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Vol 10, No 2 (2022)

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Clinical studies

Comparative evaluation of the sensitivity and specificity of clinical and magnetic resonance methods of assessing damage to the fibrocartilage lip in pediatric patients with traumatic instability of the shoulder joint

Lukyanov S.A., Proshchenko Y.N., Baindurashvili A.G.


BACKGROUND: The shoulder joint provides the greatest degree of freedom in movement, making it one of the most unstable and frequently dislocated joints, accounting for almost 50% of large-joint dislocations. Recurrent instability of the shoulder joint develops in 96%–100% of children and adolescents, making it important to accurately diagnose possible anatomical causes of persistent pain syndrome violating the habitual function of the shoulder. At the same time, the symptoms of intra-articular injuries of the shoulder joint are often vague, and a definitive diagnosis cannot be made without the use of instrumental research methods.

AIM: To compare the diagnostic value of clinical examination and magnetic resonance imaging in detecting intra-articular pathology in adolescents with anterior instability of the shoulder joint of traumatic origin.

MATERIALS AND METHODS: This retrospective study included parameters of clinical examination and instrumental methods of investigation of 72 children (72 shoulder joints) with habitual shoulder dislocation of traumatic origin. The age of the examined persons ranged from 13 to 17 years.

Magnetic resonance, clinical, arthroscopic, and statistical methods of research were employed in this work. The arthroscopic method was considered as a reference research method for assessing the sensitivity and specificity of clinical examination and magnetic resonance imaging. Sensitivity and specificity were evaluated, followed by an assessment of the prognoses of positive and negative results for MRI data and clinical research methods.

RESULTS: The MRI data was characterized by a significantly greater sensitivity and specificity in detecting lesions (95.4% and 71.4%) than those of clinical examination (79.1% and 60%). Thus, MRI is better at detecting damage to the fibrous-cartilaginous lip in traumatic instability in adolescents than clinical examination.

CONCLUSIONS: In our opinion, for the most reliable preoperative planning of surgical treatment of children, a full-fledged clinical examination should be used and data from instrumental research methods should be included, considering the advantages and disadvantages of each method.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):113-120
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Comparative analysis of the results of correction of congenital spinal deformity in isolated semivertebrae in preschool and primary school-age children

Vissarionov S.V., Filippova A.N., Kokushin D.N., Khardikov M.A., Ryzhikov D.V., Shabunin A.S., Serikov V.V.


BACKGROUND: Despite a detailed study of the natural development of congenital spinal deformity in isolated semivertebrae and methods of surgical correction of this pathology, some issues remain unclear. The age at which surgical correction of congenital spinal deformity should be performed is a debated issue among specialists.

AIM: To conduct a comparative analysis of the effectiveness of correction of spinal deformity in children with congenital kyphoscoliosis with isolated semivertebrae of preschool and primary school-age children.

MATERIALS AND METHODS: We included 26 patients aged 21 months to 69 months (10 girls and 16 boys) with congenital kyphoscoliosis caused by an isolated semivertebra. The patients underwent partial or complete resection of the semivertebral disk with adjacent intervertebral disks from dorsal or combined access, correction and stabilization of congenital spinal deformity with a posterior multisupport metal structure. Participants were sectioned into two age groups: the first group — children under 4 years (14 children), the second group — children 6 years and older (12 children).

RESULTS: Metal fixation during surgical treatment in children of primary school age as well as in preschool children was carried out in the majority of cases polysegmentarily. Regarding the choice of surgical treatment access, dorsal surgical access was more often preferred in the second group of patients. The duration of surgical intervention and volume of blood loss between different age groups were similar with dorsal and combined access. In the group of preschool children, destabilization of the metal structure was noted in the early postoperative period when performing control radiographs after surgical treatment in three cases. In the second group, spinal deformity of dysplastic genesis after surgical treatment was detected in three cases.

CONCLUSIONS: The effectiveness of surgical treatment of congenital deformity is significantly higher in younger children compared to that in school-age patients.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):121-128
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Study of reactions of the sensorimotor system in adolescents during and after surgical correction of spinal deformity

Shchurova E.N., Saifutdinov M.S., Akhmedova M.A., Savin D.M., Bogatyrev M.A.


BACKGROUND: Little attention has been paid to the study of delayed sensory and motor reactions in adolescents with spinal deformities after surgical treatment.

AIM: To study the reactions of the sensorimotor system of adolescents after surgical correction of spinal deformity.

MATERIALS AND METHODS: The state of the sensory and motor spheres was analyzed in the immediate postoperative period in 21 adolescents with idiopathic scoliosis and in 13 with congenital deformities of the spine. A complex of methods involving global and stimulation electroneuromyography was used. The amplitude of motor, reflex potentials and interference electromyogram was evaluated at the maximum arbitrary tension of the lower limb muscles. Using an esthesiometer, thermal pain sensitivity in Th1–S2 dermatomes was explored. In the process of surgical correction, intraoperative neuromonitoring was performed with registration of motor evoked potentials of the lower limb muscles.

RESULTS: At the beginning of surgical intervention, high-amplitude, well-reproducible motor evoked potentials were obtained in all patients. In the group of patients with idiopathic scoliosis, compared with those with congenital deformities, smooth flow of surgery prevailed (p > 0.05) without significant changes in motor potentials relative to the baseline (p > 0.05). The number of observations of motor potentials decreased in the both groups and did not exceed 10%; the differences were not significant (p > 0.05). The study of the reactions of the sensorimotor system in the immediate postoperative period triggered an increase in the amplitude of M-responses of m. rectus femoris, m. flexor digitorum brevis, m. gastrocnemius, and a decrease in the amplitude of the total EMG of m. rectus femoris. Values of H-reflexes remained at the preoperative level. The analysis of thermal pain sensitivity demonstrated the presence of a more pronounced reaction than that of the motor component. Changes in indicators of this type of sensitivity in groups of adolescents with idiopathic and congenital scoliosis were opposite. In idiopathic scoliosis, negative dynamics of the values prevailed, while in adolescents with congenital deformities of the spine, positive dynamics prevailed. This was because the amount of correction of the main and compensatory curves of the deformity in the group with idiopathic scoliosis was 48% greater (p = 0.0004) and 51% greater (p = 0.011), respectively.

CONCLUSIONS: After surgical correction of spinal deformities in adolescents, the reactions of the sensory system of thermal pain sensitivity were more pronounced than those of the motor sphere.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):129-142
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Analysis of X-ray parameters of the acetabulum in patients with cerebral palsy

Novikov V.A., Vissarionov S.V., Umnov V.V., Zharkov D.S., Umnov D.V.


BACKGROUND: Among the orthopedic consequences of cerebral palsy, instability of the hip joints is one of the most common. Most children with cerebral palsy at birth have close to normal relationships in their hip joints that gradually deteriorates. Progressive instability of the hip joint leads to subluxation and then dislocation of the hip, to a decrease in the range of motion in the joints, to movement disorders and a defect in the ability to sit, as well as an impairment in hygienic care of the child.

AIM: To analyze the X-ray anatomical structure of the acetabulum in unstable hip joint in children with cerebral palsy.

MATERIALS AND METHODS: We examined 42 hip joints in 23 patients with cerebral palsy. Participants were divided into two groups. The main group included the results of the examination of unstable hip joints (31 studies), and the control group included the results of the examination of stable joints (11 studies).

RESULTS: The average index of anteversion of the acetabulum in the main group with a functioning Y-shaped cartilage was 2.5° more than the average value of the norm (p = 0.029), with a nonfunctioning Y-shaped cartilage at 6° less than the normal value (p = 0.017). There was a positive moderate correlation between the anteversion of the acetabulum and the anterior margin angle (r = 0.424, p = 0.017), and a positive moderate correlation between the acetabular index and the anterior margin angle (r = 0.398, p = 0.027).

CONCLUSIONS: The study showed that changes in the acetabulum in patients with pathological dislocation or subluxation of the hip against the background of spastic cerebral palsy were manifested by deformation in the horizontal plane due to retroversion of the acetabulum.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):143-150
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Assessment of comparative parameters of leg length discrepancy in children using temporary epiphysiodesis with 8-plates

Petrova D.A., Kenis V.M.


BACKGROUND: Epiphysiodesis is used to correct the leg length discrepancy in children. The results of the effectiveness in different studies using epiphysiodesis with 8-plates. Forecasting is a fundamental provision of the methodology to apply epiphysiodesis.

AIM: To determine the comparative effectiveness of temporary epiphysiodesis with 8-plates in correcting the difference in size of the lower limbs in children, depending on the age of the patient and the segment of epiphysiodesis.

MATERIALS AND METHODS: We included data from a retrospective analysis of the results of correcting the leg length discrepancy using the method of guided growth in 94 patients. The technique included the use of two 8-plates. The calculation of comparative indicators was used, while the difference in the ratios of lengths of the epiphysiodesed and paired segments before epiphysiodesis and at the time of completion of guided growth (removal of metal structures) was determined as an indicator of the effectiveness of treatment.

RESULTS: The maximum efficiency was observed with epiphysiodesis of the femur in children of the younger age group (a change of 7.59% in the length of the bone), the minimum was observed with epiphysiodesis of the tibia in children of the older age group (a change in length of 2.04%). The decrease in the effectiveness of femoral epiphysiodesis depending on age was linear, while that between the efficiency indicators in the younger and middle groups was 1.85%, and between the middle and older groups was 2.8%. In epiphysiodesis of the tibia, the difference between the efficiency indicators in the younger and middle age groups was 2.42%, and that between the middle and older age group was 0.34%.

CONCLUSIONS: Temporary epiphysiodesis with 8-plates is effective in correcting the LLDs in children. The use of the comparative efficiency indicators obtained in different age groups allows us to plan the intervention more accurately and avoid unnecessary operations.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):151-160
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Nonvascularized toe-phalange transplantation to the hand in congenital and acquired pathology (Part 1)

Shvedovchenko I.V., Koltsov A.A., Matveev P.A., Komarova A.V.


BACKGROUND: Restoration of the form and function of underdeveloped fingers in congenital pathology and consequences of severe trauma remains an unsolved problem, especially in young children during growth.

AIM: To evaluate the feasibility of surgical treatment in children with congenital and acquired hand pathology using transplantation of the nonvascularized phalanges of the toes.

MATERIALS AND METHODS: We analyzed the immediate surgical treatment results of 41 children at the age of 10 months to 11 years with congenital malformations and posttraumatic hand deformities after undergoing nonvascularized toe-phalange transplantation. The main group of interventions was performed in children with ectrodactyly, adactyly, and hypoplasia of the hand. Predominantly, the proximal phalanges of the I, II, and III fingers were restored. The proximal and middle phalanges of the 2nd and 4th toes were mainly used as transplants.

RESULTS: We assessed indications and contraindications for nonvascularized toe-phalange transplantation in the treatment of patients with congenital and acquired pathology of the hand. The technologies for performing reconstructive operations have been developed, and the optimal sequence of actions has been determined. The next publication will be devoted to the analysis of the data obtained.

CONCLUSIONS: Nonvascularized toe-phalange transplantation in the treatment of patients with congenital and acquired pathology of the hand is a method that should be studied from the point of view of indications, technology of execution, as well as long-term results. The undoubted advantage of the discussed technology is the execution available for the surgeon of standard training, as well as the absence of the need for expensive material and technical support, including an operating microscope, specialized instrumentation and suture materials.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):161-170
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Experimental and theoretical research

The effect of proinflammatory cytokine inhibtors on the course of aseptic necrosis of the femoral head in a model experiment

Shabaldin N., Shabaldin A.V., Bogdanov L.A., Igisheva L.N., Zinchuk S.F., Chervov A.E.


BACKGROUND: One of the most relevant areas of study of Perthes’ disease is the search and scientific justification of new targets for the treatment of osteodestructive processes. At the same time, an important link in the regulation of bone homeostasis is the cytokine system that affects the processes of differentiation and activation of osteoclasts through the RANK-RANKL-OPG signaling pathway. Inhibition of the biological action of proinflammatory cytokines in the early stages of aseptic necrosis is a promising direction in the study of antiresorptive therapy.

АIM: To assess the effectiveness of monoclonal blockers of proinflammatory cytokines in the treatment of aseptic necrosis of the femoral head in a model experiment on Wistar rats.

MATERIALS AND METHODS: A model experiment was performed on small animals (24 Wistar rats). All animals underwent surgical induction of aseptic necrosis of the femoral head. The rats were divided into four groups: group 1 did not receive treatment, group 2 were administered a monoclonal IL-6 blocker, group 3 was administered a TNFα binding inhibitor, and group 4, a monoclonal IL-1β blocker. Moreover, histological, X-ray, biochemical, and immunological studies were equally performed.

RESULTS: We revealed the influence of monoclonal blockers of the biological action of proinflammatory cytokines on the processes of osteogenesis during the manifestation of aseptic necrosis of the femoral head. The most favorable outcomes of the course of aseptic necrosis of the femoral head in the form of greater preservation of the cartilaginous, bony structure were obtained in rats treated with a monoclonal blocker of the proinflammatory cytokine, IL-6.

CONCLUSIONS: Genetically engineered biological agents of receptor blockers of proinflammatory cytokines affect aseptic inflammation, especially during osteodestruction. Further studies of the properties of the IL-6 monoclonal blocker is a promising aspect in the study of its effect on bone metabolism disorders in osteolysis.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):171-182
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Сase report

Differentiated approach to the treatment of patients with consequences of multiple localization hematogenic osteomyelitis (Clinical observation)

Garkavenko Y.E., Belokrylov N.M.


BACKGROUND: Disseminated osteomyelitis in children leads to the demise of many joints. Osteolysis of the head and femoral neck leads to the complete degradation of the hip joint, while the possibilities of organ-preserving disorders are extremely rare. Damage to the epiphyseal zone during growth causes deformation and dysfunction of the joints of other segments, which requires staged treatment.

CLINICAL CASE: We presented the case of a patient with multiple consequences of epiphyseal osteomyelitis with pathological dislocation of the hips as a result of osteolysis of the heads and necks of the femur. Arthroplasty was performed successively at the age of 7 and 8 using demineralized bone and cartilage allografts according to the method stipulated by the Institute G.I. Turner with shortening osteotomies of the hips. At the age of 13, lengthening of the left femur was performed with correction of the axis of the affected segment of the lower limb.

DISCUSSION: Many authors refrain from or do not have the opportunity to use organ-preserving surgical aids, relying on early endoprosthetics for pathological dislocations. However, the lifespan of a joint and endoprosthesis makes it necessary to look for ways to extend the functional suitability of musculoskeletal system, especially during the growth phase of a child. In our opinion, the use of organ-preserving interventions at the level of the hip and other segments in children with the consequences of osteomyelitis is recommended. The possibility of elongation at the level of segments, where arthroplasty was performed was earlier with preservation of one’s own tissues. Correction of the axis and alignment of the length of the limbs can be effectively carried out on previously operated segments subject to certain technical features.

CONCLUSIONS: Bilateral arthroplasty of the proximal femur with demineralized cartilage allografts in osteomyelitis is a completely acceptable option for organ-preserving interventions. It is possible to effectively lengthen and correct the previously operated femur while maintaining good limb function. Ultimately, the expediency, the nature of surgical interventions, and the choice of a segment for correction in such patients are determined by the characteristics of the functional adaptation of the affected segment(s).

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):183-190
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Two-stage tendoplasty of the flexor digitorum profundus in a small child

Zolotov A.S., Mbeki J.A.


BACKGROUND: Injuries to the flexor tendons of the fingers are uncommon in young children, and chronic injury is an extremely rare injury. Many issues of damage diagnosis, surgical intervention and rehabilitation techniques remain unresolved. In this regard, the treatment of chronic damage to the flexor tendons of the fingers in young children has practical and theoretical significances.

CLINICAL CASE: A 16-month old underwent a two-stage treatment of chronic damage to the flexor tendons of the small finger. At the first stage, scars were removed from the fibro-synovial canal, and a silicone rod was inserted into the canal. At the second stage, the silicone spacer was replaced by a tendon autograft. The surgical treatment and postoperative management of the patient was described in detail. The full range (270 degrees) of active and passive motion was restored five months after the second stage of tendoplasty. Two years after the operation, good hand function.

DISCUSSION: The analyzed publications mainly present the results of treatment of patients older than 1 year and 4 months. Only in the study by S.L. Piper et al. (2019) the youngest patient at the time of injury was 7 months old, at the time of first stage of tendoplasty – 1 year and 3 months. The final volume of active motion was 160 degrees. In our case, the functional result was higher. Considering the undoubted rarity of damage uncharacteristic for this age, we intend to continue monitoring the patient.

CONCLUSIONS: Comprehensive long-term treatment of a serious injury to the hand, considering the anatomical and physiological characteristics of a small child, made it possible to obtain a good functional result.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):191-196
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Surgical treatment of a patient with erythromelalgia (Mitchell’s syndrome) using invasive spinal cord stimulation: A Clinical case

Toriya V.G., Vissarionov S.V., Savina M.V., Baindurashvili A.G.


BACKGROUND: Erythromelalgia is a rare hereditary disorder manifesting the basic triad of symptoms: erythro – redness, melos – limb, and algos – pain. It was first described by the American neurologist, S. Weir Mitchell in 1878. Clinical manifestations of the disease worsen the physical and psychological condition of the patient leading to reduced quality of life, increased morbidity and mortality. Currently, etiotropic therapy for erythromelalgia that demonstrates high efficacy in individuals with this pathology, has not been developed. Moreover, there is no consensus on treatment strategies for this category of patients, emphasized by the absence of clinical guidelines for the treatment of erythromelalgia. Treatment of patients with erythromelalgia is currently based on sequential pharmacotherapy in order to select the most effective therapy.

CLINICAL CASE: We presented the result of surgical treatment of erythromelalgia in a 15-year-old adolescent using invasive spinal cord stimulation.

DISCUSSION: Erythromelalgia remains an understudied condition with the lack of sufficient understanding of its etiology and pathogenesis. For the first time in Russia, a technique of invasive spinal cord stimulation was used in a pediatric patient with erythromelalgia, which resulted in a significant reduction of neuropathic pain, restoration of vasomotor regulation in the form of reduced edema and hyperemia.

CONCLUSIONS: In a patient with prolonged and pronounced refractory neuropathic pain caused by erythromelalgia, spinal cord stimulation was the only effective treatment technique alternative to symptomatic and drug therapy. Spinal cord stimulation should be considered as a method of treating neuropathic pain associated with pharmacoresistant forms of erythromelalgia.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(2):197-205
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