Vol 23, No 4 (2017)

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Use of a pneumatic tourniquet during total knee arthroplasty is an effective option allowing reduction of the time of surgery and intraoperative blood loss. At the same time, there are a lot of researchers who advocate differing tactical approaches to the duration of the tourniquet application — the so-called “early” and “late” releases.

Purpose of the study. To assess the effectiveness and safety of various methods of tourniquet use during primary total knee arthroplasty.

Material and methods. 72 patients with end-stage knee osteoarthritis were randomly divided into two equal prospective groups: 1) keeping the tourniquet throughout the surgery, including wound closure (late release); 2) performing knee arthroplasty using the tourniquet until after implantation of the prosthesis component and implementation of hemostasis after the release of the tourniquet (early release). Such aspects as perioperative blood loss and changes in blood counts, blood transfusion volume, and severity of pain on the VAS scale, the rate of recovery of the knee joint function and number of postoperative complications were assessed during hospital stay of patients.

Results. The duration of procedures was 70±15,4 min for the Group I with tourniquet throughout surgery (late release) and 95±27,5 for the Group II with early release (p = 0,001). On the 7th day after the arthroplasty the authors observed statistically significant differences (p<0,05) in the dynamics of reducing the level of hemoglobin, red blood cells and hematocrit in patients of compared groups — in patients who underwent late release of the tourniquet, these indicators were higher. When assessing the rate of recovery of knee joint function according to the KSS -and the intensity of the pain syndrome no significant statistical differences were found in the patients of both groups.

Conclusion. Application of the tourniquet throughout the surgery to release after closure of the surgical wound does not lead to a sharp increase in the number of ischemic and thromboembolic complications, while at the same time, the application of this methodology to a large extent maintains hemoglobin indicators, red blood cells and hematocrit at a high level without a critical decrease.

The aim of the study was to evaluate the possibility of US navigation for Radiofrequency denervation (RFD) of the lumbar facets.

Material and methods. The authors performed a prospective controlled cohort study which included 50 patients with chronic pain syndrome who underwent RFD LIII-SI facets on both sides. The main group (US) included 25 patients, who underwent US guided navigation with FScontrol of the correct placement of the cannula prior to ablation. In the control group (FS) the RFD was performed only under FS control. Patients were selected after preliminary test block of medial branch with 50% pain reduction from the baseline. Patients with overweight, spinal deformity, pronounced degenerative changes, spinal stenosis and developmental anomalies were not included in the study. For the evaluation of outcomes, the numeric pain scale NRS-11 and the Oswestry index (ODI) were used, the accuracy of the cannula position was assessed and factors determining the accuracy were searched.

Results. As a result of the intervention, there was a significant decrease of NRS-11 and ODI criteria in both groups (p<0.001), a positive outcome was achieved in 18 (72%) of US patients and 16 (64%) of FS patients, p = 0.564. Of the 200 attempts to position the cannula under the ultrasound control, 169 (84.5%) were successful, in most cases (187 out of 200, 93.5%) at least 3 attempts were required to reposition the cannula. The average time for performing the procedure under the ultrasound control was 47.3±1.13 minutes. The facet angle and procedure level were defined as predictors of the cannula positioning accuracy, odds ratio 0.93 (95% CI 0.894–0.963) and 0.51 (95% CI 0.32–0.805), respectively.

Conclusion. RFD of lumbar facet under ultrasound navigation allows to achieve a relatively high accuracy of the cannula position into the zone of passage of the articular branch. The navigation capabilities are reduced at the level of LV and SI vertebrae due to structural features of the joints, namely coronary orientation of the facets with the formation of a narrow space between the transverse and upper articular process, which create difficulties for scanning. The disadvantage of ultrasound control is the lengthy procedure and the need for repeated reinsertion of the cannulae worsening the patient’s tolerance of procedure.

Introduction. Hallux varus is a relatively rare foot deformity. Commonly, hallux varus is a complication after the hallux valgus surgery and typically is the result of the first metatarsal medial eminence over resection, first and second metatarsal excessive convergence, over release of the lateral soft tissues, overtightening of the medial soft tissues and soft tissue imbalance of the first metatarsophalangeal joint.

The purpose of this study was to clarify the causes and timing of the iatrogenic hallux varus formation and to evaluate the possibility and efficiency of percutaneous techniques in its surgical treatment.

Material and methods. Thirty-one feet (31 females suffering from iatrogenic hallux varus) were examined clinically and radiologically, including 14 patients who underwent surgery. The average age of the whole group was 57 years (range, 39 to 74), the subgroup of operated patients — 60 years (range from 53 to 68). The time after primary interventions before the examination varied from 2 to 44 years. The mean follow-up after surgery was 6 months (range from 1.5 to 54).

Results. No infection or wound-healing issues were observed. Overall, the patients were completely satisfied with the outcomes of 12 surgeries and satisfied with reservation in 2 cases.

Conclusions. The visual manifestations of hallux varus are determined not only by the hallux varus angle, but also by the value of the first intermetatarsal angle. In addition to well-known factors, hallux varus formation is determined by first metatarsal bone elongation and first metatarsophalangeal joint instability. In rare cases, only one of the factors leads to the hallux varus; as a rule, we see a combination of factors with their mutual reinforcement. Despite the demonstration of usage possibility and the efficiency of percutaneous techniques in hallux varus correcting, a small number of observations in the study does not yet allow giving recommendations on the use of specific percutaneous techniques depending on the various clinical manifestations of hallux varus.

Purpose of the study — to analyze the changes in knee articular cartilage and synovial membrane during distraction external fixation of the tibia in combination with plating.

Material and methods. Articular cartilage and synovial membrane of the knee joint were studied using histomorphometry methods in 9 mongrel dogs during distraction external fixation of the tibia combined with plating. Tibia and fibula osteotomies were performed at the border of middle and upper third, plate was fixed on tibia diaphysis. Lengthening was achieved at rate of 1 mm per day in four stages during 21–28 days. Animals were withdrawn from experiment in 30 and 90 days. After autopsy of knee joints the authors excised sections of synovial membrane from suprapatellar area, articular cartilage with underlying subchondral bone from loadable surface of femoral condyles. Thickness of articular cartilage, its area and volumetric density of chondrocytes was measured, proportion of chondrocytes within isogenic groups from the overall number of chondrocytes as well as proportion of empty lacunae. In synovial membrane the authors measured thickness of surface layer and numeric density of micro vessels. Articular cartilage of 5 intact animals was used as a control group.

Results. After 30 days of plate fixation a hyperplasia of the integument layer, mild synovitis, and hypervascularization were observed in synovial membrane. Density of micro vessels increased to 363.93±33.71 (control group — 335.05±28.88). The authors also observed subperineural and endoneural edema as well as destruction of nerve fibers in subsynovial layer. Articular cartilage retained the zonal structure. Destructive changes were manifested by fibers separation in the superficial part of surface zone and by partial loss of chondrocytes. The following parameters were reduced: cartilage thickness, area and volumetric density of chondrocytes, proportion of isogenic groups; empty lacunae exceeded the values in controls by 18.2%. After 90 days of plate fixation, thinning of the cover layer of synovial membrane was reported. The numerical density of micro vessels decreased to 325.81±36.39. In nerves of subsynovial layer the edema and vacuolization of myelin sheaths of preserved nerve fibers as well as the formation of Büngner bands in place of degenerating ones were detected. Synovitis was not observed. Fibers separation of extracellular substance in upper superficial part of the surface cartilage zone was retained. There was a tendency to increase in cartilage thickness, area and volumetric density of chondrocytes, proportion of isogenic groups; and to decrease of empty lacunae number.

Conclusion. The histological changes in the articular cartilage during distraction external fixation of the tibia in combination with plating corresponded to the initial stages of osteoarthritis of grades 1—2 according to histological classification of International Society for Study of Osteoarthritis (2006) and were accompanied by hypovascularization and denervation of synovial membrane.

Worldwide population aging and associated with it epidemics of osteoporosis, widespread of bone and joint reconstructive surgery and first of all joint replacement lead to explosive growth of interest in bone grafting.

Although autografts are still the golden standard in bone regeneration, allogeneic bone substitutes have reached a state that allows for their application with satisfying clinical results. However, it has repeatedly been supposed that the different allogeneic materials underwent different purification processes, which modifies bone regeneration properties of these materials and also for different safety conditions. In the present publication, the treatment of the precursor tissue, the safety conditions, and the regenerative possibilities of C+TBA bone blocks based in preclinical and clinical data are described. Thus, it is described how the risks of infections and also immunological reactions becomes completely eliminated, while the special purification process allows for preservation of the native structure of the bone block. Both the in vitro studies and the clinical trials including histological follow-ups showed the optimal regeneration properties of these bone blocks. It has been shown that the allogeneic bone grafts have been integrated without causing inflammatory anomalies at the implantation site. Altogether, the allogeneic bone substitute material serves as an excellent basis for the formation of new bone. Finally, the combination of the allogeneic C+TBA bone blocks with different antibiotics is described. Interestingly, it is possible to combine the allogeneic bone substitute ether with antibiotics in the sense of prophylaxis and/or with bone marrow aspirate in order to accelerate bone remodeling.

Relevance. The correct implantation of acetabular component in total hip arthroplasty is an important factor for obtaining good outcomes and long-term survival of the prosthesis. The anteversion angle is one of the significant indicators for the three-dimensional orientation of the cup. The purpose of the study — to develope the method of calculating the anteversion angle of the acetabular component using postoperative anteroposterior radiographs of the hip and pelvis.

The method. The authors used the projection ellipse formed by the opening of the prosthesis cup on the radiograph centered on the hip joint to calculate the desired value. The ratio sine of projectional diameter of the ellipse to its true diameter is a mathematical formula for finding the angle of anteversion. The comparison of the calculated index on anteroposterior radiographs centered on the hip joint and on the pelvis is necessary to identify the distinction between anteversion and retroversion of the acetabular component. In negative anteversion, or retroversion, the projectional diameter on the pelvic radiograph is larger than on the radiograph focused on the hip joint.

Conclusion. Measuring of anteversion angle of acetabular component on postoperative radiograph allows to gain an optimal orientation of acetabular component which decreases postoperative complications rate. X-rays of any scale can be used for measurements while the ratio but not the absolute value of measured diameters is important for the result.

Heterotopic ossification is characterized by bone tissue formation in soft tissues that possess no osteogenic properties. The authors present a clinical case of a female patient with massive heterotopic ossification in anteromedial aspect of the right knee joint with 10 years history before admission for treatment. An abrupt knee hyperextension became a trigger mechanism for the present lesion. MR tomography demonstrated af ormation pushing off the healthy tissues along the anteromedial surface of the right joint. Computer tomography visualized a massive calcination of soft tissues. During the arthroscopic procedure the authors observed a formation of a dense consistency with round borders which demonstrated minor cohesion with surrounding tissues. The formation wasremoved. Diagnosis was confirmed by histological findings. Control x-rays in 6 months after the procedure verified absence of new areas of heterotopic ossification. Removal of ossificational lowed to obtain a good clinical outcome.

The authors conducted an analysis of national and foreign scientific publications dedicated to the problems in treatment of patients with ruptures of the anterior cruciate ligament of the knee joint. The results of the analysis demonstrated that such lesions still remain the key knee pathology resulting from sports injuries that significantly affect knee function and require timely reconstructive surgical correction. Based on the study the key areas of improvement in treatment for mentioned category of patients have been identified. This is the biomechanically justified single bundle anatomical ACL reconstruction which is currently widely applied in the clinical practice by using of an isometrically located autograft. Such technique represents a radically new stage in the development of treatment methods for young and middle-aged patients with high functional demands.

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Introduction. Techniques that use growth factors to improve bone fragment consolidation and to treat the inflammatory and degenerative diseases of the musculoskeletal system have become very popular. Many researchers are actively searching for personification of this therapy and the reasons for delayed consolidation. The purpose of the study – to identify the biomarker for delayed bone consolidation.

Materials and Methods. The study groups consisted of patients with high-energy tibia open fractures with normal (group 1) and with delayed (2nd group) consolidation of bone fragments. The enzymatic activity of platelet-derived growth factor (PDGF) in blood serum was studied after 7 days and in 1, 3 and 6 months after bone fragments reduction. Spectrophotometric technique (Specord-200) was used.

Results. In patients with normal consolidation of bone fragments, the enzymatic activity of PDGF was statistically significantly higher in comparison with the group with delayed healing. At the same time, the highest activity was reported on day 7, and by third month it was becoming lower.

Conclusion. Bone healing depends on PDGF enzymatic activity, besides significant differences on various stages of healing were observed. Further study the reasons for the PDGF enzymatic deficiency and its correction are of a great interest for reducing the timing of consolidation.

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