Vol 5, No 4 (2017)


Loss of temperature and pain sensation as risk marker of neurological complications in surgical correction of severe spinal deformity

Shchurova E.N., Saifutdinov M.S., Ryabykh S.O.


Background. Treatment of severe spinal deformity remains a challenging surgical problem, with an iatrogenic injury to the spinal cord being a critical complication. There is a high risk of neurological deficit following surgical correction of a severe spinal deformity.

Aim. To determine the relationship between the extent of disturbed thermal and pain sensations at Th1-S2 dermatomas and the intensity of the spinal cord pathways’ responses to surgical correction of the severe spinal deformity.

Material and methods. We reviewed 58 patients with severe spinal deformities of different etiologies (mean age, 15.7±0.8 years). All patients underwent surgical deformity correction followed by thoracic/thoracolumbar spine fixation by using a variety of internal transpedicular fixations. Intraoperative neurophysiological monitoring (IONM) with transcranial motor-evoked potentials (MEPs) was used during operative interventions. Preoperative and postoperative thermal and pain sensations were assessed in Th1-S2 dermatomas to the right and left by using an electrical aesthesiometer.

Results. The extent of disturbed preoperative and postoperative thermal and pain sensations in Th1-S2 dermatomas before and after correction of spinal deformities correlated with the response type scale (I–V) of the spinal cord pathways to the surgical correction we offered. Correlation between the response type and characteristics of thermal and pain sensations was mostly revealed by the test results for the thermal pain threshold (thermal analgesia). The incidence of postoperative thermal analgesia increased monotonically from patients with response type I (persistent MEP form and amplitude-time parameters close to the baseline) to patients with response type V (higher risk of neurological complications). The overall rate of thermal analgesia increased after surgical correction of the spinal deformity relative to the baseline and was higher (≤8%) in patients with response type V.

Conclusions. Surgeons and neurophysiologists who perform IONM should give careful attention to patients with severe spinal deformity who exhibit marked postoperative thermal analgesia.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):5-15
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Complications after toe-to-hand transfers in children with pathologies of the hand

Golyana S.I., Tikhonenko T.I., Govorov A.V., Zaytseva N.V., Balashov A.V.


Background. Complications after microsurgical toe-to-hand transfer is a problem for which there is no common approach to treatment.

The aim of this study was to analyze the ischemic complications after microsurgical operations in children with pathologies of the hand to improve the quality of surgical treatment.

Materials and methods. From 2007 to 2016, we performed 210 microsurgical toe-to-hand transfers involving 306 transplants, 267 (87.3%) of which were performed in patients with congenital pathologies and 39 (12.7%) in patients with post-traumatic deformities of the hand. In total, 352 fingers were reconstructed.

Results. Blood supply disturbance following toe transplants occurred in 19 (6.2%) of the 306 transplants, most often in the early postoperative period (73.7%). The main cause of microcirculatory disorders was thrombosis of the venous or arterial trunks (8 cases). In 6 patients, the blood supply disturbance occurred because of thrombosis of autovenous grafts. Two patients underwent necrectomy at days 7 and 18 because conservative and operative treatments were not successful.

Conclusion. The treatment method of choice after the first appearance of signs of blood supply disturbance in a transferred toe is conservative therapy, which includes disaggregants, anticoagulants, and hirudotherapy. Conservative therapy should be performed within 3 hours from the beginning of ischemia; if ischemia is absent, the patient must undergo surgery. The operation includes soft tissue decompression, mechanical pumping across vascular anastomoses, and if necessary, excision of the abnormal vessel part with subsequent autoplasty.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):16-23
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Reducing radiation exposure in newborns with birth head trauma

Kriukova I.A., Kriukov E.Y., Kozyrev D.A., Sotniкov S.A., Iova D.A., Usenko I.N., Iova А.S.


Background. Birth head trauma causing intracranial injury is one of the most common causes of neonatal mortality and morbidity. In case of suspected cranial fractures and intracranial hematomas, diagnostic methods involving radiation, such as x-ray radiography and computed tomography, are recommended. Recently, an increasing number of studies have highlighted the risk of cancer complications associated with computed tomography in infants. Therefore, diagnostic methods that reduce radiation exposure in neonates are important. One such method is ultrasonography (US).

Aim. We evaluated US as a non-ionizing radiation method for diagnosis of cranial bone fractures and epidural hematomas in newborns with cephalohematomas or other birth head traumas.

Material and methods. The study group included 449 newborns with the most common variant of birth head trauma: cephalohematomas. All newborns underwent transcranial-transfontanelle US for detection of intracranial changes and cranial US for visualization of bone structure in the cephalohematoma region. Children with ultrasonic signs of cranial fractures and epidural hematomas were further examined at a children’s hospital by x-ray radiography and/or computed tomography.

Results and discussion. We found that cranial US for diagnosis of cranial fractures and transcranial-transfontanelle US for diagnosis of epidural hematomas in newborns were highly effective. In newborns with parietal cephalohematomas (444 children), 17 (3.8%) had US signs of linear fracture of the parietal bone, and 5 (1.1%) had signs of ipsilateral epidural hematoma. Epidural hematomas were visualized only when US was performed through the temporal bone and not by using the transfontanelle approach. Sixteen cases of linear fractures and all epidural hematomas were confirmed by computed tomography.

Conclusion. The use of US diagnostic methods reduced radiation exposure in newborns with birth head trauma. US methods (transcranial-transfontanelle and cranial) can be used in screening for diagnosis and personalized monitoring of changes in birth head trauma as well as to reduce radiation exposure.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):24-30
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The use of cellular technologies in the treatment of children with congenital cleft palate

Stepanova Y.V., Tsyplakova M.S., Usoltseva A.S., Enukashvili N.I., Bagaeva V.V., Semyonov M.G., Murashko T.V., Ponamareva K.G.


Background. Mesenchymal stromal cells (MSCs) are multipotent stem cells capable of differentiation in the osteogenic, chondrogenic, and adipogenic directions that are widely used in the development of new cellular biomedical technologies.

Aim. We investigated the effect of MSCs on osteogenesis in the congenital defect of the alveolar process of the upper jaw with the aim of improving the treatment results for children with congenital cleft palate.

Materials and methods. At the department of maxillofacial surgery of the Turner Institute for Children’s Orthopedics, 46 patients with a diagnosis of congenital cleft palate were observed in 2017. Six patients with congenital cleft palate in the region of the defect of the hard palate and the alveolar process of the upper jaw underwent uranoplasty and implantation of a mixture (1 : 4) of MSCs and preosteocytes derived from them on the osteogenic membrane. The control group consisted of 40 age-matched patients who underwent the same surgery but without the use of MSCs. The distance between the cleaved portions of the alveolar process of the upper jaw ranged from 0.5–1.0 cm. The follow-up period was 6–9 months.

Results. On X-ray examination 6–9 months after the operation in the bone defect area and implantation of MSCs in all patients, tissue with a density corresponding to that of bone was found. In the control group, bone tissue was not formed in the diastasis of the alveolar bone. There were no significant differences in the timing of wound healing and course of the postoperative period.

Сonclusion. Tissue engineering helped in the treatment of severe congenital malformations of the maxillofacial area. There are good prospects for using MSCs in the surgical treatment of defects of the facial skeleton.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):31-37
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Treatment of pediatric patients with lower leg deformities associated with physeal arrest: analysis of 28 cases

Vilensky V.A., Pozdeev A.A., Zubairov T.F., Zakharyan E.A.


Aim. To retrospectively analyze the results of two treatment methods for lower leg deformities associated with partial growth arrest.

Materials and methods. Group I comprised 15 children who underwent osteotomy, acute overcorrection, and external fixation by Ilizarov with subsequent lengthening of the segment. Group II comprised 13 patients who underwent epiphysiodesis of the healthy part of the growth plate by drilling, osteotomy with external fixation by use of an Ortho-SUV Frame, and subsequent gradual deformity correction and lengthening.

Results. In group I, overcorrection of varus deformities by mechanical axis deviation (MAD) was 18.28 ± 5.25 mm, overcorrection by mechanical medial proximal tibial angle (mMPTA) was 14.86 ± 4.45°, and overcorrection by mechanical lateral distal tibial angle (mLDTA) was 12.85 ± 3.02°. Overcorrection of valgus deformities according to MAD was 15.12 ± 8.28 mm, overcorrection by mMPTA was 10.38 ± 2.77°, and overcorrection by mLDTA was 7.5 ± 3.9°. Recurrence of the deformity was observed in 11 (73%) cases (range, 5–16 months).

In group II, the accuracy of correction (AC) in varus deformities for MAD was 98% and 94% for mMPTA and mLDTA. For valgus deformities, AC for MAD was 90% and 96% for mMPTA and mLDTA. The AC for anatomical proximal posterior tibial angle and anatomical anterior distal tibial angle was 96% for procurvation deformities and that for recurvation deformities was 92%. Deformity recurrence was observed in only one case within 6 months after frame removal. In 2 cases, repeat limb length discrepancy correction surgeries were performed.

Conclusion. Use of epiphysiodesis of the healthy portion of the growth plate in combination with osteotomy, computer-assisted external fixation with subsequent gradual deformity correction, and lengthening in patients with deformities associated with partial physeal arrest significantly decreased the number of deformity recurrences.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):38-47
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Application of non-invasive electric stimulation of the spinal cord in motor rehabilitation of children with consequences of vertebral and cerebrospinal injury (preliminary report)

Vissarionov S.V., Solokhina I.Y., Ikoeva G.A., Baindurashvili A.G.


Introduction. Vertebral and cerebrospinal injury and its consequences constitute an important problem in modern medicine. In recent years, studies have shown that percutaneous electric stimulation in patients with these injuries can influence the neuronal networks of different parts of the spinal cord to activate afferent and efferent reflex connections with complete or partial disorders of supraspinal influences of various geneses.

Aim. To investigate the effect of percutaneous electric stimulation of the spinal cord on the dynamics of recovery of neurological functions in children with vertebral and cerebrospinal injury.

Materials and methods. Seven patients aged 4 to 18 years with lesions of the spinal cord from C5-C6 to Th12-L1 and who mainly had a marked neurological deficit were examined from 1 month to 9 years after surgical treatment. All patients underwent neurophysiological studies, including electroneuromyography, electromyography, and somatosensory-evoked potentials. The patients and their parents kept a diary of urination.

Results. This clinical study showed that percutaneous electric stimulation of the spinal cord contributed to the rapid and complete restoration of the neurological functions in patients with vertebral and medullar conflict and depended directly on the early terms of surgical intervention.

Conclusion. The positive results obtained in the complex rehabilitation of children with vertebral and cerebrospinal injuries by using non-invasive percutaneous electric stimulation of the spinal cord support the use of this method in the early stages after surgical intervention.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):48-52
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Rehabilitation of children at the inpatient stage after surgical treatment of unstable fractures of the thoracolumbar and lumbar spine

Ovechkina A.V., Baindurashvili A.G., Zaletina A.V., Kozyrev A.S.


Introduction. The modern approach to the treatment of unstable fractures of the thoracolumbar and lumbar spine in children is surgical stabilization at the early stages after trauma by using metal structures that quickly restore vertical functionality to the patient and shorten the period of inpatient treatment. However, the issues related to restorative treatment have not been sufficiently addressed.

Aim. To develop an algorithm for restorative treatment of children at the inpatient stage after surgical treatment of unstable uncomplicated fractures of the thoracolumbar and lumbar spine.

Material and methods. Based on the results of treatment of 73 patients aged 9 to 17 years with unstable uncomplicated vertebral fractures, an algorithm of stage-by-stage rehabilitation by means of therapeutic gymnastics depending on the severity of the injury, method of surgical stabilization of the spine, physical condition of the child, and time passed after the operation was developed.

Results and discussion. The use of differentiated groups of respiratory gymnastics and isometric and dynamic exercises for muscle groups restored vertical functionality to patients in 1–3 days after surgery, restored spine and motor functions, and shortened the duration of inpatient treatment to a range of 10–14 days.

Conclusion. The developed algorithm for physical rehabilitation of children after surgical treatment of unstable injuries of the thoracic and lumbar spine by using metal structures at the inpatient stage contributed to the selection of the most rational and effective program of restorative treatment.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):53-59
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Maternal attitude as a resource for overcoming the psychological consequences of a severe form of an orthopedic disease

Pyatakova G.V., Vissarionov S.V., Lebedeva E.I.


Introduction. Idiopathic scoliosis in a surgical pathology stage creates a difficult situation in the life of sick adolescents. There may be signs of marked neuropsychic stress, fear, helplessness, and behavioral deviations in adolescents suffering from the scoliotic disease. Hence, it is important to study the factors of protection and external adaptation resources that are crucial for coping with psychological difficulties in adolescence. One such resource is the maternal attitude, including emotional support.

Material and methods. Sixty women were enrolled in the study, 30 of whom were mothers of patients of a pediatric orthopedic clinic who had been diagnosed as having idiopathic scoliosis of 3–4°, and 30 were mothers of adolescents without disorders of the musculoskeletal system. The method used the A.Ya. Varga and V.V. Stolin diagnostics of parental attitude, the SF-36 quality of life questionnaire, and C.D. Spielberg’s self-evaluation technique for determining the level of situational and personal anxiety (adaptation of Y.L. Khanin). Average statistics were calculated, the statistical significance of differences in comparisons was calculated by performing Student’s test, and correlation analysis was performed by calculating Spearman’s correlation coefficients.

Results. The attitudes of the parents of the healthy adolescents and those of adolescents with idiopathic scoliosis were characterized by a predominance of positive feelings and a desire to provide emotional support to the adolescent proportionally while recognizing the difficulties in the child’s life situation. A mother’s positive attitude toward her child under treatment in a surgical clinic for correction of a severe spinal deformity may be distorted by her anxiety and depressive feelings, which may reduce the mother’s ability to provide emotional support in a situation difficult for the child. An important component in the system of psychological care for adolescents with idiopathic scoliosis may be professional psychological support focused on harmonization of child–parent relations.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):60-67
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New approaches for full-thickness grafting of the face

Porhanov V.A., Bogdanov S.B., Gilevich I.V., Fedorenko T.V., Kolomiyceva E.A., Bogdanova Y.A.


In addition to the physical injury, deep burns of the face also can cause psychological injury. The purpose of this study was to develop new technical methods for improving engraftment of full-thickness autografts. Since 2017, autologous fibroblasts have been used for skin facioplasty of one full thickness autograft in Scientific Research Institue, Reginal Clinical Hospital No 1. Isolation of fibroblasts was performed by using an enzymatic method and a skin sample with an area of 10 cm2. Cultivation of autologous fibroblasts was performed for 22 days according to a standard procedure. The prepared culture of autologous fibroblasts was used together with a full-layer autologous transplant to close the wound on the face. We found that autologous fibroblasts provided faster adaptation of the autograft. There were no signs of fibrous tissue over the long term. We concluded that fibroblasts promoted rapid engraftment and adaptation of the full-thickness autograft. Improvement of facial plastic surgery methods can help achieve maximum cosmetic treatment results.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):68-73
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Brief concept of hip preservation

Madan S.S., Chilbule S.K.


Restoration of the anatomy of the hip joint and biomechanics across it, carry the immense importance to prevent future osteoarthritis of the joint. The aim of this review is to provide the brief concept of the methods to preserve the hip, especially in young adults.

Attempts to preserve the hips start with the intense preoperative planning of the corrective procedure. Different parameters regarding the femur and acetabulum in all 3 dimensions need to be assessed. Especially, measurement of the anteversion of the femur and acetabulum is a significant step to avoid osteoarthritis. In addition, the suprapelvic and infrapelvic (spine and lower limb lengths) alignment needs to be considered in the planning.

Correction of the femoral side of the hip needs the understanding of the blood supply of the proximal femur which carries the risk of avascular necrosis more so with intracapsular osteotomies. Acetabular reorientation, to re-distribute the forces over the weight bearing part, can be carried out with re-directional osteotomy such as periacetabular osteotomy. It needs the understanding of the acetabular anatomy and the force distribution in it.

To conclude, correction of both femoral and acetabular side parameters need to be considered in decision making depending on the alterations due to various etiologies causing the hip disorders.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2017;5(4):74-79
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