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Vol 10, No 4 (2022)

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Clinical studies

On the treatment of high unilateral congenital hip dislocation in older children: Minimizing the inequality of limb length

Kozhevnikov O.V., Kralina S.E., Kuznetsov A.S., Gribova I.V.


BACKGROUND: Treatment of high congenital hip dislocation in older children remains controversial in terms of the choice of the method of reducing the femoral head to the level of the acetabulum. In most cases, significant shortening of the hip is performed to eliminate dislocation, which leads to secondary deformities.

AIM: This study aimed to evaluate the results of treatment of high hip dislocation in older children, in which pre-reduction skeletal traction and economical shortening of the femoral segment are rationally combined to lower the femoral head.

MATERIALS AND METHODS: From 2011 to 2021, we observed 13 patients aged 5–13 years with grade 4 high unilateral congenital hip dislocation according to the international Tonnis classification.

RESULTS: The treatment results were traced for 1–9 years. When assessing hip joint function according to McKay criteria, excellent and good results were obtained in 84.6% of the patients. X-ray evaluation by Severin also included 84.6% in groups 1 and 2. Signs of avascular necrosis of the femoral head according to the criteria of Kalamchi and MacEwen were detected in four patients (group 1, n = 2; group 2, n = 1; group 3, n = 1). The difference in the length of the n/limbs in eight patients was 1.5 cm on average, and in the remaining children, a clinically insignificant asymmetry was observed in the length of the n/limbs, i.e., 0.5–0.7 cm.

CONCLUSIONS: The choice of the method of surgical correction of high hip dislocation largely depends on the age of the child. In children aged >5 years, with a significant displacement of the femoral head and limb shortening, a combination of reduction methods is rational, i.e., use of preoperative skeletal traction with economical shortening of the femoral segment, open reduction, and correction of the acetabulum. The optimal combination of the distraction method and surgical correction makes it possible to achieve successful reduction and a good functional result.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):351-364
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Evaluation of radiological indices of the spine and pelvis ratios in children with a severe form of slipped capital femoral epiphysis

Barsukov D.B., Bortulev P.I., Vissarionov S.V., Pozdnikin I.Y., Baskaeva T.V.


BACKGROUND: Slipped capital femoral epiphysis is one of the most severe diseases of the hip joint in children and is characterized by the displacement of the proximal femoral epiphysis, occurring as a result of a decrease in the mechanical strength of its growth plate. Some pathological processes in the hip joints and lumbosacral spine cause changes in the position (vergence) of the pelvis in the sagittal plane and the development of degenerative dystrophic diseases. The analysis of the spine–pelvis relationships in children with slipped capital femoral epiphysis may provide the basis for the development of new approaches to the surgical correction of the deformity of the hip component of the affected joint.

AIM: To assess the radiological parameters of the frontal and sagittal spine–pelvis relations in children with proximal femur deformity in slipped capital femoral epiphysis.

MATERIALS AND METHODS: The study included 30 patients (30 hips) aged 11–14 years with a severe form of slipped capital femoral epiphysis characterized by the presence of a posterior displacement of the epiphysis of >60° combined with the downward displacement of no more than 10° in one of the joints and absence of displacement (pre-slip stage) in the other. Patients underwent clinical and radiological examinations. The radiographs taken in the standing position were used to assess the values of thoracic kyphosis and lumbar lordosis, pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), sagittal vertical axis (SVA), and spine–sacral angle (SSA). The obtained data were subjected to statistical processing.

RESULTS: The patients had pelvic retroversion (decreased values of the PI and SS indices and increased PT index) and formed hypolordotic type of vertical posture according to P. Roussouly classification. In addition, thoracic hyperkyphosis occurred, and the SVA shifted to the front, which can be considered a mechanism of trunk balance compensation for the existing pelvic retroversion and reduction of lumbar lordosis to maintain the ability to move in an upright position.

CONCLUSIONS: Children with this severe form of slipped capital femoral epiphysis are characterized by pelvic retroversion, decreased lumbar lordosis and increased thoracic kyphosis, positive trunk imbalance, and PT toward the affected limb. Planning and reconstructive restorative interventions on the affected hip joint should consider existing pathological changes to restore the correct spine–pelvis relationships and prevent degenerative dystrophic processes in the lumbosacral spine.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):365-374
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Free flaps to replace extensive and deep limb defects in children

Grankin D.Y., Golyana S.I., Avdeychik N.V., Safonov A.V., Tikhonenko T.I., Galkina N.S., Zakharyan E.A., Afonichev K.A., Arakelian A.I.


BACKGROUND: Extensive and deep limb defects remain a difficult problem of reconstructive surgery in children. Free microsurgical flaps are used to resolve this problem. Free flaps can be complex in composition and include muscles and bone parts, which allow replacing large and multicomponent limb defects. The technique is used in patients with posttraumatic deformities, burns, acquired limb deformities, and congenital deformities of the extremities.

AIM: To retrospectively analyze free flaps in children for the replacement of limb defects.

MATERIALS AND METHODS: This single-center retrospective study analyzed 120 cases of microsurgical autotransplantation of free flaps to replace defects of the upper and lower extremities in children. The patients were children aged 1–17 years who had injuries and burns, acquired limb deformities, and congenital limb deformities.

RESULTS: The average age of the patients was 9.5 years, and 72% of the patients were boys. Moreover, 95% of the children had posttraumatic deformities, burns, and acquired pathologies. Free latissimus dorsi flaps were used in 70% of the patients. The recipient area was the upper limb in 53% of the cases. The survival rate of free flaps was 96%. The general surgical complications were inflammation, pneumothorax, deformities, and specific vascular thrombosis.

CONCLUSIONS: Replacement of extensive limb defects with free flaps remains a practical method in children.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):375-384
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Speech development in children with sequelae of obstetrics palsy

Agranovich O.E., Agranovich Z.E., Ermolovich E.I., Petrova E.V., Blagovechtchenski E.D.


BACKGROUND: Obstetrics plexus occurs in 0.4–4 cases per 1000 newborns. Moreover, 70%–92% of the patients have mild injuries that spontaneously recover within 2 months after delivery, and the remaining patients have secondary deformities of the limbs, leading to motor disorders of varying severities. Studies have reported that the limited or absence of hand motor functions can lead to cognitive deficits and speech underdevelopment.

AIM: To study the features of speech development in children with obstetrics palsy.

MATERIAL AND METHODS: From 2020 to 2021, we performed speech examination of 33 children with obstetrics palsy from the age of 3–15 (average age, 8.10 ± 3.71) years. All patients were divided into four groups: group 1 (3–4 years, n = 6), group 2 (5–6 years, n = 10), group 3 (7–10 years, n = 9), and group 4 (11–15 years, n = 8). Speech examination and orthopedic, neurological, and statistical tests were performed. The results of the examination were analyzed statistically.

RESULTS: In this study, 78.8% of the patients with obstetric palsy had speech pathology. Children with speech disorders had more severe neurology and motor disturbance than children without speech pathology. In group 1, speech disorders were identified in 66.7%; group 2, 90.0%; group 3, 66.7%; group 4, 87.5%. Group 1 had speech development delay and phonetic–phonemic underdevelopment. Group 2 had general speech underdevelopment and phonetic–phonemic underdevelopment. Group 3 had general speech, lexical–grammatical, and phonetic–phonemic underdevelopment, Group 4 had general speech and lexical–grammatical underdevelopment. Moreover, 73.1% of the children had minimal dysarthria (predominantly in children of groups 1 and 2). Groups 3 and 4 had written expression disorder.

CONCLUSIONS: The study demonstrates a high incidence of speech disorders in children with obstetrics palsy. These children demand early speech examination and timely correction of existing disorders.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):385-396
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Psychological analysis of the life situation of adolescents with orthopedic diseases

Pyatakova G.V., Okoneshnikova O.V., Vissarionov S.V.


BACKGROUND: The situational approach is a promising direction in the study of the determinants of mental development and behaviors in modern psychological research. This study considered the possibility of using a situational approach in the study of psychological problems of children and adolescents with orthopedic diseases and discussed the objective and subjective characteristics of the life situation associated with orthopedic diseases and surgical treatment.

AIM: The study aimed to examine the peculiarities of life situations in adolescents with various orthopedic diseases.

MATERIALS AND METHODS: The study involved adolescents aged 12–17 years diagnosed with idiopathic scoliosis (n = 54) and juvenile chronic arthritis (n = 44) and healthy adolescents (n = 43). Clinical–psychological and psychodiagnostic methods were used. Mathematical and statistical data processing was carried out.

RESULTS: The life situation of adolescents with idiopathic scoliosis and juvenile chronic arthritis was characterized by events that cause traumatic experiences. Objective factors of the life situation and traumatic life events presented in the mental picture of the disease of adolescents agree with the pronounced emotional problems of patients with orthopedic diseases. Compared with healthy adolescents, adolescents with orthopedic diseases had higher general index of PTS, which indicates a pronounced subjective difficulty of the life situation of adolescents with orthopedic diseases. The results are confirmed by the severity of the subjective negative emotional reactions to certain characteristics of the disease. The objective and subjective characteristics of the life situation of adolescents with idiopathic scoliosis and juvenile chronic arthritis may determine the degree of difficulty and the degree of risk in the occurrence of emotional trauma for illness, hospitalization, and treatment.

CONCLUSIONS: Understanding the life difficulties of adolescents with orthopedic diseases can improve the prediction of behavioral problems and adaptation opportunities in hospital settings and provide timely psychological assistance to adolescents with severe orthopedic diseases, taking into account situational variables.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):397-406
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Experimental and theoretical research

Biocompatibility of an interspinous implant made of titanium alloys

Orlov V.P., Nashchekina Y.A., Nashchekin A.V., Ozeryanskaya O.N., Mirzametov S.D., Svistov D.V.


BACKGROUND: At present, metal implants are widely used in neuro-orthopedics, of which titanium alloys are of particular interest. A team of authors developed an original combined implant for posterior spinal fusion as an import substitution, which can be used from one-way access during minimally invasive operations on the lumbar spine. The implant was manufactured at the Endocarbon Enterprise in Penza. For better osseointegration, it is made of VT6 alloy and titanium nickelide. The middle part of the implant is laser-treated to create an uneven surface in the hope of better integration in the tissues of the body. This study was conducted to assess the cytotoxicity and biocompatibility of this implant for its further application in clinical practice.

AIM: To determine the cytotoxicity of an interspinous implant made of titanium alloys for its further introduction into spinal surgery.

MATERIALS AND METHODS: To determine the cytotoxicity of titanium samples of interspinous implants, a methyltetrazolium test was conducted to assess the viability of stromal cells in the presence of a nutrient medium after incubation with the test material. The biocompatibility of the material was analyzed using scanning electron microscopy of samples 1 and 7 days after cell culture.

RESULTS: The viability of cells cultured in the presence of a nutrient medium after incubation with samples of titanium VT6 was 105% and that of titanium nickelide was 98%, which were comparable to the viability of cells in a standard nutrient medium. With electron microscopy, after 1 day of cultivation, cells form a monolayer on a titanium surface, all cells were well spread out and formed intercellular contacts, and after 7 days of cultivation, the number of cells increased and they formed a dense monolayer.

CONCLUSIONS: The interspinous implant, which includes alloys of titanium VT6 and titanium nickelide, is biocompatible with cultured cells and can be introduced into spinal surgery.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):407-415
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Exchange of experience

Hip arthroplasty using the cartilaginous part of the greater trochanter in the treatment of the sequelae of epiphysal osteomyelitis in children

Belokrylov N.M., Polyakova N.V., Belokrylov A.N., Antonov D.V., Zhuzhgov E.A.


BACKGROUND: Alternative methods of hip arthroplasty as a result of the complete destruction of the epiphysis and femoral neck using the preserved part of the apophysis of this segment are not widely reported, which may be useful for specialists who are faced with the choice of providing such assistance.

AIM: To present the long-term results of treating children with the hip joint reconstruction method developed in the clinic using trochanteric arthroplasty by utilizing the intact cartilaginous part of the greater trochanter apophysis for the treatment of defects resulting from osteolysis of the femoral head and neck after epiphyseal osteomyelitis.

MATERIALS AND METHODS: The results of the surgical treatment of seven children (two of them had a bilateral process) who underwent reconstruction of nine hip joints according to the proposed method were analyzed. The procedures were performed at the age of 2–10 years. The intervention involved the surgical preparation of the acetabulum with repositioning of the greater trochanter after proximal angulation osteotomy of the hip at the metadiaphyseal level. In four patients with a unilateral process, Salter innominate osteotomy was additionally performed in one or two stages. In five patients with a unilateral process with further growth, limb lengthening was performed. The efficiency index was evaluated using both anatomical and functional results. In a bilateral process, the assessment considered the function of the worst operated joints.

RESULTS: In six children, good and, in one child with a bilateral process, satisfactory long-term clinical and functional results were obtained (assessed 10–20 years after the first reconstructive surgery). All of them had restored limb support without pain, with a sufficient range of motion. The method was organ-preserving, which enabled an opportunity for walking, and an anatomically favorable situation for further arthroplasty has been created, the timing of which has been postponed to a mature period.

CONCLUSIONS: The method developed in the clinic for the surgical use of the greater trochanter for the reconstruction of the hip joint after infectious osteolysis of the head and neck of the femur is effective, allowing for a long time to maintain leg support using the patient’s tissues.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):417-427
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Reconstructive surgery in the treatment of congenital pseudarthrosis of the tibia in children using microsurgical techniques: Reconstruction or amputation?

Zakharyan E.A., Chigvariya N.G., Garkavenko Y.E., Pozdeev A.P., Grankin D.Y., Afonichev K.A.


BACKGROUND: Numerous methods are available for the treatment of congenital pseudarthrosis of the tibia, but none of them offers a 100% satisfactory result and does not exclude the development of repeated refractories. One of the treatment methods is vascularized transplantation of a fragment of the fibula into the position of the defect of the tibia. However, the achievement of consolidation of the bone fragments of the lower leg does not stop the series of interventions necessary to restore the function of the affected segment. Therefore, specialists were asked about the advisability of performing amputations as an alternative to long-term and multistage interventions.

AIM: To analyze the results of the use of microsurgical techniques for the treatment of patients with congenital pseudarthrosis of the tibia and, using the example of a patient, to show the way of multistage reconstruction of the lower limb.

MATERIALS AND METHODS: The results of the use of microsurgical techniques in the elimination of a defect in the bones of the leg in five patients with congenital pseudarthrosis of the tibia were analyzed. Age, sex, presence of type 1 neurofibromatosis, bone defect size, autograft size, duration of consolidation, osteosynthesis index, refractory, range of joint motion, and secondary deformities of the segments after consolidation were assessed. The course of the patient when performing severe reconstructive interventions to restore the weight-bearing capacity of the limb was described. Vascularized autograft transplantation was performed by a qualified microsurgical team.

RESULTS: The mean age was 7.8 ± 2.2 years. Boys predominated, and type 1 neurofibromatosis was detected in 60% of the cases. The average defect size was 8.8 ± 1.6 cm, and the autograft size was 10.8 ± 1.6 cm. The duration of fixation was 260 ± 90 days, and the fixation index was 24.6 ± 10.6 days/cm. In two cases, 1 year after the fibula transfer, refractories were noted at the bone–graft interface. In 100% of the cases, patients had fibrous ankylosis at the level of the ankle joint, with a loss of functional range of motion, and in 40% of cases, there were flexion–extension contractures of the knee joints with an extension deficit of up to 20°. For this observation period, 3 of 5 patients underwent additional surgical interventions to correct the deformities of the affected limb.

CONCLUSIONS: The use of VFT in patients with congenital pseudarthrosis of the tibia allows restoring the integrity of the tibia. Multiple interventions performed on the same segment can lead to irreversible secondary changes in adjacent joints and loss of function of this limb.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):429-439
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Сase report

Use the Orto-SUV frame in children with congenital radial clubhand: A clinical case

Avdeychik N.V., Zakharyan E.A., Grankin D.Y., Safonov A.V.


BACKGROUND: The shortening of the forearm in children with congenital radial clubhand and multi-plane deformity of the ulna is challenging to treat by surgery. The literature shows single studies using the Ortho-SUV frame for the correction of forearm deformity in multiple exostosis chondrodysplasia and patients with posttraumatic deformities.

CLINICAL CASE: A 17-year-old patient with congenital radial clubhand who had a relapse of hand deviation undergo correction of forearm deformity. The elimination of radial hand deviation and ulnar deformity correction in the distal part with subsequent elongation were performed.

DISCUSSION: No data on the use of the Ortho-SUV frame for the correction of ulnar multiplanar deformity in radial clubhand are available. Indicators, i.e., fixation index, osteosynthesis index, lengthening, and complications, were compared with the indicators used for ulnar elongation with a small angle of radial deviation of the hand.

CONCLUSIONS: Personalized plan of forearm deformity correction based on the anatomical features of the congenital radial clubhand and X-ray indicators allowed achieving good cosmetic and functional results.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):441-448
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Multistage surgical treatment of early-onset scoliosis in patients with Ehlers-Danlos syndrome: A series of observations

Mikhaylovskiy M.V., Suzdalov V.A.


BACKGROUND: Ehlers–Danlos syndrome (EDS) is a group of hereditary pathological conditions caused by various disorders of collagen biosynthesis. The study analyzed the results of multistage surgical treatment of early scoliosis in patients with severe spinal deformities due to EDS. No similar observations have been found in the literature.

CLINICAL CASES: Four patients with a verified diagnosis of EDS and progressive spinal deformities were subjected to multistage surgical treatment using the VEPTRII instrumentation, which included periodic distractions and “final” spinal fusion with segmental instrumentation. Stage-by-stage surgical treatment was initiated from the age of 3 to 6 years. In 3 of 4 cases, the kyphotic component prevailed over the scoliotic one (86°–140° vs. 21°–110°). The number of staged distractions ranged from 6 to 10. The age of the final stage (correction and dorsal fusion) was 9–14 years (surgery was performed in three of four cases). The primary correction was 30°–56°, the loss of correction before the final stage was 14°–35°, and the correction during the final stage was 22°–40°. A significant correction of the frontal and sagittal imbalances of the spine was noted. Blood loss during the “final” fusion was 540–750 mL, and the operation time was 310–350 min. Ten complications occurred, of which 9 were associated with implants and disappeared during staged distractions. No neurological and vascular complications occurred.

DISCUSSION: Scoliosis occurring in the first decade of life in patients with EDS is characterized by early-onset, rapid progression, and tendency to form a significant kyphotic component of spinal deformity.

CONCLUSIONS: Multistage treatment of early scoliosis in patients with EDS using VEPTRII tools allows for obtaining quite satisfactory results and has not severe complications. The “final” fusion gives a significant corrective effect; however, new research and accumulation of data are needed to optimize the treatment process.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):449-457
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Sacral neuromodulation in pediatric bladder and bowel dysfunctions: Literature review

Khodorovskaya A.M., Novikov V.A., Zvozil A.V., Umnov V.V., Umnov D.V., Zharkov D.S., Vissarionov S.V.


BACKGROUND: Sacral neuromodulation is a neurosurgical method for the correction of bladder and bowel dysfunctions of various origins that are refractory to conservative treatment.

AIM: To analyze chronic sacral neurostimulation results as a correction method for pediatric bladder and bowel dysfunction of various origins.

MATERIALS AND METHODS: The results of chronic sacral neurostimulation for treating urination and defecation disorders of various origins in children reported in the world literature were analyzed. The literature search was performed in the open electronic scientific databases eLIBRARY, PubMed, and Cochrane Library. The source selection was limited by 2002–2022.

RESULTS: Most authors report good and satisfactory results in the treatment of bladder and bowel dysfunction by sacral neurostimulation. However, the level of evidence on the effectiveness of sacral neurostimulation remains low because data were obtained from small and heterogeneous groups of patients and studies employed different criteria for inclusion and methods for analyzing the results.

CONCLUSIONS: Conducting randomized trials will allow for the assessment of the efficacy and safety of sacral neuromodulation in children with bladder and bowel dysfunctions of various origins that are refractory to standard conservative treatment.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):459-470
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Surgical treatment of children with asymmetric pectus excavatum: Literature review

Dolgiev B.H., Ryzhikov D.V., Vissarionov S.V.


BACKGROUND: The surgical treatment of children with pectus excavatum is regarded as an urgent problem still demanding solution despite the multitudes of surgical correction methods available nowadays. The currently available well-known techniques cannot be considered perfect because they are not proper enough for solving all the tasks, not to mention the problem of asymmetric forms of pectus excavatum treatment.

AIM: To analyze publications containing information on the methods of surgical treatment used for children with pectus excavatum.

MATERIALS AND METHODS: The study presents the results of literature review on the methods of surgical correction of pectus excavatum. Information was retrieved in PubMed, Google Scholar, and eLibrary scientific databases using keywords. Consequently, 63 foreign and domestic scientific sources over the period from 1609 to 2022 were identified. Among them, 29 publications refer to the latest decade.

RESULTS: Given the variety of methods used for chest deformity correction, thoracoplasty by D. Nuss has become the “gold standard” for the treatment of pectus excavatum. However, according to the search results, it is impossible to name one universal method of surgical intervention that could solve all the urgent problems at present. Modern surgery methods used for pectus excavatum correction can be considered only as modifications of treatment methods having been used before.

CONCLUSIONS: The shortcomings of modern thoracoplasty determine the necessity to keep searching for new techniques and improve those available at present. Besides, the standard suitable for both surgeons and patients should be elaborated.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):471-479
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Historical Article

Classifications of congenital hand deformities: View through the prism of time

Oppedisano M.L., Artyukh L.Y., Karelina N.R.


This medico-historical analysis focused on the formation of present classifications of congenital hand deformities. Its implementation became possible thanks to the study of 163 literary sources, the search of which was carried out in the scientometric databases of Scopus, PubMed, Google Scholar, and Web of Science. The depth of the exploration has exceeded 180 years (from 1829 to 2017). Those dates make obvious that the initial steps in the systematization of regarded vices were taken in 18th–19th centuries. Publications at that time became the foundation that pushed many scientists to develop the wide range of descriptive classifications. The complexity of their practical use required the creation of fundamentally different concepts of dividing anomalies. It became possible due to the discovery of the embryogenesis of the hand. The result of long-term studies was the acceptance of the actual method of the systematization of upper limb defects by IFSSH in 2014. The comprehension of stages, preceding its formation, is quite important for the medical community and facilitates the assessment of individual patients’ features.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2022;10(4):481-490
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