Vol 7, No 3 (2019)

Original studies
Surgical correction of severe forms of idiopathic kyphoscolyosis in children
Vissarionov S.V., Filippova A.N., Kokushin D.N., Murashko V.V., Belyanchikov S.M., Khusainov N.O.

Background. Significant results have been achieved through the use of hybrid and transpedicular metal structures. However, when spinal systems are implanted during surgery in patients with severe forms and idiopathic scoliosis, a number of limitations arise. Not only the performance of corrective maneuvers during the operation but also the creation of mobility on the top of the main arc accompany the strategies of surgical treatment. Traditionally, mobilizing discectomy at the top of the spark is performed in patients with idiopathic scoliosis. Pedicle subtractional vertebrotomy and Ponte and Smith-Petersen osteotomy are most common in neuromuscular scoliosis and spinal deformity, with a predominance of the kyphotic component. Problems with correction of extremely low and “neglected” forms and idiopathic scoliosis in children remain.

Aim. The present study aimed to provide a comparative analysis between using transpedicular spinal systems alone and in combination with a wedge osteotomy of the apical vertebra to correct spinal deformity in children with extremely severe right-sided idiopathic thoracic scoliosis.

Materials and methods. The surgical treatment results of 20 children 15 to 17 years old with extremely severe forms of right-sided idiopathic thoracic kyphoscoliosis were included in the analysis. All patients underwent standard preoperative examination, including radiology, computed tomography, magnetic resonance imaging, and neurophysiological studies. The patients were divided into two groups according to the method used during the second stage of surgical treatment — correction of deformity with the transpedicular system (1) alone or (2) in combination with a wedge osteotomy of the apical vertebra.

Results. Patients from the first group showed an amount of scoliotic and kyphotic component correction ranging from 25% to 62% and from 21% to 56%, respectively. In patients from the second group, who underwent additional wedge osteotomy of the apical vertebrae during the operation, correction of the scoliotic and kyphotic components ranged from 36% to 74% and from 50% to 70%, respectively.

Conclusion. In children with idiopathic thoracic kyphoscoliosis, performing a wedge corpectomy of the apical vertebral body is an effective additional mobilizing component, which allows achieving significant correction of both scoliotic and kyphotic curve components, restoring the physiological profile of the spine and body balance during the surgical intervention, and maintaining the achieved result during the long-term observation period.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):5-14
Relative overgrowth of the greater trochanter and trochanteric-pelvic impingement syndrome in children: causes and X-ray anatomical characteristics
Pozdnikin I.Y., Baskov V.E., Barsukov D.B., Bortulev P.I., Krasnov A.I.

Background. The formation of multiplanar deformities of the proximal femur, in most cases combined with hypertrophy of the greater trochanter (relative overgrowth of the greater trochanter (ROGT)) and its high position relative to the femoral head, up to the development of pelvic and pelvic spine syndrome (trochanteric-pelvic impingement), has been considered one of the most common problems in the treatment of children with hip joint pathology of various etiologies.

Aim. The aim of this study was to determine the causes of and characterize the X-ray anatomical changes in children with ROGT.

Materials and methods. This study is based on an analysis of the survey results of 350 children 3 to 17 years old with an emerging high position of the greater trochanter due to various diseases of the hip joint. Details of the radiological indicators characterizing the change in the growth of the greater trochanter relative to the head and neck of the thigh were examined in 68 of these children (112 joints).

Results. Most often, hypertrophy of the greater trochanter was observed in children with the sequele of ischemic disorders that occurred during the conservative treatment of hip dysplasia and developmental hip dislocation, as well as due to previous hematogenous osteomyelitis. It was revealed that in the affected hip joints, there was a regular decrease in the articulo-trochanteric distance index; simultaneously, TTD values, which characterize the isolated growth of the greater trochanter, were almost the same in normal and pathological conditions (p < 0.05).

Conclusion. Damage to the growth plates of the pineal gland and neck of the femur of various etiologies was the reason for ROGT formation. The X-ray anatomical changes include progressive shortening of the femoral neck. Moderately pronounced in preschool-age children, they progress with the child’s growth and become the cause of chronic trauma injuries of the components of the hip joint.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):15-24
Posterior artrolysis of the elbow, as a method of correction extensor contracturing of the elbow in children with arthrogryposis
Petrova E.V., Agranovich O.E., Trofimova S.I., Kochenova E.A.

Background. In children with arthrogryposis, a lack of elbow flexion with extensor elbow contractures limits the child’s self-care.

Aim. The aims of this study were to follow and analyze treatment results after posterior arthrolysis of the elbow joint with lengthening (Z-plasty, according to the V-Y technique) or without lengthening the triceps of the shoulder in children with arthrogryposis in different age groups.

Materials and methods. Data from 109 patients with arthrogryposis with extensor contractures in the elbow joints (158 joints) who underwent posterior arthrolysis of the elbow joint to increase passive flexion in the elbow joint from 2005 to 2018 were included in this study. Clinical, and X-ray examination of patients was carried out.

Results. The children were divided into nine groups depending on their age at the time of the operation and the method of surgical correction (with or without lengthening of the triceps muscle). The follow-up period in the postoperative period in the main group of patients (67.1% of cases) was 4.5 years. Good treatment results were observed in 95.83% of children younger than 3 years who did not lengthen the triceps compared with 85.56% of children of the same age who extended the triceps tendon. The amplitude of passive movements after surgery was greatest in children younger than 1 year and was greater with lengthening (104.00° ± 16.24°) than without lengthening (91.38° ± 10.27°) of the triceps tendon (p < 0.001). However, in cases where lengthening of the triceps tendon was not performed, extension was less limited. Over 3 years, m. triceps br. showed satisfactory results with Z-extension and V-Y extension, increasing to 19.44% and 36.51%, respectively. Results of treatment in children older 7 than years were comparable with those of children 3–7 years old.

Conclusions. In children with arthrogryposis after posterior arthrolysis of the elbow joint, receiving a passive range of motion in the elbow joint allowed the child to use adaptive mechanisms for self-care. The results of treatment with extensor elbow contracture after posterior artrolysis depended not on the elongation technique (V-Y or Z-plasty) but on the angle at which the triceps tendon was sewed, the patient’s age at the time the operation was performed, and the postsurgery rehabilitation of the child.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):25-34
Long-term results of plasty of granulating wounds of the distal extremities with mesh and solid skin autografts of burn wounds in children
Filippova O.V., Afonochev K.A., Nikitin M.S., Govorov A.V.

Background. The widespread and not always justified use of mesh autografts in children with burns leads to the development of severe contractures and dislocations in the joints in the first year after the restoration of the skin.

Aim. In this study, the long-term results of plasty of granulating wounds of the distal extremities with mesh skin autografts in children with burns were evaluated.

Materials and methods. In Turner Institute’s clinic of trauma sequale, from 2012 to 2018, we treated a total of 153 children who developed scar deformities of the hands and feet after plastic surgery with continuous and mesh skin autografts. The control group (42 patients) consisted of patients after wound plasty with skin autografts. The study included patients with a total area of deep burns within 1%–15% of the body surface. The follow-up period ranged from 7 months to 3 years. Objective examination with anamnestic and radiological data analysis was used. The classification by B.V. Parin (1946) was used to estimate the degree of limitation of the range of motion in the joint. A set of standard analysis tools included in SPSS Statistics v23 ×64 was used to carry out statistical data processing.

Results. The number of deformities formed on the background of the surviving mesh autograft is 2 times more than after the plasty of granulating wound with a solid skin autograft (54.4% and 20.6%, respectively). Dislocations in the wrist joints on the background of mesh plasty of wounds with a skin autograft developed in a mean time of 15.33 ± 1.28 months. Moreover, dislocations in the metatarsophalangeal joints of the foot under the extensor contracture were diagnosed after a mean of 7.52 ± 0.23 months (p < 0.05), with flexion contracture at 7.00 ± 0.38 months, and multiplanar deformity with dislocation at the subtalar and metatarsophalangeal joints was observed to form at 34.0 ± 10.0 months.

Conclusion. There was a 3 times higher rate of visit among patients with scar deformities developed after the use of mesh autografts in the area of the joints of the hand and foot, and the development of deformities was 4–6 months shorter than in the plasty of granulating wounds with solid skin autografts. The lack of a differentiated approach to the choice of the restoration method of the skin and conservative preventive therapy in children with burns leads to the need for reconstructive treatment in the near future.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):35-44
Characteristics of body balance disorder in children with unilateral lower limb shortening
Nikityuk I.E., Kononova E.L., Garkavenko Y.E.

Background. In modern orthopedics, the problem of unilateral shortening of the lower limbs in children is extremely important. In the process of child growth, there occurs progression of the shortened segment, which leads to anatomical asymmetry of the lower limbs and an increase in the imbalance of the limb load. Secondary deformities of the pelvis and spine aggravate the patient’s disability. The features of abnormal postural balance of the body depending on the etiology of the disease, such as congenital or acquired, as well as the degree of preservation of motor stereotypes in children with unilateral shortening of the lower limbs, are still understudied.

Aim. The aims of this work are to study postural stability in children with unilateral shortening of the lower limbs and to assess the disorders of body balance depending on the etiology of the lesion.

Materials and methods. The standard stabilometric values of 11 healthy children (average age, 11.9 ± 0.73 years) were determined (group 1), as well as the statokinesiogram parameters in 22 patients with unilateral shortening of the lower limb. The second group included 11 children (average age, 11.9 ± 1.05 years) with congenital shortening of the lower limb (average shortening, 4.8 ± 0.8 cm). The third group also consisted of 11 children (average age, 12.2 ± 0.78 years), but with acquired shortening of the lower limb (average shortening, 4.5 ± 0.38 cm). Statistical research included correlation analysis.

Results. A significant decrease in the stability of the vertical balance was observed in both groups of patients, which was demonstrated by pronounced deviations from the nominal values of stabilometric parameters, compared with healthy children: an increased center of pressure displacement, large values of the statokinesiogram area, and the length of the pressure displacement path. It was possible to determine the state of adaptive postural mechanisms for assessing the formation of the degree of adequacy of the motor strategy in patients with unilateral shortening of the lower limb, depending on the etiology of the lesion, owing to the method of stabilometry.

Conclusion. An appropriate adaptive motor stereotype has been formed in patients with acquired shortening of the lower limb; in the new conditions, the system for ensuring postural balance is stabilized. There is a different strategy for maintaining posture stability characterized by a nonoptimal motor stereotype in patients with congenital shortening of the lower limb. The stabilometric assessment of the asymmetry of the lower limb load is a promising method for studying the formation of compensatory mechanisms for controlling the locomotion system, which is important when planning rehabilitation measures.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):45-54
Glove damage in total hip arthroplasty
Boyarov A.A., Tikhilov R.M., Shubnyakov I.I., Midaev A.I.

Background. Glove damage during orthopedic operation can reach an incidence of 26.1%, whereas perforations in gloves go unnoticed by surgical team members in most cases (up to 82%), which certainly increases the risk of wound contamination and hemocontact infection transmission.

Aim. The aim of this study was to assess the frequency of glove damage among hip arthroplasty surgical team members, to identify the nature, location, and risk factors of damage to surgical gloves.

Materials and methods. A total of 1418 surgical gloves (709 pairs) that were used by surgeons, assistants, and surgical nurses during 154 primary and revision total hip arthroplasty (THA) were included in the analysis in this study.

Results. Damage to surgical gloves was observed in 69 (44.8%) operations: 54 operations of the primary THA (42.2%) and 15 revision THA (57.7%). Of 1418 gloves used, 95 were damaged (6.7%); 68 of 1166 gloves (5.8%) were damaged during primary hip arthroplasty and 27 of 252 gloves (10.7%) were damaged during revision THA. During primary and revision arthroplasties, glove perforations were observed in most cases: 83.6% and 85.7%, respectively. Most of the cases of glove damage were found in surgeons (45.2% of cases), and 41.1% and 13.7% of the cases of glove damage were experience by assistants and operating room nurses, respectively. The most frequent location of damage in the gloves was on the second finger of both hands: on the left, 40.3%, and on the right, 33.3%. Gloves were damaged in 42.1% of cases in primary arthroplasties lasting up to 70 min and in 42.3% of cases in those lasting more than 70 min. In revision hip arthroplasties lasting up to 95 min, gloves were damaged in 38.5%, and in revisions that lasted more than 95 min, in 76.9% cases.

Discussion. Glove damage during revision THA most often occurs to the surgeon suturing the wound (87.4%) and usually remains unnoticed. Risk factors for glove damage are the length of the operations and the use of sharp tools, knitting needles, and wire.

Conclusion. Use of apodactyl operational techniques and periodic change of surgical gloves can reduce the risk of damage to gloves and, as a result, reduce wound contamination and the transmission of blood-borne infections.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):55-62
Comparative evaluation of options for postoperative analgesia during surgical correction of congenital spine deformity in children
Kozyrev A.S., Zaletina A.V., Kartavenko K.A., Strelnikova A.S., Pavlova M.S.

Background. In the planning of anesthesia and postoperative therapy for surgical correction of congenital spinal deformity, the volume, the spine that is operated, and the patients’ age are all factors to consider. In pediatric practice, the use of opioid analgesics for pain relief in the postoperative period after extensive and traumatic surgical interventions is generally accepted. There is very little information on the effectiveness and safety of prolonged epidural analgesia in young children in spinal surgery.

Aim. The aim of this study was to give a comparative assessment of the use of prolonged epidural blockade and constant drip of fentanyl as the main components of postoperative analgesia during surgical correction of congenital spine deformity caused by violation of the vertebra formation in children.

Materials and methods. The features of the postoperative period in 43 cases of correction of congenital spine curvature performed in the Turner Scientific Research Institute for Children’s Orthopedics from 2016 to 2018 were retrospectively evaluated. Patient age ranged from 2 to 11 years. The patients were divided into two groups: group P included 22 patients whose main component of postoperative anesthesia was prolonged epidural analgesia, and group F included 21 patients whose main component of postoperative anesthesia was fentanyl. Anamnestic data analysis and clinical, laboratory, instrumental, and statistical analyses were used as methods of assessment.

Results. The data showed that the number of patients with undesirable respiratory disorders recorded in the first day in the form of bradypnea and desaturation was higher in group F than in group P. The number of patients who experienced nausea and vomiting and those who received antiemetics on the first day after surgery were comparable in both groups. However, the number of patients with fixed nausea, vomiting, and receiving antiemetics became significantly higher in group F in the next 2 days. In addition, at all stages of the assessment, there was an increase in the recorded episodes of peristalsis inhibition in patients from group F. The number of patients, who required additional anesthesia within 3 days of observation was comparable in both groups.

Conclusion. Prolonged epidural analgesia and constant drip of fentanyl are equally effective for providing pain relief in the postoperative period, but prolonged epidural analgesia provides a significant reduction in the frequency and severity of the gastrointestinal tract dysfunction.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):63-70
The specificity and focus of psychological assistance to adolescents with spinal pathologies
Krainyukov S.V., Mamaichuk I.I.

Background. Among the most common diseases of the musculoskeletal system are pathologies of the spine, in particular scoliosis and vertebral compression fractures, most commonly found in adolescents. The psyche of such patients is negatively affected by the concomitant motor limitations, pain syndromes, cosmetic defects, long hospitalizations, the threat of surgical treatment, and disability. At the same time, there are practically no complex psychological studies of adolescents with spinal pathologies, which prevents the development of differentiated directions of psychological assistance necessary for their full rehabilitation.

Aim. This study aimed to determine the specificity and direction of psychological assistance for adolescents with spinal pathologies of various genesis on the basis of complex psychological research.

Materials and methods. The study sample consisted of 38 adolescents (15 boys and 23 girls) with dysplastic scoliosis of various severity (18 with mild severity (grade I–II) and 20 with high severity (grade III–IV)), 29 adolescents (14 boys and 15 girls) with vertebral compression fractures, and 34 adolescents (15–17 years old) without pathology of the musculoskeletal system (control group). As a method, psychological testing was used, aimed at studying the personal traits, world view, and lifestyle of adolescents.

Results. In the adolescents with scoliosis, negative reflections of various life spheres in the world view were demonstrated through a decrease in overall activity, internal restraint, disregard for one’s needs, and a reduction in the time spent on learning activities. On the other hand, adolescents with vertebral compression fractures demonstrated negative ideas about the prospects for self-realization, a decreased interest in intellectual activity, along with increased time spent on passive leisure, and a tendency to risky behavior. The revealed features differ depending on the degree of severity, sex, and relation to medical rehabilitation. Differentiated directions of psychological assistance are defined on the basis of the results obtained.

Conclusion. A differentiated approach to psychological assistance requires considering the nature of the disease (congenital or acquired), severity and duration, frequency of hospitalizations, relationship to restorative treatment, and sex.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):71-78
Clinical case report
Open traumatic distal femoral physeal fracture in a pediatric patient with tetrasomy 18p syndrome
Arain A., Moral M., Desai K., Adams C., Roberts J.

Background. Because they are associated with a high energy mechanism, open distal femoral physeal fractures are rare injuries. Appropriate management of these injuries is critical in the pediatric population due to the increased risk of damage to the physis and subsequent growth disturbance and deformity after injury. Pediatric fractures may also represent the sequelae of genetic syndromes (particularly connective tissue disorders), nutritional abnormalities, or conditions that predispose to abnormal bone mineral density.

Clinical case. In this case report, we present the case of a 9-year-old girl with tetrasomy 18p who presented with a grossly displaced right open distal femoral physeal fracture in the setting of isolated, lower extremity trauma. The patient underwent an irrigation and debridement, followed by an open reduction and cross-pinning through the distal femoral epiphysis. After the operation, the patient was made non-weight-bearing in a cast for 4 weeks, and at 6 weeks, the pins were removed. The patient had full range of motion at the 6-month follow-up and then resumed her preinjury level of play at school.

Discussion. Tetrasomy 18p results in inherent muscle weakness that may interfere in the normal soft tissue sleeve of muscles stabilizing long bones. This may result in greater displacement of fractures sustained during trauma, which may lead to a greater rate of vascular injury, physeal injury, and poor overall prognosis. It is imperative for clinicians to be familiar with tetrasomy 18p and its associated orthopedic manifestations.

Conclusion. There is scarce literature on the management of physeal fractures in patients with tetrasomy 18p. In the case described here, we report a good outcome with the standard of care using preoperative and postoperative antibiotics, irrigation and debridement, open fracture fixation, and immobilization in a cast postoperatively. The duration of non-weight-bearing was also increased by 1 week and the pins were removed 1 week later than we would have for patients without any bone or connective tissue disorders.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):79-84
Primary tumor (tumoral) calcification is a rare disease in the practice of a rheumatologist and orthopedist: experience with the use of an interleukin-1 inhibitor in combination with surgical correction
Petukhova V.V., Idrisova R.V., Snegireva L.S., Krasnogorskaya O.L., Suspitsyn E.N., Veselov A.G., Kostik M.M.

Background. Primary tumoral calcinosis is an orphan disease. There are few data in the literature on the incidence of this disease, as well as clinical recommendations for treatment.

Clinical case. This report presents the case of an 11.5-year-old boy with primary tumoral calcinosis and equinus deformity of the foot. The patient had multiple foci of the subcutaneal calcification, cannot walk, experienced fatigue, and had high fever and equinus deformity of the left foot. Immunological and genetic studies were performed, but any specific mutations were not found. After the diagnosis was verified and interleukin-1β inhibitor therapy was prescribed, there was a significant positive trend observed in the patient: a significant improvement in the patient’s general condition, a decrease in the number of calcinates, and a reduction in inflammation. Calcification of the Achilles tendon and gastrocnemius muscle was the cause of the deformity of the left foot.

Discussion. Significant improvement was achieved during treatment: the boy started walking, fatigue was decreased, no new calcificates were formed, and inflammation was under the control. Using an inhibitor of interleukin-1β as a permanent therapy of primary tumoral calcification allowed performsurgical treatment without complications from an operation site, as well as a relapse of deformity.

Conclusion. The clinical case presented here demonstrated the application of an interdisciplinary approach to the treatment of an extremely rare disease.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):85-92
Medical abilitation of patients with proximal ectromelia of the lower limbs
Yakovleva V.A., Shvedovchenko I.V., Koltsov A.A.

One of the rarest and most severe variants of underdevelopment is proximal ectromelia of the lower extremities, in which all segments of the lower limb are affected and the degree of damage decreases from proximal to distal direction. A review of the domestic and foreign literature sources that describe the various clinic-radiological variants of pathology was carried out, from the presence of a single rudimentary foot adjacent to the trunk to the presence of all three leg segments. The terminological designations of this type of underdevelopment were then analyzed. The term “proximal ectromelia” is proposed as the most appropriate clinical and radiological features of the pathology. With a severe degree of reduction of the limb, when the femur is absent or sharply hypoplastic, prosthetics is carried out in almost all patients. In this situation, surgical treatment is used as a preparatory stage to optimize the design of the future prosthesis. In addition, surgery is the main method of treatment in cases with a lighter degree of underdevelopment, in which case the technical means of rehabilitation are auxiliary. Therefore, despite the relative rarity of this pathology, its severity and medical and social significance determine the interest of specialists of the world community in the study of the problem.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2019;7(3):93-102

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