Vol 23, No 3 (2017)

The incidence of knee osteoarthritis tends to increase every year and constitutes more than 83% of overall OA morbidity. Moreover, the OA morbidity among younger patients is also increasing. However, currently available treatment methods do not provide quite satisfactory outcomes.

Purpose of the study – to evaluate safety and efficacy of intraarticular introduction of autologous adipose-derived stromal vascular fraction for treatment of knee osteoarthritis.

Material and methods. By the moment of writing the present report, 28 patients were included into the study. All patients underwent tumescent liposuction under local anesthesia. The stromal vascular fraction was isolated from lipoaspirate within 1,5 hours after harvesting and subsequently injected into the articular cavity. Follow-up period was 6 months after injections. The authors report on efficacy data of 10 patients who completed the study according to protocol and safety data of all 28 patients. Efficacy was evaluated basing on laboratory assessments and patient’s subjective assessment by validated questionnaires.

Results. Neither adverse reactions no adverse events were observed. Significant decrease of pain severity by VAS was noted in one week after injection and pain score continued decreasing during the whole follow up period. The increase of KOOS score was noted starting on the fifth week after injection. KSS part 1 score increased in 8 weeks, KSS part 2 score — in 6 months after injection. Physical health, assessed with SF-36 questionnaire significantly improved in 2 and 6 months after the procedure. There was a clear trend towards improvement of mental health.

Conclusion. Preliminary results of clinical study suggest intraarticular injection of autologous adipose-derived stromal vascular fraction to be a safe and efficient method of the treatment of knee osteoarthritis. 

Introduction. The consequences of infantile septic arthritis are quite diverse and can manifest themselves as a damage to the growth zone, deformation and destruction of the articular components, and violation of the articular relationships. To treat this pathology, technically complex and traumatic surgical interventions are used. The purpose of this work is to analyze the medium-term results of the use of these methods in the treatment of children with septic coxitis consequences.

Material and methods. The outcomes of treatment for 37 children with consequences of septic coxitis using Ilizarov apparatus were analyzed. Average age of patients at the time of the surgery was 8.2±0.5 years (from 6 to 10 years). Follow up period was from 3 to 10 years (average 4.7 years). Functional outcomes were assessed by C.L. Colton, radiologic indices — by E. Severin score and J. Kruczynski.

Results. Patients were distributed into three groups according to anatomical features. Functional outcomes of patients in the 1st group: good (12–15 points) — 3 joints, satisfactory (9–11 points) — 5 joints, unsatisfactory (8 points) — 1 joint. X-ray findings of patients in the 1st group according to J. Kruczynski criteria: good — 5 joints, satisfactory — 4 joints; by E. Severin criteria: Ia — 1, Ib –1, IIa — 2, IIb — 3, III — 2. Functional outcomes of patients in the 2nd group: good (12–14 points) — 10 joints, satisfactory (9–11 points) — 8 joints. Distribution in the second group by J. Kruczynski criteria: good — 9, satisfactory — 9; by E. Severin criteria: IIa — 14, IIb — 4. Distribution of functional outcomes in the 3rd group in accordance with C.L. Colton criteria: good (12–15 points) — 3 joints, satisfactory (9–11 points) — 7 joints. Distribution in the third group according to J. Kruczynski criteria: good — 4, satisfactory — 6; by E. Severin criteria: IIa — 5, IIb — 4, III — 1.

Conclusion. The use of the presented transosseous external fixation technique in children with the consequences of septic coxitis provides sufficient stability of the joint without causing its decompensation and stiffness. The use of the Ilizarov fixator extends the age limits for reconstructive treatment of abnormal distal hip dislocation. 

Objective — to develop and implement improved approaches to the diagnosis and tactics of surgical treatment in patients with fractures of the distal tibia metaepiphysis.

Material and methods. The study included 126 patients with fractures of distal tibia metaepiphysis of «B» and «C» types who underwent internal fixation with plates in 2005–2012. The authors analyzed surgical treatment outcomes within the period from 2.5 to 9 years (average of 5.7–2.3 years) of postoperative follow up. Average age of patients was 23.4±2.1 years. Patients were divided into the main group (64 patients) and the comparison group (62 patients). In the comparison group, traditional approaches to diagnosis and surgical treatment were used, including standard clinical examination and X-rays of the affected ankle in two views and the median access to the distal tibia metaepiphysis. In the main group, a specially elaborated algorithm for selection of optimal surgical tactics was utilized basing on the improved diagnostics program. Clinical and functional data were assessed by Foot and Ankle Outcome Score (FAOS) and SF-36 Health Survey. Roentgenological assessment was done by X-rays and CT scans. Statistical significance of the differences was evaluated by Wald-Wolfowitz and Fisher tests.

Results. Improved approaches to the tactics of surgical treatment in patients with pylon fractures of «B» and «C» types allowed to reduce the incidence of unsatisfactory anatomical and functional outcomes from 43.5% to 28.1%. The number of satisfactory and good outcomes increased by 4.7% and 10.7% respectively after application of improved therapeutic and diagnostic approaches.

Conclusion. Proposed improved approaches to verification of severe intraarticular fractures of the distal tibia metabiphysis allowed to increase the informative value of the diagnostic procedures and to avoid discrepancies between preand intraoperative assessment of fracture type by classifications of M. Mueller-AS (1989) and X. Tang, P. Tang (2012) as well as to avoid diagnostic errors in detecting the facet impression of the distal tibia metaepiphysis. 

The problem of replacement of large bone defects resulting from segmental bone resections in patients with bone tumors is still actual in modern orthopedics. Segmental defects cause the main difficulty especially in cases of disturbance of normal biomechanics while the “gold standard” of reconstruction with bone autograft is not always possible. The reason is that the defect can be so extensive that would make it impossible to harvest necessary autobone stock. Therefore, allografts based on demineralized bone with optimal properties for osteoregeneration are used as an alternative for autograft. For certain composite materials it is possible to program the properties of future graft by changing its compound. Literature analysis revealed that the effectiveness of the allograft in combination with additional components is comparable to autograft effectiveness. Mesenchymal stem cells of both bone marrow and adipose tissue can be used as an additional component to improve osteoregeneration. It is noteworthy that the analyzed studies did not reveal the influence of stem cells on the tumor recurrence. Nevertheless, the authors support the need of further researches in this area to confirm gained results. Some authors still prefer traditional methods of bone traction despite obtaining own satisfactory results of defects reconstruction with allografts. Such opinion is based on proven effectiveness of the method, structural stability of construction during treatment period and ability to adjust the process of bone regeneration at any stage. The authors goal was to analyze publications over the recent 5 years with the results of experiments and clinical studies on the replacement of large bone defects after bone tumor resection with autoand allografts. Based on the literature analysis the authors propose a general algorithm for graft selection in replacement of large bone defects after segmental bone resections. 

Background. Rib penetration into the spinal canal in patients with scoliosis secondary to neurofibromatosis type-1 (NF-1) was described in a relatively small number of publications, though it’s common in clinical practice and not always diagnosed.

Materials. The authors report on an adolescent male with NF-1 left thoracic kyphoscoliosis and rib head protrusion into spinal canal with mild initial neurological deficit.

Results. A 14-year-old male patient with NF-1 and 68 degrees left thoracic scoliosis and 65 degrees kyphosis was undergoing treatment at the authors’ institution.Preoperative CT scans demonstrated protrusion of the left T11 rib head into the spinal canal on the convexity of the curve, without spinal cord compression. Surgical procedure for resection of the rib head and correction of the spinal deformity was performed which allowed to achieve good deformity correction. The authors also observed almost complete restoration of sensitive functions.

Conclusion. Rib head protrusion into the spinal canal can occur in cases of spine deformities with NF-1. If present, the imaging findings should be carefully reviewed for appearance of such lesion that may be obscured by the limitations of CT in the context of a dysplastic spinal deformity.

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Elimination of congenital shortening of lower limb still remains a complex and unsolved orthopaedic task which requires an improved fixation technique as well as adjusted tactics of treatment and rehabilitation procedures.

Purpose of the study — experimental approval of femur lengthening technique by external fixation with Ilizarov apparatus and internal fixation by plate.

Materials and methods. Femur lengthening was performed in 6 mongrel dogs. Average animal age was 1,5±0,3 years, average weight — 20±5 kg, femur length — 22±2 sm. External apparatus with two supports and a titanium plate of an original design were applied under general anesthesia on the right femur of animals. Lengthening was performed manually at a rate of1 mm per day in 4 stages at a distance of 10% from initial segment length. External apparatus was removed on the last day of distraction after locking the plate. X-ray examination was done on the day of surgery, in 7, 14 and 25 days from the onset of distraction as well as in 14, 30, 60 and 90 days after completion of distraction and removal of external apparatus. Three animals were taken out of experiment in 30 days of fixation, remaining three animals — in 90 days. After euthanasia the authors performed autopsy of the organic femur complex and tissues contacting the plate.

Results. The use of operated limb was not restricted during the whole distraction period. The authors observed first roentgenological signs of distraction osteogenesis on 7th day of lengthening. By the end of distraction period, at 25th day, shadows of regenerates demonstrated longitudinal striated structures in all cases. Median lucency area of 1–5 mm was located diagonally and across the regenerate or was intermittent. In 60 days of fixation X-rays demonstrated homogeneous regenerate. External fixation index was 13,9±1,5 days/sm (p≤0,05). The authors observed no cases of implants fracture or deformity during the experiment.

 Conclusion. Application of the developed plate in combination with external apparatus demonstrated high efficiency for femur lengthening in experiment study.

The aim of the study was to evaluate clinical and radiological outcomes of knee arthroplasty using patient specific guides produced using physical prototypes and 3D printing that are applied for positioning of resection blocks.

 Materials and methods. The authors analyzed the treatment outcomes of 4 patients during the period from 2015 to 2016 who underwent total knee arthroplasty for posttraumatic gonarthrosis of III-IV stage with the use of patient specific guides for resection blocks positioning. The mean age of patients was 59±12 years. Initially, all patients reported marked limitation of movement in the knee joint. The average flexion prior to surgery was 53.3±35.1°. According to FLFS roentgenography all patients had a varus deformity of the lower limb with an average value of 15.0±12.3°.

Results. In all cases the axis of the lower limb was normalized postoperatively. The average KOOS score for “pain” was 85.2±14.0, for “daily physical activity” — 74.5±14.8, for “symptoms and stiffness” — 69.0±11.0, for “quality of life” — 62.5±12.5 points. Average knee ROM after arthroplasty: flexion 113.3±5.787° and full extension. Such outcomes can be considered as excellent considering preoperative marked knee movement limitations in all patients.

Conclusion. Preoperative planning using the technology of producing patient specific guides and prototyping on physical tibia and femur models allowed to restore normal axis of the lower limb. The authors observed a significant improvement in joint function and a pain syndrome reduction in all patients. In authors’ opinion patient specific precision guides can be used in the following cases: inflammatory process or deformation of the femur in patient’s history; when the use of intramedullary guides is difficult and does not allow positioning of the prosthesis components with sufficient accuracy or is associated with an increased risk of a purulent-inflammatory process; ipsilateral hip joint prosthesis when it is desirable to avoid opening the medullary canal; substantial bone defects or massive osteophytes of the posterior portion of femoral condyles that impede correct rotation of the femoral component; severe movement limitations in the knee joint, when it is technically impossible to perform TKA using computer navigation and the use of a standard set of instruments poses significant technical difficulties.