Vol 28, No 4 (2022)

Background. For many decades arthroscopy considered to be the least invasive procedure among all surgical interventions for treatment of knee osteoarthritis (OA). In the beginning of XXI century several randomized clinical studies (RCS) demonstrated inefficiency of lavage and debridement for knee OA. The evidence regarding partial meniscectomy for this category of patients remained uncertain. Therefore the published clinical guidelines are either controversial or inconclusive.

The aim of this study was to critically review the current RCS and meta-analyses of RCS as well as actual clinical guidelines of international orthopedic societies and compare them to expert opinions.

Methods. We searched PubMed and eLIBRARY databases for high evidence research and analyzed the current clinical guidelines dedicated to partial meniscectomy for knee OA. Sixty orthopedic surgeons specialized in this field interviewed anonymously to clarify the decision making process in real clinical practice.

Results. More than patients with knee 2/3 OA of with degenerative meniscal tear benefit from non-surgical treatment therefore indication for arthroscopic partial meniscectomy is limited. The majority of current clinical guidelines consider surgery as an second option if conservative treatment failed and only for non-advanced knee OA. On the contrary experts interview demonstrated the lack of standardized approach as well as a lot of controversies in clinical decision making.

Conclusion. The future research dedicated to partial meniscectomy in knee OA should be appropriately designed to clearly differentiate the sub-population of patient who may benefit from arthroscopy in the long-term without carrying the risk of rapid disease progression with premature conversion to arthroplasty.

Background. Currently, on the general background the number of primary totak knee arthroplasties (TKA) increasing, so does the revisions. Among all the causes of revisions, periprosthetic joint infection occupies one of the leading positions. The generally accepted tactics of two-stage revisions, along with the infection suppression, implements other tasks: reducing pain, preserving and/or restoring joint function. Articular antibacterial spacers allow you to complete all the tasks and preserve/restore the quality of patients` life on staged treatment. However, studies demonstrating the results of periprosthetic joint infection treatment and the use of various articular spacers still do not clear it`s optimal design.

The aim of the study was to improve the intermediate treatment results of periprosthetic knee joint infection using articular spacer implantation.

Methods. A single-center retrospective cohort study was performed. At the first stage of the study, the results of surgical treatment of 420 patients with periprosthetic knee joint infection treated at the clinic in 2011–2019 were analyzed. At the second stage, after applying the inclusion and exclusion criteria, 182 patients were included in the analysis. Two representative groups are identified among them. In the comparison group, hand-made cement liner with articulating surface was used, in the main group — conventional one.

Results. The implantation of the endoprosthesis components with the restoration of anatomical relationships in the joint and the ligamentous balance, the replacement of the cement liner with conventional one made of ultra-high molecular weight polyethylene led to reduction in the surgery duration, intraoperative blood loss and period of hospitalization, an increase in the range of motions in the joint, greater stability of the components and suppression of infection in 94.6% of patients.

Conclusion. The use of various spacers did not significantly affect the probability of infection suppression; however, the number of infection relapses was lower in the group where the liner made of ultra-high molecular weight polyethylene was used. Optimization of surgical treatment techniques and the use of articular spacer based on a three-component conventional endoprosthesis has significantly improved the treatment results of patients with periprosthetic infection of the knee joint.

Background. Femoroacetabular impingement (FAI) is one of the most frequent causes of hip pain and limited hip mobility in young and middle-aged patients. It is a result of repeated injury of hip structures, that leads to degenerative changes in hip labrum, cartilage and subchondral bone and provokes progressive development of hip osteoarthritis.

Aim of study — to analyze own experience of treating patients with femoroacetabular impingement and identify factors affecting its outcomes.

Methods. Retrospective, uncontrolled, single-center clinical study included 128 patients with FAI which had 150 surgeries on 149 joints in in the period from 2013 to 2021. All patients underwent physical examination and X-ray diagnostics, their FAI type was identified. The alpha angle of external part of femoral head in anterior-posterior position and in the modified Dunn 45° position, as well as Tonnis angle, lateral central-marginal angle in Ogata modification and the height of articular gap along the lateral (LS) and medial edges (MS) of sclerosed acetabulum part were calculated. The i-HOT-33 and HOS scales were used to assess preoperative status and postoperative results.

Results. The average follow-up period was 3.9 years (SD 1.71; min 1.05 and max 8.16). The study included 55 (43.0%) women and 73 (57.0%) men which underwent 64 (42.7%) and 86 (57.3%) surgeries respectively. The most common types of FAI, according to our data, were mixed type (53% of joints) and сam type (27.5% of joints). Insufficient coverage of the femoral head by the acetabulum (borderline dysplasia) in combination with the сam deformity of the femoral head was observed in 18.1%. Pincer-type FAI was observed in 1.4% of joints. We obtained the worst results with a combination of сam deformity and borderline dysplasia in comparison with cam- and mix-type FAI according to the i-HOT-33 and HOS scales. Patients’ age, deep cartilage damage, irreparable labrum damage and height decrease of the lateral part of the articular gap determined negative effect on treatment results according to the i-HOT-33 and HOS scales.

Conclusion. Hip arthroscopy showed good short- and midterm outcomes in patients with FAI. Pain syndrome is most often manifested in patients with pathology of hip soft tissue structures concomitant to FAI. The combination of сam deformity and insufficient femoral head coverage, deep cartilage damage and a height decrease of the articular gap are important predictors of poor treatment results.

Background. The invasiveness of surgical approaches for hip surgeries is primarily determined by the severity of the muscle injury. To date, surgeons use from one to three surgical approaches for osteotomy of the pelvic bones and acetabulum reorientation. An analysis of the scientific literature showed the lack of studies comparing the muscle trauma at different surgical approaches for triple pelvic osteotomy in children.

The aim of this study — to evaluate the degree of muscle injury during triple pelvic osteotomy through various surgical approaches in patients with developmental dysplasia of the hip (DDH).

Methods. The study included 70 patients (70 hip joints) aged 12–18 years (15.2±1.4) with Crowe type I DDH treated between 2020 and 2021. All children were divided into two groups: group I consisted of 35 patients (35 hip joints) who underwent triple pelvic osteotomy using an anterolateral approach, group II — 35 patients (35 hip joints) who underwent triple pelvic osteotomy through two approaches (medial and bikini). In addition to standard radiometry of hip joints, pain severity based on the visual analog scale (VAS) and blood markers levels of muscle injury (lactate dehydrogenase, creatine phosphokinase, aspartate aminotransferase and C-reactive protein) were evaluated before and at 3^rd and 7^th days after surgery.

Results. Pain severity assessment by VAS was more pronounced (p<0.05) in patients who underwent surgery using an anterolateral access. Values of CPK and C-reactive protein significantly (p<0.05) exceeded those in patients who underwent triple pelvic osteotomy through two surgical approaches. The results of the study indicate greater hip muscles trauma during the anterolateral approach for triple pelvic osteotomy.

Conslusion. The use of anterior-lateral approach when performing triple pelvic osteotomy in children with Crowe type I DDH causes more (p<0.05) muscle tissue trauma compared to two surgical approaches (medial and bikini). This is evidenced by a significant increase of creatine phosphokinase and C-reactive protein, as well as a more severe pain syndrome in the immediate postoperative period.

Background. In patients with cerebral palsy (CP), secondary orthopedic deformities and violations of the walking pattern are often observed, so various methods of treatment are used for its correction, including orthosis. Abroad, orthoses (AFO) for ankle joints are most often used in clinical practice, whereas in Russia complex orthopedic shoes are used. At the same time, there are no comparative studies investigating the influence of these orthopedic products on the biomechanical parameters of gait.

The aim of the study was to compare the kinematic parameters of walking in children with cerebral palsy, depending on the type of fixation of the foot and ankle joint.

Methods. 25 biomechanical studies (9 barefoot tests; 7 tests in orthopedic shoes; 9 tests in AFO) were conducted in 9 patients with GMFCS 2 and GMFCS 3 levels of global motor function impairment.

Results. The analysis showed that using AFO compared to walking barefoot, regardless of the GMFCS level, positively affects the space-time characteristics of walking, the kinematics of the ankle and knee joints, without significantly affecting the function of the hip joint. In this regard, an improvement in the integral indicator — the gait index — was noted. The use of orthopedic shoes in patients with GMFCS 2 and GMFCS 3 levels of global motor functions led to an improvement in the kinematics of the ankle and knee joints. At the same time, in patients in the GMFCS 2 group, the use of orthopedic shoes provided an improvement in more components of the gait index, whereas in the GMFCS 3 group, the number of such variables was significantly less. A comparative analysis of the results showed that the kinematic parameters of walking in orthopedic shoes are better in patients of the GMFCS 2 group, but in the GMFCS 3 group it is significantly better when using AFO.

Conclusion. The choice of the type of foot fixation in patients with cerebral palsy, taking into account the level of global motor functions impairment, can significantly affect the correction of biomechanical parameters of walking.

Background. Intra-articular injections of autologous platelet-rich plasma (PRP), which is a natural biological stimulant and affects various parts of the regenerative process, are often used in the treatment of adhesive capsulitis. Another line of using the reparative potential of biopolymers is the application of polynucleotides (PN), which, due to their effect on fibroblasts, are able to stimulate regeneration processes during adhesive capsulitis.

Aim of study. To evaluate the clinical efficacy of intra-articular injections of autologous platelet-rich plasma and a polynucleotide-based drug in the complex therapy of shoulder adhesive capsulitis, depending on the stage of the disease.

Methods. Performed prospective cohort study included 42 patients aged 47 to 60 years with the diagnosis of adhesive capsulitis. The duration of the disease varied from 3 months to 5 years. The patients were divided into 2 groups depending on the stage of the disease at the time of the treatment: 24 patients with the first stage of the disease (group AC1) and 18 patients with the second stage (AC2). Each group was divided into 2 subgroups of patients. In subgroups either PRP or PN were administered. The results were assessed 1 week, 1 month, 3 months after the start of the treatment. Evaluation of pain management efficacy was carried out using the visual-analog scale (VAS). The change in the quality of life of patients and the function of the shoulder joint were defined using the DASH questionnaire for assessing the function of the upper limb and the Simple Shoulder Test (SST).

Results. The use of PRP made it possible to achieve pain relief regardless of the stage of the disease. Patients of the AC1 group had a progressive pain syndrome attenuation from 80 to 45 points according to the VAS scale during the first 7 days after the start of the treatment. On the contrary, patients of the AC2 group had a slight pain increase by the end of the 1st week, that was associated with growing physical activity of patients. In the group of patients treated with PN, all experienced pain regression after the first injection. 20% of patients had pain relief within 24-36 hours after the start of the treatment., Increased joint pain was registered in 2 (10%) patients, which passed spontaneously during the first day. Pain syndrome intensity decreased in patients with both stages of the disease. According to the VAS, it decreased from 90-80 to 65 points after the first injection within 4 days in the AC1 group. Patients of the AC2 group did not notice significant effect after the first injection. The second injection reduced the pain to 65-70 points.

Conclusion. The effectiveness of PN-based drugs had no statistically significant difference from that of PRP, but their effect was achieved faster.

Background. Despite the existing significant number of various techniques for ankle arthrodesis, a number of authors point to certain technical difficulties of these operations, the loss of the talus and tibia position during ankylosing, nonunion. The problem of the ankle arthrodesis technique improving requires new solutions.

The aim of the study was to compare the stability of various fixation systems in ankle arthrodesis by the finite element method.

Methods. The finite element method was used to evaluate the biomechanical characteristics of three variants of ankle arthrodesis systems: three cancellous screws, the originally designed plate combined with two cancellous screws, when the screw in the proximal plate’s hole is cortical, and the same plate combined with two cancellous screws, when the screw in the proximal plate’s hole with angular stability. The stresses and strains under the application of various types of loads are studied.

Results. In the anterior plate ankle fixation model combined with two cancellous screws and a proximal cortical screw, the implants and the talus experienced the least stresses compared to the other two models. Thus, the maximum equivalent stress in implants in the second variant was 68-124 MPa, in the first variant 92-147 MPa, in the third variant — 130-331 MPa. The equivalent stress in the talus in the second version of fixation ranged from 20 to 46 MPa, in the first and third versions — 28-58 MPa and 47-65 MPa, respectively. The indicators of maximum contact pressure at the border of the tibia and talus turned out to be the highest in the first variant compared to the other two models (34 MPa, 31 MPa and 31 MPa, respectively).

Conclusions. Among the studied ankle fixation systems for arthrodesis, an anterior plate combined with two cancellous screws and a proximal cortical screw is the most preferable in terms of biomechanics.

Background. Arthroscopic methods of diagnosis and treatment of elbow diseases have not yet become widespread due to the small volume of the joint, the close location to neurovascular bundles and the manipulation difficulty.

The aim of the study was to determine the safe zones for the minimally invasive approaches to the elbow in patients with lateral and medial epicondylitis.

Methods. A complex anatomical and clinical study was performed. The anatomical part was carried out on 30 non-fixed anatomical preparations of the upper limb. The features of the tendon-muscular and neurovascular structures surrounding the elbow were studied, depending on the angle of elbow flexion at three different levels: level I — 5 cm above the articular gap, level II — the articular gap, level III — the neck of the radius. In the clinical part of the study, the these structures were studied by MRI in 30 patients.

Results. The brachial artery at the level I is located from the bone at a distance 28.6 (28.4-28.7) mm at the elbow flexion to 90°. The radial nerve at level II is located at a distance of 15.8 (15.6-16.0) mm from the nominal medial epicondylar line (NMEL). From the NMEL the median nerve is located at a distance of 17.5 (16.6-18.1) mm, the brachial artery — 22.4 (20.5-22.8) mm. The anterior bundle of the medial collateral ligament has the following average width throughout: the proximal part — 6.2±1.4 mm; the middle part — 6.5±1.5 mm; the distal part — 9.3±1.4 mm. The average area of the medial collateral ligament attachment to the medial condyle of the humerus was 45.5±9.3 mm² and has a rounded shape. The average length of the radial collateral ligament was 20.5±1.9 mm; width — 5.2±0.8 mm, the average area of its attachment to the humerus was 13.6±1.4 mm². The average area of the extensor carpi radialis brevis on the lateral condyle of the humerus was 53.1±3.7 mm². The average distance from the entrance of the deep branch of the radial nerve into the supinator canal to the articular gap — 28 (25.5-29.6) mm.

Conclusion. The results of the study make it possible to choose the safe arthroscopic approaches to the elbow with minimal risk of damage to neurovascular structures in the treatment of patients with lateral and medial epicondylitis.

The commentary touches upon the interpretation of the term “refracture” and discusses the hemodynamic features in the area of the emerging fusion in primary and repeated fractures in children. In particular, not only the role of methods for studying blood circulation in the diagnosis of disorders of reparative processes is considered, but attention is also focused on the risk of complications in the conservative and surgical treatment of fractures of the long bones of the extremities in children. It is emphasized that in order to minimize the risks of refractory development, it is necessary to take into account the individual characteristics of a pediatric patient, the method of fixing a fracture, rehabilitation and dispensary observation. The commentary provides a brief overview of publications by domestic and foreign authors on this problem.

This review article focuses on issues of economic analysis in providing care to patients requiring total hip arthroplasty. A large number of factors affecting the final financial result force us to look at economic research in the field of arthroplasty with a certain degree of criticality. At the same time, the existing financing systems cannot fully take into account all the possible costs arising from total hip arthroplasty. For this reason, studies concerning revision total hip arthroplasty are of particular interest, where treatment costs can vary significantly depending on the etiology and complexity of the case. These differences are reflected in the works of authors from France, Germany and Great Britain, who compared the treatment costs of patients with septic and aseptic revisions. Very different data both between countries and within the same country well demonstrate the need for a critical approach to the results of cost-effectiveness studies, QALYs based on Markov and other models, as the quality of the original data can be highly variable and reproduce the error of the initially incorrect price structure. At the same time, the rapidly increasing number of operations of primary and revision hip arthroplasty and, accordingly, the increasing economic costs of these operations require clear and effective economic criteria for their evaluation. The formation and application of these criteria will be the purpose of further research.