NUMERICAL SIMULATION OF STRAIN WITHIN THE CONSTRUCTIONS FOR TEMPORARY HEMIEPIPHYSEODESIS IN PATIENTS WITH SYSTEMIC SKELETAL DYSPLASIAS

Introduction. Guided growth (temporary hemiepiphyseodesis) methods for the correction of axial deformities at the knee joint level in children are used mainly in patients with idiopathic deformities. In patients with systemic skeletal dysplasias the use of these techniques does not take into account the peculiarities of the pathological process. Purpose of study: to evaluate with radiographs the incidence of incomplete plate-bone contact at temporary hemiepiphyseodesis; to assess tensely deforming condition of metal implants using numerical simulation of strain in patients with systemic skeletal dysplasias for the prognosis of their potential failure.Patients and methods. Postoperative radiographs were analyzed for 58 children with systemic skeletal dysplasias after temporary hemiepiphyseodesis (107 extremities, 188 plates; main group) and 50 patients with the deformities of other etiology (control group). Plate-metaphysis contact was considered to be incomplete if it exceeded 2 mm. To determine the plate strains and displacement during the process of bone growth the numerical simulation using COSMOL Multiphusics Software was performed.Results. Incomplete plate-bone contact was observed in 41 (22%) out of 188 constructions. Mean contact deficit made up 4.1±1.3 mm. In control group incomplete plate- bone contact (over 2 mm) was observed only in 3 (4.5%) cases (p<0.05). When a screw is not completely inserted into the bone, its’ the most loaded part is out of the bone and the risk of screw breakage in the contact zone occurs. That was showed by the data of numerical strain simulation.Conclusion. In temporary hemiepiphyseodesis the potentiality of incomplete plate-bone contact resulting from the anatomical peculiarities of epimetaphyseal zone is up to 22%. To improve the efficacy of the guided growth method in children with systemic skeletal dysplasias the elaboration of the constructions should take into account of epimetaphyseal zone configuration.

STUDY OF RIVAROXABAN FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS AFTER LOWER EXTREMITY FRACTURES IN RUSSIAN CLINICAL PRACTICE

Thepurposeof the study was to evaluate the efficacy and safety of rivaroxaban in patients after surgical treatment for the lower extremity fractures.Patients and methods. Retrospective multicenter study included 663 patients with femur fractures, 43 patients with complications after total hip arthroplasty (periprosthetic femur fractures, recurrent dislocation) and 10 patients with shinbone fractures. The majority (81.99%) of patients were elderly or senile. In postoperative period all patients received a standard prophylactic dose of anticoagulants. Out of them 75 (main group) – rivaroxaban (10 mg/day), 241 (control group) – other drugs (enoxaparin – 40 mg/day and dabigatran etexilate 150 or 220 mg/day). The efficacy of prophylaxis was assessed by clinical picture and Doppler ultrasound scans.Results.Average bed day made up 9.28. During hospitalization no cases of PE were recorded. In the main and control groups the rate of deep vein thrombosis with clinical manifestations made up 1.89 and 3.31%, respectively. No cases of fatal bleeding occurred. Signs of continuous bleeding in the area of surgical intervention (soaking dressings or recurring wound hematomas) in the main group was recorded rarely (3.15%) than in the control one (8.29%).Conclusion.Reduction of VTE rate with no increase in bleeding risk indicates the feasibility of rivaroxaban use for postoperative PE prophylaxis in patients with lower extremity fractures.

TREATMENT OF A PATIENT WITH MUCOPOLYSACCHARIDOSES TYPE II (HUNTER SYNDROME) COMPLICATED BY CRANIOVERTEBRAL SPINAL CANAL STENOSIS

Formation of spinal canal stenosis at T12-L1 level, rarely at the level of craniovertebral junction, is a typical spinal disorder in different types of mucopolysaccharidoses that is a serious complication due to tetraparesis and tetraplegia development. Clinical, roentgenologic and therapeutic aspects of the mucopolysaccharidoses type II course in a 23 months old boy as well as the results of two-step surgical treatment for the cervical spine stabilization and elimination of spinal canal stenosis at the level of craniovertebral junction are presented.

ANALYSIS OF THE CONSERVATIVE TREATMENT EFFICACY IN PATIENTS WITH SUBACROMIAL IMPINGEMENT SYNDROME

Purpose:to evaluate the efficacy of the conservative treatment of patients with subacromial impingement syndrome (SIS) and supraspinatus muscle tendon (SMT) pathology using optimized clinical and beam algorithm.Patients and methods.Complex evaluation of the conservative treatment efficacy (physiotherapeutic treatment (PHT), exercise therapy (ET), shockwave therapy (SWT)) was performed in 128 patients 67 (52.3%) men, 61 (47.7%) women with SIS. Mean age of patients was 59±8 years (24 – 82 yrs), follow up period – 9.6 ±5.6 months (maximum 18 mos). All patients underwent optimized complex clinical and beam examination. Treatment efficacy was evaluated in dynamics at terms 3, 6 and 9 months. Dynamics of pain syndrome and structural changes in STM regress was assessed depending on the type of treatment.Results.In 3 months positive effect of conservative treatment was noted in 67 (65%), in 6 months – in 78 (77%) and in 9 months – in 84 (82%) patients. High correlation of data obtained using the elaborated pain scale for a shoulder with the visual analogue scale data at treatment monitoring (r=0,89) as well as with the monitoring US data (r=0,94) was determined. The combination of SWT+ET+PHT or SWT+PHT showed good therapeutic effect in 3 months after treatment and by 6th month excellent result was recorded in 85% of cases. Due to the long rehabilitation period in operated patients in 3 and 6 months after intervention only the satisfactory result with mean point 3.02±0.12 and 3.52±0.14 respectively was achieved.Conclusion.In patients with SIS and SMT pathology the most effective is a combined conservative treatment with SWT+ET+PHT or SWT+PHT. However a conservative treatment efficacy is significantly influenced by the SIS stage, anatomical structure of acromeonon as well as the type of SMT structural changes.

EXPERIENCE IN ARTHROSCOPIC TREATMENT OF ACUTE ACROMIOCLAVICULAR JOINT INJURIES

Purpose of study: to evaluate surgical treatment results in patients with closed dislocation of the acromial end of the clavicle.Patients and methods. Eighteen patients, aged 23-54 years, with acute acromioclavicular joint injuries of IIIIV type by Rockwood were operated on during 2015 – 2018. Surgical treatment was performed at terms up to 2 weeks after injury. Reduction of the acromial end of the clavicle, arthroscopic fixation and stabilization of acromioclavicular joint by TightRope system was performed. Postoperative follow-up was cjnducted in 4 and 6 weeks, 3 months and subsequently every 6 months after surgical intervention. To evaluate the results the Constant Score and radiographs were used.Results.Follow-up period made up 1 year. Functional result, i.e. range of motion and quality of life, by Constant Score was good already on day 14 after surgery and excellent (89.6±2.9 points) at the end of treatment course (2 months after intervention). Brachial plexopathy (reduction of the thumb and 2nd finger sensitivity and muscular force in the early postoperative period) was observed in 1 case. Six months conservative treatment resulted in positive effect. In 6 months range of motion in the operated joint was equal to that in a healthy one.Conclusion.Arthroscopic treatment of acromioclavicular joint injuries by TightRope system is a highly effective and minimum invasive method but requires experience and practical skills in shoulder arthroscopy.

SURGICAL TREATMENT FOR NON-TUMOROUS DISEASES OF CRANIOVERTEBRAL REGION

Purpose:to evaluate the efficacy of surgical treatment for the non-tumorous diseases of the craniovertebral region.Patients and Methods. Forty five patients aged 4 – 63 years (mean age 27 years) with non-tumorous diseases of the craniovertebral region were operated on. Either one- or two-step surgical interventions for spinal cord decompression were performed. Early and long term results were evaluated by Frankel, JAO and River scales. In 5 cases the assessment of volumetric craniovertebral interrelationships (VCVI).Results.Good results were obtained in 43 (96%) patients at terms from 1 to 15 years. In 1 patient with mucopolysaccharidoses the aggravation of neurologic symptoms was observed and in 1 case a fatal outcome occurred. VCVI analysis showed a significant improvement of liquor dynamics right up to its normalization in the zone of decompression.Conclusion.Treatment of craniovertebral region diseases requires a differential approach. When necessary to eliminate ventral spinal cord compression it is expedient to perform either transoral or endoscopic transnasal decompression, or transoral spinal cord (myelencephalon) decompression with anterior stabilization by custom-made device (plate).

DEPENDENCE OF THE OUTCOMES OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION ON THE TUNNEL POSITIONING

Purpose of study: based on the analysis of clinical and radiation data to determine the most favorable positioning of the bone tunnels at different techniques of anterior cruciate ligament (ACL) reconstruction.Study design: retrospective analysis.Patients and methods. Face-to-face and a remote examination was performed in 202 patients at terms from 1.5 to 5 years after primary ACL autoplasty using the graft from the popliteal muscle tendons. All patients were divided into 3 groups depending on the technique of the bone tunnels formation. The patients from the 1stgroup (n=109) were operated on using transtibial technique, from the 2nd(n=52) and 3rd(n=41) groups – using anteromedial technique with the positioning of the femoral tunnel in the central and anteromedial part of ACL attachment, respectively. Bone tunnels positioning was determined using CT with 3D reconstruction. Subjective evaluation was performed by IKDS-2000, KOOS and Lysholm knee score. To assess the tibiofemoral dislocation the anterior drawer, Lachman and pivot shift tests as well as arthrometry (comparison with the healthy side) were performed.Results.In patients from group 1 the tibial tunnel was positioned in the plane of either central or posterolateral part of ACL attachment. In groups 2 and 3 the tunnel was positioned closer to the anteromedial part. In the majority of patients form group 1 the femoral tunnel was positioned in the zone or slightly forwards of the anteromedial part of ACL femoral attachment, in group 2 – in the plane of central or posterolateral part, in group 3 – in the anteromedial part. In patients from the 1st and 2nd groups the subjective evaluation by IKDS-2000, KOOS and Lysholm knee score was comparable and much higher in the 3rdgroup (p<0.05). Objective evaluation showed positive manual tests results in 47 patients (62%) from the 1st group, 19 patients (51%) – 2ndgroup and 4 patients (11%) – 3rdgroup. Arthrometry showed the increase of anteroposterior tibiofemoral dislocation by 3.4±2.6 mm in the 1st group, 3.1±2.7 mm in the 2nd group and 1.2±1.4 mm. Statistical analysis did not reveal significant difference in knee stability between the patients from the 1stand 2ndgroups.Conclusion.Positioning of the femoral tunnel in the plane of anteromedial part of ACL attachment ensures better surgical treatment functional results. In anteromedial technique the use of posterosuperior contour of the lateral femoral condyle as a reference point enables to improve the accuracy of femoral tunnel positioning as well as to minimize the error risk at intraoperative marking.