Vol 21, No 4 (2015)


Nuances of preoperative planning of total hip arthroplasty in patients with hip dysplasia

Tikhilov R.M., Shubnyakov I.I., Denisov A.O., Boyarov A.A., Cherkasov M.A.


Purpose of the study - to evaluate in different groups of patients variability of anatomical changes that may affect the difference in the length of the lower extremities and affect on the results of the preoperative planning. Material and methods. As study material we used long film X-ays of 142 patients. A main group comprised 69 patients with varying severity of hip dysplasia. Control group consisted of 73 patients without hip pathology. All patients were performed long film X-rays, and measurements of relative and absolute lengths of the lower limbs, followed by analysis of the data. Results. Analysis of the measurements showed that none of the patients had absolutely equal length of the lower limbs, even in the control group in 56.2% of the observations noted the absolute difference of the lower extremities length more than 5 mm, and in 9.6% of patients - from 20 to 35 mm. In assessing the difference of the lower extremities length on AP pelvic view in the main group only one patient of 69 had the same length of the legs, and in 61 cases the difference was more than 5 mm, that it was clinically significant. Of practical interest is the fact that in the main group shortening of the operated limb was observed in 51 of 69 patients in AP views of the pelvis, but the results of measurements of the anatomical length of limbs long film X-rays compared with measurements of the relative shortening on the pelvis AP views showed that clinically significant difference exceeding 5 mm between measurements observed in 68.1% of cases. The greatest difference between the measurements of the limbs length on the pelvis AP views and long film X-rays observed in patients with unilateral hip dislocation and averaged 17.0 mm. Conclusion. Performing preoperative planning in patients with dysplasia only on pelvis AP views not allow properly compensate the difference of the lower extremities lengths, which may adversely affect the functional results of surgery and as a result, the patient’s satisfaction. Therefore, planning THA, especially at high hip dislocation, it is necessary to calculate the difference of the lower extremities lengths considering as the difference of the lengths on AP pelvis views and long film X-rays.
Traumatology and Orthopedics of Russia. 2015;21(4):5-14
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Adaptive bone remodeling around cementless femoral stems with two different designs: fitmore and Alloclassic

Karagodina M.P., Shubnyakov I.I., Tikhilov R.M., Pliev D.G., Denisov A.O.


Introduction. We hypothesized that a short stem preserves periprosthetic bone mass in the proximal femur after total hip arthroplasty (THA). We performed a comparative analysis of clinical efficiency and X-ray results of the BMD around two cementless femoral stems with two different designs. Purpose. To compare the clinical and radiographic results of the study of adaptive bone remodeling in the proximal femur in patients after implantation of the femoral component and Alloclassic Fitmore Material and methods. We evaluated two groups of patients (mean age 58,3): 26 patients with a short femoral stem Fitmore (Zimmer) and 20 patients with a standard stem Alloclassic (Zimmer). Clinical assessment of the hip condition was made according to Harris scale, supplemented by the evaluation of the pain level for femur by a visual analog scale at three levels. The radiological result was studied according to radiogrammetry and dual-energy X-ray absorptiometry (DXA). Results. Independently from design of the femoral component in both groups of patients was observed a significant clinical improvement. The BMD on the surgery side was measured using of analysis in Gruen zones. The first postoperative measurement was performed after surgery and further in 3, 6 and 12 months. DXA after 3 mo showed progressive loss BMD in all Gruen zones, but more significant in Gruen zones 2, 7 for Fitmore stem group, in Gruen zones 6, 7 for Alloclasic stem group. At 6 mo after THA in all Gruen zones of Fitmore vs Alloclasic femoral stems there were the phase of moderate stabilization. At 12 mo we observed decreased periprosthetic BMD in Gruen zone 1 and 7, however that there are no clinically relevant changes around two different designs of cementless femoral stems. Discussion. It isn’t dependent on design of a metal stem we showed progressive remodeling periprosthetic BMD in the proximal parts of hip (Gruen zone 1, 7) and we observed а slighter hypertrophy in the distal parts of femoral stem (stress-shielding). We conclude that using short stems have not benefit in preservation bone of proximal femur.
Traumatology and Orthopedics of Russia. 2015;21(4):15-28
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Hong-Chul L., Eshnazarov K.


Introduction. Recently, new model of Oxford mobile-bearing unicompartmental knee arthroplasty (UKA, Oxford Microplasty®, Zimmer Biomet, IN, USA) was launched to improve previous version (Oxford Phase 3, Biomet, IN, USA). Still, there are few reports demonstrating the results of this noble UKA prosthesis in the literature. Thus, the aim of this study is to report and assess the postoperative radiological outcomes of the Oxford Microplasty ® instrument. Materials and methods. From March 2013 to October 2013, twenty-one patients (23 knees) underwent mobile UKA for medial compartment osteoarthritis using this noble instrument. Postoperative radiological outcomes were measured for operated lower limb alignment and implant position, and they were compared with those of 64 UKAs using the Oxford Phase 3 which had been performed from January 2010 to August 2012. Pre-and post-operative deformity of the knee in the coronal plane, the location of the mechanical axis with respect to the center of the tibial surface, positioning of the tibial and femoral components and varus and valgus alignment for the tibial and femoral components were evaluated. Results. In the Microplasty® patients, preoperative HKA angle was 172.8±2.5° and postoperative HKA angle increased to 177.7±2.8° (p<0.001). There were no significant differences in postoperative HKA angle between Oxford Phase 3 and Microplasty group (178.4° vs. 177.7°, p>0.05). There were no significant differences in postoperative limb alignment and component position between the Microplasty group and Oxford Phase 3 group except femoral component flexion (11.9±2.1° vs. 2.6±4.1°, p<0.001). In addition, there were not any outliers in measurements of the components in the Microplasty group. Conclusion. UKA using Oxford Microplasty® includes noble tools including femoral sizing spoon, G-clamp, longer IM rod, two-peg femoral component, and IM link system to help with ease of use, precision, efficiency, and reproducibility. Increased flexion of femoral component and increased total arc of femoral component will be more suitable especially for Asian patients who perform more flexion such as squatting and sitting on the floor in daily living activities.
Traumatology and Orthopedics of Russia. 2015;21(4):29-36
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Rating of intra-operative neuro-monitoring results in operative correction of the spinal deformities

Skripnikov A.A., Saiphutdinov M.S., Ryabykh S.O., Krivoruchko G.A., Shein A.P.


Purpose of the work was filing the electrophysiological phenomena observed in the process of intra-operative neuromonitoring followed by development of the results’ scale of intra-operative neuro-physiological testing of the pyramidal tract. Materials and мethods. The selection for evaluation included data of 147 protocols of intra-operative neuromonitoring in 135 patients (53 males, 82 females), aged from 1 y. 5 m. to 52 years (14,1±0,7 years) with spinal deformities of different etiology who underwent instrumentation spinal correction followed by fixation of thoracic / thoracolumbar spine segments using various variants of internal systems of trans-pedicular fixation. Intra-operative neuro-monitoring was performed using system «ISIS IOM» (Inomed Medizintechnik GmbH, Germany). The changes of motor evoked potentials were evaluated according to this scale. Results. Five types of pyramidal system reaction to operative invasion were revealed. According to neurophysiological criteria three grades of the risk of neurological disorders development during operative spinal deformity correction and, correspondingly, three levels of anxiety for the surgeon were defined. Conclusion. Intra-operative neurophysiological monitoring is the effective highly technological instrument to prevent neurological disorders in the spinal deformity. Offered rating scale of the risk of neurological complications gives the possibility to highlight three levels of anxiety during operative invasion.
Traumatology and Orthopedics of Russia. 2015;21(4):37-45
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Clinical diagnosis of rigid flatfооt in children

Sapogovsky A.V., Kenis V.M.


Flatfeet are divided into rigid and mobile forms. Rigid flatfeet usually lead to the development of pain. The most common reason of rigid flatfeet is a tarsal coalition. Mobility of the tarsal joints is checked by specific clinical tests. The study investigated the sensitivity and specificity of foot mobility tests - the “tip toes test”, Jack test, manual examination of passive and eversion and inversion. The study found the following parameters: the sensitivity of the “tip toes test”, Jack test was 87% and 85%, specificity - 65% and 64%. The sensitivity of the manual examination of passive and eversion and inversion was - 80%, specificity - 88%. The last test has a high specificity compared to the “tip toes test” and Jack test. Detection limits the mobility of the tarsal joints can be an indication for radiography for the detection of tarsal coalitions.
Traumatology and Orthopedics of Russia. 2015;21(4):46-51
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A new technique of closed intramedullary nailing in fractures of the proximal humerus with varus deformity

Chelnokov A.N., Lavrukova E.A.


Introduction. Varus displacement is common in fractures of the proximal humerus. Development of new low invasive surgical modalities providing anatomy restoration and non-traumatic fracture fixation is actual. Purpose of the study was development of the low invasive technique of closed interlocking nailing providing reduction of the typical varus displacement in fractures and posttraumatic deformities of the proximal humerus. Material and methods. A new technique of correction of the proximal humerus in fractures and posttraumatic deformities was applied in 12 patients - 7 with two-part fractures and 5 with posttraumatic varus deformities. The surgical technique includes application of a small wire circular external frame. Its proximal part is secured to the humeral head to reduce varus displacement along with connection to the distal part of the frame, and the reached alignment is fixed by an intramedullary nail. Results. In all 12 cases we succeeded to reduce the varus deformity. At 1 year follow-up healing was reached in 11 patients, and in one patient exchange compression nailing was performed. Constant score in 1 year was 76±17 after fracture treament, and 70±16 in posttraumatic deformities, which corresponeded to good results. Conclusion. The presented technique allows to reach 40-50° angular correction without open approach and significant soft tissue damage. The obtained results confirm efficacy of the new technique and pertinence of its use in patients with fractures and posttraumatic deformities of this localization. The introduced technique of closed nailing appears to be a promising approach in reconstructive surgery of the proximal humerus.

Traumatology and Orthopedics of Russia. 2015;21(4):52-59
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Х-ray anatomical features of dislocated hip in children with arthrogryposis

Bat’kin S.F., Barsukov D.V., Agranovich O.E., Kamosko M.M.


The purpose - to identify the Х-ray anatomical features of the dislocated hip in children with arthrogryposis, to compare Х-ray and CT scans of hips in patients with arthrogryposis and DDH. Materials and methods. We examined the 98 X-rays and CT scans of the pelvis (120 hips) in children aged from 5 months to 7 years with a hip dislocation in arthrogryposis (main group) and DDH (control group). Results. Cranio-lateral displacement of the femoral head was less pronounced in the main group than in the control. Deficiency of the roof and anterior acetabular margin are typical for the comparison groups, but these changes are significantly less pronounced in the main group (p<0,0001). Also revealed that the posterior acetabular margin developed significantly greater in the main group. For the patients in the main group up to 3 years, the pathological femoral antetorsion is not typical in contrast to the control group (p<0,0001), however, it occurs in older age (p<0,14). At the compared groups the true values of the NSA do not exceed the age norm. Conclusion. Examination protocol of the hip dislocation in children with arthrogryposis must include X-ray and CT of the pelvis for reliable evaluation of the femoral and acetabular component and preoperative planning.

Traumatology and Orthopedics of Russia. 2015;21(4):60-69
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Immediate results of treatment periprosthetic femoral fractures after hip replacement

Khominets V.V., Metlenko P.A., Bogdanov A.N., Kudyashev A.L., Miroevsky F.V.


Periprosthetic fractures are one of the most serious complications after hip replacement. Nineteen periprosthetic femoral fractures operated on during the period 2011-2015 were followed-up retrospectively. Periprosthetic fractures were classified according to the Vancouver classification. The functional results were evaluated using Harrison scale. Bone healing and implant stability were evaluated clinically, on plain radiographs and computed tomography. The periprosthetic fractures in all patients occurred in the postoperative period. Time from operation until fracture varied from 2 weeks to 11 years. A wedge-shaped cemented or cementless stems were implanted during the first surgery: Versys ET, Spotorno, CPT (Zimmer, США): cementless fixation was performed in 16 (84,2%) patients, hybrid -in 2 (10,5%) and cemented fixation - in 1 (5,3%) patient. The fractures of greater trochanter were diagnosed in all patients with type A periprosthetic fractures. In type B1 periprosthetic fracture (8 patients) open reduction, cerclage wiring and internal plate osteosynthesis were applied. Loosening stems in 3 patients with type B2 fractures were replaced with Wagner cementless revision component (Wagner SL Revision Stem). Angle-stable plate osteosynthesis and cerclage wiring were also performed. Closed reduction and internal minimal invasive plate osteosynthesis were performed in patients with type C periprosthetic fractures. Bone consolidation was achieved in 18 (94,7%) patients, the average term was 14,3±5,2 weeks. The average Harris hip score in all patients 3 months after treatment was 64,9±16,7 points, and in 12 patients (63,2%) after a year - 86,5±15,9. Femoral periprosthetic fractures require a specialized approach to choosing the treatment tactic depending on the fracture type and quality of bone tissue. It is necessary to evaluate the femoral component stability, especially in differential diagnosis of type B1 and B2 periprosthetic fractures. Computed tomography is one of the necessary methods of diagnosis.

Traumatology and Orthopedics of Russia. 2015;21(4):70-78
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Kalensky V.O., Kononova K.Y., Glukhov D.A., Ivanov P.A., Berdyugin K.A., Chelnokov A.


Проведен ретроспективный анализ результатов лечения 36 пациентов (42 операции), которым был выполнен внутрикостный остеосинтез пяточной кости штифтом: на базе УНИИТО - 30 пациентов, на базе НИИСП -6 пациентов. Средний возраст пациентов составил 40,4 года. Билатеральные переломы диагностированы у 8 пациентов. У 4 пациентов имела место сочетанная травма. У всех пациентов переломы были закрытыми. В обоих лечебных учреждениях применялись сходные диагностический и лечебный алгоритмы. Предоперационное обследование включало рентгенографию и КТ. Оперативное вмешательство включало два этапа. Первым этапом выполнялась предварительная репозиция с помощью дистракционного аппарата и восстановление формы суставной поверхности через мини-доступы. Вторым этапом в пяточную кость вводили штифт и производили его блокирование. В послеоперационном периоде проводилась активная разработка движений в суставах стопы, пациенты обучались ходьбе при помощи костылей без нагрузки на поврежденную стопу. Сращение оценивали по контрольным рентгенограммам. Репозиция и элевация суставной площадки у всех пациентов, кроме одного, признана удовлетворительной. Средний срок наблюдения в серии УНИИТО составил 5,3 месяцев, в серии НИИСП - 9,8 месяцев. Ни у одного из пациентов в двух описанных сериях не наблюдалось гнойно-воспалительных осложнений и вторичного смещения отломков. В серии УНИИТО имел место один случай миграции винта. Консолидация наступила в срок от 2 до 3 месяцев после операции у всех пациентов. Внутрикостный остеосинтез пяточной кости штифтом характеризуется сочетанием минимальной травматизации мягких тканей стопы, сохранением кровоснабжения латеральной кортикальной пластинки и стабильной фиксации, что значительно снижает риск инфекционных осложнений и расширяет показания к оперативному лечению. Применение данного метода возможно не только в условиях посттравматических местных нарушений трофики тканей, но и при наличии таких факторов риска, как сахарных диабет и курение. Для оценки функциональных исходов требуется продолжение исследования.

Traumatology and Orthopedics of Russia. 2015;21(4):79-86
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Surgical treatment of children with non-traumatic old atlanto-axial rotatory fixation

Gubin A.V., Burtsev A.V., Ryabykh S.O., Savin D.M., Ochirova P.V., Korkin A.A.


Atlanto-axial rotatory fixation (AORF) develops on the background of acute torticollis. Widely adopted terms such as C1 subluxation or atlantooccipital rotational subluxation do not reflect the core of this pathology and carry negative weight in the diagnostics and treatment of AORF. Retrospective analysis of the diagnostics and treatment outcome of 5 children with confirmed AORF diagnosis and literature review were performed. Clinical method, radiography and functional computer tomography were used to verify the diagnosis. De-rotational halo-traction and open correction with screw fixation were applied for treatment. Head position was managed to be improved in all patients. In one case the reduction was performed using correction in suboccipital segments and in other 4 cases the correction and fixation by Harms and de-rotational halo-traction allowed to correct torticollis. The pain syndrome had been arrested completely. Disease outcome resulted in formation of C1-C2 fibrous or bone fusion regardless the method of treatment. The patients with neglected AORF represent a great challenge for diagnostics and treatment. When conservative treatment fails it is necessary to involve de-rotational halo-traction with possible application of open reduction and posterior fusion. The purpose of treatment is to eliminate torticollis and pain using creation of proper C1-C2 alignment. The motions in atlantooccipital joint do not restore due to formation of the fibrous or bone fusion.

Traumatology and Orthopedics of Russia. 2015;21(4):87-94
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2D planning for hip arthroplasty

Kavalersky G.M., Sereda A.P., Murylev V.Y., Rukin Y.A., Gavrilov A.V., Arkhipov I.V., Yatchenko A.M., Bychkov I.Y.


Hip arthroplasty is a common surgery, the success of which largely depends on its planning. Traditionally, arthroplasty planning performed on X-ray film, but this method has many shortcomings, including the well-known systematic repression for analogue X-ray systems to digital. The wide range of implant templates for the planning available in numerous of foreign special planning programs for arthroplasty, but all of them are very expensive. A team of authors from Sechenov First Moscow State Medical University, Lomonosov Moscow State University and Petrovsky National Research Centre of Surgery developed an original computer program for hip arthroplasty planning that allows to plan not only in the DICOM format, but also in photographs of traditional X-ray film. In the process of their work, it has been proved that the projection distortion when photographing X-ray applied to the X-ray viewer without a tripod is 1.95%. Practical testing of the planning program was carried out with 316 total hip arthroplasty surgeries. It turned out that for acetabular component the number of matches was 301 (95.3%), and for femoral components - 304 (96.2%). There were no cases of changing the type of components during surgeries. Thus, the created domestic import-substituting planning program allows working with a variety of image formats and making it possible to digitize X-ray film.

Traumatology and Orthopedics of Russia. 2015;21(4):95-102
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Long-term results of revision hip arthroplasty in patient with congenital hip dislocation after aseptic loosening of acetabular component (case report)

Mashkov V.M., Dolgopolov V.V.


The authors presented uncommon case of revision hip arthroplasty performed for aseptic loosening of the acetabular component implanted in a false acetabulum in patient with high hip dislocation. During revision surgery both components were replaced with implantation of cup to the true acetabulum. After 10 years after surgery the support ability of the operated limb is maintained, functional outcome - 82 points on Harris scale.
Traumatology and Orthopedics of Russia. 2015;21(4):111-117
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Complications after use of extracortical clamp device in combined and consecutive external and internal fixation of femoral bone

Solomin L.N., Sabirov F.K.


Introduction. Extracortical Clamp Device (ECD) is a tool that, unlike conventional wires and pins, does not perforate long bone cortex. Therefore, its use simplifies methods of combined and consequtive use of internal and external fixation, osteosynthesis in periprosthetic fractures and deformities. Purpose of the study - to compare the rate of complications and their structure depending on extracortical clamp device application and conventional transosseous elements in combined external fixation of femur. Materials and methods. We analyzed the complications arising in treatment of 66 patients with frames where ECD were used (group «ECD»). The results were compared with the results of treatment 29 patients, when utilizing combination of external and internal fixation, external fixation device included conventional transosseous elements only (group «W-P»). Results. In the group «ECD» inflammation of the soft tissues around fixing elements was identified in 14.8% of cases. In these patients complication arisen at 45.5% of the all used fixing elements; of them - 18.2% around ECD. In the group «W-P» pin-tract infection occurred in 29.2% cases. ECD breaking was in one case (3.7%) breaking of wires or pins in «W-P» group was diagnosed in 3 cases (13.6%). In the treatment of periprosthetic fractures and deformities with ECD soft tissues around fixing elements was in 16.7% of cases. In the treatment of similar fractures and deformities without prosthesis pin-tract infection were diagnosed in 21.5% cases. All of these complications did not affect the outcome. Other complications (neuropathy, contracture of the knee) were not depending on the application of ECD.
Traumatology and Orthopedics of Russia. 2015;21(4):103-110
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Post-traumatic pelvic deformity with old injuries of rectum and urogenital tract: 18-year follow-up

Runkov A.V., Shlykov I.I., Bliznets D.G., Bogatkin A.A.


The authors described a case of management the severe combined pelvis trauma in female patient with 18 years follow-up. At the age of seven, the patient was injured: the open vertical unstable pelvis injury with severe damage of urogenital tract and rectum. Numerous operations on the pelvic organs without surgical treatment of pelvic ring fractures were accompanied by complications. At the age of 21 (14 years later) the patient was subjected to the surgery according to the techniques designed in the Chaklin Ural Scientific Research Institute of Traumatology and Orthopaedics: percutaneous osteotomy of posterior and anterior pelvis, external pelvis fixation using circular device with a further gradual (within 1.5 months) correction of the deformity with apparatus and subsequent internal fixation with screws. There were achieved partially elimination of shortening of the right lower limb, correction of the pelvic ring form, increasing the pelvic cavity volume, elimination of vaginal impingement, that allowed to correct urological problems with the possibility of further recovery of the vagina and hip replacement surgery. This case showed that the management of patients with complicated pelvis injuries required a multidisciplinary approach: emergency fixation of the unstable injuries and application of techniques to correct long-standing pelvis deformities to restore stability and shape of the pelvic ring, which created the more favorable conditions for reconstructive surgery of the pelvic organs.
Traumatology and Orthopedics of Russia. 2015;21(4):118-125
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Pulsed radiofrequency ablation for treatment of severe pain after shoulder arthroplasty (case report)

Zabolotsky D.V., Portnyagin I.G.


A case of refractory neuropathic pain syndrome in patient who underwent monopolar shoulder replacement is presented. The patient had right lung tumor metastasis in the right humeral head. Severe neuropathic pain syndrome, not responding to 6-months conservative treatment, developed in post-operative period. Pulsed radiofrequency ablation of C4-C6 nerve roots via interscalene access was performed. The procedure allowed the patient to stop taking painkillers and improved his quality of life. The patient was monitored for 2 months.

Traumatology and Orthopedics of Russia. 2015;21(4):126-130
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Biologically rational ways of bone mass loss prophylaxis and treatment

Avrunin A.S., Doktorov A.A.


Aim. Based on own and literature date to define biologically rational elements of complex approach to bone mass loss prophylaxis and treatment. Nowadays there are two points of view regarding bone mass loss prophylaxis and treatment. The first favor pharmaceuticals as a basic and physical exercises as additional. According to the second, therapeutic and prophylactic significance of physical exercises in maintenance and development of structural and functional capacities of musculoskeletal system is fundamental. The latter approach correspond to evolutionary formed biological model in that muscles act upon levers - bones that connected by means of joints and provide the movement of the body against gravity. The present work from pathogenethically point of view establish the systemic approach to the bone mass loss prophylaxis and treatment. It is based on physical exercises while additional pharmacotherapy that should aim for optimization of regulatory function of bone cells, first of all osteocytes providing for adaptational reorganisation of bone structures.
Traumatology and Orthopedics of Russia. 2015;21(4):131-143
pages 131-143 views

Microsurgical reconstruction in patients with calcaneal deformities and defects (review)

Tsybul’ E.S., Rodomanova L.A.


The data of scientific literature on various aspects of the treatment of patients with deformities and defects of the calcaneus for the period from 1976 to 2015. Basic search and selection of publications conducted using PubMed search engine and eLIBRARY. The aim of the study was a comparative analysis of current approaches to the treatment of these patients with the study of the role, place, opportunities and prospects of application technologies of reconstructive microsurgery. It was established that the key challenges for the treatment of patients with lesions of the calcaneus is to achieve stable remission of the infectious process, the maximum possible recovery of the biomechanical properties of the hindfoot and creation, thus, opportunities for achieving a normal gait stereotype. Their solution was developed and proposed to use the set of fundamentally different in its essence surgical techniques. But the possibility of the practical use of most of them are limited to the unfavorable state of the soft tissues of the heel and the heel bone, and often - and its complete absence. Technology reconstructive microsurgery, despite its complexity, high cost and large labor intensity, today represents the most effective means of solving these problems.

Traumatology and Orthopedics of Russia. 2015;21(4):144-153
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Free biostatistical software

Khromov-Borisov N.N.


This report provides information ang brief description of current freely available computer programs for statistical analysis of the results in biomedical research.
Traumatology and Orthopedics of Russia. 2015;21(4):154-159
pages 154-159 views

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