Vol 11, No 2 (2004)

Experience of the orthopaedic and trauma clinic of the Moscow Regional Scientific Research Clinical Institute in large joints replacement is presented. Hip replacement was performed to 458 patients with sequelae of the joint injury. Depending on the severity of hip joint injury all patients were subdivided into 2 groups. In the first group of patients joint replacement was performed by standard technique, in the second group of patients certain technical modifications were required. Use of special implant constructions and methods to supplement standard techniques was considered in relation to concrete anatomic and functional changes. The results of large joints replacement were successful in 96% of cases with maximum observation period of 21 years.

System for the evaluation of the main clinical indices of the hip joint condition in dysplastic coxarthrosis has been worked out. The system is based on the objective and subjective signs of the pathologic process and for that the author introduces a concept of «conditional pain». Maximum total score of the objective and subjective signs is the same - 44 points. Depending on the conditions of examination performance and physician's experience, 12 more points have been assigned to the signs that can be both objective and subjective. For the accurate evaluation of the «conditional pain» trustworthiness coefficient has been introduced. This coefficient takes into account the age of patient and possible concomitant diseases. Examples of this coefficient application are given. For the automated processing of clinical data a computer program «Automated methods for the evaluation of pre- and postoperative observation results and stages of dysplastic coxarthrosis development.

The dynamics of immunologic indices in the acute and early periods of the traumatic disease was analyzed in 30 patients (25-60 years) with polytrauma. Even during the period of early manifestations of the traumatic disease the signs of immune deficiency are already determined as a disturbance of T-lymphocytes differentiation, T-helpers in particular. The changes in the system of cellular immunity coincide by time with the occurrence of clinical signs of secondary posttraumatic immune deficiency, i.e. pneumonias, pleurities, purulent endobronchites. The obtained data are indicative of the fact that patients with polytrauma already require immunostimulation during the period of early manifestations of the traumatic disease.

The results of treatment of 337 patients, aged from 15 to 75 years, with femur (175 patients), shin (41), arm (76) and forearm (45) fractures were analyzed. Open injuries were present in 42 (12,5%) and closed ones in 295 (87,5%) patients. According to AO classification type A fractures were diagnosed in 146 (43,3%), type В - in 103 (30,6%), type С - in 88 (26,1%) patients. In all patients osteosynthesis with plates and fixing screws was performed. In 37(11%) patients destruction of the implant took place. The dependence of that complication on the pattern of injury and type of fracture is detected: in open and comminuted fractures the rate of implant destruction was reliably higher. Mechanical destruction of the internal fixation system was presented by two variants: either break of a plate in the zone of the most intensive stress and a screw, or bone destruction in the site of screw insertion. In all cases of implant destruction the nonunion of fractures due to devitalization or absence of intermediate fragments was observed.

New composite «material for osteoplasty» was used for the treatment of 70 children, aged from 1.5 to 15 years, with various orthopaedic pathology. "Material" consists of defatted spongy and cortical-spongy bone matrix soaked with copolymer containing bioactive drugs as well as fetal bone tissue. Preliminary testing showed that the suggested implants were of high firmness. To assess the stimulating effect of "material for osteoplasty" upon the process of bone tissue reparative regeneration, monitoring of regional microcirculation by ultrasound Doppler mapping was used in complex with other methods. Osteoconductive and osteoinductive characteristics of the implants were observed in 76% of cases. The results of ultrasound Doppler mapping showed good correlation with the morphologic picture.

The questionnaire for the evaluation of daily life activity in patients with wrist pathology is presented. This questionnaire has been elaborated taking into account social and cultural peculiarities of Russians life and includes 33 questions reflecting the possibilities of carrying out of personal every day activities (hygiene, dressing, putting on shoes, cooking, eating etc.). The functional activity of patients with various wrist pathology ( bone fractures, traumatic wrist and fingers avulsion, multicomponent wrist injuries, tendon injuries, Dupuytren's contracture) was assessed by that questionnaire. Analysis of data obtained showed the conformity of questionnaire to modern requirements of psychometry - high validity, sensitivity and reliability. This questionnaire should be used for the evaluation of rehabilitation efficacy of patients with wrist pathology.

Technique of chest reconstruction after sternum resection in its metastatic lesion is presented. This technique includes three methods of reconstructive surgery. For pleura defect closure greater omentum on a vascular pedicle is used. Bony frame is reconstructed using special fast hardening plastic plates. These plates are produced during surgical intervention. Whole construction is covered by vascularized thoraco-dorsal muscular-cutaneous flap. The application of that technique enabled to successfully perform radical operation in 3 with severe metastatic lesions.

Thirty eight patients with posttraumatic reflex sympathetic dystrophy (RSD) of upper extremities and 28 healthy individuals of the same age (control group) were examined using computer laser doppler flowmetry (LDF) and wavelet-analysis of amplitude-frequency spectrum of fluctuations of microvascular circulation. RDS prevailed in patients with primary warm forms, increase ofportion of shunt circulation, decrease of sympathetic activity and its breakdown at activation. Patients with primary cold forms were characterized by inconstant increase of neurogenic tonus of microvessels at rest. Prolong activation of peptidergenic function of sensory fibres supporting neurogenic inflammation, edema and pain syndrome were typical. One could not exclude that sympathetic vasomotor function and sympathetic support of pain may innervated by different groups of sympathetic neurons. Objective assessment of perivascular innervation and tissue microcirculation is of great clinical importance for individual RSD treatment protocol. Use of LDF is reasonable for early diagnosis of RSD, determination the role of sympathetic and peptidergenic mechanisms in RSD pathogenesis and indications for sympathetic blockades and capsaicin.