N.N. Priorov Journal of Traumatology and Orthopedics

BACKGROUND: Femoral neck fractures are among the most common injuries of the human skeleton. If in 2004 in Russia the incidence of fractures of the proximal femur in patients over 50 years of age was 105.9 per 100,000 of the population (and in women this figure was almost twice as high as in men), it is expected that by 2025 the number of victims worldwide will have doubled, and by 2050 it will be almost 4.5 million. Existing osteosynthesis techniques do not take into account the peculiarities of the uneven distribution of bone density in the femoral head, which can lead to the placement of fixators in a deliberately weakened area, reduced strength of osteosynthesis, migration of fixators and, as a result, non-union of the fracture.

AIM: To compare the long-term results of dynamic derotation osteosynthesis with the results of femoral neck fracture osteosynthesis with cannulated screws, dynamic hip screws, and V-wires.

MATERIALS AND METHODS: The study was based on the analysis of the results of surgical treatment of 259 patients with femoral neck fractures. In the treatment of 114 (44%) patients (study group), the titanium dynamic derotational fixator Targon FN manufactured by Aesculap B. Braun (Germany) was used. The comparison group included 145 (56%) patients who underwent osteosynthesis using a dynamic femoral screw (40 patients), tensioned V-wires (60 patients) or 3 AO screws (40 patients). There were no significant differences in the distribution of patients by age in the groups considered, which was confirmed by pairwise tests using Holm's multiple comparison correction method.

RESULTS: In Garden III femoral neck fractures, 59.6% of the study group achieved consolidation compared to 34.5% with dynamic hip screw implantation, 22.7% with V-wires and 28.0% with cannulated screws. In Garden IV fractures, consolidation did not occur in any of the observations. The incidence of avascular necrosis of the femoral head is highest in Garden III fractures: 39.2% with dynamic femoral screw implantation, 30.1% with V-wires, 34.2% with cannulated screws and 21.8% with dynamic derotational osteosynthesis. When evaluating the long-term results in patients with consolidated fractures, claudication of the operated limb was observed (in Garden III type fractures in 64% of cases — when using a dynamic derotational fixator, 65% — when using a derotational femoral screw, 100% - when using cannulated screws and V-wires). The maximum femoral neck offset shortening of more than 15% was observed in 7 patients (39%) with dynamic derotational osteosynthesis, in 6 patients (67%) with dynamic femoral screw implantation, in 5 patients (60%) with cannulated screws and in 8 patients (80%) with V-wires.

CONCLUSION: Garden I fractures of the femoral neck do not lead to avascular necrosis of the femoral head. As the angle of the fracture plane increases and the blood supply to the femoral head decreases, the incidence of avascular necrosis increases. The development of claudication in the patients was caused by the reduction in femoral offset length due to osteolysis, which occurred as a result of both the localisation of the fracture plane (fracture factor) and the dynamic function of the implant (fixator factor). Lameness was therefore considered to be the 'payback' for the consolidation of the fracture.

BACKGROUND: Measurement and evaluation of anthropometric data of children with cerebral palsy are essential for the development of national patient registers. Studies of the patients' anthropometric parameters observed in rehabilitation centres make it possible to form a broad sample for research.

AIM: To study the growth patterns of children with cerebral palsy depending on the degree of impairment of global motor functions, age, and gender; to compare the developmental patterns with published reference data of children with cerebral palsy; to evaluate the range of treatment used and the frequency of its elements in children treated and monitored in rehabilitation centres who participated in the study.

MATERIALS AND METHODS: In a prospective study, measurements were collected through 2023 at five rehabilitation centers. 178 patients met inclusion criteria. The parameters of height, weight, BMI and their deviations from reference data for children with cerebral palsy were studied. The range of treatments provided in addition to physical rehabilitation was examined.

RESULTS: We found a significant difference in height indices (z-score values were higher than 0.7) compared to previously proposed North American reference anthropometric data for children with cerebral palsy. In our cohort, the increase in height score was independent of age, sex and GMFCS level. On the other hand, the concordance of weight and BMI was close to the reference charts. We believe that in order to monitor the development of children with cerebral palsy, it is necessary to create our own database of anthropometric data, calculating charts and percentiles of development.

CONCLUSION: The strategy for future research should also focus on the creation of regional registries of patients with cerebral palsy, which are necessary for multifactorial analysis taking into account epigenetic factors. In our sample of patients, the range and choice of treatments can be considered quite satisfactory — the frequency of orthopaedic surgery for secondary orthopaedic complications is around 40% of cases.

BACKGROUND: Spinal cord injury is a leading cause of disability in the adult population. Although spinal cord injuries represent a small proportion of trauma cases, they require special attention due to poor functional outcomes with serious negative socio-economic consequences.

AIM: To analyse demographic data, mechanism, location and type of injury in patients with spinal fractures treated at a level I trauma centre in Tyumen over a five-year period.

MATERIALS AND METHODS: We retrospectively analysed the medical records of all patients with spinal fractures who were treated at the State Budget Institution of Tuymen Regional Clinical Hospital No. 2 between 2018 and 2022.

RESULTS: Spinal fractures were diagnosed in 1521 patients, i.e. 35.4 cases per 100,000 population per year; 5.5% had complicated fractures. The mean age of the injured was 53.5±12.5 years, and the majority of the patients were men (54.3%). The main cause of spinal fractures was falls — 68.0%; in the age group over 65 years, falls from own height (<2 m) predominated — 49.6%. Road traffic accidents were the cause of injury in 18.2% of patients and were more common in the 25–34 age group. Injuries to the L1 vertebra (21.0%) were the most common in terms of location, with single fractures occurring in 75.1% of cases.

CONCLUSION: During the five-year follow-up period, there was an increase in the number of spinal fractures. In addition, there was an annual increase in the number of spinal fractures in the over-65s, which was higher than in younger patients. Despite this increase, a significant number of spinal fractures continue to be diagnosed in the 35–64 age group. This study could help predict and improve the prevention and treatment of spinal fractures.

BACKGROUND: Today, the molecular mechanisms of pain development and the role of neoinnervation in the articular cartilage (AC) degradation in osteoarthritis (OA) have been revealed.

AIM: Analysis of the mechanism of pharmacological regulation of chondroitin sulfate (CS) neoinnervation in the subchondral bone (SB) at late stages of OA based on a retrospective analysis of the results of an open prospective controlled randomized study of the effectiveness of highly purified CS in parenteral form in individuals with OA of the knee joint (KJ) stage III according to Kellgren-Lawrence and functional insufficiency of the joints of stage II.

MATERIALS AND METHODS: Total knee arthroplasty (TKR) was performed in 67 patients (24 men and 43 women, aged 41 to 73 years) with knee OA in two groups: the control group (CG; n=35) and the main group (MG; n=32). All patients received non-steroidal anti-inflammatory drugs at a standard daily dose upon inclusion in the study. MG patients additionally received a parenteral form of CS, a course of 25 injections for 50 days, 2 months before TKR (according to C. Ranawat). X-ray of the knee was performed. The innervation of the joint tissues was studied using biosamples of the SC, SC, and the joint capsule obtained during TKR: histopathological assessment of the synovial membrane according to GSS, histological assessment, histochemical assessment of the SC according to H. Mankin as modified by V.B. Kraus et al., on the OARSI scale. An enzyme immunoassay was performed on the blood levels at visits 0, 1, and 2: C-reactive protein (CRP), interleukin-6 (IL-6), nerve growth factor β (βNGF), calcitonin gene-related peptide (CGRP), potassium, and calcium.

RESULTS: In patients in the CG, a significant number of capillary loops were found in the AC from the SC side and nerve endings in the AC thickness. In the MG, along with adaptive restructuring, the absence of neoangiogenesis from the SC side and neoinnervation in the AC thickness was shown. At discharge from the hospital and 3 months after TKR, a significant decrease in βNGF, CGRP, VEGF, CRP, IL-6, potassium and calcium in the blood of patients in the MG was recorded.

CONCLUSION: The effectiveness of parenteral HS (Chondroguard^®) in relation to OA progression may be due to its effect on neoinnervation and is a new direction in therapeutic targeting of OA.

BACKGROUND: Osteonecrosis of the femoral head in Gaucher disease type I is an irreversible bone manifestation of the disease. The cause and mechanisms of osteonecrosis in Gaucher disease are still unknown, and their clinical and radiological characteristics must be taken into account when choosing treatment strategy.

AIM: To analyze the radial and morphological changes in the proximal femur after osteonecrosis of the femoral head in type I Gaucher disease.

MATERIALS AND METHODS: The study included 251 adult patients with type I Gaucher disease from the Russian National Registry; histological examination of 22 removed femoral bone fragments obtained during total hip replacement in 20 patients with Gaucher disease and 9 in patients of the control group was performed.

RESULTS: Aseptic necrosis of the femoral head was found in 30% adults with Gaucher disease, and in 20% patients it was associated with femoral head collapse. Osteosclerosis of the cancellous bone of the metaphysis, enlargement / swelling of the medullary cavity with secondary osteopenia and osteoporosis of the proximal femoral diaphysis often accompanied osteonecrosis of the femoral head, causing technical difficulties during surgery. The histological findings revealed a picture of chronic bone tissue ischaemia of the proximal femoral metaphysis, which was confirmed by the detection of widespread areas of osteosclerosis on radiography and MRI. Bone marrow infiltration by Gaucher cells in histological preparations persisted regardless of the duration of enzyme replacement therapy against the background of preserved regenerative potential of bone tissue.

CONCLUSIONS: The features of the radiological, MRI and histological picture should be taken into account when planning and performing orthopaedic surgery for aseptic necrosis of the femoral head in patients with type I Gaucher disease.

BACKGROUND: Gonarthrosis is the most common form of osteoarthritis (OA) and chronic low-grade inflammation plays a central role in its pathogenesis. Obesity plays an important role in the development of gonarthrosis — it is also favoured by the presence of a relatively large fat depot in the knee joint — the infrapatellar fat pad (IPFP) — which releases pro-inflammatory cytokines and causes local inflammation in the knee joint. There is conflicting data on the relationship between IPFP volume, body mass index (BMI) and stage of gonarthrosis. Given the significant prevalence of OA in the population and the limited options for its effective treatment, it seems relevant to further investigate the role of BMI in the pathogenesis of gonarthrosis, which may further contribute to the development of new targeted therapeutic strategies.

AIM: To evaluate the relationship between IPFP volume, BMI and stage of gonarthrosis in order to improve the effectiveness of preventive counselling and the possibility of further development of new treatment approaches.

MATHERIALS AND METHODS: We retrospectively analysed the data of magnetic resonance imaging of the knee joints performed on 32 patients with gonarthrosis in 2022-2023 at the Centre for Radiological Diagnostics of the FEFU Medical Centre (Vladivostok, Primorsky Krai). The patients were divided into two groups according to their BMI.

RESULTS: The mean IPFP volume for all patients in both groups was 33.01±8.79 cm³. Statistically significant differences were found when analysing the IPFP volume in men and women. Linear correlation analysis of the relationship between Hoffa's fat pad volume and OA stage in the female group showed a moderate inverse relationship and statistical significance. Multivariate statistical analysis showed that IPFP volume and BMI were most closely related to each other compared to other variables. No statistically significant differences in IPFP volume were found between the normal and increased BMI groups. A moderate negative correlation was found between BMI volume and OA stage in overweight patients. IPFP volume correlated with BMI in non-obese patients and weakly negatively in obese patients.

CONCLUSIONS: In the present study, greater IPFP volume was observed in overweight and obese patients compared to those with normal BMI, but these differences were not statistically significant. In patients with gonarthrosis, IPFP volume was associated with comorbid obesity, gender, age, height and weight. These data may be useful in developing individualised approaches to the prevention and treatment of OA.

BACKGROUND: Titanium alloys are widely used in medicine due to their high biocompatibility, corrosion resistance and mechanical strength. However, standard titanium implants have a limited ability to integrate with bone tissue, which can lead to various complications and the need for revision operations. Modification of the implant surface with various biologically active compounds is a promising direction for solving this problem. Among the possible approaches, special attention should be paid to the use of inorganic coatings such as calcium oxides and phosphates, which combine high resistance, corrosion resistance and good mechanical properties.

AIM: Determining the modification effect of the titanium (Grade 2) mesh surface on the biocompatibility and osseogenic properties of materials with in vivo experiments using the small laboratory animals.

MATERIALS AND METHODS: The titanium mesh surface was modified by microarc oxidation in electrolyte with dispersed hydroxyapatite (HAp). The effectiveness of the surface modification was in vivo tested with a trepanation model in the skull of Wistar rats.

RESULTS: The formation of a structured regenerate at the bone surface without a significant defect reduction was revealed. The tissue reaction to the implantation of metal meshes in the defect of the parietal bones of the skull was weak, relatively mature dense connective tissue capsules were formed around the meshes, in which vascularization and inflammatory infiltration were minimal, bone regeneration was observed along the defect edges. Surface modification with microarc oxidation led to more pronounced bone regeneration compared to a surface-unmodified mesh.

CONCLUSION: Modification of the surface of the titanium-based mesh by micro-arc oxidation in the electrolyte with dispersed HAp has a positive effect on bone regeneration when closing defects of flat bones.

BACKGROUND: Progressive spinal cord compression in spinal deformities leads to neurological deficit, creating a high risk of patient disability. Modern 3D modeling technologies allow for the production of individual implants and the creation of full-size models of the spine and spinal cord, which radically improves the approach to treating patients with severe spinal deformities. These technologies are especially effective in congenital anomalies, tumors, and post-traumatic defects, providing a better spatial representation of the pathology and the possibility of personalized surgical treatment of neurologically complicated spinal deformities.

CLINICAL CASES DESCRIPTION: The results of two patients with kyphoscoliotic deformities of the spine combined with spinal cord compression using custom metal structures and 3D modelling capabilities are presented. Clinical examples show the choice of surgical tactics in the treatment of progressive kyphoscoliotic deformities leading to spinal cord compression. Methods of spinal cord decompression and surgical planning using individual full-size 3D models of the spine and spinal cord are presented, as well as the possibility and effectiveness of using individual plates to fix spinal deformities.

CONCLUSION: Surgical treatment resulted in stable fixation of the deformity and regression of the neurological deficit, helping to prevent disability and restore functional activity.

BACKGROUND: Aneurysmal bone cysts (ABC) of the spine in children and adolescents are an urgent problem in modern traumatology–orthopedics, oncology and neurosurgery. Spinal ABC is recorded in 8–30% of all cases of ABC detected, while they account for up to 15% of all spinal tumors. The most rare area of ABC lesion is the sacral region, which accounts for less than 4% of reported cases. The treatment methods described in the literature can be divided into conservative, minimally invasive and surgical. The authors report on such methods as the introduction of adjuvant drugs into the cyst cavity, selective arterial embolization, etc. Some sources also mention the use of the drug denosumab. In the literature, you can find materials on surgical treatment in the form of open resection, bone grafting, cementing, as well as a combination of several techniques.

CLINICAL CASES DESCRIPTION: Results of treatment aimed at reducing ABC activity, bone tissue repair, restoration of sacral support capacity, regression of neurological symptoms in its presence and pain syndrome. The material consisted of 8 patients (4 patients were described in a series of clinical cases) with a diagnosis of aneurysmal bone cyst of the sacrum, who were treated at the Department of Pediatric Bone Pathology and Adolescent Orthopedics of the Priorov National Medical Research Center of Traumatology and Orthopedics. A brief review of the literature is based on a search for articles in PubMed, Cyberlinenka, eLibrary, Google Scholar. The assessment of tumor changes at the treatment stages was carried out by measuring intracystal pressure using a Waldman device in mm of water. The program of the diagnostic arm “Gamma Multivox” (GC “Gammamed”, Russia) made it possible to evaluate the result of treatment according to CT data. The significance of changes in tumor parameters was assessed using the Wilcoxon landmark rank criterion for treatment stages involving at least 5 measurements. Statistical analysis was performed using the SciPy Stats package and Python programming language software.

CONCLUSION: The result of the treatment was traced over a period of 1 to 8 years. Step-by-step puncture treatment reduces the activity of ABC, starts the process of bone tissue repair, restores the support capacity of the sacrum and reduces the volume of the tumor, promotes regression of pain and neurological symptoms due to the decompressive effect.

BACKGROUND: Aseptic necrosis of the femoral head (ANFH) is a serious disease that often affects young and middle-aged people (20–50 years) and accounts for up to 4.7% of degenerative-dystrophic hip disorders. In its late stages, it usually leads to destruction of the femoral head and functional failure of the hip joint as a whole due to impaired blood supply and low bone remodelling capacity. The clinical picture in the early stages of ANFH is often asymptomatic, although patients may develop groin pain that may radiate into the knee joint or ipsilateral buttock. On physical examination, patients usually have limited range of motion in the hip joint and pain on forced internal rotation. Modern diagnostic methods available include radiography, scintigraphy, functional bone assessment, computed tomography, histological studies and magnetic resonance imaging (MRI), which has recently become the most widely used by many clinicians. Early signs of osteonecrosis can only be detected by MRI, which allows the most accurate determination of the stage of the pathological process, assessment of the prevalence of the lesion, structural changes in the bone marrow, the presence of fluid in the joint, the state of the articular cartilage and other soft tissues of the hip joint. Contrast MRI shows delayed perfusion of the contrast agent in the necrosis zone.

CLINICAL CASE DESCRIPTION: The article describes an original method of organ-preserving surgery — minimally invasive multiple tunneling of the femoral head with aseptic necrosis without collapse, and presents a clinical observation. The positive outcome of the surgical procedure was confirmed functionally (preservation of the range of motion of the operated joint, absence of pain syndrome) and by MRI data (preservation of the shape of the femoral head, signs of remodelling of the necrosis focus).

CONCLUSION: At present, the diagnostic possibilities of detecting aseptic necrosis of the femoral head at the pre-radiological stage are becoming a routine examination due to the increasing availability of MRI in the medical and preventive facilities. With the emergence of new technological possibilities in modern medicine, minimally invasive treatment of the lesion by multiple tunnelling to improve blood circulation in combination with cellular stimulation of reparative processes with growth factors in the femoral head makes it possible to preserve the viability of the femoral head and avoid joint endoprosthesis.

The review considers the use of generative artificial intelligence technologies in surgery, traumatology and orthopedics. Definitions of key generative artificial intelligence technologies are given, as well as the difference between discriminative and generative models of artificial intelligence. An analysis of publication activity on the use of generative artificial intelligence in surgery, traumatology and orthopedics in world macroregions is conducted. The potential role of various generative artificial intelligence models at the preoperative, intraoperative and postoperative stages of healthcare is analyzed. Data on the results of clinical application of generative artificial intelligence and the most common problems associated with the practical use of various generative artificial intelligence applications are provided including issues of quality and safety of surgical care. The review proposes potential solutions and research directions to address these problems.

Shoulder arthroplasty is still an important issue in modern traumatology and orthopaedics. This type of surgical treatment is associated with a relatively high number of complications and unsatisfactory results, which are often extremely difficult to correct. Glenoid deformity is a common obstacle faced by surgeons performing reverse total shoulder arthroplasty.

Currently, regenerative medicine (cell therapy) or motor rehabilitation approaches are being used to overcome the consequences of spinal cord injury. However, the efficacy of these approaches at the preclinical research stage does not always translate into successful implementation in clinical practice. In particular, complete recovery from functional deficits caused by severe spinal cord injury is often not possible. In this context, the development of combined approaches based on cell transplantation and neuromodulation is needed to enhance the neuroregenerative effect. The addition of dosed motor training to the overall treatment plan and in the context of combined approaches may have a significant supportive effect. In this review, we focused on evaluating clinical trials that used combinations of different approaches to gain an understanding of the mechanisms underlying their therapeutic effects. Despite the positive therapeutic outcomes of combined approaches, further research is needed into the emerging cellular and molecular changes involved in the reorganisation of neuronal connections.

At least 240 million people worldwide have symptomatic osteoarthritis and its prevalence is increasing. Current protocols for non-surgical treatment are very limited, and the number of surgical interventions on joints is increasing. Given the global prevalence of this disease, an effective disease-modifying strategy is needed to relieve symptoms and slow progression. Search literature using: PubMed, eLIBRARY.RU, CyberLeninka. Search keywords: osteoarthritis, obesity, gut microbiota, dietary, gut-joint axis, inflammation, osteoarthritis, obesity, intestinal microbiota, gut-joint axis, inflammation. The depth of the review was mainly for the last 5 years. Unsaturated fatty acids and n-6 polyunsaturated fatty acids have a more pronounced pro-inflammatory effect, while n-3 polyunsaturated fatty acids have an anti-inflammatory effect. The gut-joint axis hypothesis is based on possible cross-connections between the joint and the gut. To date, there are four mechanisms by which bacteria can influence the development of arthritis. There are studies examining the modulation of gut microbiota through the use of prebiotics and probiotics. Thus new trends in non-surgical treatment of osteoarthritis include: influence on pro-inflammatory and anti-inflammatory factors, modeling nutrition, modification of the microbiota.

On 13 and 14 December 2024, the XI Priorov Orthopedic Forum was held on the site of the Monarch Hotel in Moscow, dedicated to the anniversary date — the 100^th anniversary of Professor Konstantin Mitrofanovich Sivash, an outstanding physician and scientist, a pioneer in the field of endoprosthetics. The report highlights the main events of the forum.