Vol 11, No 3 (2023)

Ten years ago, the first issue of the journal Pediatric Traumatology, Orthopaedics and Reconstructive Surgery was published in September 2013. During this time, the journal has become a worthy scientific edition and earned popularity and authority among scientists in Russia and the world. We express our gratitude to all members of the editorial board, authors, and readers! We congratulate the journal on its anniversary and wish further development and new achievements!

September 29, 2023, is a significant date for Russian medicine. It is 165 years since the birth of an outstanding physician and an honored scientist of the RSFSR, Professor Henry Ivanovich Turner.

A person of high culture and a talented organizer, Professor Turner is widely known in Russia and abroad as a prominent scientist, a unique orthopedic specialist, and a brilliant public figure. His name rightfully stands among great scientists in Russian surgery and orthopedics.

Henry Turner organized and became the head of the first Russian department and clinic of orthopedics in the Military Medical Academy and initiated the foundation of the first Society of Orthopedic Surgeons in the country. He was the first in St. Petersburg to promote “first aid” and physical training for the military. Despite the abundance of his scientific and clinical achievements, he mainly focused on the struggles for the fate of children with musculoskeletal disorders.

BACKGROUND: Flexion–distraction injuries of the spine result from high-energy trauma (traffic accidents and falls from a height). This type of injury is commonly found in the thoracolumbar junction. Among combined injuries in the presence of flexion–distraction fractures of the vertebral column, injuries of the chest or abdominal organs are often observed, which are crucial for patient survival, and their diagnostic measure is complex because of the severe and unstable conditions of the patients.

AIM: To analyze a cohort of pediatric patients who underwent surgery for flexion–distraction injury of the spine.

MATERIALS AND METHODS: We analyzed the data of clinical and instrumental studies and surgical outcomes of 28 pediatric patients (aged 2–17 years) with flexion–distraction injuries of the spine. The standard preoperative examination included clinical and laboratory studies, spondylography, multislice spiral computed tomography and magnetic resonance imaging of the damaged area, electrocardiography, and ultrasonography of the abdominal organs and kidneys. All patients underwent surgery for the correction and stabilization of traumatic spinal deformity with a multisupport metal structure and posterior local fusion. The analysis included an assessment of the mechanism of injury, concomitant injuries, time elapsed after the injury before admission to the hospital, level of the damaged segment, and treatment. Data were processed statistically using an online calculator. The nonparametric Mann–Whitney method was used.

RESULTS: Catatrauma was the leading cause of injury in 50% of the patients, compared with traffic accidents in 36%. In 80% of the patients, spinal injury was localized at the thoracolumbar junction and lumbar spine. Moreover, 71% of the patients were transferred to the National Research Center for Children’s Orthopedics and Trauma Surgery for surgical treatment on the spine in the early stages after injury (up to 7 days), and 8 children (19%) were admitted within 10–45 days (average 16 days). In 19 (68%) patients, in addition to spinal injury, concomitant injuries occurred, with skeletal trauma and injuries of the abdominal cavity organs as the most frequent. All patients achieved complete correction of the deformity at the level of the damaged segment.

CONCLUSIONS: Flexion–distraction fractures of the spine in children are characterized by a high incidence of concomitant injuries, which dictates the need for a full examination to identify them and correctly interpret the data. The elimination of mechanical instability in the early stages in this type of injury can reduce the extent of fixation and contribute to the restoration of the physiological profile and disk apparatus of the spinal column.

BACKGROUND: The choice of techniques for the treatment of children with congenital spinal deformities remains one of the most significant problems of spinal surgery. This topic is relevant given the peculiarities of the disease course, severity and rigidity of deformities, their steady and rapid progression, formation of compensatory curvature, and a significant decrease in the quality and life expectancy of patients.

AIM: To compare screw misposition, adverse outcomes, intraoperative blood loss, and time required for pedicle screw placement with further deformity correction under computed tomography (CT) guidance with intraoperative navigation versus fluoroscopy.

MATERIALS AND METHODS: This single-center, prospective comparative study was conducted from 2019 to 2022 at the National Scientific Center of Traumatology and Orthopedics named after academician N.D. Batpenov. Patient demographics and surgical outcomes were obtained from the medical records. All patients underwent a comprehensive clinical and radiological examination before surgery, after surgery, and at the stages of dynamic observation. Data of patients with congenital malformations of the spine were analyzed. The study involved 42 patients aged 3–18 years with congenital kyphoscoliosis of the thoracic and/or lumbar spine. The patients were divided into two groups according to the method of surgical correction used: the O-arm navigation group and the C-arm group.

RESULTS: Data of patients who underwent surgery for congenital scoliosis of the spine were analyzed. The patients were divided into the O-arm navigation group, which included patients who underwent surgery using the O-arm mobile intraoperative CT with the seventh-generation Stealth Station navigation system in combination with intraoperative neuromonitoring, and the C-arm group, which included patients who underwent surgery under the control of the intraoperative C-arm. In both groups, 364 screws were placed, of which 189 screws were placed under neuronavigation, and 175 screws were placed using the C-arm. The effectiveness of the intraoperative neuronavigation system in combination with neuromonitoring showed 97.11% correct placement (grades A and B) of pedicle screws. The use of an intraoperative C-arm showed 89.63% (grades A and B) correctness. The proportion of misplaced screws corresponding to Gertzbein–Robbins classes C–E was higher in the C-arm group (10.37%) than in the navigation group (1.49%) (p ≤ 0.005). No severe neurological disorders, postoperative infection, or adverse clinical outcomes were observed in both groups.

CONCLUSIONS: The installation of pedicle screws using CT-guided navigation (O-arm) did not prolong the operation time, did not increase blood loss, and reduced the risk of screw mispositioning compared with freehand and fluoroscopy pedicle screw placement.

BACKGROUND: A combination of movement disorders with contractures in the joints is a feature of upper limb lesions in patients with spastic forms of cerebral palsy. As part of the “spastic hand” syndrome, contractures are differentiated into primary and secondary. Primary contractures are caused by muscle spasticity, whereas secondary contractures are caused by the structural shortening of the muscle motor segment in relation to the bone, which can subsequently lead to deformities of articular surfaces. In theory, the use of diagnostic blockade as a mandatory procedure in patient examination before selective neurotomy of the peripheral nerves on the upper limb makes it possible to optimize the result of tone-lowering treatment because of the accurate selection and exact category of patients in whom neurosurgical treatment can be effective.

AIM: To assess the prognostic effectiveness of diagnostic blockade for modeling the result of selective neurotomy of the motor branches of the musculocutaneous nerve in patients with cerebral palsy.

MATERIALS AND METHODS: This longitudinal prospective study included an examination of 31 patients aged 5–17 years with spastic forms of cerebral palsy. Before neurosurgical treatment, each patient underwent a diagnostic blockade of the n. musculocutaneus under ultrasonography and neurostimulation. Before and after the diagnostic blockade and after the neurosurgical treatment, each patient was examined for the amplitude of passive and active joint movements, muscle tone, hand functionality, and dynamometry.

RESULTS: Results of the data analysis showed a significant relationship between the state of the elbow joint during the simulation of surgical treatment and after neurosurgical treatment.

CONCLUSIONS: The study showed the high prognostic effectiveness of diagnostic blockades when deciding on the techniques of treating tonic flexion contractures of the elbow joint as part of the “spastic arm” syndrome. The diagnostic blockade of the musculocutaneous nerve during the planning of surgical treatment makes it possible to create a reliable temporal model of selective neurotomy of the motor nerve branches.

BACKGROUND: The clavicle in children is a site of multiple types of injuries, post traumatic pathology being predominant, and generally presents no diagnosis problems; in contrast non-traumatic lesions of the clavicle are rare and may pose a diagnostic and therapeutic problems for the orthopaedic surgeon.

AIM: The objective is to show that the clavicle in children can be a site of infectious, congenital and tumor lesions involving the functional and vital prognosis of the child.

MATERIALS AND METHODS: A retrospective study including 9 patients over an 9 year period from January 2013 to January 2022 was conducted. 4 boys and 5 girls were admitted in our institute with a mean age of 11.2 years (range 6–16 years). The right clavicle was affected in 8 patients, with no bilateral lesions.

RESULTS: There was a predominance of tumor lesions (4 benign and one malignant). Two patients had a clavicular osteomyelitis. The diagnosis of congenital pseudarthrosis of the clavicle was noted in the other two patients.

CONCLUSIONS: The aetiologies are variable, biopsy remains the key to establish the diagnosis in the majority of cases. Treatment varies according to the type of disease and may include symptomatic, expectant management, drugs therapy or surgical treatment.

BACKGROUND: The most rare and extremely rare malformation of the upper limb is polymelia, i.e., doubling (triple) limb. In the literature, no more than 20 cases of an increase in the number of lower limbs and only three cases of doubling (triple) of the upper limb (in humans) have been described.

CLINICAL CASE: A 2-year-old child diagnosed with polymelia of the right upper limb was examined and treated at our clinic. Clinical examination revealed two shoulder blades and one clavicle, with a normal anatomical location and development. Behind, an upper limb ended with the stump of the forearm, represented by an underdeveloped ulna. Moreover, the elbow joint was in a state of flexion contracture at an angle of 170°, and the ulna was turned posteriorly and 15°–20° medially. The “anterior” humerus in the proximal section was underdeveloped, and in the distal section, it articulated in a normally formed elbow joint with the radius and ulna. The hand had five fingers with moderate underdevelopment and deformity of the 5th finger. After examining the bone, muscle, and vascular anatomy of the doubled limb, surgery was performed; as a result, a nearly complete anatomical and functional limb was reconstructed from the two segments of one upper limb.

DISCUSSION: Polymelia is an extremely rare variant of a congenital anomaly of the limbs; thus, only a few cases are reported in the literature, which differs significantly from each other in clinical manifestations. Many questions related to the etiology and pathogenesis of these malformations are unexplored. The doubling of the limbs in animals is caused by both teratogenic environmental factors and genetic mutations. In any case, reconstructive surgery makes it possible to effectively treat children with such anomalies in the development of the limbs and obtain good results.

CONCLUSIONS: The restoration of the upper limb of children with polymelia is quite difficult, but doable. Adequate analysis of all examination data and rational planning of surgical intervention in such cases creates conditions that enable achieving the maximum anatomical and functional results of upper limb reconstruction in children with this developmental anomaly.

BACKGROUND: A spinal cord injury can lead to paralysis of the respiratory muscles, resulting in a significant reduction in breathing ability. People with a spinal cord injury face an increased risk of developing various respiratory complications. To date, existing effective technologies positively affect the long-term recovery of respiratory function and create conditions for neuroplasticity in the injured spinal cord. The high relevance and lack of systematization of these techniques in the world literature served as the basis for describing a topical approach in electrostimulation for the correction of respiratory disorders in patients with traumatic spinal cord injuries.

AIM: To formulate an algorithm for topical electrostimulation of the spinal cord and respiratory muscles to correct respiratory dysfunction in patients with spinal cord injury based on the latest scientific literature.

MATERIALS AND METHODS: This article presents the results of the analysis of peer-reviewed articles that investigated the effects of various electrostimulation techniques on respiratory function in patients with spinal cord injury. Searches were performed on ScienceDirect, Google Scholar, and PubMed for the period from 2000 to 2022.

RESULTS: A spinal cord and muscle electrostimulation algorithm was formulated to personalize the treatment approach for patients with spinal cord injury depending on the level and period of traumatic spinal cord injury.

CONCLUSIONS: Electrostimulation techniques were found to be effective in the treatment of spinal cord injuries, particularly for the correction of respiratory disorders. The choice of the appropriate neurostimulation technique depends on the severity, injury level, and period of injury. Noninvasive techniques, such as FES and TSSM, can be used from the acute period to the chronic period, whereas invasive techniques, such as epidural stimulation and respiratory pacemaker placement, are appropriate in the chronic period. Despite the positive results of these techniques, further research is needed to develop effective treatment plans and improve their effectiveness and long-term outcomes.

BACKGROUND: Aseptic necrosis of the femoral head in children remains a subject of great interest among specialists, despite its long history of study. The Legg–Calvé–Perthes disease is the most common form of aseptic necrosis of the femoral head in children. The necrotic lesion in the femoral head results from the blockage of the arterial blood supply to the epiphysis, leading to its infarction. Some children experience a more aggressive disease course, with signs of osteoarthritis, which can result in the early development of coxarthrosis. Numerous publications have demonstrated the successful use of bisphosphonates in adult patients with aseptic necrosis of the femoral head.

AIM: To generalize data on the use of bisphosphonates in children with the Legg–Calvé–Perthes disease presenting with signs of osteoarthritis through the analysis of contemporary global literature.

MATERIALS AND METHODS: A literature search was conducted in the open databases of PubMed, Science Direct, and Google Scholar, and the analysis depth spanned 20 years. The search terms used included “Legg–Calvé–Perthes disease,” “aseptic (avascular) necrosis of the femoral head,” and “bisphosphonates.” The review encompassed the literature on bisphosphonates, their biological action, effectiveness of their use in patients with aseptic necrosis of the femoral head, and results of our research.

RESULTS: Studies on the efficacy of bisphosphonates in children with Legg–Calvé–Perthes disease are limited. Currently, the effect of bisphosphonates on disease course and outcome is unknown. Despite this, mechanisms of chronic inflammation are increasingly mentioned in the literature, which may directly or indirectly influence the clinical course and outcome of the disease. The key is the hyperactivity of osteoclasts in osteonecrosis. The experience of using bisphosphonates in adult patients with aseptic necrosis of the femoral head had positive results in preventing the progression of the deformity of femoral head deformity.

CONCLUSIONS: Bisphosphonates are specific inhibitors of osteoclast activity, which has been used in many diseases. The results and inferences of using bisphosphonates in children with Legg–Calvé–Perthes disease will lead to the formulation of a new treatment algorithm.

BACKGROUND: A complex biopsychosocial approach to the diagnosis and treatment of patients of different ages and pathologies is a doctrine of modern medicine. However, this approach is slowly being implemented in practical healthcare, and a biomedical orientation and approach remains the dominant model.

AIM: To demonstrate the possibility of using the primary express diagnostics of PSAF autodesadaptation as the first unifying step to realize the biopsychosocial approach in the examination of adolescents and young adult patients with orthopedic pathology and traumatic injuries.

MATERIALS AND METHODS: The article presents the analysis of literary sources to substantiate the relevance of the biopsychosocial approach in medicine. Clinical examples and preliminary analysis of the express diagnostics of PSAF autodesadaptation in seven inpatients were also presented.

RESULTS: The expression and structure of patients’ complaints were obtained. Thus, individual-oriented recommendations for the treatment and rehabilitation of these patients were developed.

CONCLUSIONS: Further development and refinement of the technique of the primary express diagnostics of PSAF autodesadaptation, given its simplicity and accessibility, can allow its use during admission in a specialized hospital and outpatient admission when carrying out rehabilitation measures.

This is a commentary to the article by Wenger D.R., Mauldin D., Speck G., Morgan D., Lieber R.L. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2023;11(2):253–264. DOI: 10.17816/PTORS321250.

On August 14, at the 76th year of life, after a short illness, Sergei Pavlovich Mironov, an outstanding scientist, an excellent organizer, a great clinician, an erudite teacher, a remarkable public figure, doctor of medical sciences, professor, and academician of the Russian Academy of Sciences, passed away suddenly. Domestic healthcare suffered an irreparable loss.