Vol 24, No 1 (2018)

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Recurrence of a giant cell tumor or a malignization of the bone (osteoclastoma) is a common complication after surgical treatment. Increased surgical radicality in such pathology is an acute issue. Ablastic procedure can be performed by exposure to ultralow temperatures.

Purpose — to improve the surgical treatment efficiency of osteoclastoma by uncontrolled cryodestruction of the visual cells and tissue elements in the resection of the tumor-affected bone.

Material and methods. Experimental studies on tumor fragments in vitro. Pathological tumor tissue was three times treated with liquid nitrogen (boiling point −195.8°C). The time of each freeze-defrost cycle was up to three minutes. In the clinical practice, the same cooling agent instillation of the bone defect after resection and mechanical removal of the tumor was used in 67 patients (52 cryosurgical interventions and 15 traditional resections).

Results. In the study the authors used the methods of evidence-based medicine. After instillation of liquid nitrogen on giant cell tumor the temperature of −154°C was noted. In the area of cryotreatment 80% of necrotic tumor tissue was identified morphometrically. The study of 67 operated patients demonstrated that positive results were obtained in 40 cases among patients exposed to cryogenic treatment and recurrent was observed in 8 cases. Good outcomes after conventional surgery were observed in 7 patients and recurrence of tumor was reported in 5 cases.

Conclusion. Positive experience of cryosurgical procedures allows to restrict indications for articular and extensive segmental resections in favor of intrafocal and marginal resections with cryodestruction and bone defect grafting. The method allows to expand a preservation trend in orthopedic oncology.

Periprosthetic fracture associated with joint replacement is a common reason for revision arthroplasty and is increasing. Establishing universal principles of management is essential for good outcomes and a classification system that not only classifies, but offers these principles, is critical to achieve this. The Vancouver Classification System (VCS) for periprosthetic fractures involving total hip arthroplasty is validated across North America and Europe. It does not, however, consider other periprosthetic fractures in different joints. The Unified Classification System (UCS) was developed to incorporate the classification and treatment principles of all periprosthetic fractures in any anatomic location. The system is based on the simple mnemonic “ABCDEF” which corresponds to fractures characterized by the following anatomic descriptors: 1) apophyseal; 2) bed of the implant; 3) clear of the implant; 4) dividing the bone between two arthroplasties; 5) each of two bones supporting one arthroplasty; 6) facing and articulating with an implant. Initial validation for the UCS shows substantial and near-perfect inter and intra-observer agreement. Given this performance, it has the potential to evolve into the gold standard classification system for periprosthetic fractures in any joint that they occur.

Introduction. Subcutaneous rupture of achilles tendon is a frequent trauma and most patients with such pathology are men of working age. Even though it is not difficult to diagnose such ruptures, especially those that need surgical treatment, there are numerous cases when patients come to a surgeon with a big delay. In such cases, the rupture becomes «chronic» or «neglected» and can be no longer treated as an acute rupture. There are many techniques of operative treatment of chronic achilles tendon ruptures, but still there is no consensus on which technique is to be considered the most simple, effective and safe.

The aim of this study is to evaluate the effectiveness of using peroneus brevis tendon as a graft for treatment of achilles tendon defects type 3 in Kuwada classification. Will this technique bring good and excellent results that are comparable with end-to-end suture after acute achilles tendon ruptures?

Materials and methods. The present study includes 13 patients in which peroneus brevis was used for treatment of neglected achilles tendon rupture (group I) and 18 patients after end-to-end suture after acute achilles tendon rupture (group II). Group I consisted of patients with neglected rupture of achilles tendon that was not previously treated due to various reasons and with a significant defect.

Results. Mean surgery duration in group I was 91.9±6.6 (Me — 100) min, in group II — 43.2±2.2 (Me — 45) (p = 0.0001). damaged limb was evaluated using achilles Tendon Total Rupture Score, mean post-op follow up was around 1 year. The results were: group I — 86.6±2.28 (Me — 87), group II — 93.4±1.01 (Me — 94) (p = 0.04). This means, that despite quite high scores in group I, they are still statistically worse than scores after suture of acute rupture in group II. There was no difference in post-operative complication rate between the groups (p>0.05). The most common complication for both groups was range of motion restriction in ankle joint. None of the patients had ankle joint instability after surgery.

Conclusion. Management of neglected ruptures of achilles tendon type 3 (in Kuwada classification) with peroneus brevis autologous graft is an effective and safe technique, that achieves good and excellent results in treatment of this group of patients, in absolute numbers is comparable to functional outcomes after end-to-end suture of acute achilles tendon ruptures, but statistically demonstrates significantly worse results.

Background. Injuries of meniscus are the frequent lesions in the knee joint (KJ). A big number of false-positive and false-negative outcomes may mislead not only a patient but also a specialist in traumatology and orthopedics. Functional and biomechanical studies of the knee joint might provide additional data for clinical decision making and diagnostics.

Materials and Methods. The authors studied 47 patients with traumatic and degenerative tears of the KJ meniscus. All patients were divided into 3 groups. Group I included 10 patients analyzed before and after the arthroscopic treatment, Group II included 22 patients analyzed before treatment only and Group III included 15 patients analyzed after the surgical treatment only. The authors studied the gait biomechanics as well as hip and knee function. In Group I the time from disease onset to the surgical treatment was 9.7 months. The grade on the KOOS scale was 29.4 points before the treatment and 80.2 points after the treatment. In Group II, the grade was 34.2 points. In Group III, the grade was 85.6 point.

Results. The temporal characteristics of the gait cycle did not exhibit any differences from the normal state in all the groups. In Group I a statistically significant increase of the hip extension amplitude was observed, both for the operated and the intact leg. In Groups II and III the authors did not observe this pattern. The abduction-adduction and rotation motions in the hip did not exhibit any significant changes in all the three groups. In Group I knee joint kinematics at the affected side did not differ from intact leg prior to the treatment. After the surgery the value of magnitude phase during the basic knee flexion at the operated side significantly decreased. The amplitude itself increased, but the difference did not reach a statistical significance due to high data dispersion. Patients of Group II and III also demonstrated significant difference in the phase of basic flexion with the same value on the intact side. The abduction-adduction motions were decreased at the intact side after the surgery in the first group.

Conclusion. Thus, the meniscus injury results in slight disorder in the walking and biomechanics of the knee which are successfully compensated during one year after arthroscopic treatment.

Introduction. Celecoxibum being one of high-selective COX-2 inhibitors is specifically inhibiting COX-2 in vivo not influencing protective effect of COX-1. Celecoxibum systemic administration after primary arthroplasty in combination with local infiltration anesthesia has a number of advantages. Purpose of the study. To evaluate the efficiency of postoperative pain relief by Celecoxibum in primary hip arthroplasty using standard and minimally invasive approaches as well as to analyze the pain syndrome dynamics by a method of local infiltration anesthesia (LIA).

Material and methods. The study included 91 patients with hip arthritis of grade III-IV without severe anatomical alterations who underwent primary hip arthroplasty in the Vreden Research institute of traumatology and orthopaedics during 2017. Patients were randomized by type of surgical approach used (standard or minimally invasive), the authors compared monotherapy by Celecoxibum with a multimodal anesthesia which included systemic Celecoxibum administration in combination with LIA. Additional evaluation of two LIA methods was conducted in the group of patients with standard approach.

Results. Pain syndrome dynamics was comparable in all groups — minimal intensity within first day after the surgery and almost complete absence of pain on day 7. However, on day 3 variance between the subgroups increased: the best outcome was observed in the group of minimally invasive approach combined with LIA VAS score was 1.0 (95% CI, 0–1); in the group with standard approach without LIA VAS score was 4.5 (95% CI, 2–7); in the group with standard approach with a single LIA VAS score was 2.6 (95%CI, 0–5); in the group with standard approach with threestage LIA VAS score was 2.4 (95%CI, 0–5); in the group with minimally invasive approach without LIA VAS score was 3,9 (95% CI, 0–2). On day 7 the parameters in all groups demonstrated no statistically significant variances with a minor elevation in cases when LIA was not performed and with average VAS score of 0.8 (95% CI, 0–4). By day 14 pain syndrome was absent or within a range of 1 point in all patients, by this treatment stage Celecoxibum medication was stopped in 37 out of 91 patients (40.7%).

Conclusion. Administration of Celecoxibum per os (200 mg twice per 24 hours) in combination with LIA by Ropivacaine and dexamethasone solution in primary hip arthroplasty provides fast relief of pain facilitating early mobilization of patients and accelerated rehabilitation. Celecoxibum safety in therapeutic dose was also proven.

Background: anterolateral ligament (ALL) is known since it was found in 1879 by Paul Segond. During more than 130 years this anatomical structure was not popular, later it became especially relevant, when its involvement in knee joint rotational stability was demonstrated by different studies. However, data about anterolateral ligament in the knee joint is controversial and limited so further research is necessary.

Purpose of the study: to investigate frequency of occurrence, severity and features of topography of anterolateral ligament of the knee joint in the context of stabilizing procedures on the knee joint.

Materials and methods: the study included 60 samples of lower limbs obtained from 30 unfixed corpses of people who died at the age from 69 to 99 years. Topography-anatomical study was performed with knee bent at 90° with internal rotation of lower leg using basic surgical instruments set and precision preparation instruments set. When the ligament was identified, relationship with the lateral meniscus body was evaluated, relationship with peroneal collateral ligament (mainly by connective fibers) and the presence of lateral lower knee vessels (artery and veins) were evaluated. Also, the place of ligament attachment on lateral epicondyle of femur and lateral condyle of tibia were measured.

Results: the incidence of ALL in studied age group is 56.6 percent. ALL was observed in both knee joints in 100% of cases. In women ALL was observed in 66.7% (24 joints out of 36), in men — 41.6% (10 joint out of 24). The average length of the ALL was 38.5±4.4 mm. The average width at the level of joint gap — 4.45±0.85 mm.

The location of the attachment to the lateral epicondyle of the femur was represented in three anatomical variants: posterior and proximal to the lateral collateral ligament — 64.7%, anterior to the lateral collateral ligament — 23.5%, in the place of attachment of popliteal muscle tendon or next to it — 11.8%. The place of attachment on lateral condyle of the tibia is typical — approximately in the middle of the line from fibula head to Gerdy tubercle.

Conclusion. Based on the authors’ findings and findings of foreign studies the optimal area for proximal channel formation is the posterior position and proximal to place of lateral collateral ligament beginning. Also, the anatomical regularity of lateral lower knee vessels is obtained, that allows to preserve one of the main blood supply sources of anterolateral area of the knee joint.

The authors present a case report of a patient with pseudarthrosis of the right tibia complicated by chronic postoperative osteomyelitis. The development of the osteomyelitis process is caused by locked intramedullary fixation of the right tibia by a retrograde nail. Unstable fixation led to the development of acute periimplant infection and osteomyelitis.

A radical surgical debridement of the focus site of chronic infection was performed by removing locking screws and nail, removal of necrotic bone tissues by handling the tibial medullary cavity by special reamers. The authors used the pulse lavage with active removal of the solution for an additional sterilization of the surgical wound and medullary cavity. A reinforced spacer impregnated with vancomycin and polyvalent bacteriophage was placed in the medullary cavity to ensure local prolonged antimicrobial therapy. Instead of the removed monomer the polyvalent bacteriophage was introduced into the polymer composition including phages against the main infectious agents in patients of traumatology and orthopedics clinic.

Three months after the first stage of treatment and stabilization of laboratory parameters the patient was readmitted to the clinic. The second stage of procedure included removal of spacer, closed antegrade locked internal fixation of the right tibia and talus by a nail with an antimicrobial coating of bone cement impregnated with vancomycin and a polyvalent bacteriophage. Antimicrobial coating of the nail was made intraoperatively using an original mold.

Two stage procedure allowed to achieve a stable remission of chronic osteomyelitis and stable internal fixation of tibia pseudarthrosis with preservation of the supporting function of the lower limb.

The authors report a case of a gunshot complex combined skeletal and soft tissue defect of the upper extremity complicated by chronical wound infection successfully treated with fibula osteoseptocutaneous free flap. A military man had sustained a gunshot-comminuted fracture and diaphyseal defect of both bones in the middle third of the right forearm fixed by Ilizarov external fixator. There also was a soft tissue defect on the radial aspect of the right forearm and persisting chronic wound process. A free vascularized osteoseptocutaneous fibula graft was harvested from the right lower extremity, prepared and inserted between radius fragments. Fixation of the graft was made by locking intramedullary nail. All wounds and the donor site healed primarily. Postoperative x-rays at 5 months demonstrated healing at both ends of the fibular graft.

Venous thromboembolic events including deep venous thrombosis of lower limbs, tromboembolia of the pulmonary artery as well as non-symptomatic venous thromboembolic events are identified via venography and are considered to be potentially life-threatening implications after such major surgeries as total hip and knee arthroplasty. The need for tromboprophylaxis is well realized at present, and there is a wide range of medications with the indication of post-surgical prophylaxis of venous thromboembolic events.

In this report the attempt has been made to carry out the comparative analysis of various currently used functional national guidelines on prophylaxis of venous thromboembolic events after total hip and knee arthroplasty. Moreover, having done the research in the systems PubMed (http://www.ncbi.nlm.nih.gov/pubmed, 2007–2017 гг.) and eLIBRARY (http://elibrary.ru, 2007–2017 гг.) the data of the last 10 years of experience in administration of oral anticoagulants has been collected and thoroughly analyzed (dabigatran etexilat, rivaroxaban, apixaban) and antiaggregant (acetylsalicylic acid) in clinical practice, besides comparative data has been also collected based on results obtained from laboratory control of anticoagulative effect of thrombin and x-factor direct inhibitors, even though the opportunities that laboratory control can provide are so far highly limited.

At present the efficacy of pharmacological prophylaxis of venous thromboembolic events after total hip and knee arthroplasty is absolutely proven, and the issues concerning the safety of anticoagulants administration are the main focus. These issues frequently require personalized approach to selection of medication for tromboprophylaxis in accordance with the patient’s characteristics and the type of surgery chosen. All these aspects should become the focus for further research.

The authors performed an analysis of published stadies devoted to osteoporosis situation in Russian Federation including epidemiological, social, medical and economical aspects of this pathology. The analysis demonstrated that osteoporosis is reported in every third woman and every forth man of 50 years old and older. Seven vertebra fractures happen every minute and one fracture of proximal femur — every 5 minutes in Russia. An overall number of all key osteoporotic fractures will increase from 590 thousand up to 730 thousand cases by the year 2035. Osteoporosis is financially demanding for healthcare due to high treatment cost of fractures that are accompanied by life quality deterioration, high mortality and invalidization of patients. Epidemiological studies demonstrated that due to high fracture risk the osteoporosis therapy should be assigned to 31% of female and 4% of male patients over 50 years old. Such factors of osteoporosis risks are widespread in the society: smoking, low food calcium consumption, vitamin D deficit, low physical activity. The authors analyzed the problems in organization of medical care to patients with osteoporosis and osteoporotic fractures and possible solutions to existing issues. The organization of healthcare should be addressed at identification of high risk patient groups, early diagnosis and assignment of corresponding treatment aimed at decreasing potential fracture risk as well as at pathology prophylaxis.

Diagnostics and treatment of wrist joint pathologies still remain one the key problems in hand traumatology and orthopaedics. Extremal sports availability as well as new options for recreation transportation means only sustains the statistics of such injuries. On the other hand, the technological improvements allowed to develop precise optics for surgeries on small joints. Possibilities of minimally invasive closer visualization at magnification substantially changed not only the approach to treatment of wrist joint pathology but also allowed to describe types of lesions unknown earlier. The authors describe basic principles of wrist joint arthroscopy and features of its application in various injuries: scaphoid fractures, intraarticular fractures of distal radius metaepiphysis, triangular fibrocartilage complex injuries.

135th anniversary of Albrecht Federal Scientific Center for Rehabilitation of Disabled Persons.

Introduction. Sclerosing hematogenous osteomyelitis of Garré (SHO) holds a significant place among cases of latent hematogenous osteomyelitis. Pathomorphological studies of sclerosing hematogenous osteomyelitis are needed to improve differentiated diagnostics, to prognosticate morphology specifics of nidus and to choose the optimal treatment tactics.

Purpose of the study — to identify statistical differences between manifestation patterns of various disease types and correlation between clinical, laboratorial and morphometric criteria of bone lesions in patients with sclerosing hematogenous osteomyelitis.

Material and methods. The authors studied tissue fragments of affected bones of 25 patients with SHO which was diagnosed by clinical, laboratorial, visualizing and morphological methods. Gradation morphometric criteria were used to reflect condition of nidus tissues. The authors made the analysis of qualitative characters and correlation analysis of dependencies between clinical and laboratorial criteria on the one hand, and with morphometric criteria — on the other, and identified association factor.

 Results. Pathomorphological study of SHO nidus demonstrated variances of bone lesions in separate disease cases despite the overall similarity of morphological manifestation. About 2/3 of all cases correspond to fibrosing type whereby even small exudative inflammation sites are absent. In about 1/3 of all cases apart from fibrosis, osteosclerosis and remodeling, the osteomyelitis niduses contain microabscesses indicative of suppurative inflammation as well as the authors observed small sequestration. The maximum differences in patients with various types of SHO were identified in such parameters as share of stab microphages and erythrocyte sedimentation rate (ESR). In cases of long term morbidity the fibrosing disease type is prevailing, in cases of short term lesion (1–2 years) — a fibrosing type with microabscesses formation.

A series of correlation dependencies was reported between clinical and laboratorial criteria on the one hand, and with morphometric criteria — on the other hand.

Conclusion. Pathomorphological features of bone lesions in sclerosing hematogenous osteomyelitis are nonhomogeneous. Every case in the study demonstrated stereotype alterations such as substantial diffuse fibroses of marrow spaces in cancellous bone and bone regenerate, remodeling of bone tissues with gradual acceleration of osteosclerosis and persisting productive inflammation. Only in sone cases featured small sites of exudative inflammation — microabscesses with microsequestration.