Vol 8, No 1 (2020)

Experimental and theoretical research

Experimental evaluation of the efficiency of chitosan matrixes under conditions of modeling of bone defect in vivo (preliminary message)

Vissarionov S.V., Asadulaev M.S., Shabunin A.S., Yudin V.E., Paneiakh M.B., Popryadukhin P.V., Novosad Y.A., Gordienko V.A., Aganesov A.G.


Background. Despite the wide range of studies, the development of osteoplastic material, which has not only osteoconductive but also osteoinductive properties, remains an extremely topical issue in modern medical materials science. This work is devoted to experimental evaluation of the effectiveness of synthetic osteoplastic composite material based on chitosan and hydroxyapatite.

Aim. This study aimed to determine the effects of spongy implants based on chitosan and its composite with hydroxyapatite nanoparticles in an amount of 50 wt. % on early osteogenesis in the area of the through defect of the ileum.

Materials and methods. The studied materials were sponge implants based on chitosan and its composite with hydroxyapatite nanoparticles in an amount of 50 wt. %. Comparison groups include those without implant placement and those with replacement with commercial Reprobone osteoplastic material. Materials were implanted into the zone of the through defect of the ileum of rabbits for a period of 28 days.

Results. A high rate of resorption of materials based on chitosan in bone tissue and active growth of reticulofibrotic bone tissue along the edges of the defect was established, and the formation of cartilaginous islands and bone marrow was recorded in the group of chitosan implants with hydroxyapatite. The aseptic effect was observed with the use of implants made of chitosan and hydroxyapatite.

Conclusions. The data obtained allow us to argue about the osteoconductivity of the studied materials and the prospects for further development in this direction.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):53-62
pages 53-62 views

Original Study Article

Pathological fractures of the spine in children (review of the literature and clinical and morphological monocenter cohort analysis)

Zorin V.I., Mushkin A.Y., Novitskaya T.A.


Background. Pathological vertebral fractures are rare and occur in inflammatory, tumor, and dystrophic lesions.

Aim. This study aimed to analyze clinical features and morphological structure of pathological fractures of the spine in children.

Materials and methods. The authors examined and operated 62 children aged 2–17 years for pathological vertebral fractures. We investigated the clinical, radiological, and morphological features.

Results. The average age of children at the time of hospitalization was 10 years. Lesions of thoracic vertebrae prevailed (78%) with the maximum frequency of occurrence at the apex of physiological kyphosis Th7–8. In 10 cases, multiple lesions were noted, including the pathology of other parts of the skeleton. In 69% of observations, clinical symptoms were not dominated by mechanical back pain. Palpation pain (34%) and local spinal deformation (27%) were noted. On average, local kyphosis was 24°. Eleven patients (18%) manifested a neurological deficiency, of which nine fractures were a consequence of the tumor process. In 16% of observations, the fracture of the vertebra was detected to be an accidental Х-ray finding. Among the radiation manifestations, all cases (12 patients) registered the decrease in the height of the vertebral body in the form of collapse. Destruction was manifested by various options other than blastic. Therapeutic and diagnostic interventions were performed in 56 patients, and in six children, manipulation was limited to trepan biopsy. The pathological fracture was caused by an inflammatory process in 50% of observations and tumors in 42%, of which 31% is malignant.

Conclusions. Pathological spinal fracture in children should be considered as a syndrome, which in most cases is based on an inflammatory or tumor process. The high frequency of neoplastic, including malignant processes, requires active invasive diagnosis. Therapeutic tactics are determined by the clinical, radiation, and morphological characteristics of pathology.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):5-14
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Analysis of causes of metal structure destabilization in correction of congenital spinal deformation in children of a younger age group

Kokushin D.N., Vissarionov S.V., Khardikov M.A., Khusainov N.O., Filippova A.N., Ilin V.V.


Background. One of the most common vertebral malformations that lead to the occurrence and progression of congenital scoliosis is disorders of vertebral formation. Most specialists adhere to the active tactics of surgical correction of spinal deformity in early childhood.

The aim. To evaluate the variants and causes of the transpedicular spinal system destabilization, which is not related to the violation of its integrity, in the surgical treatment of children with congenital spinal deformities.

Materials and methods. The case histories of 286 children under the age of 6 years undergoing surgical treatment in H. Turner National Medical Research Center for Сhildren’s Orthopedics and Trauma Surgery between 2014 and 2019 were analyzed. Depending on the outcome of the surgical treatment, the patients were divided into groups: the main group (n = 7) included those with spinal system destabilization and the control group (n = 12) consisted of those without spinal system destabilization. During the study, the sizes of the bases of the arcs adjacent to the abnormal vertebra, the magnitude of the scoliotic and kyphotic components of the deformation, and the correct position of the supporting elements of the spinal system on the Gertzbein scale were determined.

Results. Patients of the studied groups were identified according to their age and the magnitude of scoliotic and kyphotic components of spinal deformity. The average diameter of the arc base in the studied groups varied (p < 0.05). In all patients, the complete correction of the congenital curvature of the spine was achieved after surgery. In the long-term postoperative period in patients of the study group after radiation analysis, the malposition of supporting elements relative to the base of the vertebral arch and a loss of correction of spinal deformity by an average of 25° were revealed, which required the repeated surgery in order to restore the stability of the spinal system and to correct deformation.

Conclusions. The reasons for the spinal system destabilization during the correction of the spinal congenital deformations are the peculiarities of vertebral anatomical-anthropometric parameters in the curvature zone, as well as tactical aspects during surgery. The main reason for the spinal system destabilization without violating its integrity is the small size of bases of adjacent vertebral arches relative to the abnormal one. The small size of the bases of the vertebral arches and the significant amount of necessary correction of congenital spinal deformity necessitate the installation of a longer spinal system in order to restore physiological profiles in the curvature zone.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):15-24
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The benefits of early surgical treatment of deep cervical burns in children

Gnipov P.A., Baindurashvili A.G., Brazol M.A., Mitrofanova E.V., Melnikov M.R., Mashevskiy G.A.


Background. The frequency of deep cervical burns in children is four times higher than that of deep face burns. Currently, there is no consensus on the methods for surgical treatment of deep burns in cervical areas; meshed skin autografts continue to be used.

Aim. To evaluate the benefits of early surgical treatment of deep сervical burns in children between the third and fifth days from the moment of injury.

Materials and methods. Case-control study. Surgical treatment was performed in 81 children with deep cervical burns. The main group with early surgical treatment included 46 children and underwent surgical treatment at 3.37 ± 0.14 days from the moment of injury; the control group received autograft during stage treatment for 35 children at 27.17 ± 0.18 days. The treatment results were evaluated by the following indicators: the number of dressing changes, the period of skin restoration, and the area of graft success. In the long term, functional and cosmetic treatment results were evaluated.

Results. In the study and control groups, 7.93 ± 0.45 and 18.75 ± 0.61 dressings were required to complete the treatment, respectively (p < 0.001). The skin restoration periods were 16.54 ± 0.68 and 36.94 ± 0.89 days, respectively (p < 0.001). The graft success areas were 99.50% ± 0.13% in the main group and 93.91% ± 2.68% in the control (p < 0.001). During the staged surgical treatment, one patient showed a loss of 90% of the graft, which required regrafting. Other complications in the treatment process have not been noted. When assessing long-term cosmetic results using the Vancouver Scar Scale, the average score was 4.0 ± 0.26 points in the main group and 7 ± 0.28 points in the control (p < 0.001). The presence of post-burn cicatricial contracture in the main group was noted in 12 (26%) people and the absence in 34 (74%) children. In the control group, 20 (57%) patients required surgical removal of post-burn deformity, and 15 (43%) children did not need further surgical interventions.

Conclusions. Early surgical treatment of deep cervical burns in children on the third and fifth days from injury allows not only to accelerate the process of restoration of the skin but also to directly affect the cosmetic and functional results in a better way.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):25-34
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Effect of brachial plexus block on the incidence of arterial hypotension and bradycardia events during shoulder arthroscopy in adolescents

Trukhin K.S., Zabolotskii D.V., Koriachkin V.A., Kuleshov O.V., Zakharov K.I., Сherednichenko A.A., Kulikov A.Y.


Background. The role and significance of the technical aspects of interscalene brachial plexus block in the occurrence of sudden arterial hypotension and bradycardia events during shoulder arthroscopy in a semi-sitting position are ambiguous.

Aim. The study aimed to assess the effect of interscalene brachial plexus block on the incidence of hypotension-bradycardia events during shoulder arthroscopic surgery in adolescents in a semi-sitting position.

Materials and methods. This retrospective analysis of anesthesia protocols included 288 patients who underwent arthroscopic shoulder surgery in a semi-sitting position under the interscalene brachial plexus block. Regional blockades were performed with neurostimulation in Group 1 (n = 23), neurostimulation and ultrasound navigation without repositioning the needle in Group 2 (n = 70), and neurostimulation and ultrasound navigation with multiple precision repositioning the needle in Group 3 (n = 195).

Results. Hypotension-bradycardia events were detected in 26 patients out of 288 (9%). There was a statistically significant difference in the frequency of hypotension-bradycardia in all groups: 10 (43.48%) in Group 1, 15 (21.43%) in Group 2, and 1 (0.51%) in Group 3 (p = 0.000). A direct correlation between hypotension-bradycardia episodes and local anesthetic volume (r = 0.405; p < 0.05), and Horner’s syndrome (r = 0.684, p < 0.05) was found.

Conclusions. Interscalene brachial plexus block with a target delivery of low volume of local anesthetic and dual navigation reduces the risk of hypotension-bradycardia. Horner’s syndrome can be considered an early predictor of hypotension-bradycardia events.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):35-42
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Protective behavior of adolescents with acquired orthopedic diseases in the conditions of rehabilitation treatment

Pyatakova G.V., Kozhevnikova A.O., Kudryavtseva S.V.


Background. Teenagers with orthopedic diseases are in a difficult life situation, accompanied by experiences of an extraordinary level. Adaptation mechanisms play an important role in overcoming emotional difficulties. An important component of the adaptation process is psychological defense mechanisms. The article discusses the structure and effectiveness of the protective disposition of personality in adolescents suffering from various forms of acquired orthopedic diseases.

Aim. This study aimed to determine the structure and effectiveness of the protective disposition of personality in adolescents suffering from various forms of acquired orthopedic diseases.

Materials and methods. The study involved adolescents suffering from acquired orthopedic diseases: juvenile chronic arthritis, idiopathic scoliosis, and adolescents with long-term consequences of physical trauma on the basis of voluntary informed consent. All teenagers received treatment in the children’s orthopedic clinic. The study involved 139 adolescents with acquired orthopedic diseases and 36 healthy adolescents aged 12–17 years. Clinical psychological and psychodiagnostic methods were used to survey the respondents.

Results. The general and specific features of the protective system of personality in adolescents with various forms of orthopedic diseases and their healthy peers were revealed. The role of mechanisms of psychological protection in the development of post-traumatic symptoms in adolescents with various forms of acquired orthopedic diseases in the situation of rehabilitation treatment is revealed.

Conclusions. Taking into account the features of the protective disposition of the personality of adolescents with orthopedic diseases allows a differentiated approach to psychological correction at the stages of rehabilitation treatment, to develop individual approaches to providing psychological assistance in a hospital.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):43-52
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Exchange of experience

Orthopaedic sequelae of meningococcemia in children: options for the correction of lower and upper limb deformities (preliminary message)

Garkavenko Y.E., Khodorovskaya A.M., Dolgiev B.H., Melchenko E.V.


Background. Мeningococcal infection with damage to various organs and systems, including the musculoskeletal system, causes growth plate dysfunction, which usually leads to the formation of orthopedic consequences, including axis deviation and/or limb length discrepancy.

Aim. This study aimed to analyze the features of limb deformities and methods for their correction in children with consequences of meningococcemia.

Materials and methods. The retrospective analysis was performed on patients with consequences of meningococcemia who were examined and surgically treated in the clinic between 2012 and 2018. A total of 12 patients (six boys and six girls) were included, with an age range of 2–15 years. The examination included clinical, X-ray, and physiological methods. Treatment methods consisted of a combination of angular deformity correction and limb lengthening.

Results. In 12 patients, 76 growth plate arrests of long bones were found. Most frequently (17.1%), growth plate arrests of the distal femur and proximal tibia were observed, which resulted in limb shortening and/or axis deviation. For restoration of limb alignment in 10 (83.3%) patients, transosseous compression-distraction osteosynthesis was performed. For limb deformity correction, guided growth technique was applied by using eight-plate for temporary epiphysiodesis of active functioning part of the growth plate in four (33.3%) patients, whereas partial growth plate arrest resection with following epiphysiodesis was achieved in two (16.6%).

Conclusions. Meningococcal septicemia leads to long bone growth plate dysfunction. The main complaints in this patient are limb shortening and their deformity. Along with the transosseous compression-distraction osteosynthesis technique, using the guided growth method by carrying out temporary epiphysiodesis of the remaining functioning part of the growth plate of damaged bone was appropriate.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):63-72
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Open reduction and K-wires fixation of medial humeral epicondyle fractures with intra-articular elbow entrapment in children

Massetti D., Marinelli M., Coppa V., Falcioni D., Specchia N., Giampaolini N., Gigante A.


Background. Medial epicondyle fracture (MEF) is a common injury of all elbow fractures in the pediatric and adolescent population and is often associated with elbow dislocation. Traditional management by cast immobilization increasingly is being replaced with early open reduction and K-wires or screws fixation. A consensus about the correct treatment of MEF is currently lacking in the medical literature.

The aim of this study was to report the clinical and radiographic outcomes and the complications of patients affected from MEF with intra-articular fragment incarceration treated by open reduction and K-wire fixation.

Materials and methods. Thirteen children (aged 8–13 years) with medial epicondyle fractures (MEF) with intra-articular elbow entrapment were retrospectively reviewed. All the enrolled patients were surgically treated with open reduction and k-wire fixation without exploration of ulnar nerve. Clinical outcomes were evaluated using upper limb alignment in the frontal plane, elbow range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and with the Visual Analogue Scale (VAS). Radiographic outcomes and complications were also evaluated.

Results. At a mean follow-up of 24.1 months no patients showed axial deformity of the upper limb or instability of the elbow and with preserved elbow ROM. The mean MEPS was 98.8 and the mean value of the VAS score was 1. The final X-rays showed fracture healing in 11 patients while 2 (15.3%) reported asymptomatic nonunion. Six patients of 13 presented with preoperative paresthesia in the ulnar nerve field but all of them reported a complete recovery after a mean of 4.3 months. All patients returned to their sporting activities at a mean of 5.4 months after surgery. One patient (7.7%) reported a superficial surgical wound infection treated with oral antibiotic medication without further surgery. No other complication was found.

Conclusions. The results demonstrate that open reduction and K-wires fixation without exploration of ulnar nerve for MEF with intra-articular elbow entrapment treatment is a safe and effective procedure.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):73-82
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Сase report

Loeys–Dietz syndrome (literature review and case description)

Agranovich O.E., Semenov S.Y., Mikiashvili E.F., Sarantseva S.V.


Background. The Loeys–Dietz syndrome is a rare autosomal dominant connective tissue disorder characterized by the pathology of the cardiovascular system in combination with various anomalies of the musculoskeletal system. In modern literature, there is neither any information about the frequency of pathology nor any algorithm of examination and treatment for patients with this syndrome.

Clinical case. The article presents a clinical observation of a 7-year-old patient with Loeys–Dietz syndrome with a genetically confirmed diagnosis.

Discussion. This article provided a literature review, examined diagnosis issues and differential diagnosis, and presented the clinical picture of the syndrome. The main symptoms of Loeys–Dietz syndrome are artery aneurysms (most often in the aortic root), arterial tortuosity (mainly the vessels of the neck), hypertelorism, and bifid (split) or broad uvula. However, the combination of these symptoms is not found in all patients with this disease.

Conclusions. The article emphasized the importance of a genetic verification of the disease, as well as a multidisciplinary approach to treatment with mandatory dynamic monitoring by specialists such as a cardiologist, neurologist, orthopedist, and pediatrician, which help prevent the development of complications and increase the life expectancy of this group of patients.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):83-94
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Against all odds: traumatic thumb amputation following ring avulsion injury

Hamzan M., Jeffrey M., Halim A., Mat Saad A.


Background. Replantation of an avulsed digit often poses a surgical challenge even to an experienced microsurgeon. Therefore, it is often difficult to choose the treatment path for traumatic amputation of digit following ring avulsion injury, be it completion amputation or replantation. We discuss the surgical challenges encountered and management strategies used in this case of an unfortunate child who sustained an amputation of his dominant thumb.

Clinical case. We present the case of a 10-year-old boy who sustained a complete amputation of his right thumb following a ring avulsion injury which was reconstructed with multiple approaches and surgical techniques to address difficulties at different stages. We replanted the avulsed thumb, reconstructed the tendon, soft tissue coverage with the use of allograft skin and local flap, and improvised surgical tactic to overcome complications encountered intra- and post-operative states such as thrombosis of arterial anastomosis and venous congestion.

Discussion. There is scarce literature on the management of ring avulsion injury of the thumb and to the author’s best knowledge, there was only one reported case in children. In the case described here, we report a good outcome with complex reconstructive surgery despite all odds in an attempt to salvage the thumb, especially in a pediatric population. Post-surgical reconstruction, the boy achieved a successful and acceptable outcome in terms of function and aesthetic appearance.

Conclusion. The journey through replantation of an amputated digit following avulsion injury poses various challenges both to the microsurgeon and patient. The decision of surgical tactics must be tailored and thoroughly reason based on the knowledge, experience, and good microsurgical skill. A good surgical outcome can be achieved even in a complex injury in the pediatric population with careful planning and the right intervention in each complication peri-operative.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(1):95-100
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