Vol 4, No 4 (2016)

Articles
Clinical implications of the neurosegmental level of injury in the treatment of hip dislocation and subluxation in children with spina bifida
Baindurashvili A.G., Ivanov S.V., Kenis V.M.
Abstract

Background. Hip dislocation and subluxation are common in children with spina bifida.

Aim. To determine the influence of the neurosegmental level on surgical treatment of hip dislocation and subluxation in children with spina bifida.

Materials and methods. A total of 114 pediatric patients with spina bifida and hip dislocation and subluxation were treated at The Turner Scientific and Research Institute for Children’s Orthopedics (Saint Petersburg, Russia) from 2006 to 2015. The patients were divided into two groups according the Sharrard classification of neurosegmental lesions: a study group of 62 patients who underwent hip stabilization surgery and a control group of 52 patients who did not undergo hip stabilization procedures.

Results. For patients with a high neurosegmental level (thoracic and L1-L2), surgical treatment for hip dislocation and subluxation, which included most cases (72%), led to motor deterioration (retrospective study). Of 40 patients with a neurosegmental level of L3-L4 and L5-S1, motor level improved in 13 (32.5%) but deteriorated in 10 (36%) of 28 patients in the control group.

Conclusion. Determination of the neurosegmental level enables the prediction of motor level and reveals indication for surgical treatment.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):6-11
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Pathological changes of the cervical spine in children with cervical pain syndrome
Bakhteeva N.K., Ionova T.A., Belonogov V.N., Bazhanov S.P., Ostrovskij V.V.
Abstract

Background. Interpretation of cervical pain syndrome in children is complicated, resulting in delayed diagnosis of developmental juvenile osteochondrosis. Thus, updating the diagnostic methods of this pathology is particularly important.

Aim. To improve methods of cervical spine diagnostics in children with cervical pain syndrome at the base of vertebral and basilar arteries using duplex ultrasound.

Material and methods. The study cohort included 148 pediatric patients aged 4–18 years who were divided into two groups: a treatment group of 108 children with cervical pain syndrome and a control group of 40 healthy children. Clinical, radiological (ultrasound, X-ray, and MRI), and statistical methods were used for comparisons.

Results. Duplex ultrasound of 108 patients revealed pathological changes of qualitative and quantitative features of C- or S-shaped, corner bend, mesh, excessive, and wave-shaped tortuosity deformities, as well as a reduction or expanse in diameter of one or two of the spinal arteries (SAs). The absence of an influence of osseous cervical spine structures on SAs was considered a sign of congenital genesis of SA deformity, while segmental instability of C2-C3 and/or C3-C4, atlanto-axial subluxation, and a Kimmerle anomaly were considered signs of extravascular compression of SAs. Regardless of the deformity genesis, blood flow was deficit in the vertebral basilar basin because of local hemodynamic disorders at the site of the deformity, particularly in older children. MRI revealed signs of intervertebral disc hypohydration at C2-C3 and/or C3-C4.

Conclusion. Pathological changes in SAs of both congenital and acquired genesis resulted in hemodynamic disorders in the vertebral basilar basin in children with cervical pain syndrome, particularly older children.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):12-20
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Treatment of pediatric patients with lower extremity deformities using software-assisted Ortho-SUV Frame: analysis of 213 cases
Vilensky V.A., Pozdeev A.A., Zubairov T.F., Zakharyan E.A., Pozdeev A.P.
Abstract

Aim. To retrospectively assess treatment outcomes of long bone deformities of the lower extremities accompanied by shortening in pediatric patients using a software-assisted Ortho-SUV Frame.

Materials and methods. The accuracy of deformity correction (AC), period of deformity correction (PDC), external fixation index (EFI), and number of complications in 213 patients were retrospectively analyzed.

Results. According to different parameters, AC of femur deformity correction (group 1) varied from 90% to 96%. The average length increase was 47 ± 12 mm. The average distraction duration was 38 ± 14 days. The average PDC was 8 ± 6 days for simple deformities (SDs), 14 ± 7 days for moderate deformities (MDs), and 23 ± 12 days for complex deformities (CDs). EFI was 26 ± 8 days/cm for SDs, 31 ± 6 days/cm for MDs, and 35 ± 12 days/cm for CDs. According to different parameters, AC of the lower leg deformity correction (group 2) varied from 89% to 95%. The average length increase was 52 ± 20 mm. The average distraction duration was 45 ± 18 days. PDC was 11 ± 5 days for SDs, 16 ± 9 days for MDs, and 27 ± 16 days for CDs. EFI was 32 ± 14 days/cm for SDs, 42 ± 12 days/cm for MDs, and 49 ± 8 days/cm for CDs. There were 48 (50.5%) complications in group I with the majority (71%) classified as Caton grade I and 29% as grade II. There were 62 (45%) complications in group 2, where 50% were Caton grade I and 50% were Caton grade II. There were no serious complications (Caton grade III) in either group that influenced the final functional results.

Conclusion: Use of a software-assisted Ortho-SUV Frame increased the efficiency of treatment of pediatric patients with long bone deformities because of the great accuracy of deformity correction.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):21-32
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Effectiveness of intraoperative neurophysiological monitoring during spinal surgery
Kuzmina V.А., Suynduykov A.R., Nikolaev N.S., Mikhailova I.V., Nikolaeva A.V.
Abstract

Aim. To assess the application of intraoperative neurophysiological monitoring (IONM) for spinal surgeries in accordance with the Federal Center of Traumatology, Orthopedics and Endoprosthesis (Cheboksary, Russian Federation)

Material and methods. A total of 366 spinal surgeries, Federal Center of Traumatology, Orthopedics and Endoprosthesis from 2009 to 2015. From 2009 to 2013, the wake-up test was used as a control method in 116 (65.9%) cases.

Results. Application of IONM revealed time-dependent risks and facilitated a reduction in the incidence of postoperative neurologic complications by 3-fold (from 2.6% to 0.8%). In the second half of 2013, IONM was introduced for use in clinical practice. Since then, 250 surgeries were performed with IONM. Of these, the wake-up test was required in 9 (3.6%) patients. Clinical implementation of IONM extended the benefits of surgery to patients with severe pathologies. The number of surgeries for congenital pathologies increased by 10-fold (from 1% to 10%) and by 2.6-fold for degenerative diseases. IONM possibility allows control of intraoperative neurologic complications among patients with spinal injuries (5%) and neuro and muscular scoliosis.

Conclusions. The application of IONM minimized the need for the wake-up test and significantly decreased the incidence of neurological complications caused by injury to the spinal cord and spinal roots during execution of spinal manipulations.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):33-40
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Clinical forms of shoulder instability in pediatric patients
Proshchenko Y.N., Baindurashvili A.G., Brianskaia A.I., Prokopovich E.V., Nikitin M.S., Afonichev K.A.
Abstract

Background. The recurrence rate of adolescent chronic shoulder instability is approximately 56%–68%. However, this pathology is often missed in childhood and adolescence.

Aim. To identify the clinical forms of shoulder joint instability in pediatric patients.

Materials and methods. The authors present the data from 57 pediatric patients aged 3−17 years with a total of 61 unstable shoulder joints. All patients were divided into groups according to the form of instability. Traumatic chronic shoulder instability was identified in 40 patients (Bankart and Hill–Sachs injuries). Of these, non-traumatic shoulder instability was diagnose in 17, including five with recurrent dislocation, and spontaneous shoulder dislocation due to dysplasia of glenoid and labrum was diagnosed in 12. Of the 57 patients in the study cohort, 53 underwent surgery. Postoperatively, two patients developed recurrent shoulder dislocation (Andreev–Boichev technique) due type III shoulder dysplasia in the first patient and multidirectional injury in the second.

Conclusions. Shoulder joint instability should be considered as the traumatic or non-traumatic form. Treatment decisions should be based on anatomical characteristics that predispose to recurrent dislocation.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):41-46
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Clinical, neurological, and neurophysiological evaluation of the efficiency of motor rehabilitation in children with cerebral palsy using robotic mechanotherapy and transcutaneous electrical stimulation of the spinal cord
Ikoeva G.A., Nikityuk I.E., Kivoenko O.I., Moshonkina T.R., Solopova I.A., Sukhotina I.A., Vissarionov S.V., Umnov V.V., Gerasimenko Y.P.
Abstract

Introduction. Rehabilitation of patients with cerebral palsy (CP) remains a very difficult task. Stable and growing movement restrictions in such patients cause a life-long need for treatment and rehabilitation. Neurorehabilitation of children with CP at various stages includes not only traditional physical rehabilitation methods, but also extensive use of robotic mechanotherapy techniques and new technologies in the field of neurophysiology. One of such technology is non-invasive percutaneous electrical stimulation of the spinal cord.

Aim of the study: To assess the effect of transcutaneous electrical stimulation of the spinal cord to improve the motor function of children with spastic diplegia using the “Lokomat” robotic mechanotherapy system.

Materials and methods. A clinical rehabilitation study of 26 patients aged 6–12 years with CP was conducted. The treatment group included 11 patients who received one course of robotic mechanotherapy using the “Lokomat” system combined with transcutaneous electrical stimulation of the spinal cord. The control group included 15 patients who received one course of robotic mechanotherapy only.

Results. A comparative analysis of the two groups based on the results of clinical examinations using specific scales (GMFCS, GMFM-88, Modified Ashworth Scale of Muscle Spasticity), locomotor tests (L-FORCE, L-ROM), and evaluations of muscle activity using electromyography showed that one course of rehabilitation resulted in improvement in motor function in all patients of both groups, but positive dynamics were more significant in the treatment group that underwent percutaneous electrical stimulation of the spinal cord.

Conclusion. Based on clinical data, changes in indicators of the locomotor tests L-FORCE and L-ROM, as well as assessment of changes in muscle activity, showed that motor rehabilitation of children with spastic diplegia using the “Lokomat” robotic mechanotherapy system combined with transcutaneous electrical spinal cord stimulation was more effective than robotic mechanotherapy only.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):47-55
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Psychological aspects of idiopathic scoliosis: the specificity of the mother-daughter relationship
Pyatakova G.V., Vissarionov S.V.
Abstract

Background. The relationship between teenager girls with idiopathic scoliosis and their mothers may be a source of mental strain during complex restorative treatment.

Aim of the study. To assess the mother-daughter relationship of adolescent girls with severe idiopathic scoliosis.

Materials and methods. The experimental group consisted of 30 women with teenager daughters diagnosed with idiopathic scoliosis of the 4th degree. The control group included 30 women with teenager daughters with no orthopedic pathology. The questionnaire “Diagnostic of parental relationship” (Varga and Stolin) and the methodology “Teenagers on their parents” (Schafer, Mateychik, and Rzhichan) were used as research methods.

Results and discussion. General and specific characteristics of the mother-daughter relationship in families of adolescent girls with idiopathic scoliosis and families of healthy girls were identified. Mothers of girls with idiopathic scoliosis and mothers of girls with o orthopedic disorder demonstrated a pronounced positive attitude to their daughters. Mothers of daughters with idiopathic scoliosis, in contrast to mothers of healthy daughters, were more likely to actively cooperate with their daughters in various aspects of life, including treatment. We investigated the mother-daughter relationship and how to assess this relationship with adolescent girls. Emotionally, non-judgmental acceptance of a daughter with severe idiopathic scoliosis is perceived by the daughter as the mother's desire for an emotionally close and trusting relationship. The attitude of the mother regarding an ill daughter as a failure will be perceived as hostility manifested as strict control by the mother. The mother's attitude to a healthy daughter manifesting as overprotection is perceived by adolescent girls as an authoritarian attitude by the mother.

Conclusion: General and specific characteristics of the mother-daughter relationship in families of adolescent girls with idiopathic scoliosis and families of healthy adolescent girls were revealed. In the context of complex surgical treatment, preventive measures are necessary to address psychological difficulties in adolescent patients with idiopathic scoliosis.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):56-63
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Guided Growth for Correction of Knee Flexion Contracture in Patients with Arthrogryposis: Preliminary Results
Trofimova S.I., Buklaev D.S., Petrova E.V., Mulevanova S.A.
Abstract

Background. Knee flexion contractures frequently present in children with arthrogryposis and significantly alter kinematics of walking and reduce efficiency of ambulation or render it impossible. There are variety of surgical options for contracture correction, including entire soft-tissue release or its combination with Ilizarov ex-fix and supracondylar femoral osteotomy. Choosing of the most effective surgery is challenging because every method has limitations.

Aim. To evaluate the treatment outcomes of knee flexion deformity correction by guided growth in patients with arthrogryposis.

Materials and methods. A total of 12 patients (20 knee joints) with arthrogryposis who underwent anterior distal femoral hemiepiphysiodesis with 8 plates for knee flexion contracture correction were included in the study. The average age at surgery was 6.5 ± 0.5 (range, 4.3–9.6) years. Clinical and radiological methods were used with statistical analysis of the data.

Results. The mean preoperative knee flexion deformity angle was 48.5° ± 4.04° (range, 20°–80°). After distal femoral hemiepiphysiodesis, a reduction of knee flexion contracture was observed in 17 (85%) patients during a follow-up period of 18–36 months. The average correction was 20° ± 2.67° (range, 0°–40°) (p < 0.05). The residual deformity angle was 28.5° ± 6.03° (range, 0°–60°). Patients with contractures up to 50° demonstrated the most significant correction (by 90% compared with the initial value) (p < 0.05). This group included patients with severe flexion contractures, treated by serial casting, combined with an extension devise before surgery, which contributed to a significant reduction of the contracture.

Conclusion. Distal femoral hemiepiphysiodesis is an effective, safe, and reproducible surgical option for knee flexion contractures in patients with arthrogryposis. Combination with additional methods enables significantly reduction of knee flexion deformities from severe to moderate, thereby rendering treatment more effective with a shorter duration, which allows prompt improvement in ambulatory capacity.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):64-70
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Relationship between flexion contractures of the joints of the lower extremities and the sagittal profile of the spine in patients with cerebral palsy: a preliminary report
Umnov V.V., Zvozil A.V., Umnov D.V., Novikov V.A.
Abstract

Background. The considerable incidence of kyphosis in patients with cerebral palsy (CP) causes back pain and aggravates movement disorders. However, few studies have investigated the pathogenesis of this condition.

Aim. To identify the relationship between patient motor abilities, the severity of flexion contractures of the knee and hip joints and spinal sagittal profile changes, and the impact on the latter by surgical correction of flexion contracture of the knee joint.

Material and methods. The study cohort included 17 pediatric CP patients (11 boys and 6 girls) with a mean age of 13.1 ± 1.3 (range, 10–16) years and level 2–4 spastic diplegia according to the Gross Motor Function Classification System. The relationship between radiological indicators of the spine sagittal profile and motor abilities of children, as well as the severity of flexion contractures at the hip and knee, and the degree of insufficiency of the active extension of the knee were investigated. Of these 17 patients, 12 underwent surgery to correct flexion contracture of the knee, which involved lengthening of leg flexors, to analyze the impact of contracture on the sagittal profile of the spine. The following radiological indicators were assessed: angle of thoracic kyphosis (CC), lordosis angle (UL) of the lumbar spine, and sacral inclination angle (SS). The study included patients with a CC of at least 30°.

Results. Results of an X-ray study showed that the severity of kyphosis was 50.7° ± 2.1°, lordosis was 30.3° ± 4.3°, and SS was 30.5° ± 3.3°. There was a significant association between kyphosis and flexion contracture of the knee joint, as well as between lordosis and insufficient active extension of the knee joint. After elimination of the flexion contracture of the knee, the degree of severity of the CC (thoracic kyphosis) was unchanged, while UL (lordosis angle) and SS (sacral inclination angle) increased by approximately 10°.

Conclusion. The severity of kyphosis in patients with CP is mainly dependent on the degree of flexion contracture of the knee joint. Although elimination of contractures does not lead to kyphosis correction, it increases the degree of lumbar lordosis and tilting of the sacrum.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):71-76
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A plantographic study of the support function of the foot in children with the malformations of the forefoot
Nikityuk I.E., Kovalenko-Klychkova N.A.
Abstract
Assessment of the anatomical and functional state of the feet in of children with malformations of the anterior foot has significant theoretical and practical value. The purpose of this study was to investigate the morphological and functional parameters of the feet in children with malformations of the anterior foot to assess load imbalance and to identify structural and functional disorders using computed plantography techniques. A plantogram analysis was conducted in 64 children aged 5–16 years with foot malformations followed by mathematical processing of plantographical characteristics of the feet (angles, indices, and ratios). The nature of the revealed deviations indicates disturbances of the statics of the affected foot and the inferiority of its dynamic functions (disturbed phase of rolling through the forefoot when walking), which indicates the appropriateness of surgical reconstruction of the anatomy of the foot to improve function.
Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):77-83
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Perspectives of stem cell use in reconstructive maxillofacial surgery
Semyonov M.G., Stepanova Y.V., Troshchieva D.О.
Abstract

The discovery of stem cells is one of the greatest achievements of molecular and cell biology, and associated research has confirmed the possibility of self-renewal and differentiation into specialized tissue stem cells. The use of cellular technologies is an important trend in modern medicine. The aim of this article is to briefly review current findings on the use of stem cells in cardiology, endocrinology, neurology, traumatology, and maxillofacial surgery. All data were retrieved from experimental and clinical studies using various cell technologies. The material is part of ongoing maxillofacial surgery research to investigate the possible use of stem cells in reconstructive maxillofacial surgery for jaw bone pathologies in children. Present tissue engineering methods provide some opportunities for solving difficult clinical problems in oral and maxillofacial surgery. Despite some international achievements of effective application of IC in various diseases, clinical use in reconstructive surgery requires further investigation.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2016;4(4):84-92
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