Vol 25, No 2 (2019)

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The aim of this study was the assessment of early outcomes of patient-specific three-dimensional titanium cones with specified porosity parameters to compensate for extensive metaphysical-diaphyseal bone defects in RTKA.

Materials and Methods. Since 2017 till 2019 30 patient-specific titanium cones (12 femoral and 18 tibial) implanted during 26 RTKAS. Clinical outcomes evaluated using KSS, WOMAC and fjS-12 scoring systems on average 10 (2–18) months after surgery. At the same time the stability of implant fixation analyzed using frontal, lateral and axial knee roentgenograms.

Results. During all procedures there were no technical difficulties in positioning and implantation of custom-made titanium cones. At the time of preparation of the publication, none of the patients had indications for further surgical intervention, as well as intra- and postoperative complications. Six months after surgery all scores improved significantly: KSS from 23 (2–42, SD 19.96) to 66.5 (62–78, SD 7.68), WOMAC from 59 (56–96, SD 28.31) to 32.25 (19–46, SD 11.76), the index FJS-12 was 29.16 points (0–68.75, SD 30.19). The average scores continued to improve up to 18 months: KSS — 97.5 (88–108, SD 9.14), WOMAC — 16.5 (9–24, SD 6.45), FJS-12 — 45.85 (25–75, SD 22.03). No radiolucent lines were noticed during this period of observation.

Conclusion. The original additive technology of designing and producing patient-specific titanium cones for compensation of extensive metaphyseal-diaphyseal bone defects in RTKA is a valid solution at least in the short term. A longer follow-up period is required to assess its medium-and long-term reliability compared to existing alternative surgical solutions.

The objective of the study was to evaluate the effectiveness and safety of high-volume local infiltration and epidural analgesic techniques after primary total knee arthroplasty versus standard systemic multimodal analgesia in the context of the postoperative analgesia protocols.

Materials and Methods. A single-center randomized comparative study included 84 patients who, from august 2017 to august 2018, underwent a primary total knee arthroplasty. Depending on the method of postoperative analgesia, we randomized patients into 3 groups. Group A consisted of 32 patients who received intraoperative infiltration of periarticular tissues with 0.2% solution of ropivacaine in combination with adrenaline and subsequent bolus injection of a local anesthetic solution via a catheter inserted into the wound. Group B included patients who received epidural analgesia with a constant infusion of a 0.2% solution of ropivacaine (n = 28). In patients of group C, neither regional nor local analgesia techniques were used for postoperative analgesia (n = 24). All patients received standard systemic multimodal analgesia using nonsteroidal anti-inflammatory drugs and tramadol. The pain intensity was measured by vas when the patient was motionless, and during knee flexion (before surgery, after surgery on resolution of motor block and during the initial postoperative 24 h), side-effects were recorded.

Results. The patients of Group C, during knee flexion in the postoperative period, reported the highest pain scores (6 (5; 8) during the initial postoperative 12 h and 6 (5; 6) during the initial postoperative 24 h). Severe pain, resistant to therapy and requiring the administration of narcotic analgesics (morphine 1.0 mg), was noted in 5 (15.6%) patients in group A and in 10 (41.6%) in group C, in contrast to patients of group B, where no pain was recorded in any patient, p = 0.056, p = 0.037 and p<0.0001. Hypotension was observed only in group B in 6 (22%) patients. Intra-articular and other infectious complications among all patients were not recorded.

Conclusion. High-volume local infiltration analgesia as a modality of postoperative analgesia is not inferior in the effectiveness to the epidural analgesia, does not require strict monitoring and is accompanied by a lower incidence of side-effects and complications, which can make it the procedure of choice in multimodal analgesia schemes for total knee arthroplasty.

Purpose — to evaluate mid-term outcomes of primary hip replacement in patients with end-stage chronic renal disease and to develop an algorithm for selection of surgical tactics and perioperative treatment.

Materials and Methods. The authors evaluated outcomes of primary hip replacement in 45 patients receiving renal substitution therapy and 47 patients without chronic renal disease. Patients with end-stage chronic renal disease (CRD) were divided into two groups: group I included 30 (66.6%) patients receiving chronic hemodialysis (CH) and group II included 15 (33.4%) patients after renal transplantation (RT). Group III of 47 (51.1%) patients without any signs of CRD who underwent hip arthroplasty within relevant period of time was established to evaluate the effectiveness of primary hip replacement. Blood serum Ca²⁺ and P⁵⁺ levels as well as levels of parathyroid hormone (PTH) and 1.25-dihydroxyvitamin D were measured to determine the rate of calcium- phosphoric metabolism disturbance. Multi-spiral CT scans of hip joint were performed to identify bone mineral density and the mean Hounsfield (Hu) value was calculated for which the data was obtained from five various points on the proximal femur and acetabulum. Beta-2 microglobulin (B2M) blood test was performed to confirm amyloid bone disease.

Results. The authors did not observe statistically significant differences for arthroplasty outcomes in patients of group II and III. Patients receiving long-term hemodialysis demonstrated significantly lower parameters of Harris score and Barthel’s index of social adaptation after hip replacement as compared to groups II and III: patients of group I demonstrated outcomes improvement at 19.55%, in group II — at 13.03%, in group III — at 10.15% as compared to preoperative status. Decrease of 1.25-dihydroxyvitamin D below 20,0 mcg results in resorption of cancellous bone in proximal femur and acetabulum along with myopathy of gluteus muscles. Sharp increase of parathyroid hormone level (over 600 pcg/ml) was accompanied by inhibition of osteoblasts proliferation and differentiation resulting in substantial impairment of mineralization.

Conclusion. According to the algorithm suggested by the authors the key parameters that need to be evaluated in preoperative period are parathyroid hormone (PTH) and 1.25-dihydroxyvitamin D. Five-fold increase of PTH (>600 pcg/ml) demands parathyroidectomy as the first stage of treatment to decrease risk of early aseptic loosening of hip prosthesis and development of periprosthetic fracture.

Relevance. Surgical decompression and decompression with stabilization are highly effective for treatment of spinal canal stenosis at the level of lumbar spine. However, complications developing after application of rigid fixation systems resulted in active introduction of dynamic implants into clinical practice.

Purpose of the study — to compare effectiveness of nitinol and titanium nails for lumbosacral fixation in surgical treatment of degenerative spine diseases.

Materials and methods. 220 patients who underwent surgeries in 4 hospitals were randomized into two groups, each consisting of 110 patients (1:1 ratio): a group of patients who underwent stabilization of the vertebral motor segments with rods of nitinol with the required volume of decompression at the operation level and a group of patients who underwent stabilization of the vertebral motor segments with standard rods of titanium with the required volume of decompression at the intervention level. Patients suffered clinically significant spinal canal stenosis in one or two adjacent segments: from L3 to S1. Outcomes were evaluated during three years postoperatively by VAS scale for spine and lower limbs, and by ODI and SF-36 scales.

Results. All scales demonstrated better values in both groups of patients, namely, significant decrease of pain syndrome and improvement in mental and physical health. X-ray examination of all patients during the study period demonstrated restoration of lumbar lordosis. Group of patients with dynamic nails featured less complications rate related to metal implants including adjacent segment disease.

Conclusion. Transpedicular fixation of lumbosacral spine by nitinol nails is an effective technique allowing to preserve motion along with stable fixation.

Purpose of the study – to evaluate the antibacterial activity and biological compatibility of alloy coatings based on two-dimensionally ordered linear chain carbon (TDOLCC).

Materials and Methods. Coatings based on TDOLCC were synthesized using alloying additions like nitrogen (TDOLCC+N) and silver (TDOLCC+Ag) on the surfaces of titanium plates and polystyrene plates by the ion-stimulated carbon condensation in a vacuum. The authors examined the superficial bactericidal activity of the coatings and its resistance to mechanical effects. Coated plates were evaluated in respect of rate of microbial biofilms formation by clinical isolates with multiple and extreme antibiotic resistance. Specimens were colored with crystal violet solution to visualize the biofilms. Cytotoxic effect of coatings was evaluated in respect of primary culture of fibroblasts and keratinocyte cell line HaCaT.

Results. The authors observed pronounced superficial bactericidal effect of TDOLCC+Ag coating in respect of microorganisms of several taxonomic groups independently of their resistance to antibacterial drugs. TDOLCC+Ag coating proved capable to completely prevent microbial biofilm formation by antibiotic resistant clinical isolates of S. aureus and P. aeruginosa. Silvercontaining coating demonstrated mechanical resistance and preservation of close to baseline level of superficial bactericidal activity even after lengthy abrasion treatment. TDOLCC based coatings did not cause any cytotoxic effects. Structure of monolayers formed in cavities coated by TDOLCC+N and TDOLCC+Ag was indistinguishable from the monolayers in cavities of control plates.

Purpose of the study — to evaluate possible impact of cryoablation on a healthy bone and to identify probable causes of postoperative fractures.

Materials and Methods. The authors performed cryoablation of the femur in the experiment on 8 mature rabbits of Soviet Chinchilla (SC) breed with a follow up for up to two months. Anitrogenous cryoprobe of 1.5 mm in diameter was introduced into the femur through a perforation hole. The bone was completely frozen up to -180°С in two cycles with continuous thermometry. Pathomorfological examinations were performed after 7 and 55 days along with assessment of bone hardness. Preparation of material stipulated sawing the bone at the fracture site along the bone axis. One half-bone was used for histological examination, and another one — for measuring mechanical properties by local pressing of a diamond indenter onto the bone at certain applied force. The distance between measurement points along the bone was 250 μm. Statistical processing included variance significance analysis using t-test.

Results. The authors reported bone fractures at the site of cryodestruction in all animals in one week after the procedure. Statistical analysis of the measurements and histological examination demonstrated that freezing of the entire bone diameter up to -180°С results in its complete destruction. Strength reduction around the fracture site corresponded to the temperature distribution area in the range from -9ºС to -15ºС. However, areas of cooling below -40ºС exhibited some bone segments with normal hardness. Mosaic pattern of strength reduction is explained by microcirculation disorders. Histology confirmed thrombosis of intraosseous blood vessels in the area of cryotherapy. The first focal signs of osteomalacia emerged by the end of the first week after cryoablation. Subsequently, the bone preserved its regenerative properties, but by the end of the second month after the procedure the histogenesis was still not completed and the bone did not regain its strength.

Conclusion. The authors believe that a limited number of cases, the specific features of the angioarchitecture of animal bones and their ability to produce a heavy periosteal response do not allow to apply obtained quantitative outcomes of the present study to clinical situations. However, complete freezing of the entire bone diameter inevitably results in fracture formation.

One of the main causes of lumbar spine pain is spondylolysis. The purpose of this review is to present the current state of the problem of diagnosis and treatment isolated and multilevel spondylolysis.

Materials and Methods. The review includes 86 publications on the problem of spondylolysis for 2005–2019, obtained from electronic databases: PubMed, Cochrane Library, eLIBRARY, CYBERLENINKA.

Results. There is still the only known classification of spondylolysis by P. Niggemann et al, which includes four severity of this pathology — from mild to very severe: A, BI, BII, BIII. The classification is based on the nature of changes in the area of bone defect of the vertebral arch when the patient performs functional tests. In some cases, the pathology can be regarded as a transition between different degrees of severity of type B. The treatment of spondylolysis can be both conservative and operational. The conservative therapy consists of physical activity restriction, physiotherapy, wearing a corset, massage, and pharmacotherapy. The purpose of surgical treatment is the removal of fibrous tissue from the zone of spondylolysis and the achievement in this area the bone fusion via a bone autoplasty and(or) osteosynthesis with different metal frameworks. Reasoned arguments about the need for a combination of conservative and surgical treatment of patients with spondylolysis are also reflected in the publications. Information on multilevel spondylolysis is represented by a small number of articles. only 15 authors described clinical cases of multilevel spondylolysis in a total of 21 patients. Spondylolysis is a high risk factor for the spondylolisthesis formation. Among the various categories of patients suffering from spondylolysis and lumbar spondylolysis spondylolisthesis, pregnant women are of particular interest. Hormonal restructuring and changes in the biomechanics of the spine in women during the gestational period often leads to the appearance or intensification pain syndrome in lumbar spine complicating the pregnancy, and hence a fetus development.

Conclusion. Timely diagnosis of spondylolysis and the subsequent development of individual rehabilitation not only improves the quality of life of patients, but in some cases can prevent such a serious pathology as spondylolisthesis.

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Background. Pathological changes in the size and structure of Hoffa’s fat pad can cause pain in the anterior section of the knee joint. Therefore, they should be diagnosed. The objective of the paper is to improve the diagnostics of Hoffa’s fat pad disease on the basis of a detailed study of the clinical anatomy of the infrapatellar (Hoffa’s) fat pad and magnetic resonance imaging (MRI) findings in normal and pathological conditions.

Materials and Methods. Protocols of 86 MRI examinations of knee joints with anterior knee pain syndrome and no clearly defined traumatic history nor positive clinical tests indicating damage to the intra-articular and periarticular elements with identified structural changes in the fat pad were selected retrospectively. The control group consisted of data from 24 examinations of asymptomatic knee joints. In all cases, the pathology was confirmed during diagnostic and therapeutic arthroscopy.

Results. The MRI findings showed the normal structure of the infrapatellar fat pad, as well as pathological changes in the form of tearing, local edema, diffuse edema, synovial proliferation and fibrosis. Depending on the location and type of changes, 4 pathological syndromes were identified: “classic” Hoffa’s disease — 49 (57%) cases, infrapatellar synovial fold syndrome — 11 (13%), infrapatellar synovial fold separation syndrome — 6 (7%), and impingent syndrome of upper lateral adipose tissue — 20 (23%) cases.

Conclusions. To identify a pathology, a precise synchronization of clinical and morphological changes is required. Accurate differentiation of syndromes is possible due to knowledge of the detailed anatomical and magnetic-resonance features of the fat pad in normal and pathological conditions. This allows to diagnose the cause of pain in the anterior sections of the knee joint, specify the diagnosis, and choose the optimal plan of treatment.

Partial rotator cuff tears are the most common pathology of the shoulder joint. Diagnostic of such conditions is a challenging problem for trauma surgeon.

Purpose of the study is to analyze the diagnostic significance of manual tests and the standard MRI of the shoulder joint.

Materials and Methods. The study is a retrospective analysis of disease history data of 25 patients (15 males, 10 females) treated at the authors’ hospital during the period from 2014 to 2017. Examination was performed according to a standard protocol: assessment of shoulder range of motion, palpation, manual examination, including “full/empty can” test, a painful arc symptom and the Hawkins – Kennedy test. All patients underwent MRI of the shoulder joint. The mean age of patients was 50.8 years. Shoulder joint arthroscopic inspection was considered the gold standard for diagnostics.

Results. After data analysis, the following results were obtained: sensitivity of the “full can” test was 68%, the accuracy was 68%; “empty can” test sensitivity and accuracy were 76%, respectively. MRI sensitivity for diagnostics of supraspinatus tendon ruptures was 84% with the accuracy of 84%. The combination of the Hawkins – Kennedy test with the symptom of painful arch demonstrated accuracy and sensitivity of 64%. The study evaluated the effectiveness of MRI for diagnostic of the rupture type: sensitivity for injury from the joint surface — 80%, from the subacromial space — 70%; specificity for ruptures from the articular surface — 90% and from the subacromial space — 93%. The accuracy was 84% for both types of ruptures.

Conclusions. Combined application of manual tests and MRI of the shoulder joint allows to diagnose partial rotator cuff tears in the majority of cases.

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