卷 19, 编号 3 (2013)

In the article the results of 67 procedures of soft tissue reconstructions for the patients with open tibia fractures were analyzed. In the group, where the authors used skin rotational flaps, afterwards there were 3 (37.5%) patients with deep infection. The skin flap necrosis was diagnosed in 5 (62.5%) cases. In the group, where the authors used the reverse sural flap the deep infection occurred in 2 (28.6%) cases, but the flap necrosis developed in 3 (42.9%) cases. In the group where the authors used local muscular flaps, the deep infection occurred in 5 cases (13.2%) and the flap necrosis developed in 5 cases. In the group where we used the free muscular flap there was only 1 patient who got the deep wound infection and there were 2 patients who got necrosis. The clinical results that demonstrated the best healing and minimal complication rate of muscular flaps were confirmed high blood flow data in those flaps, measured by laser Doppler flowmetry. It means that using muscular flaps technique is most suitable for the soft tissue reconstructions in open tibia fractures. The type of the flap’s utilization is not important. Skin flap is a second line method of choice if it’s not possible to use muscular flap technique.

Purpose: a clinical rationale for using reference structures of the intercondylar space to determine the femoral footprint of the ACL. Material: sixty one patients with ACL deficiency who underwent anatomic anterior cruciate ligament reconstruction using single-bundle «bone-patellar tendon-bone» autograft. Methods: radiography and radiometry, computed tomography, arthroscopy, arthrometry. Results: lateral intercondylar and lateral bifurcate ridges can be verified arthroscopically with a frequency of 94% and 48%. Orientation of the femoral tunnel formed using reference structures is more horizontal in coronal plane and has increased sagittal slope compare with traditional technique. Conclusions: The lateral intercondylar and lateral bifurcate ridges can be used as reference structures for femoral tunnel formation during anatomical anterior cruciate ligament reconstruction.

The purpose of the study was to expand the possibilities of metatarsus primus varus percutaneous correction through the development of surgical technique, taking into account the advantages and disadvantages of known techniques. Materials and method: by the example of 67 surgeries the results of the first metatarsal displaced distal percutaneous osteotomy fixed by the screw were reviewed. Surgical technique was described. Proposed intervention was applicable over a wide range of the first intermetatarsal angle (from 12 to 29° in this series). Immediate fool weight-bearing was authorized. An average hospital stay was 1.02 due to the painless early postoperative period. Results: desired correction of the first metatarsal has been achieved in the course of all surgical interventions. Partial or complete loss of correction in the postoperative period, that did not affect final results, was registered in three patients after interventions on four feet. The average first intermetatarsal angle after surgery was 10.6 ° (4-16). No transfer metatarsalgia, infectious or other complications were noted, as well as unsatisfactory results. Conclusions: first metatarsal fixed displaced distal percutaneous osteotomy together with previously proposed percutaneous first metatarsocuneiform joint arthrodesis technique allows percutaneous correction of any degrees of metatarsus primus varus.

Objective - to reveal the phenotypic features of undifferentiated connective tissue dysplasia in the form of dysplastic syndrome. Material and methods. The study included 477 children (240 boys and 237 girls) with cerebral palsy (CP) aged from 1 year to 17. The control group consisted of 134 healthy children (70 boys and 64 girls) aged from 2 to 16. For verification of undifferentiated connective tissue dysplasia international phenotypic Glesby scale, Abakumova scale and Kadurina and Gorbunova scale were applied. Results. Depending on used criteria, the clinical signs of dysplastic syndrome were found in 77,3-80,9% of children with cerebral palsy compared with 14,2-15,7% in the control group. There were statistically highly significant (p <0,001) difference in the number of markers and the severity of the dysplastic syndrome in children with cerebral palsy compared with healthy children and children with double hemiplegia in comparison with other forms of cerebral palsy. It was concluded that the CP should be seen as a manifestation of systemic organ dysplasia (dysplastic syndrome). This should be considered during the examination, choosing the tactics of conservative treatment with the principle of "control ripening," The timing and methods of surgical repair of motor disorders in children with cerebral palsy.

The structure of cancellous bone of the proximal tibial epiphysis using CT and measurement of Leeb hardness was investigated. The author found that subchondral layer as thick as 10 - 15 mm which corresponds with the thickness of impressed fragments of tibial condylar fracture has the density and elasticity modulus up to 84,4% of lowest threshold value of the compact bone. In more deep layers from cartilage the cancellous bone progressively loose it’s density and hardness and deeper than 40 mm they reach their lowest threshold value. Higher level of plating with screwing through impression fragment can persist significantly more (p<0,05) cyclic loading (24066±2015) even without bone grafting, than the same fixators inserted lower with deeper than 20 mm screwing through the bone graft (2133±446 cyclic loading). Such application of the plate with passing screws through subchondral layer of impression fragments at the level of 5-7 mm from joint cartilage can be achieved by anatomic preoperational pre-bending of any fixator.

The three-dimensional kinematics of both the ankle and the subtalar joints was examined after cutting and subsequent repairing the lateral ligaments using three anatomical procedures: direct repair, tendon graft and carbon-fibre implant. All procedures restored the original kinematics of the subtalar joint, except the plantar/dorsiflexion. For the talocrural joint, the tendon graft and the carbon fibre implant left a minimal laxity for the inversion/eversion and internal/external rotation movements. The direct repair procedure restored the physiologic kinematics almost completely and gave the best results, allowing to restore almost completely the physiologic kinematics. Each procedure respected the insertion points and the directions of the original ligaments. However, the different results for the direct repair and the other two anatomical procedures show that this condition alone is not sufficient to restore the kinematics of the talocrural and subtalar joints perfectly. None of the procedures caused a movement restriction. Thus, we recommend the direct repair of the ligaments as the method of choice. If the quality or the conditions of the ligaments do not allow a direct repair, we recommend to use another anatomical reconstruction.

Purpose - to study the roentgenomorphological features of the lower limb long bones in patients with chronic osteomyelitis using the technique of multi-spiral computer tomography (MSCT), and to propose the complex of parameters to assess bone quality. Material and methods. Roentgenography and computer tomography of the hips were performed in 49 patients with chronic osteomyelitis of long bones of lower extremities. The studies made using computer tomographs GE Light Speed VCT, Toshiba Aquilion-64, Somatom Smile. Results. The changes in bone structure of proximal femur were characterized by extremely marked polymorphism, and they almost didn’t repeat in the anatomical component. The cortical plate had heterogenous structure with resorption zones in the area of its transfer to the shaft. The character of roentgenomorphological changes in the shaft was individual in all the patients, but there were common manifestations as well which consisted in thickening of the cortical plate, different intensity of periosteal and endosteal layers. The cortical plate was significantly different in density, which exceeded 1700 HU in some places. When osteomyelitic process localized in the knee marked changes affected its all components, they manifested themselves in extended osteoporosis and local osteosclerosis. When osteomyelitic process localized in proximal tibia extensive resorption zones observed, the cortical plate thinned in proximal parts, its density was not more than 350 HU. Conclusion. The data demonstrated that bone quality in patients with chronic osteomyelitis had significant deviations from normal values in terms of changing both its density and architectonics. The deviations consisted in bone density decrease in the meta-epiphyseal part regardless of the process localization, in highly variable density values of the cortical plate as a result of its thickening or thinning, presence of resorption or sclerosis areas.

The analysis of results of surgical treatment of 154 patients with a vertebral and spinal trauma of chest and lumbar departments of a backbone aged from 16 till 75 years is carried out. All patients were operated in Bryansk city hospital N 1. The volume and sequence of surgeries, and existence were defined with the combined damages, character of an injury of a backbone and a spinal cord or absence free part bone bodies of the injured vertebra compressing a spinal cord defined different accesses on a backbone. So, surgeries at 125 (81,2 %) patients were carried out from one back access, at 23 (14,9 %) patients - to the combined back and lobbies and at 6 (3,9 %) patients - front and back access. In all cases for fixing of a spine implants “Sintez” firm (St. Petersburg) were used. Results of treatment were estimated on neurologic dynamics, restoration of an axis of a backbone, a gleam of the vertebral channel and restoration possibility of a support of a backbone. Good results of treatment are received at 87 (56,5 %), satisfactory - at 55 (35,7 %) and unsatisfactory - at 12 (7,8 %) patients.

Smith-Lemli-Opitz syndrome is rare genetic disorder with multiple limb malformations and neurological manifestation, caused by inborn defect of cholesterol metabolism. Congenital deformities of feet and hands are most common orthopedic symptoms in this syndrome. Description of a girl with Smith-Lemli-Opitz syndrome demonstrates specific features of this disorder and emphasize the importance of proper interpretation of orthopedic malformations for early diagnosis of genetic conditions.

Objective: to improve the results of surgical correction of flexion contracture of knee joint in patients with cerebral palsy. Material and methods. 196 patients with cerebral palsy aged from 2.5 to 18 years old were examined. In 131 patients aged from 8 to 18 years old we performed lengthening of tibia flexors with posterior capsulotomy and without it, in 4 patients aged from 11 to 16 years old the contracture was corrected after preliminary reduction of muscle tone using lumbar dorsal selective rhizotomy (LDSR). Among 246 operated segments a slight contracture in 23 cases was eliminated only with lengthening of tibia flexors, in the remaining 223 cases in addition after lengthening of tibia flexors the residual contracture was corrected by the method of pre-dosed correction in plaster cast. In 16 segments if there was a severe contracture we performed a posterior capsulotomy of knee joint. Besides, we investigated the dependence of contraction degree from phase-tonic activity of tibia flexors, as well as the influence of LDSR on the possibility to correct flexion contracture in 65 knee joints of patients aged from 2.5 to 16 years old. Results. The high degree of dependence of knee flexion contracture (KFC) from tone increase of tibia muscle flexors (correlation coefficient r p<=0,01 in patients aged from 2.5 to 7 years old is 0,942, 8-16 years old - 0,712). Probably that is why in 65 investigated joints using LDSR the contracture was corrected in the younger age group in 50 %, in elder age group - in 46 % cases after reduction of muscle tone - tibia flexors by 59% and 37%. Taking into consideration the data we worked out the indications for different variants of surgical correction of KFC depending on the degree of its intensity and with account of muscle hypertonia. As a result of the appliance of differentiated approach the contracture was corrected in 91,6 cases. Conclusion. The main causes of knee flexion contracture in patients with cerebral palsy are contractures and muscle imbalance in contiguous segments, predominance of tibia flexor tone and weakness of soleus muscle. Differentiated approach allows correcting contracture in most cases.

This report presents the results of the operative correction of the pectus excavatum in 45 children aged from 5 to 15 years. In relation to the elasticity degree and age of the patients there was performed correction of the pectus excavatum by method of D. Nuss and in modification with application of a metal plate of the own construction. At normal elasticity (degree I) of the anterior sternocostal complex in 22 (48,9%) patients was executed operative intervention by method of D. Nuss, with good result in 21 (95,4%) and satisfactory in 1 (4,5%) patient. At moderate degree of elasticity (II-degree) in 13 (28,9 %) patients procedure of D. Nuss in modification of our clinic was performed. The correction of the pectus excavatum was carried out by chondrotomy of the deformed ribs and placement of the metal plate under the sternocostal complex. The good results were noted in 11 (84,6 %) patients, satisfactory - in 2 (15,4%). At the hypopastic sternocostal complex (degree III) the deformation was removed by Т-shaped or cross sternotomy with chondroresection of some ribs and then placement of the metal plate of D. Nuss under sternocostal complex. The good results were found in 7 (70 %), satisfactory - in 1 (10 %) and unsatisfactory - in 2 (20 %) patients. Thus, the long-term results of treatment depend on the elasticity of sterno-costal complex and the child’s age.

The authors have evaluated the clinical examination of the patients with axial malalignments in the knee by the original method and device which was named varovalgometer. The measurements were conducted by tension of the cord through the spina iliaca anterior superior and the middle of the lower pole of patella. The deviation of the center of the ankle estimated by metal ruler which was positioned perpendicular to the lower leg axis on the level of the ankle joint line. The results of comparison of our method and computer navigation in 53 patients during the TKA show no statistically significant varieties but they differ by average 5° of valgus in clinical examination in comparison with mechanical axis which was identified by computer navigation. The dynamic control of axial malalignment can be used in clinical practice for estimation of the results of treatment of pathology with axial deformities in the knee; for the control of reduction and secondary displacement of the fractures around the knee; for assessment of instability; in planning of correctional osteotomies and intraoperative control of deformity correction; for estimation of Q angle in subluxation and recurrent dislocation of patella; in planning of TKA; during the growth of child it allows to assess the progression of deformity.

The article in generalized form acquaints with the publications devoted to the bases of proximal humeral fractures treatment. A brief digression on anatomy and biomechanics of the humeral joint allows to consider the main morphological features of it. The most commonly used classification of proximal humeral fractures concisely classify many types of damage. According to the clinical and anatomical characteristics of fractures tracked the historical aspect, the development and the current state of the most common methods of treatment. In his review collected works authors share their experience in the application of methods. It allows to further the perspective directions.

The objective - to study the psychological characteristics of response to the stress associated with hospitalization in patients with injuries admitted to the emergency or the purpose of perform routine reconstructive plastic surgery for the consequences of injuries. Material and methods. The assessment of emotional response to the hospitalization stress was performed in 60 patients with injuries and its consequences. The study was carried out using Spielberger - Hanin scale, Luscher eight-color test, the scales of Covey and Tsung. The levels of personal and reactive anxiety, and the presence of somatoform disorders were determined. Results. When emergency and planned hospital admissions for injuries and its consequences the level of personality anxiety was corresponded to parameters of the «moderate anxiety», but the definition of the level of reactive anxiety showed a statistically significant increase in the index in the study group - 44,4 ± 6,5 in comparison with 39,9 ± 4,0 (p = 0.034). There was a significant number of patients in the main group with somatic diseases (headaches, dizziness, tachycardia, extremity tremor, etc.). Conclusions. It is advisable to take into account the significant influence of psychogenic factors and psychosomatic disorders on treatment outcomes and to consider the psycho-emotional profile of patients with trauma and orthopedic diseases. If necessary, the methods of psychological correction should be applied.

The article is devoted to the history of the methods of surgical treatment of the peripheral nerve injuries. The analysis of domestic and foreign publications on this question has shown the basic surgical operations used today for nerve’s repair were developed and introduced by surgeons - innovators in second half of 19th century. These operations had unequal popularity in a different historical period. The subsequent generations of surgeons basically have improved earlier invented surgical procedures.