Vol 6, No 1 (2018)

Original papers
Comparative characteristics of the efficiency of different methods of operational treatment for pectus excavatum in children: a multicenter study
Razumovsky A.Y., Alkhasov A.B., Razin M.P., Axel’rov M.A., Tsap N.A., Kirgizov I.V., Abushkin I.A., Slizovsky G.V., Skryabin E.G., Skobelev V.A., Yagovkin M.A., Nekrasova E.G., Satyvaldayev M.N., Molchanov A.V., Aprosimova S.I., Dudarev V.A., Malchevsky V.A., Broder I.A., Olenina N.V., Aleksandrova N.S., Kuzhelievsky I.I.

Background. Congenital malformations of the chest are observed in 1%–4% of the population, and the most common among these is pectus excavatum (90%).

Aim. We aimed to conduct a retrospective multicenter study to compare the effectiveness of various methods of operative removal of pectus excavatum in children.

Material and methods. We retrospectively analyzed the results of the surgical treatment of funnel-like deformity of the thorax in children conducted in clinics of pediatric surgery in seven regions of Russia (1,226 patients). The ratio of boys to girls in the study population was 2.2:1. The study population was divided as per their age into the following groups: 4–7 years (n = 180, 14.7%), 8–14 years (n = 731, 59.6%), and > 14 years (n = 315, 25.7%). The average age at which most children were operated was 11.83 ± 1.24 years. All children underwent a standard preoperative laboratory examination, including a general blood test, urine tests, a biochemical blood test, a hemostasiogram; radiographic diagnostic methods were used with the calculation of the Gizycka index; functional methods of investigation, such as electrocardiography, spirography, and radioisotope scintigraphy of the lungs were also used. Children with second- or third-degree pectus excavatum underwent surgical treatment almost exclusively. The symmetrical forms of the pectus excavatum were more prevalent. In most cases, the main pathological course was complicated.

Results and discussion. The operated patients were divided into the following 3 groups: the first (n = 62): operations with the resection of the curved cartilages and external fixation of the sternum-rib complex (Bairov’s operation), the second (n = 374): thoracoplasty with the resection of warped cartilages using internal metal fixators by Timoshchenko, Ravitch, Paltia, Kondrashin), and the third (n = 790): minimally invasive operations without resection with internal fixation (Nuss operations: original and modified). In the first group, favorable results of surgical treatment were noted in 80.6% of the patients, satisfactory results were observed in 6.5%, unsatisfactory results were seen in 12.9%, and the overall effectiveness of operative correction was 87.1%. In the second group, good results of surgical treatment were recorded in 88% of the patients, satisfactory in 6.4%, and unsatisfactory in 5.6%; the overall efficiency of operative correction was 94.4%. In the third group, good results of surgical treatment were recorded in 95.3%, satisfactory in 3.8%, and unsatisfactory in 0.9%; the efficiency of operative correction was 99.1%.

Conclusion. Today, the authors consider acceptable the operations by Timoshchenko and Paltia for complex of indicators, the optimal operation is Nuss.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):5-13
Special aspects of the support function of lower limbs in children with the consequences of unilateral lesion of the proximal femur with acute hematogenous osteomyelitis
Nikityuk I.E., Garkavenko Y.E., Kononova E.L.

Background. Acute hematogenous osteomyelitis in the lesion of the proximal femur causes hypofunction or destruction of the metaepiphyseal growth zone of the femur. Theoretically, this leads to the formation of orthopedic consequences, including shortening of the lower limb.

Aim. The study aimed to examine the plantographic characteristics of the feet in children with a lesion of the proximal femur and analyze the influence of the regularities of plantar pressure distribution in the asymmetry of the load on the lower limbs.

Material and methods. Total 15 pediatric patients aged 6–16 years with consequences of acute hematogenous osteomyelitis of the proximal femur and shortening of the affected lower limb by 1.0–6.0 cm were examined. In addition, 15 healthy children belonging to the same age were examined for comparison. Stabilometry and plantography methods were used, and the statistical study included correlation and regression analysis.

Results. When we conducted tests with a double-support load on the feet, in comparison to healthy children, pediatric patients exhibited a significant decrease in the value of the anterior index of the support t in both the affected and unaffected sides. The parameters of other support indices (namely, m, s, and l) of the contralateral feet in patients were within the normal range, indicating the functional consistency of the corresponding arches of the feet, providing static and dynamic limb support ability. However, the correlation and regression analysis showed that, in comparison with the norm, the foot support ability in pediatric patients is implemented due to the strengthening of the functional relationship between the inner and the medial longitudinal arches of the foot on the intact side and the inversion of the interaction of the longitudinal arches with the transverse arch on the side of the lesion.

Conclusion. In children with consequences of acute hematogenous osteomyelitis of the proximal femur, the parameters of the plantographic characteristics indicate a change in the activity and consistency of the muscles that form all the feet arches on both the affected and intact lower limbs.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):14-22
Baby walkers and the phenomenon of toe-walking
Krivova A.V., Sharov A.N.

Background. There is limited data in the literature regarding the clinical impact of baby walkers (BWs).

Aim. In this study, we examined the hypothesis that the formation of abnormal motor pattern in the form of preferred moving without support on the heel, while using a BW.

Objectives. We aimed to determine certain epidemiological impact of the use of infant walkers in order to identify the toe-walking pattern to determine the accuracy of its connection with the walker for estimating the volume and characteristics of the phenomenon.

Methods. Three retrospective cohort studies were conducted. All the children included in the sample (n = 749) and 363 infants used BWs. Method selected anamnestic survey of parents on a specially designed, anonymous questionnaires and statistical analysis of data.

Results. The study population had been using BWs for several years. The reasons for the use of infant walkers were identified. The relative risk of walking without heel support in the BWs user groups RR2 = 3.555 (2.535–4.990, 95% CI) and RR3 = 2.766 (1.178–6.494, 95% CI) was calculated for the second and third studies, respectively. There was an increase in the correlation between toe walking and the use of BWs with longer duration of use. The risk of toe walking in the BW user group (PAR = 19.647%) was calculated. The study revealed no static deformation associated with the use of BWs.

Conclusion. The use of BWs was identified as a factor contributing to the formation of the toe-walking pattern and as a possible causal factor of idiopathic toe walking.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):23-32
Conservative treatment of pronational contracture of the forearm in children with cerebral palsy
Novikov V.A., Umnov V.V., Zvozil A.V., Umnov D.V., Nikitina N.V.

Aim. We aimed to evaluate the effectiveness of conservative treatment for pronational contracture of the forearm, depending on the contracture severity.

Materials and methods. This study was based on the results of the examination and treatment of children experiencing cerebral palsy with upper limb involvement. The main criterion for patient selection was the presence of pronational contracture of the forearm, both isolated and in combination with other contractures in the upper limb joints. Three patient groups were formed based on the pronounced pronation contracture of the forearm.

Results and conclusions. Previous research has established that with the increase in the degree of severity of pronation contracture, the effectiveness of conservative treatment decreases in general. Conservative treatment of patients with a deficiency of active supination of the forearm of > 90° is ineffective. The use of botulinum toxins type A and RFD in groups II and III is ineffective. Conservative treatment with botulinum toxins type A achieved good results only in patients of group I.

The RFD method had a longer lasting; however, there were significantly more complications. The use of botulinum toxins type A (m. pronator teres) among patients with pronational contracture of the forearm with the possibility of active supination of the forearm > 90° significantly improved the result of basic conservative treatment.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):33-38
Isolated free fluid in children with blunt abdominal trauma: Does it alters the management approach?
Khan R.A., Wahab S.

Introduction. Isolated free fluid (IFF) on abdominal computed tomography in children with blunt abdominal trauma poses a diagnostic dilemma.

The aim of this study is to present our experience of the entity and its role in management of these children.

Methods. A prospective study was performed over a period of two and half years on all the children less than 14 years of age admitted to our hospital with blunt abdominal trauma and in whom the CT abdomen was done which demonstrated isolated free fluid with no sign of visceral injury. Demographic data, presenting clinical status, imaging data and management (nonoperative progress and operative findings) were collected and analyzed.

Results. A total of 108 children were admitted with blunt abdominal trauma and who underwent abdominal CT during the period from July 2015 to December 2017. Isolated free fluid (IFF) was found in 26 children (24%). The mean age was 7.8 years with male predominance. Motor vehicle collisions were the most common mechanism of injury. At presentation abdominal tenderness was present in 8 of these children. Twenty two children had small IFF and 2 each had moderate and large fluid collections and the most common site being the hepatorenal pouch. One child each from moderate and large IFF group needed subsequent exploration.

Conclusion. Children of blunt abdominal trauma with isolated free fluid on abdominal CT are managed conservatively. However, they need admission and repeated clinical assessment for early detection of delayed presentation of visceral injury entailing surgical intervention.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):39-44
Rehabilitation of adolescents after surgical treatment of dysplastic coxarthrosis
Bortuleva O.V., Baskov V.E., Bortulev P.I., Barsukov D.B., Pozdnikin I.Y.

Background. The prevalence and severity of stage II and III dysplastic coxarthrosis determine the medical and social importance of its prevention and treatment. For a practicing orthopedic surgeon, there are two established stages of orthopedic treatment: the surgical stage and the restorative stage. The domestic and foreign literature from the previous 25 years comprises few publications regarding the rehabilitation of young children after reconstructive hip joint surgeries. Thus, the issues regarding the rehabilitation of teenagers following extra-articular operations on the hip joint remain unexplored.

Aim. To evaluate the effectiveness of the developed program of rehabilitation for children after the surgical treatment of dysplastic coxarthrosis stages I and II.

Material and methods. We analyzed the results of the surgical and rehabilitative treatment of 40 children (100%) with dysplastic coxarthrosis stage I and II; the study population included 27 girls (67.5%) and 13 boys (32.5 per cent) aged 13–18 years (total 54 joints). The rehabilitation period was divided into the following 4 stages: I preoperative, II postoperative day 1–2, III postoperative day 3–21, IV outpatient treatment (after hospital discharge to 1 year postoperatively).

Results. By the time of discharge, the range of motion in the hip joint was as follows: bending 950° ± 40°, withdrawal 150° ± 50°, and extension 100° ± 30°. According to the results of the electromyography performed 3 months postoperatively, there was an increase in the amplitude of biopotentials for the gluteal muscle. The long-term result was evaluated after 1 year. The average modified Harris Hip Score and a scale developed in the The Turner Scientific and Research Institute for Children’s Orthopedics, significantly (p < 0.05) differed from preoperative ones.

Conclusion. Early rehabilitation allows an increase in the strength and tone of muscles and restores the amplitude of movements in conditions of altered anatomical and biomechanical relationships in the hip. The verticalization of patients with the learning of proper load distribution on the parts of the foot enables effective recovery of the correct gait pattern. Comprehensive treatment of adolescents with dysplastic coxarthrosis according to the proposed method not only improves the condition of the affected hip joint and lower limb as a whole, but also improves the child’s quality of life.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):45-50
Exchange of experience
Intertrochanteric hip fracture in a 6-year-old girl treated with pediatric sliding hip screw: case report
Lopes A.L., Maio M., Mota P.T., Sapage R., Branco C.B., Branco R.J., Pintado C.E.

Hip fractures are very common in adults, but are rare entities in children, comprising less than 1% of all pediatric fractures. The authors present a clinical case of a 6-year-old girl with an intertrochanteric hip fracture — displaced Delbet’s type IV — treated with a pediatric sliding hip screw. The osteosynthesis material was removed 10 months later.

The Delbet type IV hip fractures corresponds to 12% of all pediatric hip fractures. This type of fractures in children older than 3 years old should be treated with internal fixation with a sliding hip screw or a proximal femur locking plate. Preferably the reduction of the fracture should be done within 24 hours. Despite the delay of the surgical procedure, the patient got an excellent recovery without any of the complications described in the literature with a follow-up of 26 months upon the implant-removal surgery.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):51-54
Osteochondropathy of the coronoid process of the ulna in a child: case report
Nikitin M.S., Proshchenko Y.N.

Osteochondropathy of the proximal ulnar bone is a rare disease that affects not only the ulnar, but also the venous process. To our knowledge, the existing domestic and foreign medical literature does not provide a description of osteochondropathy of the coronal process, a topic of considerable interest from the point of view of diagnosis and treatment.

Here, we describe a clinical case of osteochondropathy of the coronal process and present a clinical picture of the defect of the elbow joint in the patient, with radiographs taken before and after the surgery. In the present clinical case, postoperatively, the patient reported pain; however, the elbow joint function was fully restored, indicating the success of the treatment and that active surgical treatment of this disease is adequate and timely.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):55-57
Development of contractures in spastic forms of cerebral palsy: Pathogenesis and prevention
Klochkova O.A., Kurenkov A.L., Kenis V.M.

The origin of contractures in spastic forms of cerebral palsy (CP) is unclear. Tomorrow the early appearance and persistence of spasticity are not qualified as the main reason of growths disturbances, musculo-skeletal system deformations and secondary orthopedic complications. The latest investigations have shown prominent changes in the spastic muscles on the different structural levels and stages of muscle development. This study describes the histological, morphological, and biomechanical changes in the spastic muscles that play a pathophysiological role in the formation of CP contractions. The authors discuss the changes in the muscle fiber size, differentiation and elastic properties, degrees of the lengthening resistance in the bundles of muscle fibers, extracellular matrix proliferation, structural and mechanical changes, disturbances in gene expression and regulation in the tendons and muscle tissue, changes in the length and number of sarcomers, as well as the length and cross-section of the whole muscle.

Therefore, the movement limitations and contractions in CP do not depend on one universal mechanism. It is a combination of different structural changes in the muscles and the failure of the central movement and postural control.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):58-66
Objectification of motor disorders in children with cerebral palsy: what we know so far
Borzikov V.V., Rukina N.N., Kuznetsov A.N., Belova A.N.

This study provides an overview of the recent literature regarding the assessment methods of the functional state of the locomotor system in children with cerebral palsy. The objective methods of quantitative assessment of motor disorders in cerebral palsy are presented, including the measurement of stability, biomechanical assessment of walking, and video analysis of movements. The influence of the cognitive load on the ability to maintain the vertical posture in children with cerebral palsy as well as the changes in the stability of the vertical posture with closed eyes were observed. Changes in the walking parameters with an increase in the speed were also recorded in children with cerebral palsy.

Methods that assess hand motion in children with cerebral palsy include tests involving the moving of objects, tests for speed assessment in joint movements, and video analysis of motions.

The methods and tests for such an evaluation require to be valid and reliable, allowing an objective assessment of the severity of motor disorders in cerebral palsy.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(1):67-77

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