卷 22, 编号 1 (2016)

Purpose of the study - to validate the selection algorithm of surgical treatment for patients with advance stage of ankle joint deforming arthrosis based on comparative analysis of risk factors for failed cases of fusion and joint replacements. Material and methods. The authors analyzed poor treatment outcomes and reasons therefore after ankle joints fusion and replacement surgeries performed at Vreden Russian Research Institute of Traumatology and Orthopaedics starting 2003 till 2014. First study group included 63 patients who underwent biarticular fusion of ankle and subtalar joint by intramedullary locked nail; second study group included 71 patients after ankle joint replacement using the following implants: Mobility (DePuy) - 27 patients, Hintegra (NewDeal) - 37 and STAR (Waldemar Link) - 7 patients accordingly. Clinical and radiological examination of patients as well as their surveying on pain rating scale and AOFAS scale was carried out in the period starting 6 months to 10 years from surgery. Results. Study results proved that severe deformities of ankle joint bones particularly varus or valgus deformities with angle above 100 preclude the possibility to correctly position the implant components and do not promise long term and successful functional recovery. Thus, fusion of affected joint should be recommended as treatment option to patients with abovementioned heavy deformities of angle joint. Reasonable fusion angles for ankle joint around 90950 in sagittal plane could diminish potential rapid arthrosis progression in midfoot joints. Conclusion. In view of identified risk factors for development of morbid conditions that account for poor surgical outcomes of ankle joint fusion and replacement, basing on own research results and specialized literature data the authors have validated and presented the selection algorithm of surgical treatment options for patients with end stage of deforming arthrosis

Introduction. Approximately 90% of the rheumatoid arthritis patients present with foot symptoms. Rheumatoid foot is characterized by toe dislocations and chronic wounds due to the corticosteroid treatment. In case of surgical intervention metatarsophalangeal joints excision arthroplasty remains the standard. To perform second through fifth metatarsal head resection extensive transverse plantar or longitudinal dorsal incisions are routinely used. The rate of the wound-healing problems after rheumatoid foot surgeries is 23-45%. The purpose of this study was to demonstrate the possibilities and advantages of the rheumatoid arthritis patients with severe forefoot deformities minimally invasive surgical treatment and to develop mini-invasive approach for central metatarsal heads resection. Material and methods. By the example of 23 rheumatoid arthritis female patients (30 feet) surgical treatment possibilities of percutaneous techniques in severe forefoot deformities correction were demonstrated. The average age of the group was 54.5 years (range, 39 to 72). There were 24 primary surgeries and 6 repeated. Four feet had chronic wounds. Percutaneous techniques were used to correct all the forefoot deformities components but central metatarsal head resections (7 cases). To make them minimally invasive plantar approach has been developed. Surgical technique of the central metatarsal heads resection using proposed approach was presented. Decision-making algorithm for choosing appropriate surgical technique (to perform first metatarsophalangeal arthrodesis with central metatarsal heads resection or joint-preserving surgery) was proposed, including functional test, performed under fluoroscopic control and tricks for the dislocated fifth toe reduction. Results. The mean follow-up was 12 months (range, 3 to 52). The average hospital stay was 1.23 days. No infectious or wound-healing problems were noted. Chronic wounds have healed in four weeks after surgery. Overall, patients were satisfied with the result of the 12 surgical interventions and satisfied with reservations with the result of 18 surgeries. Unsatisfactory results were not noted. Average preoperative AOFAS score was 23.7 points (range, 0 to 34); postoperative 79.2 points (range, 52 to 100), the average AOFAS score increase was 55.5 points. Conclusions. Percutaneous techniques allow correction of nearly all severe forefoot deformities components in rheumatoid arthritis patients, eliminating the need for first and fifth metatarsal head resection and significantly reducing the need for central metatarsal head resection. If central metatarsal head excision is necessary, they can be removed using minimally invasive 2-3 сm plantar approach, proposed by the author, thus reducing the risk of wound-healing complications.

We have analyzed the results of 32 TKA of 32 patients after fractures of the proximal tibia, which were operated in the period from 2011 to 2014. We have used intramedullary stems for tibial component in 28% of cases, CCK implants in 15.6% of cases, metal augments for bone defects in 25%, in 59.4% of cases autologous bone, cementation for minor defects was performed in 68.8% of patients. 12 of 32 (37.5%) operations were performed under the control of computer navigation (Orthopilot). Average KOOS score one year after the operation in subscales was as follows: "pain" - 86.1 (69,4-97,2), "daily physical activity" - 80,8 (57,4-92,6), "symptoms and stiffness "- 67,8 (57,1-85,7)," physical activity in sports"- 30,0 (5,0-70,0)," quality of life "- 50.0 (37,5- 81.3). The average ROM after the operation was as follows: flexion 100 degrees (90-120), extension 0 degrees (0-5), which corresponds to good and excellent results. There was only one case (3.1%) of septic instability, requiring a two-stage revisional surgery by articulating spacer. All the patients after surgery had a significant improvement of joint function and reduction of pain. However, these patients are at risk for postoperative complications and require a special approach when performing arthroplasty. Treatment outcomes are due to the restoration of axial and rotational alignment, normalization of the joint line by the use of augments, elimination of instability in the joint by application of CCK implants.

Purpose - to assess the correlation between tunnel position according to radiological data after ACL reconstruction and surgeon’s estimation during surgery. Material and methods. The study included 86 patients who underwent primary ACL reconstruction with the same surgeon and surgical technique in European Clinic of Sports Traumatology and Orthopedics between 2013 and 2015. In all cases hamstring autograft was used and patients received coronal and sagittal radiographs on the first day after surgery. Surgical data on tunnel position were obtained directly from the OR as dictated by the performing surgeon and fixed in the special registry. Radiological data were exported to eFilm, Merge Healthcare software for graphical analysis. Results. The study group included 54 male and 32 female patients, mean age 35.2 ±1,13, range from 17 to 56 years. Analysis of surgical data showed the median femoral tunnel angle on coronal plane to be 45° (IQR 45° - 60°), angle which occurred most often was 45°, median tibial tunnel angle on coronal plane appeared to be 30° (IQR 30° -35°), angle which occurred most often was 30°. According to radiological coronal plane data median femoral tunnel angle accounted 32° (IQR 28° -36°), angle which occurred most often was 35°, while median tibial tunnel angle accounted 20° (IQR 17-25°,) angle which occurred most often was 19°. Coronal plane mean tibial plateau width was 90,2±,1,1mm with tibial tunnel center located on the 48.55% from the medial side. Sagittal plane mean tibial plateau depth was 53,8 ± 0,6 mm with tibial tunnel center located on the 43.95% from the ventral side. Median tibial plateau posterior slope on the sagittal plane accounted 8° (IQR 6°-9°). Conclusion. Tunnel placement during arthroscopic ACL reconstruction could hardly be standardized. Anthropometric differences between patients can lead to different bone tunnel positions even if the procedure is performed by the same surgeon and surgical technique.

The tibialis posterior tendon is the most superficial structure, passing behind the medial malleolus in the groove, which continue to strong fibro-osseus tunnel. Dislocation of the tibialis posterior tendon - a rare pathology, caused often by trauma. Analysis of foreign literature revealed that at present, since 1968, there is a description of only 34 cases of such injury. In russian literature such cases have not been described. The first case of this pathology is described by C. Martius in 1874. The authors analyzed the recent literature on this issue, and present a case of surgical treatment of the posterior tibial tendon dislocation. Patient had an injury during playing football and it was a direct trauma. During the MRI, radiologist had suspected dislocation of posterior tibial tendon, and the patient was sent to Vreden Institution of Traumatology and Orthopedics. Patients underwent surgery: recess medial malleolus groove was deeped, a flexor retinaculum flap was made, then it was fixed by transosseous sutures to the tibia. At one year follow-up patient showed a complete range of motion in the joint, the absence of any pain and returned to the previous sports activity. This article shows the difficulty for the diagnosis of traumatic dislocation of the posterior tibial tendon and shows the possibilities of surgical treatment in such cases.

Radial head fractures constitute about 3% of all fractures and 30% within the group of elbow joint injuries. Conventional open surgical treatment is accompanied by an extensive soft tissue incision and sometimes by capsule release for adequate visualization. Arthroscopic methods feature relatively insignificant soft tissue trauma, allow to reduce pain syndrome in postoperative period and to accelerate rehabilitation. Besides, arthroscopy improves surgical view in cases of intraarticular fractures and facilitates a better anatomical reduction of articular surface. The authors demonstrate a clinical case of a patient with closed fractures of radial head and ulna coronoid process with displacement of left elbow joint fragments where arthroscopic surgery provided for good anatomical and functional results.