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Vol 8, No 4 (2020)

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Original Study Article

Vertebral fractures in children during the COVID-19 pandemic

Skryabin E.G., Akselrov M.A., Zotov P.B., Kurmangulov A.А., Bukseev A.N.


Background. The COVID-19 pandemic has had a significant influence on the main epidemiological indicators of emergency trauma, as well as on the pediatric population.

Aim. This study aimed to analyze the incidence of compression fractures of vertebral bodies in children between January and July 2020 (the first months of COVID-19 pandemic).

Materials and methods. A comprehensive examination and treatment of 82 children and adolescents aged 3–17 years, who received compression fractures of the vertebral bodies in the period from January 1 to July 31, 2020, was carried out. A group of 96 children of the same age who sustained a similar type of injury at the same time in 2019 was studied as a control. To make a clinical diagnosis, we used methods of traditional research examination for emergency traumatology. The severity of vertebrogenic fractures was determined according to the AO/ASIF classification.

Results. The total number of patients diagnosed with vertebral fractures during the COVID-19 pandemic was 14.58% less than that in the same period in 2019. Patients in the comparison groups were comparable in sex, average age of injury, and age group in which the spine was most often injured. The most frequent mechanism of spinal injuries in patients of the comparison groups was a fall from a height. More often than others, ThVI and ThVII vertebral bodies were broken. The severity of vertebral fractures in all cases corresponded to type A, subtypes A1 and A2. For treatment, conservative methods were used in most cases. During the period of strict self-isolation, in April 2020, no children of the main group had vertebral fracture because they were forbidden to leave their apartments unnecessarily. In May 2020, the number of children with vertebral fractures was half the number in the same month in 2019. In June 2020, the incidence of vertebral fractures was in line with the pre-crisis average.

Conclusion. Strictly following restrictive anti-epidemic measures during a pandemic is an effective method of reducing the number of cases requiring emergency treatment for compression fractures of the vertebral bodies in children.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):373-382
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Choice of surgical treatment for slipped capital femoral epiphysis with severe chronic displacement of the epiphysis

Barsukov D.B., Baindurashvili A.G., Bortulev P.I., Baskov V.E., Pozdnikin I.Y., Krasnov A.I.


Background. The spatial relationship between the epiphysis and the acetabulum in slipped capital femoral epiphysis (SCFE) with severe chronic epiphysis displacement is restored by different corrective extra-articular femoral osteotomies and a standard Dunn procedure. Severe residual deformity of the femoral component of the joint with symptoms of femoroacetabular impingement and a large number of severe ischemic complications forced the surgeons to improve the technique of these surgical interventions. In particular, a modified Dunn procedure was proposed using a low traumatic surgical hip dislocation. However, the selection of surgical treatment in these patients remains a subject of discussion.

Aim. This study aimed to improve the results of treatment in children with SCFE with severe chronic epiphysis displacement.

Materials and methods. Data of preoperative and postoperative clinical and radiological studies of 40 patients (24 male and 16 female) aged 12–15 years who were suffering from SCFE with severe chronic epiphysis displacement were analyzed. In all cases, on the lesion side, displacement was found in typical directions (posterior-downward or only posterior), and in the contralateral joint, the disease was still at its initial stage (pre-slip). In group 1 (n = 20 children), a corrective extra-articular femoral (anterior-rotational or rotational-valgus) osteotomy was performed according to the method we have proposed in 2011 [22], and in group 2 (n = 20 children), the modified Dunn procedure that strictly followed our technique was performed. The follow-up period after surgery in both groups ranged from 1 month to 2.5 years.

Results. At 2.5 years after surgery, good anatomical and functional outcomes were observed only in 1 (12.5%) of 8 patients in group 1, while they were observed in 7 (87.5%) of 8 patients in group 2. Poor results were determined by residual epiphyseal displacement (from 22° to 28°) and/or step-like transition of the anterior femoral neck surface to the head in 5 (62.5%) children in group 1 and by femoral head avascular necrosis (diagnosed in 6 months after surgery) in 1 (12.5%) child in group 2.

Conclusion. The results allow us to make a preliminary conclusion about the high efficiency of the modified Dunn procedure and the low efficiency of the corrective extra-articular femoral osteotomy in SCFE with severe chronic displacement of the epiphysis. The modified Dunn procedure corrects the pronounced deformity of the femoral component of the affected joint and femoroacetabular impingement in the above-mentioned anatomical situations.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):383-394
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Role of combinations of polymorphisms of cytokine genes in the diagnosis of Legg–Calve–Perthes disease in children

Shabaldin N.A., Shabaldin A.V., Apalko S.V., Tsepokina A.V., Rovda Y.I.


Background. Legg–Calve–Perthes disease (LCPD) is an idiopathic avascular femoral head osteonecrosis. The early disease stage is associated with the development of synovitis of the hip joint linked to the overproduction of factors induced by hypoxia as well as of interleukin (IL)-6. Associations of individual polymorphic variants of cytokine genes with LCPD have been shown. Moreover, alterations in the cytokine regulatory cascade are considered an important link in the pathogenesis of synovial inflammation in the early stages of LCPD. Accordingly, this process may be associated with a certain combination of polymorphic variants of the genes for pro-inflammatory and anti-inflammatory cytokines.

Aim. This study aimed to study the associations of polymorphic variants of the genes for pro-inflammatory and anti-inflammatory IL with LCPD.

Materials and methods. In this case–control study, the main and control groups were composed of 26 children with LCPD and 40 healthy children (all aged 3–11 years), respectively. Genotyping of IL10 (rs1800896), IL13 (rs20541), IL18 (rs187238), IL18 (rs5744292), IL1a (rs1800587), IL1RA (POL_GF_58), IL-1Ra (rs4251961), IL1B (rs16944), IL1B (rs1143634), IL4 (POL_GF_59), IL4 (rs2243250), IL6 (rs1800796), IL6 (rs1800795), INFγ (rs2430561), TGFβ (rs1800469), and TNF (rs1800629) was performed by polymerase chain reaction (PCR) using TaqMan probes to the corresponding polymorphic variants of genes produced by Thermo Fisher Scientific (USA) on an amplifier ViiATM 7 RealTime PCR System (Life Technologies, USA). Statistical processing of the results was carried out using the SNPstats program and multifactor dimensionality reduction.

Results. The study revealed three separate LCPD-potentiating genotypes of polymorphic variants of cytokine genes: IL10 (rs1800896; T>C)*T/C (OR 6.50), IL4 (POL_GF_49, VNTR, Intron4)*2R/2R (OR 12.32), and IL-6 (rs1800796; G>C)*G/C (OR 4.08). Two polymorphic variants of the IL4 gene (POL_GF_49, VNTR, Intron4, and rs2243250; C>T) had a pronounced synergism with respect to the diagnosis of LCPD. Moderate synergy with respect to the diagnosis of LCPD demonstrated the intergenic interaction of IL6 (rs1800796, G>C) with tumor necrosis factor-α (rs1800629, G>A). Moderate antagonism between LCPD and intergenic interactions was obtained for polymorphic variants of IL18 (rs5744292, T>C) and transforming growth factor-β (rs1800469, A>G) genes.

Conclusions. The pathogenesis of synovitis and subsequent osteonecrosis in LCPD is associated with a combination of polymorphic variants of the genes of pro-inflammatory and anti-inflammatory cytokines, as well as of DNA variants of the pro-allergic IL4 gene.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):395-406
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Correlation between clinical and radiographic parameters of the feet in children with flatfoot

Sapogovskiy A.V., Boyko A.E.


Background. Flatfoot in children is one of the most common reasons for visiting an orthopedic specialist. The main criteria in determining various types of flatfoot are clinical (severity of arch flattening, hindfoot valgus, and degree of the foot dorsiflexion) and radiographic (angular values calculated from lateral and anteroposterior radiographs). The primary assessment of the degree of flatfoot is based on the clinical criteria. Detection of changes in the foot shape is the reason for the radiographic assessment.

Aim. This study aimed to determine and analyze the relationship between clinical and radiological parameters of the feet in children with flatfoot.

Materials and methods. The study group included patients with flatfoot observed in the outpatient clinic of H. Turner National Medical Research Center within the period from 2018 to 2020. The study population consisted of 30 children (53 feet) with flexible flatfoot and 65 children (111 feet) with flatfoot and short Achilles tendon. The patients were 10 (8.3; 12) years old. Clinical parameters (valgus value, longitudinal arch angle, and degree of foot dorsiflexion) and radiographic data (Kite’s angle, Meary’s angle, calcaneal pitch, talotibial angle, longitudinal arch angle, talonavicular coverage angle, and forefoot adduction angle) were analyzed. Statistical differences were determined between groups of patients with flexible flatfoot and patients flatfoot and short Achilles tendon, and correlations between the studied parameters were identified.

Results. Strong correlations were revealed in the following pairs of criteria: lateral Kite’s angle and lateral Meary’s angle; talotibial angle and lateral Meary’s angle; radiographic longitudinal arch angle and lateral Meary’s angle; talotibial angle and lateral Kite’s angle; foot dorsiflexion and foot dorsiflexion with great toe extension; and radiographic longitudinal arch angle and calcaneal pitch. Only moderate and weak correlations were found between clinical and radiographic parameters of the feet.

Conclusion. The relationship between clinical and radiographic parameters of the feet in patients with flatfoot is characterized by a moderate and weak correlation. Results suggest that the assessment of the clinical parameters of the feet in this population does not provide complete information about the degree of flatfoot.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):407-416
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Preliminary results of surgical treatment of flexion-adduction contracture of the first ray of the hand in combination with dislocation in the metacarpophalangeal joint in patients with infantile cerebral palsy

Umnov D.V., Umnov V.V., Novikov V.A., Savina M.V.


Background. Surgical methods of treating flexion–adduction contracture of the first ray of the hand in combination with dislocation in the metacarpophalangeal joint in patients with infantile cerebral palsy are divided into surgical interventions on soft tissues and bone surgeries aimed at stabilizing the metacarpophalangeal joint. We have developed a technique of temporary arthrodesis of the metacarpophalangeal joint in combination with the previously used operation to widen the first intercarpal space, combining the positive effects of both groups of operations: stability of arthrodesis with an installed metal structure that enable active movements in the joint in sufficient amplitude after its removal and early postoperative rehabilitation with a stabilized joint.

Aim. This study aimed to evaluate the effectiveness of a new method of surgical correction of flexion–adduction contracture of the first ray of the hand in combination with metacarpophalangeal joint dislocation in the form of temporary arthrodesis of this joint and widening of the intermetacarpal space in patients with cerebral palsy.

Materials and methods. The study analyzed treatment outcomes of patients (n = 11) who underwent temporary arthrodesis of the metacarpophalangeal joint with an extra-bone plate for a period of 1 year and expansion of the first intermetacarpal space. Comparative analysis of the results was carried out 6 months after the operation, 1 year after the operation, and after hardware removal. The amplitude of passive and active movements in the metacarpophalangeal joint was analyzed. The functionality of the upper limb was assessed according to the international classification system MACS 2002 and the “block and box test.”

Results. At 1 year after surgery and removal of the fixation structure, the amplitude of both passive abduction (32.0°) and extension (9.5°) in the metacarpophalangeal joint increased, and the amplitude of the same movements (leads) increased by 25.5° in abduction and by 4.0° in extension when performed actively. The MACS indicator improved by 1 point. The average dynamics of the “block and box test” was seven additional cubes.

Conclusion. The proposed technique for temporary extra-articular arthrodesis of the metacarpophalangeal joint does not affect the intra-articular structures, unlike intra-articular arthrodesis, and therefore has clear advantages over the latter. This surgical treatment method is effective in increasing the amplitude of active and passive movements of the first ray of the hand and reduces muscle imbalance, which ultimately improves the function of the upper limb as a whole.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):417-426
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Congenital dislocation of the knee: a morphological study

Kruglov I.Y., Agranovich O.E., Rumyantsev N.Y., Razmologova O.Y., Kolobov A.V., Omarov G.G., Kleshch D.S., Rumiantceva N.N.


Background. Congenital knee dislocation is a rare disease of the musculoskeletal system (1 in 100,000 live births). In the literature, few studies have described the anatomical changes characteristic of this pathology, which are only revealed during surgical treatment.

Aim. This study aimed to evaluate the pathomorphological features of the ligamentous–articular apparatus and thigh muscles with congenital knee dislocation on autopsy material.

Materials and methods. The study included two fetuses with bilateral congenital knee dislocation after spontaneous miscarriage at 18 and 20 weeks of gestation and one stillborn fetus with bilateral congenital knee dislocation at 29 weeks of gestation. The comparison group was composed of two fetuses after spontaneous miscarriages at 18 and 20 weeks of gestation and one stillborn fetus at 25 weeks of gestation without anomalies of the lower extremities.

Results. Various abnormalities and displacements of the anatomical structures, as well as degenerative dystrophic changes in the soft tissues during histological examination, were found. Pathomorphological changes in the control group were not detected.

Conclusion. Pathomorphological changes are the main manifestations of congenital knee dislocation in the studied fetuses.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):427-435
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Exchange of experience

Possibilities of using microsurgical autotransplantation of tissue complexes in children

Avdeychik N.V., Golyana S.I., Grankin D.Y., Safonov A.V., Tikhonenko T.I., Galkina N.S.


Background. Applications of traditional treatment methods in children with congenital and acquired pathology of the musculoskeletal system are often limited, as wound defects of significant area and depth with a soft tissue and bone deficit may occur during the reconstruction of the segment. Microsurgical techniques, including autotransplantation of blood-supplied tissue complexes, make it possible to realize the aims of musculoskeletal segment reconstruction and reduce surgical treatment time.

Aim. This study aimed to perform a retrospective (statistical) analysis of using microsurgical autotransplantation of tissue complexes in children.

Materials and methods. Treatment outcomes of 871 patients with congenital and development deformities of the musculoskeletal system who underwent 1048 microsurgical autotransplantations of various tissue complexes in 1984–2018 were analyzed. Complications associated with impaired blood supply to transplanted autografts, requiring revision microsurgical interventions, were also statistically processed.

Results. The mean patient age was 5.8 years (range, 10 months to 17 years). In children with congenital pathology (n = 597), transplantation of blood-supplied tissue complexes in 85.9% of the cases was performed in cases with hand deformities. In 285 cases of acquired deformities, post-traumatic finger stumps accounted for 45.5%, scar changes of soft tissues for 39.6%, and other pathological conditions for 14.9%. Most of the microsurgical operations were toe-to-hand transfers, which accounted for 81.8% of the total number of surgeries. In 79.4% of the cases, the second toe was used for the toe-to-hand transfer. Accordingly, the remaining toes were transferred in 20.6% of the cases. When replacing soft tissue defects, a thoracodorsal flap was used in 84 cases, which was 5.6% (of the total number of autotransplantations), and a groin flap was used in 22 patients. To replace bone defects, a blood-supplied fibula graft was used in 47 patients and a metatarsal bone graft in 41 children. Circulatory disorders in the postoperative period were noted in 5.9% of the total operations, which in 3.1% of cases resulted in the necrosis of the transplanted autograft.

Conclusion. The treatment outcomes of using microsurgical autotransplantation of blood-supplied tissue complexes in the reconstruction of tissues and segments of the musculoskeletal system confirm their high efficacy.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):437-450
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Сase report

Clinical and genetic characteristics and orthopedic manifestations of the Saul–Wilson syndrome in two Russian patients

Markova T.V., Kenis V.M., Melchenko E.V., Demina N.A., Gundorova P., Nagornova T.S., Dadali E.L.


Background. Saul–Wilson syndrome (SWS, microcephalic osteodysplastic dysplasia) is a rare genetic variant of skeletal dysplasia and is determined based on the modern classification for “thin bone dysplasias.” To date, 16 patients with SWS from different countries have been identified.

Clinical cases. We presented the first description of the clinical and genetic characteristics of two Russian patients with SWS and compared them with published data. The main clinical manifestations of SWS are characterized by a combination of nanism and pathology of long tubular bones, spine, and eyes. Changes in the phenotype of patients in different age groups were analyzed.

Discussion. In the analysis of the clinical manifestations of the observed patients and patients described in the literature, typical dysmorphic features of the face and radiographic data help in the diagnosis of SWS upon clinical examination. In the majority of the described patients, the nucleotide substitution c.1546G>A is the major mutation in the gene responsible for SWS, which leads to the replacement of the amino acid Gly516Arg in the protein molecule.

Conclusion. Based on the identified specific features of the phenotype of patients with SWS and the presence of a major mutation in the COG4 gene, a priority analysis of gene mutations is necessary. Orthopedic manifestations of SWS can lead to life-threatening conditions (cervical spine instability) and motor limitations (progressive osteoarthritis) and thus should be monitored dynamically.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):451-460
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Atrophic non-union with severe osteolysis of the radius in a healthy child: successful rescue surgery. Management with fibular allograft and autograft growth factors in a paediatric patient

Priano D., D'Errico M., Peretto L., Memeo A.


Background. Forearm fractures are the most frequent fractures in children and adolescents and they are more common in males than in females. In the last 20 years the increase of surgical indications have resulted in more complications, among them the non-unions, considered extremely rare and severe in children, have increased in incidence. We report a successful treatment of misdiagnosed forearm atrophic non-union with severe osteolysis using fibula allograft and autograft growth factors in a previously healthy 4-year-old child.

Clinical case. A 4 year-old boy presented to our hospital with massive bone loss and a negative bone biopsy for Gorham-Stout Syndrome, he also showed reactive bone tissue with abnormal vascularity, necrotic osteocartilaginous fragments and giant mononucleated cells. Other lab tests did not show any modifications, so all the causes of paediatric osteolysis were ruled out. He had already undergone a few surgeries on that fracture and we performed others before achieving a good result, obtained with an autologous fibula graft with medullary growth factors stabilized with Kirschner wire. At the follow up 28 months later, the patient showed total consolidation of the initial area of non- union, no neurovascular deficit and no joint deficiency.

Discussion. Non-union in paediatric patients is rare and therefore difficult to treat and diagnose. Since all of our tests ruled out the main causes of paediatric non-union, we managed the case with strategies usually applied to adult patients, carefully respecting the growth plates.

Conclusion. Although this is a single-case report, it underlines the importance of early diagnosis, the difficulty to rule out some pediatric causes of bone loss and the complicances of a wrong diagnosis/treatment. It also shows that the use of allograft bone and autograft growth factors in a pediatric patient, who has undergone multiple surgeries, can lead to excellent results

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):461-466
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Retroclival hematoma: two case reports and a literature review

Khodorovskaya A.M., Kondrashev I.A., Mandal V., Lyapin A.P.


Background. Тraumatic hematomas in the posterior fossa rarely occur, which account for 0.01%–0.6% of brain injury cases. Retroclival location for such hematomas is uncommon, as they are mostly epidural and diagnosed almost exclusively in the pediatric population.

Clinical cases. Herein, we report two pediatric cases of traumatic epidural and traumatic subdural retroclival hematomas that developed after high-energy trauma in motor-vehicle accidents.

Discussion. Related studies were reviewed, and anatomical features and neuroimaging findings associated with various compartments of the retroclival hemorrhage in children were discussed.

Conclusion. Considering the nonspecific clinical features and special topographic correlation of anatomical structures in this region, neuroimaging is regarded as the most reliable method to diagnose and correctly classify this pathology, which is essential for further treatment.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):467-472
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Accelerated versus standard Ponseti method for idiopathic congenital talipes equinovarus: a systematic review and meta-analysis

Savio S., Maharjana M.


Background. The standard Ponseti method is a mainstay of treatment for children with congenital talipes equinovarus (CTEV); involving weekly manipulation and long-leg casting, this approach has proven to produce good long-term outcomes. However, it takes approximately 4–5 weeks to correct all deformity components, making compliance a challenge for patients with limited economic resources and difficulty reaching healthcare centres.

Aim. This study aims to compare treatment outcomes between standard Ponseti and an accelerated protocol — applying the same casts but changing them more frequently, every 2-5 days — for the CTEV pathology.

Methods. A systematic search was conducted based on PRISMA guidelines to identify relevant studies through PubMed, Google Scholar, and Cochrane Database. A total of seven studies (324 patients, 408 feet) were included in the meta-analysis. Five outcomes were compared between the two procedures: post-procedure Pirani score, relapse rate, tenotomy rate, number of casts, and total duration of treatment.

Results. For total duration of treatment, the accelerated Ponseti method was superior to standard Ponseti (24.25 vs. 41.54 days, p < 0.00001). On the other hand, it achieved comparable efficacy as measured by post-procedure Pirani score (1.01 vs. 0.87, p = 0.19). Furthermore, the two procedures were also comparable in terms of the total number of casts needed (4.94 vs. 5.05, p = 0.76), tenotomy rate (73.29% vs. 65.27%, p = 0.07) , and relapse rate (27.72% vs 25.23%, p = 0.56).

Conclusion. Accelerated Ponseti offers similar efficacy and shorter duration of treatment compared to the standard Ponseti technique.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):473-484
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Modeling spinal cord injuries: advantages and disadvantages

Vissarionov S.V., Rybinskikh T.S., Asadulaev M.S., Khusainov N.O.


Background. Spinal cord injuries have diverse characteristics and associated traumatic changes; they are known as the most severe injuries of locomotorium. The creation of an optimal experimental model of spinal cord injuries using experimental animals, which would have similar changes in humans, is important to assess and analyze the pathological processes, as well as to develop complex treatment methods.

Aim. This study aimed to analyze various experimental models of spinal cord injury using laboratory animals by assessing its advantages and disadvantages for further research and implementation in clinical practice.

Materials and methods. A literature review was performed on the capabilities of experimental models of traumatic spinal cord injury in laboratory animals. A literature search was carried out using databases of PubMed, Science Direct, E-library, and Google Scholar for the period from 1981 to 2019; the keywords are shown below. In total, 105 foreign and 37 domestic articles were identified, 59 articles were analyzed after exclusion, and 75% of studies were published in the last 20 years.

Results. The review of available experimental options of spinal cord injury in laboratory animals revealed that a generally accepted universal model is not yet established. The experimental animal models had characteristics that do not correspond to the same parameters in an actual clinical situation. Besides, some difficulties were encountered in the estimation of pathological processes of experimental animals, translations with clinical changes, and interpretations of achieved functional results in experimental animals, which complicated the application in clinical practice.

Conclusion. Development of experimental models of spinal cord injury that can consider multifactorial aspects of the trauma process, including its biomechanics and time factor, is necessary.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):485-494
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Scientific and practical conference: Turner readings 2020 – online

Solovyova K.S., Zaletina A.V., Ovechkina A.V.


The annual all-Russian scientific and practical conference on topical issues of pediatric orthopedics and trauma surgery, named Turner readings, was held on October 8-0, 2020. All meetings, symposia, and workshops were held online due to the ban on mass events during the coronavirus pandemic. In total, 102 articles from Russia and neighboring countries were submitted for publication in Turner reading conference proceedings. The organizing committee chose to present reports that contained data on new research and opened up prospects for the future. Approximately 900 people were registered to participate in the conference as listeners. The sessions were broadcast simultaneously on three players. During the broadcast, more than 400 people were connected to listen simultaneously. This article briefly presents the topics of the meetings and interesting messages.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2020;8(4):495-500
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