Vol 23, No 1 (2017)

Introduction. Hallux rigidus is observed in approximately 2.5% of the adult population. Until now neither a unified classification of hallux rigidus appears to exist nor any clear principles to choose the surgical method. The variety of clinical and radiological signs explains the difficulties in establishing a comprehensive classification system and in selection of the criteria for surgical procedure. There are few published reports about hallux rigidus percutaneous surgical treatment. Existing papers are dedicated to a limited number of percutaneous techniques.

The purpose of this study was to evaluate the efficacy of percutaneous techniques for surgical treatment of the first metatarsophalangeal joint osteoarthritis; to specify factors determining the choice of procedure; to develop a grading system of the hallux rigidus severity which will help in selection of surgery.

 Materials and methods. Based on 156 surgeries (107 patients) the author demonstrated the possibilities of percutaneous techniques in the surgical treatment of hallux rigidus of different stages as well as provided a brief description of used surgical techniques.

Results. The mean age of patients was 48.8 years (ranged from 18 to 73). The mean follow-up was 7 months (ranged from 3 to 54). At the specified time the treatment outcomes of 103 patients (150 feet) were analyzed. Mean hospital stay was 0.78 days (ranged from 0 to 1). No infectious or wound-healing problems were observed. Overall, the patients were completely satisfied with the outcomes of 89 surgical treatment, qualified satisfaction was reported with patients in respect of outcomes of 57 surgeries. Four unsatisfactory outcomes were observed. The role of the relatively long first metatarsal in the development of hallux rigidus was confirmed.

 Conclusion. Percutaneous techniques provide successful treatment for all stages of hallux rigidus. The choice of a specific surgical technique may be challenging and requires consideration of a variety of clinical and radiological signs of the pathological process as well as other factors determined by a surgeon only after detailed discussion with the patient. Grading system, proposed in the study, is intended to help the surgeon in selection of individualized surgical approach. It’s recommended to use the proposed classification with the explanations to it provided in the study. 

Background. Osteoarthritis (OA) is the most common disease among all rheumatological diseases. Approximately 70-80% of all OA cases of are gonarthritis. Routine X-ray examination is not informative to assess non-bone structures. Magnetic resonance imaging (MRI) allows visualizing all the structural elements of a joint, such as articular soft tissue structures and subcortical parts. To achieve objective data, the researcher needs to adhere a protocol allowing to assess of all joint parts, the so-called method of evaluation of the whole body (Whole Organ Magnetic Resonance Imaging Score –WORMS). Aim. to determine predictors of OA progression for X-ray 0 stage on the basis of the knee MRI procedure byWORMS.

Methods. A cohort study. The sample consisted of patients with gonarthritis in all hospitals inArkhangelsk,Northwest Russia. The main inclusion criterion was clinically confirmed with knee OA by Altman 1991 without X-ray pathological changes. X-ray examinations of the knee joints were performed during the initial diagnosis and after one year. After the first X-ray examination patients underwent an MRI provided by machines with a magnetic field strength of 1.5 Tesla. The study included 76 patients, 22 patients were lost to follow up. Altogether, 54 (71.1%) patients completed the study. MRI evaluation of the data was carried out byWORMS protocol.

Results. The progression of X-ray 0 stage into the first stage by Kellgren-Lawrence after one year has occurred in 45 (8.3%) patients of the 54 patients. Clinically significant predictors of progression of OA of the knee based on MRI were: degeneration of the medial meniscus (OR = 5.0, 95% CI: 1.1-22.5), and synovitis (OR = 7.0, 95% CI: 1.5-33.1), degeneration of the medial meniscus and synovitis were included Regression model. Regression model revealed the most significant predictor of progression of knee OA was synovitis (OR = 5.49, 95% CI: 1.13-26.72). The sensitivity of model was 95,1% (95% CI: 85.8-94.9), specificity was 71,4% (95% CI: 33.3-94.4), positive predictive value was 5,6% (95% CI: 89.6-99.1), negative predictive value was 55,6% (95% CI: 25,9-73,4).

The findings of this study revealed the only significant MRI predictor of the transition X-ray 0 stage into the first stage was synovitis which increased the risk of the progression in 5.5 times during one year.

Purpose – to assess the influence of combined femoral fixation technique during arthroscopic ACL reconstruction on the femoral tunnel widening at long term follow-up.

Material and methods. 99 patients with primary hamstring tendon (HT) ACL reconstruction performed in 2007-2008 were analyzed. In the study group (42 patients) on the femoral side a combined cortical suspension (Endobutton CL, Smith & Nephew) and transverse (Rigid Fix, Depuy Mitek) fixation of graft was used. In control group, isolated cortical suspension fixation (Endobutton CL, Smith & Nephew) was used. On the tibial side for graft fixation a biodegradable screw (Biointrafix, DePuy Mitek) was used in all cases. Tunnel widening was calculated in percentage against primary tunnel diameter created during the surgery. MRI data were exported to eFilm (Merge Healthcare software), measurement of femoral tunnel diameters was performed on T1 sequences in coronal and sagittal planes on three different levels.

Results. The mean age at the last follow up in the study group was 38.9±1.4, in control group – 38,6±1,08. The median time from surgery to follow up was 9 years and 4 months in the study group and 8 years 7 months in the controls. The incidence of graft failure in the study group was reported as 14.3%, while in the control group as 17,5%. The median femoral tunnel widening was larger in the control group at the joint aperture and midsection levels both in coronal and sagittal plane, although there was no statistically significant differences (p>0,05).

Conclusion. The combination of cortical suspension and transverse HT femoral graft fixation technique is likely to reduce tunnel enlargement at the long term follow-up. However further research and larger sample groups are required. 

Purpose – to improve the tactics for surgical management of bicondylar tibia fractures to gain better outcomes.

 Materials and methods. The authors analyzed outcomes of surgical management of 69 patients within 36 months after the procedures. Two comparison groups were created to assess the effectiveness of the proposed techniques: the main group of 27 patients (39.1%) and control group of 42 patients (60.9%). In the main group the advanced and new techniques were applied (two-staged protocol of surgical correction, internal fixation with joint distraction, a combination of new L-shaped external and L-shaped internal approaches, bone grafting with b-TCP, carbon nanostructure implant and «Osteomatriks» xenograft). In the control group the conventional internal fixation was used. The difference in tibiofemoral (ΔFTA) and plateau-diaphyseal (ΔPDA) angles at various follow up stages were checked to evaluate reduction stability. P.S. Rasmussen score was used to assess the functional status and life quality of patients. Statistical methods of evaluation included parametric and non-parametric test to check confidence value of variances.

Results. In 36 months postoperatively ∆FTA >5° in the main group was observed 1.97 times less than in control group (23.1% and 45.5% respectively); ∆PDA >5° in the main group was observed 1.66 times less than in control group (30.8% and 51.5% respectively). Total number of excellent and good results the main group 36 months postoperatively according to P.S. Rasmussen score was reported as 1.81 times higher than in the control group (50% and 27.6% respectively).

 Conclusion. The paper proves the efficiency of the proposed surgical procedure for bicondylar tibia fractures management.

Treatment of chronic periprosthetic joint infection (PJI) is connected with high reinfection rate and financial costs. Two stage reimplantation with the use of dynamic and static spacers on the first stage is an effective treatment algorithm of such complication.

Purpose of the study – to evaluate the influence of a spacer type on infection eradication and intraoperative features of two-stage surgical treatment in patients with PJI after TKA.

Material and methods. From year 2007 to 2015 161 patients with PJI were treated: 80 patients with dynamic spacers and 81 – with static spacers. The mean follow up period was 65 months (95% CI: 12–91). The mean age was 62 years (95% CI: 30–84). The outcomes included analysis of infection eradication effectiveness and intraoperative features (operation time, blood loss, type of implant). We excluded 57 patients with severe bone defects (AORI 2B, 3), reinfection after the first stage and, finally, analyzed 104 patients with appropriate including criteria.

Results. Effectiveness of the first stage was 70,1%. The second stage demonstrated 90,1% effectiveness. There was statistically lower reinfection rate after the first stage in patients treated with dynamic spacer 88,1%, compared with 59.1% in patients with static spacers. The mean period between stages was 196 days. Sanation surgery with further implantation of dynamic spacer was followed by statistically (p<0,02) lower blood loss – 522.6 ml (95% CI: 150–1300), compared with static spacers – 727.8 ml (698,1 ml (95% CI; 300–1600), but the operation time was comparable (p = 0.8): 140.2 (95% CI; 75–240) и 142.9 min (95% CI: 85–210) respectively. Revision knee arthroplasty after static spacer was followed by frequent (р<0.05) use of extended surgical approach, constrained implants (p<0,05) and long operation time (p<0.02) compared with dynamic constructions.

Conclusion. Two stage reimplantation with the use of dynamic spacers provides better infection control, knee function between stages, less traumatic sanation and revision knee arthroplasty. Inability to comply recommended interval between stages, due to specifics of financing, makes the implantation of dynamic spacers in patients with PJI on the first stage more preferable.

Hip joint X-ray examination is one of the most accessible and prevalent method of roentgen diagnostics despite the emergence and development of new research options such as CT and MRT. X-ray study is the first method used for patients with hip pain. The main problem that arises in the analysis of radiographs is the incorrectly performed examination. Technically correct X-ray examination reveals the majority of changes contributing to the progression of deforming hip arthrosis, to identify changes in the early stage and to choose the best method of treatment. The article describes the basic X-ray studies and the required minimal measurements for assessing hip condition.

Purpose of the study – to design the algorithm of selection for rational surgical tactics for treatment of patients with coxo-vertebral syndrome.

Material and methods. 175 patients with coxo-vertebral syndrome were included into the study who underwent total hip replacement in the period from 2009 till 2016. The authors analyzed outcomes of treatment of 134 patients at midterm follow up of 9 months (range from 8 to 10 months) after the surgery. Mean age of patients was 54,4±12,7 y.o. Patients were subdivided into a test group (94 patients) and control group (81 patients). Standard THR approaches were used in the control group by restoring anatomical center of rotation and lower leg length. The suggested algorithm of the optimal procedure selection was applied in the test group. Clinical and functional data was evaluated by Harris Hip Score and Oswestry score. Radiographic evaluation was performed based on x-rays of vertebral-pelvic complex in standing position, by functional x-rays, CT and MRI. Evaluation of differences significance between the groups was performed by MannWhitney U-test and McNemar test.

Results. Application of proposed surgical approaches allowed to increase the number of patients with good clinical and functional outcomes (test group – 82,4%, control group – 26,7%) and achieve better function of hip joint and patients’ life quality in short-term postoperative period. Excellent outcomes by Harris hip score were observed in 53,2% of patients, in control group – in 9,7%. Share of the patients complaining of lumber pain, limping and need for a walking stick after THR in the test group was less than in control group. Share of patients demonstrating pain at palpation of spinous processes, with positive test of elevated extended leg and radicular syndrome was also significantly less in test group as compared to control group.

Conclusion. Practical application of proposed algorithm for selection of a rational tactics of surgical treatment for patients with combined degenerative and distrophic pathology of the hip joint and spine allows in short-term after THR to statistically significantly improve treatment outcomes in comparison with patients that underwent conventional preoperative planning and THR.

.

Until present no data was available inArmeniain respect of incidence of low energy fractures that are typical of osteoporotic locations which consequently did not allow to evaluate the scope of this problem across the country.

Purpose of the study – to identify the incidence of low energy fractures in proximal femur, in distal forearm, in proximal humerus and in distal tibia across population ofArmenia aged 50 years and older.

Materials and methods. An observing population study was performed in two regions of Armenia during 2011-2013 where the frequency of selected locations in cases of moderate trauma was identified. During 2011-2012 the information was collected based on traumatology service records adding in 2013 other sources including primary level of healthcare due to observed infrequent applications for medical help in cases of trauma. Results. In 2013 the incidence of proximal femur fractures in men was reported as 136 cases per 100 000 of population aged 50 years and older, in women – 201 cases per 100 000. At the same time only 57.7% of patients with proximal femur fractures were admitted to hospital. Distal forearm fractures incidence in men and women was observed correspondingly 56/100 000 and 176/100 000 cases, proximal humerus fractures – 39/100 000 and 86/100 000 cases and distal tibia fractures – 39/100 000 and 86/100 000 cases. The predicted annual number of proximal femur fracture in Armenia amounts to 2067 cases, distal forearm fractures – 1205, proximal humerus fractures – 640.

Conclusion. Epidemiological data that was collected for the first time on low energy fractures incidence confirmed the acute osteoporosis issue inArmenia and revealed the problems in organization of medical care for the group of senior patients with injuries.

Nowadays the clinical application of digital technologies became a growing trend at every stage of orthopedic patient treatment: from diagnostic procedures and pre-operative planning to intra-operative control of surgical manipulations and evaluation of final results later. The aim of thi sresearch was to analyze the studies dedicated to application of computer-assisted surgery (CAS) for femur and tibial osteotomies in patients with gonarthrosis. The hypothesis was that CAS improves the precision of leg alignment correction in frontal and sagittal planes that positively influencing both functional result of treatment and longevity of clinical effect. The PubMed, PubMedCentral, GoogleScholar and eLIBRARY searched for relevant studies using following key words: knee, osteoarthritis, gonarthrosis, osteotomy, CAS, navigation and its russian analogs. The majority of publications favored CAS in comparison to traditional osteotomy techniques both for leg alignment and tibial slope control. Despite generally researchers paid less attention to functional results after CASosteotomies than to precision of surgical manipulations it is possible of confirm that there is strong tendency to better knee scores after navigation while the difference is not always statistically significant. Rare publications dedicated to long term results favor CAS: 10 years survival rate is 97% that correspond to outcomes of modern total knee arthroplasty. Hence, the current literature confirms the hypothesis of our study and don’t reveal increase of complications rate associated with CAS.