Vol 8, No 3 (2020)

Experimental and theoretical research

Automation analysis X-ray of the spine to objectify the assessment of the severity of scoliotic deformity in idiopathic scoliosis: a preliminary report

Lein G.A., Nechaeva N.S., Mammadova G.М., Smirnov A.A., Statsenko M.M.


Background. A large number of studies have focused on automating the process of measuring the Cobb angle. Although there is no practical tool to assist doctors with estimating the severity of the curvature of the spine and determine the best suitable treatment type.

Aim. We aimed to examine the algorithms used for distinguishing vertebral column, vertebrae, and for building a tangent on the X-ray photographs. The superior algorithms should be implemented into the clinical practice as an instrument of automatic analysis of the spine X-rays in scoliosis patients.

Materials and methods. A total of 300 digital X-rays of the spine of children with idiopathic scoliosis were gathered. The X-rays were manually ruled by a radiologist to determine the Cobb angle. This data was included into the main dataset used for training and validating the neural network. In addition, the Sliding Window Method algorithm was implemented and compared with the machine learning algorithms, proving it to be vastly superior in the context of this research.

Results. This research can serve as the foundation for the future development of an automated system for analyzing spine X-rays. This system allows processing of a large amount of data for achieving >85% in training neural network to determine the Cobb angle.

Conclusions. This research is the first step toward the development of a modern innovative product that uses artificial intelligence for distinguishing the different portions of the spine on 2D X-ray images for building the lines required to determine the Cobb angle.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):317-326
pages 317-326 views

Original Study Article

Foot abduction brace noncompliance in children with idiopathic clubfoot: how the deep squatting posture might help

Sailohit P., Limpaphayom N.


Background. Compliance with the foot abduction brace (FAB) is essential for idiopathic clubfoot (ICF) managed by the Ponseti method. The deep squatting posture (DSP) was correlated with favorable outcomes in ICF.

Aim. The aims of the study were to identify the noncompliance rate with the FAB, and assess how the routine practice of ankle stretching and Asian-style DSP affected the ICF correction during the Ponseti method.

Materials and methods. Of 42 children with ICF, 63 ICF underwent the Ponseti method at an average age of 8.7 ± 12.6 weeks using an average of 5.4 ± 1.7 casts followed by FAB wear. The children practiced the DSP exercise as an adjunct to the FAB protocol. Children noncompliant with the FAB protocol but compliant with the DSP exercise (group A) were compared with children noncompliant with both FAB protocol and DSP exercise (group B).

Results. At an average follow-up of 3.5 ± 1.4 years, 8 of 42 children compliant with the FAB protocol. The FAB protocol deviation was documented at an average of 10.3 ± 4.8 months. Children who did not adhere to the practice of the DSP exercise had a higher recurrent rate of any ICF deformity (OR 7.82, 95% CI 1.35–53.79, p = 0.003). Of the 34 children (48 feet) noncompliant with FAB, the children in group A (39 feet) had lower recurrence rate (p = 0.02), a better Dimeglio grade (p = 0.005), and a better Pirani score (p < 0.001) at the most recent evaluation than children in group B (nine feet). However, recurrent metatarsus adductus was more prevalent in group A.

Conclusion. The DSP exercise should be advocated as a supplemental modality but cannot substitute the regular use of FAB.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):241-248
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Trochanteric epiphysiodesis in complex treatment of children with hip pathology: analysis of preliminary results

Pozdnikin I.Y., Baskov V.E., Barsukov D.B., Bortulev P.I., Kostomarova E.A., Imomov K.D.


Background. The relative overgrowth of the greater trochanter is one of the most common deformities of the proximal femur in association with several disorders of the hip joint.

Aim. To analyze the dynamics of proximal femoral growth after trochanteric epiphysiodesis as well as to determine the options for using this method in the complex treatment of children with hip pathology.

Materials and methods. We analyzed the data of clinical and radiological examinations and surgical treatment (permanent trochanteric epiphysiodesis with metal fixation) outcomes for 43 (52 joints) patients aged 4–12 years with a developing high position of the greater trochanter.

Results. The surgery enabled slowing down of the growth of the greater trochanter on the side of intervention by (average) 50% (p < 0.05), although the values of the neck-shaft angle both on the affected side and the side opposite to it did not change (p < 0.05).

Conclusion. In moderate disorders of the growth plate of the femoral head epiphysis, trochanteric epiphysiodesis can prevent the progression and, in some cases, correct disturbed ratios of the hip joint, thereby avoiding the need for larger surgical interventions.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):249-258
pages 249-258 views

Comparative analysis of arthroscopic techniques of anterior cruciate ligament reconstruction in adolescents

Salikhov M.R., Avramenko V.V.


Background. According to the considerably contradictory information across the international literature, both the anatomical and transtibial reconstruction of the anterior cruciate ligament (ACL), under similar conditions, yield good functional results from treatment. Therefore, it is important to evaluate the comparative effectiveness and the prospects of certain methods of ACL reconstruction. The purpose of this study was to analyze the possibilities and advantages of anatomical technologies for the reconstruction intervention.

Aim. To compare the outcomes of ACL reconstructions among adolescent children using different methods.

Materials and methods. The outcomes of 94 arthroscopic reconstructions of the ACL in adolescents were analyzed. The patients were categorized into 3 groups: Group 1 included 32 patients (34%) who underwent isometric plastic surgery of the ACL, wherein the femoral canal was formed using the transtibial technique. Group 2 included 30 patients (32%) who underwent anatomical plastic surgery of the ACL, with the formation of the femoral canal through additional anteromedial arthroscopic access. Group 3 included 32 patients (34%) who underwent the “all-inside” anatomical reconstruction of the ACL.

Results. A comparative analysis of the outcomes of reconstruction of the ACL among adolescents revealed that the anterior-posterior and rotational stability of the knee joint was better in group 3 patients than in groups 1 and 2 patients. In fact, the group 3 patients showed a significantly less positive pivot-shift (0 degree to 87.5%; I+ the extent of 12.5%) — than the group 1 patients (0 degree — 46.8%; I+ degree — 25%; II+ degree and 21.9%; III+ degree and 6.3%), followed by the group 2 patients (0 degree to 86.6%; I+ degree 6.7%; II+ degree of 6.7%).

Conclusion. Considering the safety aspects of intra-articular structures and for the better anatomical orientation of the femoral canal, the all-inside method of ACL reconstruction yielded better outcomes of postoperative anterior-posterior and rotational stability of the knee joint.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):259-268
pages 259-268 views

Spinal deformity in adolescent idiopathic scoliosis at the end of Chêneau brace treatment

Tsaknakis K., Braunschweig L., Lorenz H.M., Hell A.K.


Background. Brace treatment is frequently used in adolescent idiopathic scoliosis (AIS). However, due to different brace models, long-term results on spinal deformity development at the end of Chêneau brace treatment are not often described and differ in results.

Aim. The aim of this work was to analyze clinical and radiological data of AIS patients treated with Chêneau braces from the beginning of treatment until the end of growth and brace therapy in order to define realistic treatment results and expectations in an everyday setting.

Materials and methods. 52 AIS patients with Chêneau brace treatment were followed from the beginning of treatment until the end of growth. Clinical data such as the initial Risser sign, age at treatment, gender, curve patterns and body mass index were analyzed.

Results. At the beginning of brace therapy, the average age was 13.1 years and patients showed a mean scoliotic curve angle of 30.9°. Four months of brace use reduced the scoliotic curve to 20.1°. Nine months after the end of brace treatment and an average treatment duration of 17 months, scoliosis has increased up to 30.3° again. In children with a lower maturity status, the initial scoliotic curve was less than in more mature patients leading to less spinal deformity at the end of treatment. In addition, obese children had less scoliosis correction during brace therapy than normalweight children.

Conclusion. In patients with AIS treated with a Chêneau brace, the initial curvature correction was 35%. Nine months after the end of brace treatment, scoliotic curves identical to the deformities at the beginning of treatment could be observed.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):269-274
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Analysis of roentgenologic parameters of the articular process of the scapula in children with instability of the shoulder joint

Proshchenko Y.N., Lukyanov S.A.


Background. The frequency of occurrence of dislocation of the shoulder joint is the highest among that for all other limb joints. Simultaneously, recurrent instability of the shoulder joint develops majorly in children and adolescents, which, in the future, lead to the development of persistent pain syndrome. Past evidence indicate that the features of the spatial positioning of the articular process of the scapula can be considered as a risk factor toward the development of instability in the shoulder joint among adult patients. However, there is no reliable data in the literature regarding the influence of tilt and rotation of the shoulder blade glenoid on the occurrence of instability in the shoulder joint among children and adolescents. Encouraged, we undertook this subject for our study.

Aim. To clarify the impact of changes in the version and inclination of the glenoid on the instability of the shoulder joint among children.

Materials and methods. We analyzed the survey data of 42 children with a habitual dislocation of the shoulder of traumatic and atraumatic origins. The average ages of the examined children were 15.57 ± 1.75 and 15.07 ± 1.64 years, respectively, for those with shoulder instability of traumatic and atraumatic origins, respectively.

Results. Statistical data processing revealed no significant differences in the versioning and inclination of the glenoid process between the groups with traumatic and atraumatic instabilities of the shoulder joint. Notably, the average values of versioning and inclination indicators were in the normal range.

Conclusion. Based on our results, we suggest that, in the childhood, the dynamic and static soft tissue stabilizers of the shoulder joint play the leading role in the formation of instability of the shoulder joint.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):275-280
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Surgical treatment outcome of wrist flexion contracture in children with cerebral palsy through temporary extra-articular arthrodesis

Novikov V.A., Umnov V.V., Umnov D.V.


Background. The surgical approaches adopted for the treatment of wrist flexion contracture can be categorized into soft tissue intervention (such as lengthening or transplantation of tendons) and bone operations that stabilize the wrist joint. We developed a technique for temporary arthrodesis of the wrist joint to combine the main advantages of both the approaches, that is, the stability of arthrodesis by the installed metal construction and the possibility of active movements in the wrist joint after removal of the structure.

Aim. To compare the effectiveness of a new method of surgical treatment of wrist flexion contracture in children with cerebral palsy, such as temporary extra-articular arthrodesis and transplantation of the hand flexors to the extensors, according to Green.

Materials and methods. We conducted a comparative analysis of the treatment outcomes between the following 2 groups of patients: group 1 (n = 13) patients underwent a tendon transplantation of m. flexor carpi ulnaris on m. extensor carpi radialis brevis/longus (Green operation), while group 2 (n = 13) patients underwent temporary arthrodesis of the wrist joint with a bone plate for a period of 1 year. The patients in group 2, after the removal of metal structures, underwent a 14-day course of rehabilitation before evaluation of their treatment outcomes. A comparative analysis of the treatment results between the groups 1 and 2 was performed 1 year after arthrodesis and plate removal and at 1 year after muscle transplantation. The range of active and passive movements in the wrist joint was analyzed throughout. In addition, the functionality of the upper limb was assessed with reference to the international classification system of MACS 2002 and the “Block and Box test”.

Results. In the group 1 patients, an increase in the passive range of motion (+9.7°) was noted. In both the groups, a significant increase was recorded in the amplitude of active movements (31.9° in group 1 and 45.7° in group 2). The upper limb functionality index MACS, on evaluating the condition of the arm as a whole, appeared to be almost identical in both the groups. In the group 1 patients, the average dynamics of the “Block and Box test” as a result of treatment was 8 additional cubes, while it was only 1.6 in the group 2 patients.

Conclusion. The Green operation was less effective in comparison with the operation of temporary arthrodesis as a method of correcting the flexion contracture of the wrist joint. However, the functional performance of the Green operation was higher. The choice of the optimal surgical treatment technique can be determined as follows. In children with a high functional perspective, the Green operation is preferred. However, in children with doubtful functional prospects where the correction of severe contracture is the main aim, temporary arthrodesis may be preferable.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):281-292
pages 281-292 views

The first experience of using customized fixators in the surgical treatment of abducto-plano-valgus foot deformity in children

Kozhevnikov O.V., Gribova I.V., Kralina S.E.


Background. Abducto-plano-valgus foot deformity is one of the most common diseases affecting children and teens. Recently, various methods of surgical treatment have been proposed for the same. However, despite the availability of various operational methods, there are several contradictions in the feasibility and success of a particular operation.

Aim. To improve the technique of Evans Calcaneal osteotomy through the use of customized heel bone fixators.

Materials and methods. A total of 30 patients (42 feet) aged 9–15 years with abducto-plano-valgus foot deformity were included. We undertook clinical examination, X-ray, computed tomography, and experimental researches. The surgical treatment consisted of Evans Calcaneal osteotomy, with the use of the standard method of fixation in group 1 (n = 33 feet) and the use of a customized fixator in group 2 (n = 9 feet).

Results. The improved technique of Evans Calcaneal osteotomy using a special customized fixator allowed making the necessary correction in 100% of cases. The period of restoration of the heel bone integrity was reduced by an average of 30% (p < 0.05). The period of restoration of the support became faster by almost 45% (p < 0.05).

Conclusion. The use of a special customized fixator for Evans Calcaneal osteotomy could significantly improve the outcomes and shorted the treatment time for children with abducto-plano-valgus foot deformity.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):293-304
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The use of guide templates in the surgical treatment of preschool children with congenital scoliosis of thoracic and lumbar localization

Kokushin D.N., Vissarionov S.V., Baindurashvili A.G., Ovechkina A.V., Khusainov N.O., Poznovich M.S., Zaletina A.V.


Background. The use of transpedicular screws as support elements from the standpoint of biomechanics is preferable as compared to that of laminar fixation, albeit the former carries the risk of various complications (such as malposition screws, damage to the Dura mater, spinal cord, and major blood vessels) caused by structural changes in the vertebrae under the background of their defects, with small size of roots arcs vertebrae in young children. Thus, the issue of ensuring safe and correct installation of transpedicular screws in the surgical treatment of children with congenital scoliosis remains relevant.

Aim. We aimed to evaluate the correctness of the position of the transpedicular screws installed in the vertebral bodies in preschool children with congenital scoliosis of thoracic and lumbar localization using guide templates (SHN).

Materials and methods. We conducted a prospective analysis of the outcomes of surgical treatment of 30 patients with congenital scoliosis against the background of impaired formation of the vertebrae of the thoracic and lumbar spine. The patients included 12 boys and 18 girls of age: 1 year 8 months to 6 years 5 months (average: 3 years 4 months). Based on the computed tomography of the spine, performed postoperatively, the correctness of the position of the installed elements of the corrective multi-support metal structure was evaluated. The correctness of the position of the installed transpedicular support elements was evaluated based on the scale described by S.D. Gertzbein and co-authors (1990).

Results. The total number of implanted transpedicular screws sets was 96 (100% of the planned transpedicular screws set), and 48 SHN were used for transpedicular screws installation. The correct position of installed screws by degree of displacement revealed Grade 0 — 93.7% (90 screws), Grade I — 4.2% (4 screws), Grade II — 2.1% (2 screws), Grade III — 0%. The number of screws with a Grade 0 + Grade I offset was 94 (97.9%).

Conclusion. The results obtained with the use of SHN among preschool children with congenital scoliosis of thoracic and lumbar localization revealed high accuracy and correctness of transpedicular screws installation (93.7%) with the use of this type of navigation in clinical practice. The use of SHN for installing transpedicular screws in the surgical treatment of congenital spinal deformities in young patients allows for the selection of the optimal size and correct position of the transpedicular support elements in the vertebrae to be instrumented.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):305-316
pages 305-316 views

Сase report

The experience of using “ChitoPran” wound coating for treating a patient with combined injury

Bogdanov S.B., Karakulev A.V., Gilevich I.V., Melkonyan K.I., Polyakov A.V., Sotnichenko A.S.


Background. Resolution of problems related to burn injuries remains relevant and extremely complex in the modern medicine. Biological wound coatings are actively used in the treatment of patients with burn injury. Researchers at the Scientific Research Institute at the Ochapovsky Regional Clinical Hospital No. 1 have been using the biological wound coating “ChitoPran” since 2017. This coating creates a dry environment in the wound for borderline depth burns and after autoplasty, which contributes to the acceleration of epithelization. For deeper burns after necrectomy, the “ChitoPran” accelerates the growth of granulation tissues.

Clinical case. This article presents the clinical case of the successful treatment of a 17-year-old burn patient with a combined injury. The patient presented with a blunt abdominal injury on the background of a deep burn of the anterior abdominal wall. The patient underwent a median laparotomy on the first day and an early necrectomy with primary cutaneous autoplasty with the “ChitoPran” closing of the wounds on a day later.

Discussion. The use of the “ChitoPran” wound coating in combination with skin autoplasty for the early surgical treatment of burns contributes to the acceleration of epithelization of wounds in comparison with stage-based surgical treatment. This coating is hence comparable in terms of cellular epithelization with the use of fibroblasts.

Conclusions. Creating optimal conditions for epithelization in the wound can prevent the development of purulent complications (such as the failure of skin sutures of the anterior abdominal wall). The use of “ChitoPran” wound coating showed improved outcomes in the treatment of patients with burn injuries through accelerated restoration of the skin and reduced suppuration in the wound.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):327-332
pages 327-332 views

Hereditary sensory motor polyneuropathy

Gabbasova E.L., Komissarov A.E., Agranovich O.E., Savina M.V., Kochenova E.A., Trofimova S.I., Slobodina A.D., Shagimardanova E.I., Shigapova L.H., Sarantseva S.V.


Background. Congenital contractures are a heterogeneous group of diseases with different prognosis and different treatment modalities.

Clinical case. This article describes a family case of hereditary sensory motor polyneuropathy caused by the mutation of с.943G>A (р.Arg315Trp) in the transient receptor potential vanilloid cation channel 4 (TRPV4) (NM_021625.4). The patient’s clinical and neurological characteristics as well as the results of genetic and neurophysiological examinations are presented.

Discussion. Most often, mutations in the TRPV4 lead to 3 main diseases: autosomal dominant hereditary sensory motor neuropathy, type 2C, scapuloperoneal spinal muscular atrophy, and congenital non-progressive distal spinal muscular atrophy with contractures. The present article describes in detail the differential diagnosis of hereditary sensory motor polyneuropathy to facilitate accurate verification of this disease by clinicians.

Conclusion. Patients with congenital multiple contractures need cooperative observation and examination by orthopedic surgeons and neurologists, including neurophysiological and genetic interventions in the examination plan for disease verification in order to optimize the treatment strategy and to predict the outcomes.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):333-342
pages 333-342 views


The current view on the body mass and body mass index of children with spine deformity due to cerebral palsy: a systematic review

Shchurova E.N., Riabykh S.O., Filatov E.Y., Ochirova P.V., Ryabykh T.V.


Background. Currently, several authors believe that one of the main risk factors for the development of postoperative complications after surgical correction of scoliosis due to cerebral palsy (CP) is the body weight, changes in it, and the body mass index (BMI). However, a unified approach for the analysis of these indicators in children with CP remains unclear.

Aim. Analysis of the available data in the modern literature on the issues of body mass and BMI in children with spine deformity due to CP.

Materials and methods. A systematic search of the literature was conducted in open electronic databases of the scientific literature PubMed, Web of Science, Scopus, MEDLINE, eLIBRARY, Russian Index of Scientific Citation (RISC), and bibliography of key articles. The criteria of inclusion were systematic reviews, meta-analyses, multicenter studies, controlled cohort studies, uncontrolled cohort studies of children with spine deformities due to CP, and age of the CP patient <20 years. The criteria of exclusion were clinical cases, observations, materials of conferences, the patient’s age >20 years, and neuromuscular scoliosis of another etiology.

Results. The review primarily included 156 articles with the publication date of 1990–2020. Among them, 25 publications met the following criteria of inclusion: 3 systematic reviews and meta-analysis, 3 population studies, 1 multicenter study, 11 controlled cohort studies, 6 uncontrolled cohort studies, and 1 case-control study.

Conclusion. Body mass and BMI correlate with the functional activities of children with scoliosis due to CP. GMFCS stratified growth graphs of children with CP are the most appropriate reference indicators for assessing body mass and BMI of children with CP. Underweight body and low BMI (below the 10th percentile) are important factors that contribute to high risk of complications after scoliosis surgical correction. In the future, it will be necessary to develop national special centile tables for the optimal assessment of the anthropometric indicators in children with CP.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):343-354
pages 343-354 views

Total hip and knee arthoplasty: on the issue of indications for surgery

Vorokov A.A., Bortulev P.I., Khaydarov V.M., Linnik S.A., Tkachenko A.N.


Background. Both in Russia and across the world, the annual frequency of total hip and knee replacement has increased, which has inevitably led to an increase in the number of patients with unsatisfactory treatment outcomes. This failure can primarily be attributed to the complications that arise, some of which arise due to the wrong choice of treatment approach.

Aim. To analyze the publications on the results of treatment of patients with hip osteoarthritis and knee osteoarthritis by total hip and knee replacements.

Materials and methods. The literature data were searched in open electronic databases of scientific literature PubMed and eLibrary using the following keywords and phrases: total hip/knee replacement, complications, patient satisfaction, age, obesity. The search depth was 20 years.

Results. The data indicated a rise in the total number of such patients recorded annually. A significant number of publications, both in Russian and foreign literature, are devoted to the analysis of complications that mainly determine the patient’s satisfaction with an operation. In addition, these articles analyze the issues of determining the indications and contraindications in applying these methods of treatment. However, it is not uncommon for orthopedists to form a decision for performing an operation based on their subjective experience. At the same time, one of the circumstances that influences the decision-making is the lack of a stable system in the conservative treatment of degenerative joint diseases. According to the data from health care organizations, hip and knee replacements are the only available method for treating osteoarthritis. This circumstance may lead to an unjustified expansion of indications for arthroplasty, which would definitely affect the outcomes of treatment. In this situation, it is critical to search for precise criteria to identify the indication for total hip and knee arthroplasty.

Conclusion. Unjustified expansion of indications for endoprosthesis leads to an increase in the number of complications, which in turn leads to an increase in the number of patients who remain unsatisfied with the outcomes of hip and knee arthroplasty in the long term. This circumstance encourages special scientific research to clarify the indications and contraindications for hip and knee replacements, especially in young and middle-aged people.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(3):355-364
pages 355-364 views

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