Vol 6, No 4 (2018)

Original papers
Clinical and radiological aspects of the sagittal balance of the spine in children with achondroplasia
Prudnikova O.G., Aranovich A.M.
Abstract

Background. Changes in the spine with achondroplasia are represented by disorders of synostosis, the presence of wedge-shaped vertebrae, underdevelopment of the sacrum, changes in the size of the roots of the arches, stenosis of the spinal canal, and changes in the sagittal balance.

Aim. To investigate the clinical and radiological features of the sagittal balance of the spine in children with achondroplasia.

Materials and methods. We performed a cross-sectional clinical and radiological study of 16 patients with achondroplasia aged 6–17 years (mean, 9.2 ± 3.3 years). Radiographically, the parameters of the sagittal balance of the spine and pelvis and scoliosis were evaluated. Clinical evaluation included orthopedic and neurological status and back pain syndrome.

Results. The anatomic features of patients with achondroplasia are limb shortening, O-shaped curvature of the lower extremities with lateral instability of the knee joints, and flexural contractures of the hip joints. With restriction of mobility in the hip joints, compensatory mechanisms for correcting sagittal imbalance are triggered: pelvic incline, lumbar lordosis, and thoracic kyphosis change. The clinical manifestations of sagittal imbalance in enrolled children were hypokyphosis of the thoracic spine in 100% and an increase in lumbar lordosis in 56.25% of patients. In 50% of patients, wedge-shaped deformation of vertebral bodies was diagnosed at the level of the thoracolumbar transition with the formation of local kyphosis. Neurological disorders have not been diagnosed in children.

Conclusions. The anatomical features of the lower limbs and hip joints in achondroplasia reflect the biomechanical features of the relationship between the spine, pelvis, and lower limbs, which should be considered when planning for orthopedic and spinal surgery after prediction.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):6-12
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Postural deficiency in children with spinal stenosis
Nikityuk I.E., Kononova E.L., Vissarionov S.V.
Abstract

Introduction. Stenosis of the spinal canal can be accompanied by abnormalities of gait and body balance. At the same time, changes occurring in the postural control in children with spinal stenosis remain unexplored.

Aim. To study postural stability in children with spinal stenosis and assess the imbalance of the body depending on the level of stenosis localization.

Material and methods. This study investigated 14 patients, aged 10–17 years, with stenosis of the spinal canal. The first group consisted of seven patients with spinal stenosis due to congenital deformity of the thoracic spine with spinal cord compression at the stenosis level. The second group consisted of seven patients with spondylolisthesis of the L5 vertebra body of grades 3–4, accompanied with spinal cord root compression. The control group consisted of seven healthy children of the same age. We used stabilometry, and statistical study included correlation-regression analysis.

Results. A significant deviation of the stabilometric parameters was noted only in the first group of patients (p < 0.05). In the same group, a strong correlation was found between the parameters of statokinesiogram: area S, length L, amplitude A, and mean power level of the spectrum of f 60%, which were much higher than those of healthy children, which may indicate a pathologically high synchronization of the vertical balance control system of the body. Other changes were revealed, such as a strong relationship between L/S and A at normal stabilometric parameters and a moderate force between L/A and f 60%, indicating postural deficiency in the group of patients with stenosis at the level of the lumbosacral spine.

Correlation-regression analysis for assessing the postural balance in both groups of patients showed a correlation between parameters L, S, A, and f 60%, which were significantly higher than those in healthy children and most pronounced in the thoracic localization of stenosis.

Conclusion. The system of maintaining vertical balance of the body in children with stenosis of the spinal canal at the level of the thoracic spine has a more pronounced deficiency than that in patients with stenosis of the canal at the lumbosacral level. To reveal hidden violations of the postural balance, the relationship between length, area, amplitude, and mean power of the statokinesiogram must be evaluated.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):13-19
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X-ray evaluation of surgical treatment of the feet by using subtalar implants in patients with cerebral palsy
Aleksandrov S.A., Syundyukov A.R., Yakovleva S.K.
Abstract

Introduction. Equino-plano-valgus deformity of the feet (EPvDS) in patients with cerebral palsy is one of the most common and functionally significant pathologies of the lower extremities, which leads to changes in the shape of the feet, decreased support, and disturbance of gait biomechanics. An important task is to determine the effective methods of treating this pathology (and their combinations) to correct or reduce the severity of these disorders. The evaluation of the radiological changes occurring with the foot is also important.

Aim. The paper assesses the changes in the main X-ray significant indicators of the foot by using rammed implants in the treatment of mobile EPvDS in children with cerebral palsy.

Materials of the study. The assesses of radiological results of treatment of 64 patients from 6 to 17 years with mobile EPvDS and cerebral palsy have been analyzed using subtalar implants.

The results of study showed that 94% of cases showed good and satisfactory indicators, whereas 6% of patients showed unsatisfactory results.

Conclusion. High efficiency was shown by using subtalar implants combined with tenodesis and transposition of the anterior tibial muscle tendon in the treatment of mobile EPvDS in children with cerebral palsy of early and middle childhood.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):20-26
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Treatment of deformities in patients with healed congenital pseudarthrosis of the tibia
Zakharjan E.A., Pozdeev A.P., Vilensky V.A.
Abstract

Background. Correction of deformities and lengthening of the lower extremities in patients with healed congenital pseudarthrosis of tibia (cCPT) is associated with certain characteristics, difficulties, and complications. But even the restoration of the anatomy and length of the tibia does not solve the problem of further recurrence of the deformity.

Aim. This study aimed to evaluate the results of the correction of deformities of the tibia in patients with congenital pseudarthrosis of the tibia after achieving union by using external fixation and guided growth.

Materials and methods. The results of treatment of 19 patients with cCPT, aged 4–15 years, which were observed in the Department of the Turner Scientific Research Institute from 2013 to 2018 years, were analyzed. We analyzed the types of deformities before the stage of correction deformities, evaluated the accuracy of the correction deformities after two-level osteotomies of the tibia, and used ortho-SUv passive computer navigation. External fixation index and number of complications were also determined. The type and number of recurrence of deformities and the timing of their detection were analyzed.

Results. On the basis of clinical classification, patients with cCPT had complex deformities of the affected lower limb. The accuracy of the correction of deformities was 84% at the end of the correction period. The amount of elongation was 4.5 ± 1.5 cm. The IEF was 64.3 ± 40.6 days/cm. After the end of the external fixation period, deformities recurred in 100% of cases. In 17 patients, temporary hemiepiphysiodesis of the tibial bones, the second stage, was performed. The accuracy of the correction was 100%. The period of correction ranged from 12 to 14 months.

Discussion. In the literature, we found no studies investigating the accuracy of the deformity correction, the choice of the level of osteotomies in patients with cCPT. Considering these data and the experience of the senior author of the publication, we performed two osteotomies of the tibia, outside the consolidation zone of the pseudarthrosis. High accuracy of the correction deformities was achieved in conjunction with the use of the ortho-SUv frame.

Conclusion. The analysis showed that the deformity relapsed in 100% of children as the child grows, regardless of the accuracy of the deformity correction in children after achieving union CPT. Hemiepiphysiodesis is an effective treatment for this complication.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):27-36
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Surgical treatment of lower lumbar spine pathology in children and adolescents
Krutko A.V., Sanginov A.J., Giers M.B., Alshevskaya A.А., Moskalev A.V.
Abstract

Introduction. Analysis of the modern literature shows that the number of children complaining of low back pain of varying intensity in the spine increases annually. Publications on the surgical treatment of juvenile osteochondrosis were scarce. Currently, there are no algorithms for choosing a surgical treatment for children and adolescents with lumbar spine pathology, particularly high-grade listhesis, methods and terms of surgical treatment, and the use of reduction maneuvers remain debatable. There are no high-quality evidence studies.

Aim. This study aimed to summarize the experience of treatment of children and adolescents with pathology of the lower lumbar spine.

Material and methods. We performed a retrospective analysis of the treatment outcomes in patients with lower lumbar spine pathology who were younger than 18 years and who underwent surgery in the Neurosurgical Department No. 2 of the Tsiv’yan Novosibirsk Research Institute of Traumatology and Orthopedics between 2008 and 2018. The mean age of the patients was 15.5 years. We structured pathologies and interventions in children and adolescents and evaluated the clinical and radiological outcomes of treatment and the rate of intraoperative and postoperative complications.

Results and discussion. From 2008 to 2018, 11,428 patients with degenerative spine disease and isthmic/dysplastic spondylolisthesis underwent surgery at the Neurosurgical Department No. 2. Of these, 55 (0.5%) patients were younger than 18 years. In all patients, surgical treatment led to pain relief and physical activity recovery. Decompression/stabilization surgery through the posterior approach enabled formation of an artificial block in 100% of cases. The rate of surgical treatment complications was 8.6% and 28.6% in children and adolescents with herniated lumbar intervertebral discs and spondylolisthesis, respectively.

Conclusion. Surgical treatment of children and adolescents with pathology of the lower lumbar spine demonstrated an excellent clinical outcome. Disc herniation did not recur 4.9 years after decompression surgery for herniated lumbar intervertebral discs. Decompression/stabilization surgery through the posterior approach in children and adolescents with spondylolisthesis facilitated abolition of pain, regression of neurological disorders, full recovery of physical activity, and formation of a reliable artificial block. Potential complications were resolved without consequences and did not downplay the importance of surgical techniques in the treatment of this group of patients.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):37-47
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Review
Damage associated with the use of baby walkers
Sharov A.N., Krivova A.V., Rodionova S.S., Zakharov V.P.
Abstract

This article presents an overview of 40 literary sources regarding injuries caused by baby walkers. The data from the first studies on the submitted subjects (1981) to the present were estimated for the first time in Russian scientific literature.

Significant variations in the structure and volume of injuries worldwide were shown. This may be caused by the difference in the living quarter structure, cultural features, errors in data collection, accuracy of data sources, and improvement of the devices. However, in our opinion, two factors have the greatest influence: the design and specific technical solution of such devices and the presence of stairs accessible to the child in a residential building.

In addition, the possibility of children acquiring thermal trauma in a walker was described, including the ability to reach dangerous items, such as heaters, ashtrays, electrical connections, and hot drinks, including poisons.

The danger of walkers as a factor influencing the normal formation of bipedal locomotion and motor pattern was indicated.

The authors underline the need to inform the public regarding the dangers of walkers as much as possible or to introduce a complete ban on their use, which was done in Canada in 2004 that led to a decrease in the level of child injuries.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):48-58
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Development of techniques for greater trochanter fragment fixation during surgical treatment of the dysplastic coxarthrosis
Voronkevich I.A., Parfeev D.G., Avdeev A.I.
Abstract

Isolated fractures of the greater trochanter based on the sources of specialized literature on the subject are extremely rare. However, methods for fixing the greater trochanter are actively developed in connection with the use of various versions of trochanteric osteotomies in the surgical treatment of the dysplastic hip joint.

In this article, the anatomical features of the proximal femur, development of the ideas of reattachment of the greater trochanter in the course of total hip arthroplasty, as well as the current state of the problem, were examined. Until recently, patches were used that were fixed to the thigh using the aid of wires for osteosynthesis of a large trochanter. In 2009, studies initially reported on the use of locking plates for osteosynthesis of the trochanter in total hip arthroplasty.

Currently, greater trochanter fixation by locking plates shows the best results as previous fixation devices. However, patients sometimes experience greater trochanter pain syndrome after fixation fragment by plates. The analysis of the published works confirmed the relevance of the search for a new more advanced technique and a device for the reattachment of the greater trochanter to the femur in the surgical treatment of the dysplastic hip joint.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):59-69
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Fractures of long tubular bones in newborns: mechanisms of injuries, methods of diagnosis, and treatment
Skryabin E.G., Akselrov M.A.
Abstract

Background. Medical information on the provision of emergency trauma care to newborns with fractures of tubular bones is scarce.

Aim. This scientific review aimed to inform children's orthopedic traumatologists regarding the main mechanisms of injury, methods of diagnosis, and treatment of fractures of long tubular bones in newborns.

Material and methods. The article presents a systematic analysis of 60 scientific works of domestic and foreign authors on topical aspects of fractures of long tubular bones in newborns from 1986 to 2018. For writing the literature review, we used modern electronic databases of medical information: PubMed, MEDLINE, Ulrich’s Periodicals Directory, DOAJ, Cyberleninka, and еLibrary.

Results and discussion. Similarly from the analysis of scientific publications, the main mechanism of fractures of limb segments in newborns is intranatal trauma, in which the child can receive both during birth through the birth canal and during cesarean section. The predisposing factors for obtaining bone fractures are intrauterine osteopenia, congenital diseases of the digestive system, and prematurity. Fractures are diagnosed on the basis of clinical examination and results of ultrasound and X-ray studies of the injured limb. In the treatment of limb bone fractures, both conservative and surgical methods are used. In recent years, a tendency has been clearly observed in scientific publications, highlighting the ever-widening introduction into clinical practice of operational methods for stabilizing fractures of long tubular bones in newborns, including using the techniques of transosseous osteosynthesis.

Conclusion. The presented article fills the existing gap of summarizing scientific publications on the treatment of fractures of limbs in newborns.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):70-76
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Levobupivacaine for regional blockades in orthopedics and traumatology in children: recent evidence and future directions
Ulrikh G.E., Zabolotskii D.V., Aleksandrovich Y.S., Koryachkin V.A., Nezabudkin S.N., Ulrikh D.G.
Abstract

Levobupivacaine is an amide anesthetic, levorotatory isomer of bupivacaine. This literature review aimed to present the possibilities of levobupivacaine in the implementation of blockades for anesthesia in traumatology and orthopedics in children. Levobupivacaine is widely used for analgesia for orthopedic interventions in adults and has become an alternative to the less safe bupivacaine. The actions of levobupivacaine, bupivacaine, and ropivacaine in the implementation of neuroaxial and peripheral blockades, and the infiltration of postoperative wounds in children were compared in the present study. Levobupivacaine has been confirmed to be safe compared with bupivacaine in pediatric patients. Studies in children of different ages comparing levobupivacaine and ropivacaine, used for anesthesia in traumatology and orthopedics, indicate the same or greater analgesic potential of levobupivacaine, with a similar level of safety. Compared with ropivacaine, levobupivacaine provides comparable pain relief at lower concentrations. The presented clinical data of levobupivacaine use in children allow the expansion of the indications for anesthesia in orthopedics and traumatology. Clinical research should be continued to compare the effectiveness of different concentrations of levobupivacaine and ropivacaine in larger groups of pediatric patients. Relevant papers were obtained by searching PubMed and Scopus databases.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):77-83
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Expert opinion
Assesment of commercially available children’s orthopedic footwear
Skirmont E.I., Zimina E.L., Golubeva J.B., Gorelova I.K., Volkova V.M., Karapetyan S.V.
Abstract

Background. The term “orthopedic shoes” becomes an advertisement through which manufacturers promote their products to the market. Parents face the problem of selecting shoes that ensures normal function and development of the child’s foot. In this regard, the situation must be understood.

The aim of the study is to identify the conformity of the footwear design and the parameters of special orthopedic parts to the requirements of the current regulatory and technical documentation for footwear for specific deformation as well as to obtain information regarding consumer information on the indications and contraindications of the designation of children’s shoes, set out in the leaflet regarding the use of shoes with special orthopedic parts.

Materials and methods. This study was based on the results of a study of 23 pairs of 155-size children’s shoes. The shoes were selected by random sampling from the assortment that is in retail sale. The research was performed by the staff of the Federal State Institution Federal Scientific Center for the Rehabilitation of the disabled named after G.A. Albrecht of the Ministry of Labor of Russia, which are the developers of the national standard (R 544072011 “Orthopedic footwear. General technical requirements”).

Results and discussion. The research data showed that virtually all footwear examined was manufactured in violation of the current regulatory and technical documentation. Shoes that go to free sale for selection under the guise of “orthopedic” shoes have a very attractive appearance (seen by the design and bright colors). However, such footwear does not provide the performance of medical purposes because special orthopedic parts have parameters that do not meet the requirements of national standards.

Thus, uncontrolled implementation of orthopedic footwear for selection is unacceptable. In this regard, children without pathology of the foot and musculoskeletal system should wear standard footwear without special details. Children in need of orthopedic footwear should wear shoes strictly according to the doctor’s prescription, considering the individual anatomical and functional features of the child’s foot.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):84-91
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Clinical cases
Werner mesomelic dysplasia
Kochenova E.A., Agranovich O.E., Trofimova S.I., Nikitina A.P.
Abstract

Introduction. The term “mesomelic dysplasia” refers to a group of disorders wherein limb shortening is most pronounced in the middle segment (forearm and leg) of the extremities. Werner mesomelic dysplasia is characterized by absence or hypoplasia of the tibia, preaxial polysyndactyly on the hands and feet, as well as by triphalangeal thumbs, absence of a patella, and fibular bone dislocation. Molecular genetic causes of the disease are mutations at position 404 of the regulatory element (ZRS) of the SHH gene in the LMBR1 gene (OMIM 188740).

Clinical case. A girl with triphalangeal thumbs and polydactyly of the hands, right hip dislocation, tibia hypoplasia, fibular dislocation on both sides, and preaxial polydactyly of the feet was examined and treated at the age of 1 year. Considering the clinical and radiological picture, the girl was diagnosed with Werner mesomelic dysplasia. To verify the disease, a molecular genetic examination of the child was performed. A variant of replacement of 230 T > C in the regulatory element of the ZRS of the SHH gene was discovered in the literature.

Discussion. Differential diagnosis can be made with Laurin-Sandrow syndrome, which is characterized by doubling of the ulna and fibula with the absence of the radius and tibia and preaxial polydactyly/syndactyly of the hands and feet. The presence of nasal defects (particularly involving the columella) distinguishes this condition from other syndromes, which was not shown in this clinical observation.

Conclusion. We report the clinical case of an autosomal-dominant disease, Werner mesomelic dysplasia, which is a rare pathology with a typical clinical picture combined with congenital hip dislocation, which was not previously described. The molecular genetic examination confirms the presence of a pathogenic variant of the ZRS element of the SHH gene, which causes the development of Werner’s mesomelic dysplasia, but the mutation variant was not registered before, which requires an additional examination of the child’s relatives.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):92-97
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Treatment of congenital clubfoot in a patient with Jacobsen syndrome using Ponseti method: A case report
Kruglov I.Y., Rumyantsev N.Y., Omarov G.G., Rumiantceva N.N.
Abstract

Introduction. Jacobsen syndrome, characterized by multiple developmental anomalies, is a rare genetic syndrome caused by a partial deletion of the long arm of the 11th chromosome. The incidence is 1 : 100,000 live births. Patients of this group have malformations of the heart, kidneys, gastrointestinal tract, central nervous system, and skeleton. The severity of clinical features is diverse. Jacobsen syndrome rarely combines with a congenital clubfoot.

Case report. The clinical case of using the Ponseti method for the treatment of congenital clubfoot in combination with Jacobsen syndrome is presented. As a result, a complete primary correction of the foot was obtained, which did not relapse within 2 years.

Discussion. Only brief references to this pathology were found in the literature. In the case of our patient, a greater number of gypsum dressings were required to complete the primary correction of the foot.

Conclusion. Painless foot has been achieved, which has a full range of motion, which confirms the success of the application of the Ponseti method for the treatment of non-idiopathic congenital clubfoot and the need for using it as a starting method.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):98-102
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The use of orthotics in a patient with congenital backbone deformation after surgical treatment
Murashko V.V., Kokushin D.N., Vissarionov S.V., Lein G.A., Pavlov I.V., Redchenko I.A.
Abstract

Introduction. New questions of indications and methods of surgical treatment of children with congenital spinal deformity are covered in detail. However, straightening deformed segment of the spine and fixing with metal construction is not sufficient, and conditions for its retention and prevention of migration must be created. The expediency of the study is relevant because of lack of systematic review of the results of orthotic support as complex treatment of this group of patients, both in Russia and abroad. The problems faced by vertebral surgeons are the following: the tendency of deformation relapse as the child grows, tendency of deformation of unfixed (lower and upper) segments of the vertebral column.

Clinical case. For observation, we selected an 11-year-old patient. The diagnosis was congenital scoliosis on posterolateral hemivertebra Th4, dysplastic course of congenital spinal deformity. The surgical treatment performed was extirpation of hemivertebra Th4(S) and the correction of local congenital deformity with multicore corrective system in combination with bone grafting. We achieved complete correction of congenital local curve at the level of the posterior lateral hemivertebra and reduction of compensatory curves in the thoracic and lumbar spine. In the postoperative period, the patient was provided with corrective brace, with the aim of influencing on the compensatory curve.

Discussion. This clinical observation aimed to determine the different approaches to treatment of children with congenital deformities of the thoracic spine, which consists of surgical correction of local congenital curvature curve with subsequent correction of compensatory curves by using a correcting brace.

Conclusion. As a result of the surgical intervention, correction of congenital spinal deformity was achieved, and the use of a corrective brace in the postoperative period allowed the correction of compensatory curves and maintained the achieved result until the end of the patient’s growth.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):103-109
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History pages
The 160th anniversary of Henry Turner
Baindurashvili A.G., Vysoschuk I.D., Ovechkina A.V., Zaletina A.V., Melchenko A.N., Solovyova K.S.
Abstract

The year 2018 in the medical community was marked by the 160th anniversary of the birth of Henry Ivanovich Turner. The phenomenal energy of this person, his organizational skills, talent as a scientist and public figure, dedication, and finally, his humanism are admired to this day and will serve as a model for the education of future doctors for a long time.

Happiness and at the same time hard work to be the first. Henry Ivanovich Turner had fully experienced this happiness and this work. He was the organizer and leader of the first Russia Department and Clinic of Orthopedics of the Military Medical Academy, the initiator of the first Society of Orthopedic Surgeons, and the founder and honorary director of the USSR’s first Institute for the Rehabilitation of Physically Disabled Children. Henry Turner was one of the first in Russia to raise questions of a disabled child, pointed out the need for a systematic struggle of the state with children’s disability, and urged to come to the aid of a crippled child, initially with orthopedic treatment performed in conjunction with the upbringing, education, and training of any profession.

The article presents the biography of the outstanding person, one of the founders of Russian orthopedics, Henry Ivanovich Turner.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):110-116
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