Problems of Diagnosis, Conservative Treatment and Long-Term Results of “Mallet Finger” Fracture

Summary. Distal phalanx dorsal edge fracture is treated in a relatively simple closed manner during the first weeks after injury. The role of the distal interphalangeal joint in the upper extremity integral function reaches conventionally only a few percent. This may lead to insufficient attention and a large number of mistakes in diagnosis and treatment of such injuries, which in turn provokes complications that are much more difficult to treat than the primary injury. This article considers the most common problems of diagnosis and treatment of “mallet finger” fractures. Advantages and disadvantages of various techniques used in the treatment of such fractures in acute and neglected cases are considered and analyzed. Objective: to study the effect of distal phalanx dorsal edge avulsive fractures on function of the upper limb, quality of life, and depression rate in long term period after injury. Materials and Methods. Data from 11 patients (8 (88%) males and 3 (12%) females) with neglected cases of distal phalanx dorsal edge avulsive fractures were studied. QuickDASH questionnaire and visual analog scales were used to study impaired quality of life and depression rate in such patients. Indicators that lead to the need for surgery in long term period after injury have been identified. Results. It was determined that in long term period, in patients with a “mallet finger” fracture, function of the upper extremity suffered significantly and was 29.2±20.2 points (range 2.3-75) according to QuickDASH scale. This condition also significantly affected the general well-being of the patient. Average value of impaired quality of life was 43.6±24.6 (range 0-90 points), and depression rate due to upper extremity dysfunction was 44.6±22.7 (range 0-90 points). Conclusions. Despite the relatively minor injury, high rates of dysfunction, impact on quality of life and depression rate indicate the need to restore finger function even in long term period after injury.

Treatment of Unstable Injury of Pelvic Bones in Pregnant (Case Report)

Summary. There is no doubt in the relevance of the problem of treatment of patients with unstable fractures of pelvic bones, since these injuries involve a threat to the patient's life in the early period and often lead to disability in the future. This article presents a rare case of treatment of a patient with an unstable pelvis injury, while being 16 weeks pregnant. Patient A., born 1993, was admitted after a road accident injury. The examinations included: X-ray, CT, ultrasound, and gynecologist consultation. The patient was diagnosed with closed bilateral fracture of the pubic and ischial bones with displacement; rupture of the left sacroiliac joint with the boundary fracture of the sacrum (61-С1.3 by the Tile-AO-ASIF classification). The patient was 16 weeks pregnant. The surgery – open reduction and extramedullary metalosteosynthesis – was performed at the 9th day after the injury. The patient was discharged to outpatient treatment at the 12th day after the surgery. She started walking on crutches 3 weeks after the surgery; no additional support was needed since 1.5 months after the surgery. The patient gave birth at 39 weeks by surgical intervention (caesarean section). The baby's condition was assessed as 8 according to the Apgar scale. At the control examination 10 months after the surgery, musculoskeletal function of the patient was fully restored.

Treatment of Chronic and Complicated Ruptures of the Rotator Cuff of the Shoulder

Relevance. The etiology of ruptures of the rotator cuff of the shoulder (RC) is represented by a variety of diseases, including age-related degeneration, low- and high-energy trauma. Most often, a rupture of the RC, combined with trauma, occurs with anterior dislocation of the shoulder – in 56% of patients. The “terrible triad” of the shoulder, which leads to a loss of function and disability in patients, is diagnosed in 9-18% of patients. RC ruptures of <1-1.5 cm throughout the entire thickness of the tendon have a high risk of progression and formation of a massive rupture of the RC. According to various authors, massive ruptures occur in 40% of all RC ruptures. Objective: to evaluate the results of surgical treatment of patients with old and complicated ruptures of the RC. Materials and Methods. From 2016 to 2021, in the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine”, Department of Microsurgery and Surgery of the Upper Limb, 140 patients with a ruptured RC were treated. The patients underwent: suture of the RC under arthroscopic control, open RC suture, transposition of the latissimus dorsi tendon into the RC defect, implantation of biodegradable InSpace balloon, or implantation of a biomatrix into the RC defect and reverse shoulder arthroplasty. Results. The function was assessed before surgery and in the long-term postoperative period using the Constant-Murley Score. In 5 patients with an implanted balloon, the score increased from 34-38 to 56-61 in 8-12 months. In 7 patients with reinforced biomatrix implantation, the score increased from 34-38 to 65-69 in 9-12 months. In 7 patients with transposition of the latissimus dorsi tendon, the score increased from 35-37 to 68-75 in 9-12 months. In 10 patients with reverse arthroplasty, the score increased from 30-34 to 58-65 in 12-18 months. In 82 patients, after the suture of the RC under arthroscopic control of the shoulder, the score increased from 36-40 to 78-82 in 12-18 months. In 29 patients with an open suture of the RC, the score increased from 34-38 to 68-75 in 12-18 months. Conclusions. Early diagnosis and timely surgical treatment for the pathology of the RC make it possible to obtain the best results in the long-term postoperative period. Massive and old ruptures of the RC require a complete instrumental examination in the preoperative period. The degree of adipose degeneration and rotator arthropathy is of key importance for determining the operative tactics of surgical treatment.

Clinical Genealogical and Epigenetic Examination of Patients with Juvenile Epiphysiolysis of the Femoral Head

Summary. Slipped capital femoral epiphysis (SCFE) is a multifactorial disease caused by a number of factors, and each of them can be triggered in its occurrence. Modern research is increasingly pointing to the leading role of epigenetic structures in the origin and course of this group of diseases. In recent years, the most promising area is the study of the role of microRNAs as an epigenetic factor that plays a leading role in the pathogenesis of multifactorial diseases. Objective: to develop a methodology for genetic genealogical examination of patients with juvenile epiphysiolysis of the femoral head. Materials and Methods. The study material was 26 patients with SCFE (15 girls and 11 boys) in different periods of sexual development: prepuberty – 7 patients, induction of puberty – 12 patients, and puberty and postpuberty – 7 patients. A questionnaire developed by us was used for clinical and genealogical research of the patients. The material for the epigenetic study, namely the study of microRNA-21 expression in patients with SCFE, was venous blood. Results. The expression of microRNA-21 in the blood of patients with SCFE is different (average expression is 0.86 conventional units) from those of healthy donors (average 0.393 conventional units) of the same age (p<0.05). Analysis of dependence on the period of sexual development revealed statistical differences in indicators depending on the group (p<0.05). No dependence of the level of microRNA-21 expression in patients with SCFE on sex and the period before or after surgery (p>0.05) was revealed. The obtained data on the probability of the influence of hereditary factors on the occurrence of SCFE are statistically significant (p<0.05). Conclusions. Our results of epigenetic and clinical genealogical research of patients with SCFE showed a high probability of influence of hereditary and epigenetic factors on the occurrence and course of this disease.

Comparative Analysis of Assessment Systems of Foot Function

Summary. The assessment of foot and ankle function still remains an actual issue of the modern orthopedics. Objective: comparative qualitative analysis of the most common assessment systems of foot and ankle function. Materials and Methods. The search from PubMed databases from 1946 to 2021 was done. 8898 publications were detected in which assessment systems of foot and ankle function have been used. 12 assessment systems presented in 5705 publications were selected for analysis (inclusion criterion – no less than 40 publications): AOFAS scale, VAS, SF-36 EQL, FFI, FAOS, FAAM, FADI, BFS, MOFAQ, FFI-R, Roles&Maudsley scale, VAS FA. The analysis predicted the assessment system philosophy: numerical estimate, VAS, Likert scale, patient- or investigatororiented, and reliability evidence. Results. Most of the analized assessment systems meet criteria of reliability (r>0.8; Kronbach’s α≥0.9). For Roles&Maudsley scale and VAS, FA reliability has not been established. The validity fluctuates widely. Conclusions. The choice of an assessment system must meet the research tasks. The consideration of strong and weak sides of assessment systems promotes their adequate combinations to avoid the bias effect.

Damages of Neuromuscular System After Mechanical-Induced Limb Ischemia (Experimental Study)

Relevance. Traumatic and ischemic injury of the limbs is accompanied by damage of the skeletal muscles and peripheral nerves of the limbs. The dynamics and consequences of ischemic lesions remain poorly understood and need to be corrected. Objective: using quantitative morphological and sonographic methods, to study the dynamics of skeletal muscle damage of the limb after traumatically induced ischemia with and without the injection of platelet-rich plasma, bone marrow aspirate, and adipose tissue fraction. Materials and Methods. In 3 experiments, rabbits were modeled with 6-hour limb ischemia by applying an elastic tourniquet. After compartment syndrome detection, based on the assessment of subfascial pressure, cell suspensions were injected into the leg muscles. Sonographic and histological examination of the muscles was performed on days 5, 15, and 30. The results of sonography and morphometry were evaluated by statistical methods. Results. The developed model of ischemia consists of 6-hour immobilization of the limb, on тwhich medical elastic tourniquets were imposing. The action of the tourniquets causes high subfascial pressure and necrosis of the superficial muscle groups of the lower third of the thigh and lower leg. According to sonography, the δ-entropy of damaged tissues on day 5 is reduced relative to the intact limb, as in the case of administration of bone marrow aspirate cells. On days 15 and 30, sonography showed no difference between the comparison groups. The dynamics of morphological features of limb tissue damage consist of necrosis of superficial muscle groups, atrophy in the middle layers, and almost intact deep muscle groups. Necrosis was replaced by scar tissue, the density of which increases 11-14 times, and does not differ in the period 5-30 days. The administration of platelet plasma, bone marrow aspirate, and adipose tissue fraction did not change the dynamics of fibrotic changes in ischemic damaged muscles. Muscle atrophy is accompanied by activation of endogenous repair of single muscle fibers, which tended to intensify after injection of bone marrow aspirate. The sciatic nerve of the injured limb was not structurally damaged according to the deep topography, while the nerves of the tibia develop degenerative changes from the 15th day.

Peculiarities of Preoperative Planning of Total Hip Arthroplasty in Patients with Hip-Lumbar Syndrome

Summary. At present, no scheme of approach to surgical treatment of patients with hip-lumbar syndrome (HLS) depending on the type of vertical posture and the type of bone formation and progression of coxarthrosis is developed. The decision of these questions, interesting from the scientific and practical point of view, is an actual task of modern orthopedics and defines features of preoperative planning of total hip arthroplasty (THA) in patients with HLS. Objective: to determine the features of preoperative planning of total hip arthroplasty in patients with hip-lumbar syndrome. Materials and Methods. The basis for the development of recommendations for preoperative planning of THA in patients with HLS was the data of retrospective analysis of medical histories of 138 patients who underwent hip arthroplasty in the Department of Orthopedics and Traumatology of Adults of SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine”. The data of the clinical study of 506 patients with idiopathic, dysplastic and post-traumatic coxarthrosis conducted earlier were also taken into account, and the tactics of treatment in cementless hip arthroplasty was developed. Results. It was determined that the vertical posture affects the progression of coxarthrosis and the nature of the lesion of the lumbar spine in patients with HLS. Patients with a certain hypolordotic posture and a rapid course of coxarthrosis are recommended to undergo primary decompression of the spinal roots and THA at the second stage. In other cases, the initial implementation of THA is recommended. Recommendations for the use of the type and method of fixation and coverage of the leg of the endoprosthesis depending on the type of bone formation in the HLS of the examined patients are developed. Conclusions. Taking into account the features of preoperative planning of THA in patients with HLS will reduce the number of negative results and complications of this category of orthopedic patients.

Actual Aspects of Surgical Treatment of Dupuytren's Disease (Literature Review)

Relevance. The variety of manifestations of Dupuytren's disease, caused by the degree of lesions of the palmar aponeurosis, the duration of the disease, the nature of professional activity, and concomitant pathology of patients, has led to the development of numerous surgical techniques with different levels of effectiveness in the acute and long-term periods. A wide discussion of the issues of Dupuytren's disease in the domestic and foreign periodicals, the analysis of treatment methods, complications and rehabilitation indicate the urgency of the problem and the expediency of further research. Objective: a retrospective analysis of the leading literary sources devoted to the surgical treatment of Dupuytren's disease; the definition of modern approaches to surgical tactics and restoration of hand function. Results. The analysis of literature sources showed the advantages of differentiated approaches to the surgical treatment of Dupuytren's disease, depending on the severity of the disease. With mild and moderate lesions, there is a significant increase in needle aponeurectomy. In severe forms, the segmental aponeurectomy technique is preferred over the total one. There is some discrepancy in carrying out surgical mobilization of the proximal interphalangeal joint and the need to achieve a functional position as a result of treatment. The tactics of surgical treatment and rehabilitation of Dupuytren's disease requires an individual approach, taking into account the age and severity of the disease, and tends to spread minimally invasive fasciotomy techniques.

Tactics of Surgical Treatment of Wounded with Gunshot Injuries of the Upper Limb in Modern Conditions

Summary. Our study aimed to optimize the tactics of surgical treatment of wounded with gunshot wounds of the upper extremity by determining the factors influencing the outcome of treatment of servicemen in modern conditions of specialized and highly specialized medical care. Materials and Methods. Surgical treatment of 123 patients with gunshot wounds of the upper extremity who were treated at the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine” and the National Military Medical Clinical Center “Main Military Clinical Hospital” of the Ministry of Defense of Ukraine was analyzed. The mean age of patients was (35.3±8.7). At the level III of medical care, the largest share was occupied by wound closure (28.0%) and surgeries on the skeletal system (6.7%). At the level IV of medical care, the largest share was occupied by surgical procedures for closing unhealed wounds – 28%, due to the consequences of gunshot nerve injuries – 11.5%, fractures – 10.7%, and restorative interventions on muscles – 5.5%. Results. By calculating the odds ratio (Odds Ratio, OR), it was found that the presence of compartment syndrome reduces the probability of obtaining a positive result by 11 times (OR=11.3), and late treatment at the level IV of care reduces the effectiveness of treatment by 9 times (OR=9.1). In the group of patients with peripheral nerve damage, satisfactory results were 6.9 times less than in the group without such damage (OR=6.9); the presence of a tissue defect worsened the prognosis of treatment by almost 5 times (OR=4.7). The average time to start surgical treatment after a gunshot wound was 2.8±5.0 days at the level III and 47.2±70.4 days at the level IV. It was found that for patients admitted to the level IV facilities for up to 30 days, the percentage increase in upper extremity function was 42.6±11.8 after treatment and 28.5±10.0 at a later start of treatment. Conclusions. The results of the study of the factors influencing the outcome of treatment prove the need for early (up to 3 weeks) admission of wounded with gunshot wounds to the level IV of medical care.

Problematic Issues of the Theory and Practice of Finger Joints Endoprosthetics (Literature Review)

Summary. The proximal interphalangeal and metacarpophalangeal joints play an important role in the function of the hand as an organ of labor and self-care. The frequency of joint injuries of this localization reaches 32% in the structure of hand injuries, and unsatisfactory consequences are associated with the severity of the injury. Wrong treatment ranges between 60-80%, which gives ground to classify the problem as socially significant. The development and improvement of implant designs came through the introduction of new materials, structural changes in the fasteners and mobility. Much of the implants design became a thing of the past, giving a push to the development of new models. The need for anatomical and functional compliance of the implant with the characteristics of a healthy joint gave an impulse to research on the manufacture of individual prostheses with the help of 3D modeling. The analysis of literature sources showed a high level of unfavorable consequences of damage to the finger joints and the prospects for the development of more anatomical designs of hand joints prostheses. The development of individual geometrically similar designs endoprostheses of the finger joints of hand that will provide conditions of improvement of quality of treatment of patients remains an actual problem. The relatively short period of operational suitability of existing endoprostheses affected by a limited number of medical supervision necessitates the expansion of research in the near and long terms after prosthetics.