair.

Traumatology and Orthopedics of Russia. 2016;22(2):34-42
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RESULTS OF THE FOSFOMYCIN APPLICATION FOR THE IMPREGNATION OF BONE REPLACEMENT MATERIALS IN THE TREATMENT OF CHRONIC OSTEOMYELITIS

Konev V.A., Bozhkova S.A., Netylko G.I., Afanasiev A.V., Rumakin V.P., Polyakova E.M., Rukina A.N., Parfeev D.G.

Abstract

Aim – to evaluate in the experimental study in vitro the duration of antimicrobial activity of fosfomycin-impregnated bone cement and to study the dynamics of radiological and morphological changes depending on the local antibiotic therapy in two-stage treatment of chronic osteomyelitis in rabbits.

Materials and methods. Duration of antimicrobial activity of bone cement (depuy cmw1 gentamicin) with fosfomycin in vitro was studied in comparison to cements with vancomycin and controls without additional antibiotics. Presence of the lysis zone of bacterial cultures was evaluated (Staphylococcus aureus ATCC6538 and ATCC33591, Klebsiella pneumoniae ATCC33495 and Escherichia coli ATCC25922) after application of 10 μl of the solution, collected from the cement samples after incubation for 24 hours. For the in vivo experiment, Chinchilla rabbits (n = 20) with local osteomyelitis of the tibia underwent two-stage treatment where substitution of the bone defect at stage I was performed with PMMA and stage II – with the bioresorbable material based on hydroxyapatite and triclacium phosphate (ReproBone). In an experience group (n = 10) before setting osteoreplacement materials with fosfomycin (group FOSFO), and by control (n = 10) – vancomycin (group VANCO). X-ray imaging was performed on the 1st and 21st day after installation of the cement spacer, and 45th day after substitution of the spacer with the bioresorbable material. Microbiological analysis of the samples was performed intraoperatively and on the 7th, 14th day after each stage. Histological study was conducted in both groups on the 14th, 21th day after stage I and 45th day after stage II of the treatment.

Results. Maximal duration of antimicrobial activity in vitro was observed in samples of PMMA with fosfomycin whereas minimal – in control samples of gentamicin-based bone cement. Relief of the infection was attained in all animals while application of fosfomycin resulted in a more rapid elimination of the bacteria. Reaction of the adjacent tissue to the implanted material and results of X-ray imaging in both groups did not differ significantly. Long duration of the broad-spectrum antimicrobial activity of the bone cement with fosfomycin with the comparable perifocal reaction in vivo necessitates further study of the use of this antibiotic in bioresorbable materials for the treatment of osteomyelitis in clinical practice.

Traumatology and Orthopedics of Russia. 2016;22(2):43-56
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BIOMINERALOGICAL INVESTIGATION OF APATITE PIEZOELECTRICITY

Pawlikowski M.

Abstract

Investigation of apatite piezoelectricity was conducted in order to assess piezoelectric properties of bone. In the first stage, mineralogical analysis of different apatite crystals, regarding their purity and fitness for the experiments was performed. After the crystals had been chosen, 0.8 mm-thick plates were cut, perpendicular and parallel to the crystallographic Z axis. The plates were then polished and dusted with gold. Electrodes were attached to the opposite surfaces of the plates with conductive glue. So prepared plates were hooked up to the EEG machine used for measuring electrical activity in the brain. The plates were then gently tapped to observe and register currents generated in them. Acquired data was processed by subtracting from the resulting graphs those generated by a hand movement, without tapping the plate. Results indicate that apatite plates have weak piezoelectric properties. Observed phenomenon may be translated to bone apatite, which would explain, at least partially, piezoelectric properties of bone. Acquired results suggest that there is a relation between the mechanical workload of bones (bone apatite) and their
electrical properties. Considering the massive internal surface of bones, they may be treated as a kind of internal “antenna” reacting not only to mechanical stimuli, but to changes in electromagnetic field as well. Observed phenomena no doubt significantly influence the biological processes occurring in bones and the whole human body.

Traumatology and Orthopedics of Russia. 2016;22(2):57-63
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PARACRINE REGULATORS IN DISTRACTION OSTEOGENESIS (pilot study)

Stogov M.V., Emanov A.A., Kireeva E.A.

Abstract

Purpose – to evaluate effect of protein extracted from lengthened skeletal muscles on callus formation in dogs after tibia lengthening using Ilizarov method.

Materials and methods. The authors studied properties of distraction callus formation in three groups of dogs after tibia lengthening by Ilizarov method. In the first group (n = 10) distraction was achieved at a rate of 1 mm in four stages during 28 days. In the second (n = 4) and third (n = 4) groups distraction was done at a rate of 1.5 mm in 6 stages per day within 20 days. Mean lengthening value in all groups amounted to 14,64±0,67% of the overall segment length. At the 10th day of distraction the authors introduced to animals of the second group into anterior tibial and gastrocnemius muscles of the lengthened segment at callus level the extract of sarcoplasmic proteins in amount of 1.5ml based on 1 mg of lyophilizate per 1 kg of body weight (protein concentration in injectate amounted to 30±2 gr/l). Animals in the third group received natural saline solution in the same manner. Extract consisted of lyophilized sarcoplasmic proteins harvested from anterior tibial muscle of animal at 14th day of lengthening by Ilizarov method (rate of 1 mm per day in 4 stages). Extraction was performed according to patented method (Russian Federation patent for invention №2476234) by consecutive muscle proteins sedimentation in KCl solutions of varied ionic strength. The lyophilizate was sterilized after obtaining and dissolved in normal saline solution prior to introduction.

Results. Radiographic signs of anatomically solid callus in the first group were observed in the average at 33±1 day of fixation; in the second group – at 24±2 day; in the third group – at 39±3. Difference in mean values of fixation in animals of second group as compared to first and third groups was significant (р = 0,04). After extract introduction the animals of the second group demonstrated a greater growth of γ-globulins and α2-globulins fraction volumes.

Conclusion. Skeletal muscles of limb segment lengthened by Ilizarov method produce specific factors that impact the process of distraction osteogenesis.

Traumatology and Orthopedics of Russia. 2016;22(2):64-69
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CASE REPORTS

DIFFICULTIeS OF TOTAL HIP REPLACEMENT IN PATIENTS WITH ANKYLOSING SPONDYLITIS (case report)

Tikhilov R.M., Nikolaev N.S., Shubnyakov I.I., Myasoedov A.A., Boyarov A.A., Efimov A.V., Syundyukov A.R.

Abstract

A distinctive feature of patients with ankylosing spondylitis is the formation of hip ankylosis in an extremely unfavorable functional position combined with upset of sagittal balance of the body along with a thoracolumbar kyphosis. Treatment of these patients poses considerable technical difficulties and is often associated with complications. The authors report a clinical case of a female 40 years old patient with confirmed rhizomelic spondylitis. The patient mainly complained of fixed malposition of the right lower extremity (hip ankylosis in extreme 1450 flexion and 1500 abduction) combined with a severe fixed spine deformity (thoracic kyphosis 920, lumbar lordosis 170). Considering significant sagittal balance disorder it was decided to go for a two-stage procedure. Total hip arthroplasty of the right joint was performed at the first stage. At the second stage the authors corrected thoracolumbar spinal deformity by Th12 (type PSO 4) and L2 (type PSO 3) wedge resections and converging resected vertebral bodies by a multilevel fixation system with transpedicular support elements. The interval between the stages was 11 months. Two-stage treatment of this patient al-lowed to avoid adverse postoperative complications and to achieve a significant functional improvement in one year after treatment started. The sum of points before and after the treat-ment amounted respectively to 46 and 79 on Harris Hip Score, 17 and 38 points on Oxford Hip Score (OHS). To summarize, comprehensive treatment with planning of all subsequent steps prior to hip replacement is the method of choice for avoidance of postoperative complications in patients with ankylosing spondylitis accompanied by a significant upset of sagittal balance.

Traumatology and Orthopedics of Russia. 2016;22(2):70-79
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TRAUMA AND ORTHOPEDIC CARE

Injury patterns of finger extensor tendons in population of Ivanovo region

Vashetsky V.E., Kirpichev I.V., Klimin D.N., Roslova E.P.

Abstract

Acute injury of finger extensor tendons constitute a significant part in overall causes for hospital admission.

Purpose of the study: to evaluate injury patterns of finger extensor tendons in population of Ivanovo region.

Material and methods. The authors performed the retrospective statistical analysis of 163 medical histories of patients who underwent hospital treatment in the period from January 2011 till December 2014 at department of wrist reconstructive surgery and microsurgery of Ivanovo regional clinical hospital of war veterans. The study was carried out in full compliance with medical ethics. Excel 7.0 was applied for statistical analysis.

Results. Injury patterns of patients with finger extensor tendons demonstrated prevalence of males aging from 21 to 40 years old. Most frequent is the left hand trauma at home while handling devices with high-speed rotation mechanism. Most lesions occur in time interval from noon till 6 p.m. Patients with combined injuries prevailed. The authors observed hospital admittance within first 6 hours after trauma.

Conclusion. A typical patient with finger extensor tendons trauma is an active age male injured in everyday life and often in a state of alcoholic intoxication.

Traumatology and Orthopedics of Russia. 2016;22(2):80-86
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REVIEW

DEPENDENCY OF OSTEOGENIC EFFECTS ON CHARACTERISTICS OF MECHANICAL LOAD APPLIED TO OSSEOUS STRUCTURES

Avrunin A.S., Doktorov A.A.

Abstract

Purpose of the study: to evaluate osteogenic rate of various characteristics of mechanical loading based on the authors’ data as well as literature analysis.

Literature analysis proved that clinical outcome of physical training can be achieved not only by increasing the mechanical load but also by altering number of load iterations, rate of load acceleration, frequency of cyclic load, rest interval, distribution of load across the skeleton. Presented data provides a reasonable basis to apply alterations of all above-mentioned load characteristics to obtain clinical effect and customize every single baseline exercise plan to gain a maximum treatment and preventive effect in individuals with high risk of osteoporotic fractures.

Traumatology and Orthopedics of Russia. 2016;22(2):88-100
pages 88-100 views

Management of femur and tibia metaphyseal bone defects during revision total knee arthroplasty – methods and outcomes (review)

Bovkis G.Y., Kulyaba T.A., Kornilov N.N.

Abstract

Total knee arthroplasty (TKA) is becoming an increasingly common treatment for a wide variety of diseases, as well as treatment for consequences from knee injury. The number of primary joint replacement operations have been steadily climbing. As a result, the number of revision procedures have also grown, accounting for 6–8% of arthroplasties. The problem of bone defects compensation remains one of the greatest challenges faced by the surgeon during revision TKA and usually requires a comprehensive approach, careful preoperative planning and preparation. The compensation of small, in depth and extent, bone defects (AORI Type I and II) does not present serious difficulties and their methods are well developed. Whereas the compensation of massive defects (Type 3) is extremely difficult. Until recently, structural allografts were the only method available to surgeons and still remain relevant and demonstrate good results. In recent years, as an alternative, it has become possible to use sleeves and cones made of porous metal, which are also showing very promising mid-term results. This review demonstrates the results from recent studies of mid-term and long-term outcomes of revision TKA, in which different methods of bone defect compensation were used. The clinical evidence did not demonstrate any obvious advantage of using one method over another, therefore, research in this area continues to remain relevant.

Traumatology and Orthopedics of Russia. 2016;22(2):101-113
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MODERN APPROACHES TO SURGICAL TREATMENT OF CHARCOT NEUROARTHROPATHY (review)

Pavlyuchenko S.V., Zhdanov A.I., Orlova I.V.

Abstract

The present review addresses a pressing orthopaedic issue of surgical treatment for patients with severe foot deformities occurring as consequence to Charcot neuroarthropathy. Described pathology is a severe threatening condition causing high risk of infections and potential limb loss. The paper describes main foot reconstructive procedures employed depending on pathology stage and localization as well as identifies ways to improve surgical treatment of affected patients.

Traumatology and Orthopedics of Russia. 2016;22(2):114-123
pages 114-123 views

HISTORY OF MEDICINE

Fracture eponyms: personal names

Zolotov A.S., Mikhaylov V.V.

Abstract

The paper describes the origin of bone fracture eponyms. The authors compiled a list of 60 most established fracture names proposed by physicians in 16th-20th centuries who mainly were skilled, mature and outstanding experts from countries with advanced conventional medicine and often represented the recognized surgical schools. Eponym records are important for understanding the history and subject of the chosen profession as well as knowledge of eponymic fractures facilitates communication between physicians of allied disciplines.

Traumatology and Orthopedics of Russia. 2016;22(2):124-130
pages 124-130 views

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