Vol 28, No 4 (2022)


Arthroscopic Meniscectomy for Knee Osteoarthritis: the Gap Between Evidence Based Medicine and Expert Opinion

Saraev A.V., Kornilov N.N., Kuliaba T.A., Shubnyakov M.I., Demin A.S., Stolyarov A.A., Sereda A.P.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):5-20
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Results of Revision Knee Arthroplasty With Individual Implants

Zykin A.A., Gerasimov S.A., Gorbatov R.O., Illarionova T.V.


Background. The presence of extensive bone defects significantly complicates the possibility of stable fixation and correct spatial positioning of the revision endoprosthesis components. The primary task of revision surgery is to restore the lost bone. The use of modern implants makes it possible to replace large metaphyseal defects of the tibia and femur, including AORI type 2B и 3 bone defects.

The aim of the study was to evaluate the long-term results of surgical treatment of patients with extensive bone defects (2B and 3 according to AORI) of the proximal tibia and/or distal femur using custom-made implants for revision knee arthroplasty.

Methods. A retrospective clinical study was performed in 24 patients who underwent revision arthroplasty using individual implants (9 femoral and 18 tibial) made on a 3D printer in the period from 2017 to 2021. T3 defect according to AORI classification was diagnosed in 12 patients (50%), F3 defect — in 1 (4.17%), F2B — in 8 (33.3%), T2B — in 6 (25%). All patients before surgery and 3, 6, 12 months after surgery were surveyed according to the international scales VAS, KSS, WOMAC and SF-36.

Results. At the follow-up examination 12 months after the surgery, 9 out of 24 patients (37.5±10%) walked without additional means of support, 10 out of 24 (41.7±10%) with a cane, 4 out of 24 (16,7±8%), walkers — 1 out of 24 (4.2±10%). There were no periprosthetic fractures during surgery and in the postoperative period. When evaluating the functional state of the knee joint, an excellent result was registered in 45.8±10% and 33.3±10%; good — in 37.5±10% and 54.2±10%; satisfactory — in 16.67±8% and 12.5±7% according to the KSS and WOMAC scales, respectively. When assessed on the VAS scale, there was a positive trend in the form of statistically significant decrease in pain in all patients (p<0.01).

Conclusion. The use of individual implants made using additive 3D printing technologies in revision knee arthroplasty in the presence of extensive bone defects (2B and 3 according to AORI) allows to perform an organ-preserving surgery without loss of the statodynamic function of the lower limb. This study has limitations due to the small sample size. We believe that it is promising to study the long-term results of surgical treatment of patients with extensive bone defects (2B and 3 AORI) of the proximal tibia and /or distal femur using individually manufactured implants for revision knee replacement and a comparative analysis of these results with those using conventional implants.

Traumatology and Orthopedics of Russia. 2022;28(4):21-30
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Results of the Articular Spacer Application in Treatment of Knee Periprosthetic Infection

Mitrofanov V.N., Korolеv S.B., Presnov D.V., Komarov R.N., Akulov M.M.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):31-41
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Polymorphism of LYPLAL1 and TGFA Genes Associated With Progression of Knee Osteoarthritis in Residents Central Chernozem Region of Russia

Novakov V.B., Novakova O.N., Churnosov M.I.


Background. Кnee osteoarthritis (OA) is a multifactorial disease in which genetic factors play an important role. The share of the hereditary component in the development of OA, according to various literature sources, ranges from 40 to 65%. Кnee OA is a progressive disease that leads to a decrease in the quality of life and disability.

The study aimed to evaluate the role of polymorphic markers of candidate genes rs2820436 and rs2820443 LYPLAL1, rs3771501 TGFA, rs11177 GNL3, rs6976 GLT8D1 in the progression of knee OA in the population of the Central Chernozem Region of Russia.

Methods. The study was performed in a case-control design on a sample of 500 patients with knee OA. Case — patients with III-IV stages of the disease according to Kellgren–Lawrence (n = 325), control (individuals who do not have the analyzed sign — III-IV stages of the disease) — patients with stage II (n = 175). Genotyping of five single nucleotide polymorphisms (SNPs) of candidate genes was performed using the polymerase chain reaction method for DNA synthesis. The study of the associations of the studied polymorphic loci, the calculation of haplotype frequencies and the analysis of their relationship with the progression of knee OA was carried out by the method of logistic regression in the program PLINK v 2.050.

Results. Significant associations with the progression of OA of the knee were established for allelic variant A rs2820436 of LYPLAL1 gene according to allelic (OR = 1.48, p = 0.010, pperm = 0.012), additive (OR = 1.58, p = 0.009, pperm = 0.010), dominant (OR = 1.61, p = 0.024, pperm = 0.030) genetic models and A/A genotype of the same polymorphism (OR = 2.53, p = 0.041). The genotypes C/C rs2820436 LYPLAL1 (OR = 0.67, p = 0.043), A/G rs3771501 TGFA (OR = 0.67, p = 0.042) have a protective role in the progression of the disease. It was found that the frequency of the AC haplotype of haploblock rs2820436-rs2820443 in the group of patients with III-IV stages of the disease was significantly higher than in patients with stage II (OR = 1.83, p = 0.002, pperm = 0.002). The identified molecular genetic markers rs2820436 and rs2820443 of LYPLAL1 gene, rs3771501 of TGFA gene are associated both with the risk of developing OA according to previous genome-wide studies and, according to our data, are associated with the progression of knee OA.

Conclusions. Genetic risk factors for the development of knee OA of III-IV radiological stages are allelic variant A and genotype A/A rs2820436 of LYPLAL1 gene, haplotype AC of haploblock rs2820436-rs2820443 in the population of the Central Chernozem Region of Russia. Genotypes C/C rs2820436 of LYPLAL1 gene and A/G rs3771501 of TGFA gene have a protective value in the progression of this disease.

Traumatology and Orthopedics of Russia. 2022;28(4):42-53
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Results of Arthroscopic Treatment for Femoroacetabular Impingement

Bogopolskiy O.E., Trachuk P.A., Spetsialnyi D.V., Sereda A.P., Tikhilov R.M.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):54-65
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Total Hip Arthroplasty in Patients With Post-Traumatic Bone Defects and Acetabular Deformities

Pronskikh A.A., Romanova S.V., Lukinov V.L., Bazlov V.A., Mamuladze T.Z., Korytkin A.A., Pavlov V.V.


Backround. Total hip replacement in cases of traumatic changes of the acetabulum refers to cases of difficult primary arthroplasty and requires detailed preoperative planning and accurate restoration of anatomical relationships in the operated joint.

The aim of the study was to evaluate the structure of pathological changes in the acetabulum in patients with posttraumatic hip arthrosis, to develop a method for their detailed description and to determine the tactics of choosing the type of acetabulum implant.

Methods. The results of treatment of 194 patients with the consequences of acetabulum fractures who underwent total hip arthroplasty in the period from 2014 to 2022 were analyzed. The study was conducted in two stages, at the first stage, the structure of pathological changes, such as defect, deformation, changes in the center of rotation and offset (relatively healthy contralateral joint), was analyzed. A method was developed for choosing the tactics of implantation of the acetabulum component, based on a detailed description of the defect and deformation of the acetabulum. The second stage analyzed the results of treatment of patients for whom planning and surgical treatment was carried out in the period from 2020 to 2022 using the proposed method.

Results. During the first stage of the study, it was revealed that the magnitude of the change in the indicators of the displacement of the rotation center and offset changes by more than 8 mm. statistically significantly increases the likelihood of complications by 17.9%. The restoration of the rotation and offset center reduces the number of complications by 22.3%. The proposed method makes it possible to statistically reliably restore anatomical relationships in the operated hip joint and reduce the number of complications by 10%.

Conclusion. The proposed method allows us to qualitatively and quantitatively describe pathological changes in the bone tissue of the acetabulum. Depending on the degree of displacement of the center of rotation, the walls of the acetabulum and the nature of the defect of the supporting bone tissue, the surgeon can determine the tactics of surgical treatment.

Traumatology and Orthopedics of Russia. 2022;28(4):66-78
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Surgical Approaches for Triple Pelvic Osteotomy in Children With Hip Dysplastic Instability: Assessment of Muscle Damage

Bortulev P.I., Baskaeva T.V., Barsukov D.B., Pozdnikin I.Y.


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 3rd and 7th 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.

Traumatology and Orthopedics of Russia. 2022;28(4):79-89
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Tactics of Surgical Treatment of Slipped Capital Femoral Epiphysis Associated With Mild Chronic Epiphyseal Displacement

Barsukov D.B., Bortulev P.I., Baskov V.E., Pozdnikin I.Y., Murashko T.V., Baskaeva T.V.


Background. The appearing of data on cam-type FAI in patients with sequelae of slipped capital femoral epiphysis characterized by mild chronic epiphyseal displacement suggests that along with fixation of the proximal femoral epiphysis, modeling of the head-neck transition and restoration of the femoral offsets using arthroscopic techniques should be performed. Meanwhile, it is well known that after epiphyseal fixation, complete remodeling of the epimetaphysis and, consequently, disappearance of the morphological substrate of potential FAI can occur due to the ongoing enchondral and echondral growth. In this regard, the issue of indications for intraarticular interventions in studied patients remains currently open.

The aim of the study was to determine the incidence of FAI in the postoperative period in patients with slipped capital femoral epiphysis characterized by mild chronic epiphyseal displacement, and to estimate the requirement of further surgical treatment.

Methods. The results of the examination of 32 patients with mild chronic epiphyseal displacement in the typical posterior inferior direction who underwent cannulated epiphyseal screw fixation were analyzed for the severity of epimetaphysis remodeling and the presence of FAI in the postoperative period. Clinical, radiological, magnetic resonance, and statistical methods were used.

Results. At the age of 18-19 years, FAI with pain syndrome in everyday life was found in 9 (28.1%) patients — 8 of them did not have even partial remodeling of the femoral component of the joint, another 9 (28.1%) patients did not suffer from pain syndrome in everyday life, but had other clinical, radiological and MR signs of cam-type FAI. Complete or almost complete remodeling of the proximal femoral epimetaphysis occurred in 14 (43.8%) patients.

Conclusion. In our opinion, therapeutic and diagnostic arthroscopy of the hip joint for the purpose of modeling the head-neck transition at the age of 18-19 years is indicated for more than one quarter (28.1%) of the investigated patients because of the presence of reliable signs of FAI.

Traumatology and Orthopedics of Russia. 2022;28(4):90-101
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Kinematic Comparison of Orthopedic Shoes and Ankle-Foot Orthoses in Children With Cerebral Palsy

Koltsov A.A., Aksenov A.Y., Dzhomardly E.I.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):102-113
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Biceps Brachii Distal Tendon Ruptures: Conservative and Surgical Treatment Outcomes

Medvedchikov A.E., Anastasieva E.A., Korytkin A.A., Lukinov V.L., Kirilova I.A.


Background. Interest in the study of the distal biceps brachii tendon ruptures in the recent decade has been caused by the development of instrumental diagnostic methods, the new sports disciplines appear and by the technological workplace environment complication. The main concepts of treatment depend on the injury term, the tendon tissue damage area, the patient functional needs and his/her professional activities, the comorbidity index (CCI), so the concepts are divided into two: conservative and surgical.

The aim of the study — to identify the most effective method of treating patients with a biceps brachii distal tendon rupture.

Methods. The study included 58 patients (all men) with a biceps brachii distal tendon injury. They were divided into groups depending on the concept of treatment: a conservative treatment group — 20 (34%) patients and a surgical treatment group — 38 (66%). The surgical treatment group was also divided into subgroups according to surgical approaches, reinsertion methods and types of fixation. Patients underwent physical tests (O’Driscoll, Ruland, et al.), ultrasound to compare the proximal radio-ulnar space, degree of muscle retraction, lacertus fibrosus involvement, and MRI of the elbow joint. The functional scales VAS, DASH and ASES were used to evaluate the obtained results. The results of instrumental diagnostic methods were evaluated with the L. Perera (2012) and J. Fuente (2018) classifications.

Results. Evaluation of the results in the groups of surgical (Ns) and conservative (Nc) treatment according to functional scales after 6 (VAS, DASH) and 36 months (ASES) revealed: a decrease in subjective pain score ≤ 1 point, a decrease in DASH to 21 and 43 points (statistically significant decrease in both groups p<0.001, difference between groups p = 0.005), ASES: 91 and 71 points (dynamics in both groups and difference between groups p <0.001). Minimally invasive approaches compared with open access (nD) showed better functional outcomes according to the DASH scale: nBA vs nD — p = 0.006; nMA vs nD — p = 0.013 after 6 months, and according to the ASES scale: nBA vs nD — p = 0.007; nBA vs nD — p= 0.002 after 36 months. An reinsertion methods intragroup analysis revealed the achievement of peak indicators by ≤ 6 weeks without complications in the anatomical variant according to the VAS: nBA vs nMA — p = 0.264; DASH: nBA vs nMA — p = 0.856; ASES — nBA vs nMA p = 0.179.

Conclusion. Comparison within subgroups made it possible to identify the most effective technique — combination of minimally invasive access with an anatomical version of intracanal fixation with a cortical button. This technique has shown to have a low risk of postoperative complications.

Traumatology and Orthopedics of Russia. 2022;28(4):114-125
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Results of Shoulder Adhesive Capsulitis Treatment With the Use of Platelet Rich Plasma and Nucleotide Drugs: A Comparative Study

Lychagin A.V., Bogatov V.B., Tselishcheva E.Y., Muzychenkov A.V.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):126-135
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Comparative Biomechanical Analysis of Ankle Arthrodesis Techniques: Experimental Study

Khominets V.V., Mikhailov S.V., Zhumagaziev S.E., Shchukin A.V., Ivanov D.V.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):136-147
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Hemodynamics and Tissue Temperature in Bone Union Area of Long Bones Primary Fractures and Refractures: in vivo Experiment

Kosimov A.A., Khodzhanov I.Y., Kononovich N.A.


Background. Adequate blood flow in tissues during bone union is a factor that enables to achieve positive treatment results.

Aim of study — to study in vivo experiment the features of temperature response and blood flow in consolidation area of tibial primary fractures and refractures.

Methods. A tibial fracture was simulated in rats and then immobilized with external fixator. In series 1 (n = 13) the fixation was kept until union. In series 2 (n = 18) a refracture was simulated 21 days after the surgery and refixed until union. The blood flow and tissue temperature were studied in the fracture area in normal conditions; 21 and 35 days after fracture or refracture; 28 days after the end of fixation.

Results. The temperature and blood flow were of the same type, but of different intensity. Three types of reactions were identified: 1) reduced blood flow velocity and tissue temperature, signs of venous outflow difficulty; 2) increased blood flow, unchanged venous outflow, reduced tissue temperature; 3) slight blood flow decrease, increased venous outflow, slight tissue temperature increase. By the end of fixation (35 days) all parameters in series 1 returned to normal. 28 days after the end of fixation the tissue temperature and venous outflow returned to normal in series 2 animals with the first and the second types of hemodynamics, their blood flow velocity decreased. As for the third type, the tissue temperature returned to normal, the venous outflow and the blood flow velocity increased.

Conclusion. In case of primary fractures, the blood flow and the tissue temperature normalized by the end of fixation. In case of refractures the changes persisted 1 month after the end of fixation.

Traumatology and Orthopedics of Russia. 2022;28(4):159-169
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Safe Arthroscopic Approaches for Epicodilitis: Topographic-Anatomical Study

Salihov M.R., Midaev A.I., Fomin N.F.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):148-158
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To the Question of Reparative Regeneration in Children

Miromanov A.M.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):170-174
pages 170-174 views


Economics of Total Hip Arthroplasty: Review

Sereda A.P., Shubnyakov I.I., Dzhavadov A.A., Mametov M.V., Tikhilov R.M.


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.

Traumatology and Orthopedics of Russia. 2022;28(4):175-182
pages 175-182 views

Management of Mallet Finger: Current Status (Review)

Volkova Y.S., Rodomanova L.A.


Background. Often, an incorrect treatment tactic injuries of the “mallet finger” can cause a pronounced dysfunction of the finger. In addition, remaining finger deformation can significantly reduce the aesthetic satisfaction of the patient. The relevance of the problem of this injury type can be mainly explained by the lack of a unified algorithm for choosing treatment tactics, and, as a result, a high percentage of unsatisfactory clinical results.

Review purpose — to assess the current state of the problem and the effectiveness of the proposed methods of treatment of “mallet finger” based on the analysis of the literature

Results. The lack of a single protocol for the treatment of “mallet finger” leaves the question of choosing the optimal tactics open. The variability of interventions and indications for their implementation force specialists to rely on their own empirical experience when determining tactics in each clinical case. The search continues for the optimal type of suture and methods of immobilization with a closed injury in the Zone I to improve clinical results and minimize the risk of potential complications. The proposed modifications of blocked osteosynthesis have their own advantages, however, they require future studies on a larger cohort of patients to confirm their effectiveness. Various internal implants that allow to achieve anatomical reposition require additional studies due to the high risk of complications and insufficient stability of fixation. The obtained data are not enough to make a reasonable decision on the choice of the optimal method of treating the pathology in question. Along with a high percentage of complications, these factors significantly worsen the functional outcomes of treatment.

Conclusion. Literature analysis shows that there is an active search for new surgical methods for the treatment of mallet finger injuries among both Russian and foreign specialists. The data obtained are not enough to make a reasonable decision on the choice of the optimal method of treating the pathology in question, since the results of the studies carried out are rather contradictory or require verification. This determines the need to improve treatment concepts with the elimination of existing shortcomings in order to create a well-founded algorithm for choosing a rational technique.

Traumatology and Orthopedics of Russia. 2022;28(4):183-192
pages 183-192 views

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