卷 26, 编号 1 (2020)

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Relevance. The development of the modern principles of combined tumor treatment has significantly improved the survival of the patients. For these patients, the organ-preserving surgerybecomes now the mainstream tactics. For the restoration of the lower limb support ability and the hip function, the hip arthroplasty is now the most used type of surgery. Purpose of the study. The purpose of this work was to evaluate the long-term results of hip arthroplasty in the patients with extensive proximal femur defects caused by tumors and tumor-like lesions. Materials and Methods. The data on 126 patients with proximal femur tumors, undergone the surgical treatment in 2000–2013, were collected and summarized. The average age of the patients was 53.8 years (26–74), 94 women (74.6%), and 32 men (25.4%). There were 16 primary malignant bone tumors (12.7%), 10 benign aggressive (7.9%); 92 metastatic (73%), and 8 tumor-like lesions (6.4%). The average follow-up after the surgery was 72.6 months. The complications classification and analysis were performed according to the criteria of the International Society of Limb Salvage 2014 (ISOLS 2014). For the assessment of the functional result, patients were divided into 4 groups. In this context, the following indicators were taken into account: whether the acetabular component or the bipolar head were used, and the method of the soft tissues fixation to the femoral component of the endoprosthesis. Functional outcome was evaluated using the international Musculoskeletal Tumor Society (MSTS) scoring system at 3, 6, and 12 months. Results. The total number of complications, identified during the observation period from 2000 to 2018, was 26 (20.6%). The oncological complications, represented by local recurrence, were detected on average after 11.5 months. The total number of local recurrences is 6 (4.7%) which amounted to 23% in the structure of all complications. Dislocations of the endoprosthesis became the most frequent complication — 13 (10.3%) observations, 50% in the structure of all complications. Only one patient with aseptic instability of the femoral component was identified over the entire follow-up period. There were 4 (3.1%) patients with complications due to the destruction of metal constructions. All of them had an endoprosthesis stem fracture. The average period of onset of these complications was 122.5 months. Prosthetic joint infection was observed in 2 (1.6%) patients (7.2% of all complications), on the 14th and 31st days. The patient with the latter onset of infection underwent a twostaged revision arthroplasty. Functional result by the MSTS scale: 3 months — 74.8%, 6 months — 79%, 12 months 81.8%. In the patients under investigation, 5-, 10-, and 15-year survival for aggressive benign tumors and tumorlike lesions was 95%, 84%, 62%; for malignant primary tumors — 88%, 65%, 24%; for secondary bone lesions 55%, 43%, 12%, respectively. Conclusion. The use of a bipolar head made it possible to reduce the likelihood of an endoprosthesis dislocation. The fixation of the preserved muscle elements with a polymer mesh made it possible to obtain the best functional result already in the early postoperative period.

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The aim of the study — to develop a system for evaluation of treatment outcomes important for patients with pectoralis major ruptures. The system should include the outcome criteria that meet the patients’ expectations, and should allow the long-term outcomes evaluation. Material and Methods. The paper presents the long-term results of surgical treatment of 40 consecutive patients with pectoralis major ruptures. The results were evaluated in 65.3±17.5 months after surgery. Since pectoralis major rupture occurs mainly in people going in for sports at a quite high level (37 out of 40 people in our study), a new questionnaire was created for the results evaluation. In our opinion, the new set of questions takes into account the specific expectations for such category of patients and covers the important for them areas of treatment results. The already existing scales and questionnaires have been focused on assessing joint functions in patients with upper limb pathology in daily living conditions. Among the main areas of important results we identified the following items: restoration of sports activities, recovery of strength, absence of pain and discomfort, aesthetic results. Results. All the patients reported a complete absence of strength deficiency during everyday living activities. In 33 cases out of 37 the patients continued to go in for sports: at the same level — 18, with reduced load — 6, with improved results — 9. A subjective strength assessment in the patients continued exercising was in total 8.21±0.96. The outcomes in the group “improved results” (8.8±0.78) were better than in the group “at the same level” (8.1±0.96, p = 0.046) and in the group “reduced load” (7, 5±0.54, p = 0.0023). There were no differences between “improved results” and “reduced load” groups (p = 0.157). The reasons for the dynamics of sports results, which could be caused not only by the consequences of injury, were analyzed separately. The complete symmetry of the pectoralis muscles was achieved in 10 patients (25%), including 3 bodybuilders. In other cases, there remained a some degree asymmetry. The patients could notice it or ignore. We do not exclude the latent dissatisfaction of the patients with asymmetry, even when they report that it does not matter to them. Conclusion. The surgical treatment of pectoralis major tendon rupture allows the compete restoration of daily living activities. Although to that matter, these activities are practically preserved after the conservative treatment as well. The significance of the surgical treatment is in its ability to bring some additional benefits satisfying the patient’s other priorities: return to sport, maximum recovery of strength, aesthetic results. Our questionnaire don’t have a final point gradation, but allows to reflect the patient’s expectations, results and fears.

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The relevance of the study is determined by the high incidence of pain in the anterior knee after the locked nailing of the diaphyseal tibia fracture. The etiology and pathogenesis of this complication remain unclear. Most authors believe that the cause of this complication is a combination of several factors. Material and Methods. The study included 70 patients with consolidated diaphyseal tibia fractures undergone closed blocked nailing through the patellofemoral ligament. The results of the surgery were studied in the time frame of 2 to 4 years (average 36.96±12.05 months). Patients were divided into groups according to the presence or absence of pain in the anterior knee, the type of tibial fractures, the location of the nail in the proximal tibia metaphysis. The evaluation of the outcomes was carried out with the SF-36 questionnaire and the knee X-ray. The significance of differences in the samples was determined by the Pearson’s and Student’s criteria, and Fisher’s exact criterion. Results. The incidence of pain in the anterior knee was 46%. This complication led to a decrease in the patients’ quality of life to a greater extent and in most parameters than in the patient without pain, namely, physical components of health by 10% (p = 0.024), physical activity by 8.8% (p = 0.024), role-based functioning due to physical condition by 14.1% (p = 0.001). The intergroup analysis revealed that the extension of the end of the nail beyond the proximal tibial metaphysis was one of the factors that determeded the development the pain (p<0.05). There were differences in the frequency of pain in groups with different depths of immersion of the nail into the proximal metaphysis (p<0.05). The closer to the tibial plateau the proximal end of the nail was located, the more often the pain occurred in the postoperative period. In the patients with type C diaphyseal fractures, pain in the knee was much more common than in patients with type A and B fractures (p<0.05). Conclusion. The quality of life of the patients with pain in the anterior knee after locked nailing was characterized by a decrease in physical activity and role functioning in society. The main cause of the pain was the projection of the nail beyond the bone borders of the tibial metaphysis or the location of its proximal end in the subchondral area. The type of diaphyseal tibia fracture according to the AO / ASIF classification was a factor that determined the incidence of pain in the anterior knee.

The purpose of the study was to evaluate the nearest clinical, functional and structural (according to MRI) results of arthroscopic reconstruction of the shoulder upper capsule using an acellular dermal collagen matrix and auto-tissue of the ileotibial band in the patients with shoulder arthropathy after a massive rotator cuff tear. Material and Methods. The study included 30 patients with stage I–IV shoulder arthropathy according to K. Hamada classification. All of them were undergone the arthroscopic reconstruction of the upper part of the shoulder capsule in 2017–2018. The orthopedic procedures were performed by the same surgical team using an acellular dermal collagen matrix as a biological material (group 1) and auto-tissue of the iliotibial band (group 2). Results. The proportion of the patients with good — 8 (26.7%), satisfactory — 14 (46.6%) and poor — 8 (26.7%) surgical outcomes was determined according to the ASES functional assessment scales. Transplant ruptures were recorded in one (3.3%) patient in the group with an acellular dermal collagen matrix and in two (6.6%) patients in the group with the iliotibial autograft. Conclusion. Arthroscopic reconstruction of the upper part of the shoulder capsule is a promising method for the surgical treatment of physically active working age patients with shoulder arthropathy after massive rotator cuff tear. The main goals are restoration of the shoulder vertical stability, centered position of the humeral head towards the glenoid, and improvement of the shoulder biomechanics as a whole.

American Shoulder and Elbow Surgeons Standardized Assessment Form (ASES) is one of the most widely used shoulder outcome reporting measure. However, it has not been validated in the Russian language. Purpose of this study is a cross-cultural adaptation and validation of the ASES. Materials and methods. The group of 93 patients with various shoulder pathology (39 males and 54 females) with median age of 49 years was included into the study. In the first stage the authors performed language and cultural adaptation of the ASES questionnaire to obtain a Russian version maximally matching the original. Further the authors studied the psychometric properties of the questionnaire (reliability, validity, responsiveness), the effects of maximum and minimum values (floor and ceiling effects) and estimated the coefficients of internal consistency of Cronbach’s alpha and reproducibility. 20 patients were selected to assess reproducibility by test-retest method, those patients filled out the ASES questionnaire at first appointment with an orthopedic trauma surgeon and repeatedly in 7 days; the obtained data was evaluated by an intra-class correlation coefficient (ICC). In the framework of the present research the authors assessed the validity of the obtained scale, including the correlation of the scores of the examined questionnaire with the scores by the DASH questionnaire validated in the Russian Federation to check criteria validity. Results. The study resulted in obtaining the assessment scale fully matching the original ASES version with minor linguistic and cultural features. The ASES median results was Me = 68.7 [32.6; 93.8]; no maximum and minimum scores were obtained. The Russian version of the questionnaire has good psychometric properties with internal consistency of Cronbach alpha 0.72. The overall intra-class correlation coefficient (ICC) of the ASES questionnaire was 0.95 (p<0.05). There were no statistically significant differences between the general group and the test-retest group by gender, age and type of shoulder pathology. Correlation coefficient obtained in the scope of the present research between the ASES and DASH scales was 0.9, and the GRI index was 2.8. Conclusion. Russian version of the ASES questionnaire has good psychometric properties and may be recommended to evaluate functional status of patients with shoulder joint pathology and treatment dynamics.

Purpose of the study — to evaluate bone density at the femur fracture site with local introduction of preparations based on etidronate lanthanide ions and calcium in the experiment. Materials and Methods. The experiment included 45 male rats divided into three comparable groups equal in quantity. The experiment in control group was performed without stimulation of bone formation, preparation based on etidronate lanthanide ions and calcium were introduced to the animals of the first group and preparation containing etidronate and calcium (without lanthanide ions) were used in the second group. Preparation was introduced twice at the site of femoral fracture in the study groups of animals. The authors performed daily clinical monitoring and measured the density of the cortical bone at the fracture site using computer tomography. Results. Earlier support on the operated limb was observed after introduction of etidronate lanthanide ions and calcium. In the respective study group after introduction of the preparation the authors reported statistically significant 20% higher cortex density at earlier terms in contrast to the control group, and 24% higher density as compared to group with introduction of etidronates and calcium (without lanthanide ions). By day 30 cortical plate density in the group with introduction of preparation based on lanthanide ions was statistically significantly higher at 37% as compared to two other groups. Conclusion. The authors observed a positive effect of studied preparations on bone regenerate formation in rats. Data of the present research allows to conclude that periosteal introduction of preparations based on etidronate lanthanide ions and calcium at the osteotomy site provides formation of a cortical plate with improved density properties, and normalization of density indicators in the present group occurred in earlier terms that in the group with preparation based on etidronates and calcium (without lanthanide ions).

Relevance. Discussion of the criteria for decision making “amputation vs. preservation”, when viability of the extremity is uncertain, has been continuing. The case description. The lower extremity of a serviceman was injured by a caterpillar tractor. The severity of the damage was determined by the following conditions: open segmental fracture of the femoral diaphysis, 5 cm traction-compression damage of the popliteal artery, acute thrombosis of the popliteal and tibial arteries, sciatic nerve damage, circular detachment of the thigh skin, acute hemorrhage, II degree shock, and uncompensated lower extremity ischemia throughout 24 hours. The MESS score of the injured extremity was 8 indicating that an amputation would have been considered. Nevertheless, we choose the organ preservation solution with the revascularization of the injured limb segment. A multi-stage treatment was carried out including stabilization of bone fragments, primary reconstruction of the popliteal artery to restore the arterial blood flow in the injured extremity, reperfusion injury and myoglobinuria elimination, intensive kidney protection therapy, infection management, skin defects replacement, orthopedic surgery. As a result of the treatment, the injured limb was saved. The femur fracture healed allowing the patient to walk without assistance. Conclusion. The use of the programmed surgical treatment for severe mechanical injury of the lower extremity, an individual multi disciplinary approach, assessing the severity of systemic disorders, and timely use of extracorporeal detoxification made it possible to avoid amputation, perform organ preservation surgery, and create favorable conditions for restoring the supporting function of the lower extremity.

Relevance. The surgical treatment of spinal diseases and injuries in the patients on hemodialysis is one of the most complicated problems of the spine surgery, since such a surgery is associated with an increased risk of infectious complications and perioperative mortality. The case description. A 59-year-old female came to the clinic complaining back pain. Th8-9 vertebrae spondylitis complicated by an epidural and paravertebral abscess with pertinent neurological disorders and bilateral pneumonia were diagnosed. The patient had been on hemodialysis for 18 years due to the end-stage chronic kidney disease complicated by uremic osteodystrophy. The surgical debridement and stabilization of the spine were performed in one stage posterior approach using a titanium mesh implant in combination with autologous bone and posterior instrumentation. A regression of neurological disorders and the pain syndrome relief were achieved. In the late postoperative period, the instability of the posterior fixation developed twice, requiring restabilization. Within the following 3.5 years after the operation, the pain syndrome had not returned. Conclusion. The presence of equipment for hemodialysis and a multidisciplinary approach allow to achieve the positive results in the surgical treatment of inflammatory diseases of the spine in the patients with endstage chronic kidney disease.

Purpose of the analytical review — to evaluate the application experience of bone xenografts in trauma and orthopaedics surgery. Methods. Data search was performed in the electronic databases of PubMed and eLIBRARY with depth of 20 years. Results. The authors identified 13 papers which described the application experience of bone xenografts in trauma surgery and orthopaedics. The highest efficiency (from 92 to 100%) was reported for cases of xenografts use to replace defects in intraarticular fractures and revision arthroplasty. Unsatisfactory outcomes were related to cases with no integration and graft rejection. The least efficiency (from 41,9 to 46,1%) was reported in reconstructive foot surgery. No effect of bone xenografts was observed for replacement of defects in cases of pseudoarthrosis. The most frequent complication was graft material infection. The summarized literature data provided the calculated share of complications following xenograft use of 7,53% (18 out of 239 cases, CI 5-95%, 4,53-11,21). Two areas were identified for improvement of technical and biological properties of bone xenografts: 1. Modification of original xeno-matrix (enhancement of purification technique, alteration of structure of chemical composition of the bone matrix); 2. Augmentation of matrix volume by additional elements (biologically active agents, stem cells). It’s noted that demand for xenografts in traumatology and orthopaedics can increase after refining and expanding the indications for clinical use. Conclusion. Bone xenografts used in the modern trauma surgery and orthopaedics to replace bone defects in revision arthroplasty as well as in certain fracture types. Such material is relatively safe and its ability to be modified allows to improve its biological properties.

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The purpose of the study was to determine the capabilities of scanning electron and light microscopy in detecting fungi in surgical material from the patients with Dupuytren’s contracture. Material and Methods. The fragments of palmar aponeurosis from 27 patients with Dupuytren’s contracture were examined. Paraffin sections stained with hematoxylin-eosin and Periodic Schiff-Methenamine Silver were digitized using AxioScope.A1 microscope (Carl Zeiss Micro Imaging GmbH, Germany). For examination in JSM-840 scanning electron microscope (Jeol, Japan), the samples were dehydrated after fixation, soaked in camphene, dried, and silver sprayed in the IB-6 ionizer (Eiko, Japan). Results. In paraffin sections stained with methenamine-silver, the signs of mycotic microbiota were detected only in 2 (7.4%) of 27 patients, and with the use scanning electron microscopy — in 16 patients (59%). The morphological phenotypes and ultrastructure of intercellular contacts of yeast-like fungi were similar to Candida albicans. In all cases, the budding cells were detected. The destruction of the connective tissue of the palmar aponeurosis was observed in the form of loosening, stratification, and cavities formation (the zones of lysis). Conclusion. The scanning electron microscopy allowed to evaluate the ultrastructure of fungal cells and their interaction with surrounding tissues in the surgical material from the patients with Dupuytren’s contracture. A higher percentage of detection of fungal invasion compared to the Periodic Schiff-Methenamine staining was associated with a higher resolution and the ability of a larger area of tissue samples analysis.