ORTHOPAEDICS, TRAUMATOLOGY and PROSTHETICS

PRACTICAL ASPECTS OF INTRAOPERATIVE NEUROMONITORING IN PATIENTS WITH DIFFERENT SPINAL PATHOLOGIES

Oleksandr Barkov — 2022-02-03

Objective. To study the operating parameters and phenomena of intraoperative monitoring and to identify the specificity and sensitivity
of its different modalities associated with postoperative neurological complications in patients with different spinal pathologies.
Methods. The intraoperative neurophysiological monitoring (IOM) protocols of 88 patients who underwent spinal surgeries were analyzed:
kyphoscoliotic spinal deformities — 58 (68 %), traumatic — 12 (13.3 %), degenerative diseases — 10 (11.7 %), neoplasms — 6 (6.7 %). In 33 (38.4 %) cases, a combination of modalities of motor evoked potentials (MEP) and transpedicular screws stimulation (TSS) was used, in 36 (41.9%) — only MEP, 17 (19.8 %) — TSS. In all cases, freerun and triggered EMG was used. Results. The most stable MEPs were recorded at mm. tibibalis anterior, mm. abductor hallucis longus. It has been proven that an unfavorable and reliable factor of the anxiety sign is a unilateral sustained decrease in the MEP amplitude by more than 80 %. According to the TSS results 424 (97.5 %) screws are installed correctly, 1 (0.2 %) false negative case of incorrect installation. False positive results for the TSS test ranged from 34.7 to 15.4 %, depending on the chosen critical threshold of the current applied to the pedicle screw. We consider the threshold of the TSS test at 13 mA satisfactory, and below it, unsatisfactory. A group of patients was identified who had 72 screws (16.6% of all analyzed) who, according to the results of the TSS test, received an unsatisfactory assessment, and X-ray did not reveal any deviations in the position of the screws.Conclusions. IOM modalities are highly sensitive and specific to damage to the structures of the spinal cord and spinal nerves, but dependence on a number of external factors reduces their information content, which leads to false positive and false negative results. It was established, that the dynamics of the MEP amplitudes of the target muscles differs in information content and efficiency during surgery due to individual morphological and motor characteristics.

RESULTS OF MINIMALLY INVASIVE KNEE POSTEROLATERAL CORNER RECONSTRUCTION

Maxim Golovakha — 2022-02-03

Posterolateral rotational knee instability is one of the insufficiently studied problems of modern orthopedics. Complexity of anatomy, difficulties of diagnosis together with a small number of such injuries did not allow to formulate a clear concept and algorithm for the treatment of such patients. Only in the last 10 years, this problem has been given attention. The paper describes a new minimally invasive technique of posterolateral corner reconstruction
under arthroscopic control. Objective. To analyze the long-term results of minimally invasive posterolateral corner reconstruction under arthroscopic control. Methods. The results of treatment of 58 patients were presented, 26 of them formed a study group and 32 — comparison. The dynamics of the pain syndrome, the nature of range of motion restoration, as well as tests of rotational stability were assessed. Results. Statistical analysis of long-term results
showed that pain syndrome after minimally invasive technique is significantly lower, and the function of the knee in dynamics recovers faster. The results of knee lateral stability were better in the study group. The main classification of posterolateral corner injuries by Fanelli and Larson is mostly consistent with clinical practice. However, it does not take into account clinical cases of anterior cruciate ligament ruptures combined with injuries of the posterolateral
corner. Conclusions. The use of the proposed method of minimally invasive knee posterolateral corner reconstruction with arthroscopic grafting of the popliteal tendon provided positive short-term and long-term results of treatment of patients, reduction of pain intensity after surgery and earlier recovery of range of motion in the knee. An increase complications and deterioration of function was not detected in any case.

IPSILATERAL INJURIES OF THE ELBOW JOINT AND THE DISTAL RADIUS

Ievgen Matelenok — 2022-02-03

The elbow joint injury and the ipsilateral fractures of distal radius are rare but are different. Objective. To analyze character of the elbow joint injury and distal part radius fractures in connection with peculiarities of traumatic energy intensity, to consider of treatment options of such trauma cases. Methods. The study is based on the retrospective analyze of the clinical observation of 8 patients with the ipsilateral elbow joint injury and distal part of radius
(3 men and 5 women, average age is 39 ± 5). Besides of the distal part radius fracture 1 patient had luxation of the forearm, 5 — fracture-dislocations in the elbow joint and in 2 cases — the fractures of distal metaepiphysis of the humerus. In 7 cases of the elbow joint injuries and in 3 cases of the distal part radius fractures the surgical treatment was made. Results. Except 2 cases the injuries happened in result of landing from the height of 1–12 meters. The severity of injuries was ranking and their correlation with the indicator of falling height was analyzed. The treatment peculiarity of the elbow joint injury and the ipsilateral fractures of distal part radius is considered. Conclusions. In the majority of cases ipsilateral injuries of the elbow joint and of the distal part radius are the result of falling from the height, infrequently — the results of falling from easy posture of the body; the severity of injury depends on the falling height (correlation coefficient Spearman’s — 0.78), the character of elbow joint injury may depend on the position of the extremity at the time of landing and successive additional collision of elbow region with traumatic agent. When the patient falls from significant height may happen polytrauma, what lead to many stages of treatment. By the ipsilateral injuries substantiation of manipulations or surgical operations priorities is very important.

EXPERIMENTAL STUDY OF OSTEOSYNTHESIS STABILITY OF THE DISTAL PART OF THE HUMERUS

Оlexander Bodnya — 2022-02-03

Unresolved issue is improving of the osteosynthesis of extraarticular fractures of the distal humerus. Search for a simplified method of biological fixation, which assumes, with low trauma, to ensure the stable fixation of fragments and movements in the elbow joint in the early postoperative period. Objective.
To carry out a comparative analysis of the bone fragments displacement of the distal humerus in extra-articular fractures, stabilized by extraosseous and transosseous osteosynthesis. Methods. Biomechanical study of the distal humerus model was made. Transosseous osteosynthesis was modeled using the author’s external fixation apparatus (EFA). For comparison, we chose an osteosynthesis with a Y-shaped plate. The humeral models were loaded with an interval and a stepwise increased in the load for compression along the axis, flexion in a parallel plane, as well as perpendicular to the fixing elements of the plate and EFA. The magnitude of the load gradually increased from 0 to 250 N with a step of 50 N. The magnitude of the forces at which, due to the action of various loads, a displacement at the level of the fracture appeared. Results. The analysis of experimental studies showed that the rod apparatus and the plate provide the same stability of fixation of the fragments of the humerus under conditions of axial compression load (p > 0.05). Under the influence of bending loads of more than 100 N in a plane parallel to the fixing elements, the plate had a slight advantage (10 %). A significantly better result (p < 0.01) was obtained when an external device was used under the action of bending loads in a plane perpendicular to the fixing elements. Conclusions. In the case of fractures of the distal humerus, the transosseous osteosynthesis using the proposed external fixation rod device ensures the stability of the fragments under all loading options. It is quite reliable and can be recommended for use in clinical practice.

PREOPERATIVE DENOSUMAB THERAPY IN PATIENTS WITH GIANT CELL TUMOR OF BONE

Oleg Vyrva — 2022-02-03

Giant cell tumor of bone (GCTB) is a benign osteolytic tumor with an aggressive course, affects the metaphyseal and epiphyseal areas of bone. GCTB is RANKL-positive tumor. Therefore, RANKL is a promising target for directed influence on the processes of bone resorption. Objective. To analyze the world and own experience of denosumab using in the treatment of patients with giant cell tumor of bone. Methods. The search for publications in electronic
systems was carried out Google Scholar, PubMed, ScienceDirect, specialized archives journals and manuscripts. In addition, 57 patients with histologically verified GCTB without signs of malignancy were included. Results. Denosumab binds and inhibits RANKL, by stopping bone resorption by inhibiting differentiation, function and survival of osteoclasts. Information on the effectiveness of the drug in the treatment of patients with GCTB is contradictory.
Some researchers claim that its use in the preoperative period reduces the amount of surgical intervention and the likelihood of recurrence
of GCTB. The effect correlates with the duration of drug administration. Other authors report an increase in the percentage of local tumor recurrence with denosumab and the next performance of curettage. This is explained by the complexity of macroscopic determination of the boundaries changed by action tumor preparation and, accordingly, the difficulty of choosing reach for removal during surgery. Our own experience showed that neoadjuvant therapy with denosumab 120 mg on the 1, 8, 15, 28 days promotes the formation of clear boundaries of the tumor, its compaction and, consequently, reduces the risk of pathological fracture and allows ablastic tumor removal. Conclusions. The results of the study of the effect neoadjuvant therapy with denosumab is
ambiguous. Under conditions its use followed by curettage increase the proportion of local recurrences of the tumor. At significant differences measures of lesions of GCTB before wide resection with endoprosthesis replacement administration of denosumab promotes bone formation skeleton around the tumor and its compaction, which allows ablastically remove it and reduce the risk of local recurrences.

STUDY OF BIOCHEMICAL MARKERS OF OSTEOGENESIS IN CASE OF BONE ALLOGRAFTS INCORPORATION IN RATS WITH FOLLOWED AFTER SURGERY ADMINISTRATION OF CISPLATIN AT THE DIFFERENT METHODS OF IMPLANT STERILIZATION

Oleg Vyrva — 2022-02-03

Bone allografts are commonly used for surgical treatment of cancer patients. However, such complications as violation of allograft fusion, its lysis and fractures, infection lead to additional research in this field of medicine. Objective. To study changes in biochemical osteogenesis markers under the action of cytostatics on the process of incorporation of bone allografts. Methods. The work was performed on 20 male white rats (age at the beginning of the experiment 5–6 months). All animals have a perforated defect in the distal metaphysis of the femur filled with bone allograft (diameter 2 mm, height 3 mm), γ-radiation sterilized (Control-1 and Experiment-1) or saturation of the antibiotics sterilized (Control-2 and Experiment-2). In groups «Control» 14 days after implantation intraperitoneally injected 2.0–2.4 ml of 0.9 % sodium chloride solution, in the groups «Experiment» — cisplatin at a dose of 2.5 mg/ kg
once. 30 days after surgery, blood glycoproteins, total protein, Ca, chondroitin sulfates, acidic and alkaline phosphatase activity were evaluated. The index of mineralization (ratio of alkaline to acid phosphatases), degree is analyzed mineralization (ratio of calcium to protein). Results. In the experimental groups, compared with the control, a significant decrease in total protein and values was determined: total calcium, which indicates the suppression of processes mineralization during remodeling of bone tissue of the recipient and allograft. The highest indicators of activity acid phosphatase were recorded in groups Experiment-1 and Experiment-2, reflecting the predominance of resorption over bone formation. The degree of mineralization in the experimental groups was higher than in the control, and the mineralization index was significantly smaller. Conclusions. The detected changes in the values of biochemical markers of bone metabolism reflect the negative effect of cisplatin on osteogenesis under the conditions of allograft implantation, which leads to the lack of their fusion with the recipient bone.

MATHEMATICAL MODELING OF THE STRESS-STRAIN RELATIONS OF THE FOOT ELEMENTS IN THE CONDITIONS OF LATERAL MALLEOLUS HYPOPLASIA

Igor Shishka — 2022-02-03

One of the most common complications of long-term talocrural joint (TCJ) injury is the development of chronic instability. Among the risk factors for its occurrence - congenital or acquired shortening (hypoplasia) of the lateral malleolus of varying degrees. Objective. Determine the effect of lateral malleolus hypoplasia on the distribution of stresses in the bone and ligament elements of the foot. Methods. Mathematical modeling of the distal end of the
lower extremity was performed. There are two variants of the position of the heel bone — varus and valgus with an angle of deviation from the vertical axis in both cases 15°. A vertical distributed load of 700 N was applied to the tibial plateau. On the supporting surface of the feet model's were rigidly fixed. Measurements of mechanical stresses were performed at control points. According to the criteria for estimating the stress-strain relations (SSR), the Mises
stress was used. Results. It was determined that lateral malleolus hypoplasia increases the values of stresses on the lateral side of the distal tibial bone from 6.3 MPa to 6.4 MPa, from the medial — on the heel bone from 5.8 MPa to 6.0 MPa, talus from 2.1 MPa to 2.3 MPa. SSR on TCJ are also varies. In the case of a neutral position of the heel bone, lateral malleolus hypoplasia causes a decrease in the values of the ligaments on the lateral side of the TCJ,
which can be explained by their elongation and, consequently, the projection increase in length In the case of varus or valgus position of the heel bone under conditions of lateral ankle hypoplasia, it was found that the varus position of the heel bone overstrains the ligaments on the lateral side, valgus - from the medial. Conclusions. Decreased stress in the ligaments of the TCJ in cases of valgus or varus position of the heel bone is one of the factors reducing the functional stability of the joint and may be the cause of its chronic instability.

MATHEMATICAL MODELING OF PELVIC MUSCLE FUNCTION IN PATIENTS WITH HIP JOINT ADDUCTION CONTRACTURE AT SINGLE-SUPPORT STANDING

Olexiy Tyazhelov — 2022-02-03

Long existing hip arthritis is accompanied by the development of
pain and contractures that cause contractile muscle spasm, reduction
in the length of the adductor muscles and flexors of the thigh,
relative overstretching of the abductor muscles, which over time
leads to changes in their structure. The result is weakness of the
pelvic muscles, the clinical manifestation of which is a violation
of postural balance — lameness, torso tilts while walking, changes
in pelvic position, etc. Objective. To determine the effect of the
hip joint adduction contracture on the ability to maintain balance
standing position with mathematical model. Methods: mathematical
model is worked out that represents the pelvis with the thigh and
the vectors of action of the adductor and abductor muscles. The
muscular effort required to maintain body balance during one-leg
standing was normal and the hip position was set at 5° and 10°.
Calculations were performed for patients weighing 70; 100; 120 kg.
Results. It is determined that at the adduction contracture in 5°
m. gracilis, m. add magnus, m. piriformis are not able to perform
the functions of maintaining body balance due to the necessity to
develop greater efforts than their maximum possible, even at the
minimal patient's weight. If the patient's weight exceeds 120 kg, then
almost the entire muscular system of stabilization of the thigh works
beyond its capabilities. The adduction contracture of 10° increases
the required force of the thigh stabilizer muscles. The absolute values
showed an increase in their strength indicators. Conclusions.
The adduction contracture of the hip joint causes a change in the
biomechanical conditions of the pelvic muscles due to changes in
the angles of action of the abductor muscles, reducing the effectiveness
of their work to stabilize the pelvis. As the angle of adduction
contracture increases, there is a tendency for the pelvic muscles
to work effectively. An additional factor that negatively affects this
indicator is the patient's overweight.

THE INFLUENCE OF REGENERATIVE TECHNOLOGIES ON RECOVERY PROCESSES IN LEG AFTER TRAUMATIC ISCHEMIA (EXPERIMENTAL STUDY)

Andriy Pidlisetsky — 2022-02-03

Post-traumatic muscle ischemia results from severe injury and can lead to muscle dysfunction. Therefore, patient management and treatment are very significant in all periods of injury. New methods are performed, especially using regenerative technologies to avoid complications and improve long-term outcomes. Objective. To determine histological changes in the muscles of the injured limb after traumatic ischemia after injection of platelet-rich plasma,
Bone marrow stem cell concentrate (BMAC), and Stromal vascular fraction (SVF) prepared from adipose tissue on the 5, 15, and 30 days. Material and methods. Experiments were conducted on rabbits (Chinchilla breed). A tourniquet imposed on a lower limb, from the middle third of the thigh to the ankle joint. After 6 hours, the tourniquet was removed. The animals were divided into four groups: control, platelet-rich plasma, bone marrow stem cell concentrate, and stromal vascular fraction prepared from adipose tissue — histological muscle changes provided by Tescan Mira 3 LMU (Czech Republic) in scanning transmission electron microscopy. Results. On the 5th day after the experiment were no significant histological changes in muscles but in the contrary on the 15 days after experiment in BMAC and SVF groups detected new muscle fibers formation in necrotic areas and myonucleus organization. On the 30th day new angiogenesis was detected around muscle fibers. Platelet-rich plasma group characterized by massive connective tissue formation in necrotic areas. Conclusions. Necrosis and progressive muscle hypotrophy are unavoidably for this type of injury. It was shown that BMAC and SVF could stimulate regeneration and angiogenesis.

REPORTS

Volodymyr Filipenko — 2022-02-03

Report on the work of centers and associations of orthopedists-traumatologists

MODERN TRENDS IN THE DEVELOPMENTS OF HIP AND KNEE ARTHROPLASTY

Igor Zazirnyi — 2022-02-03

Total hip (THA) and knee (TKA) arthroplasty is an effective surgical treatment for late-stage osteoarthritis. Objective. Highlight the most significant technological developments in the design of implants and assistive technologies for hip and knee arthroplasty. Results. The development of hip and knee arthroplasty is associated with the desire to improve treatment outcomes, reduce complications and increase the survival of implants. The emphasis is placed on some of the most interesting, in our opinion, trends in this area. It has been shown that metal-to-metal friction steam implants are used to replace the articular surface of the hip joint, but the method is the best option only for active men with a large hip joint. New approaches involve the use of friction pairs «ceramic – ceramic» or «metal – polyethylene». The creation of smaller femoral components of endoprostheses (mini-legs) for THA is aimed at preserving bone tissue and achieving physiological load. Dual mobility endoprostheses are increasingly preferred for primary THA. The creation of implants with a porous surface (in particular, with the use of additive technologies) is promising to increase their osteointegration and antibacterial properties. The latest direction is the creation of robotic support systems for joint replacement operations, which will improve the accuracy of implant positioning, reduce blood loss, improve functional results, as well as achieve after TKA balance of ligaments and joint space by accurately determining its size and accuracy resection of the femur. However, high-evidence clinical trials are needed to find convincing longterm results for this approach to become standard in hip and knee arthroplasty. Conclusions. Robotic surgery is one of the most interesting developments in hip and knee surgery. The growth in the use of this technology has shown convincing long-term results.

TRAINING AND PRACTICE-CENTRIC METHOD OF PROFESSOR SULYMA

Vadym Sulyma — 2022-02-03

The paper is concerned with the current state of doctors’ training methodologies. Problems of teaching the discipline were identified: inability to memorize the amount of theoretical material, the ineffectiveness of methodological techniques for practical training, amount of new training centers. It has been proven that these faults are risky for mastering learning skills. The method of «see - repeat»preferred by coachers is not a panacea for the effective educational process during various medical interventions. Particular attention is paid to the psychological borders of young doctors in the recollection of new information that is needed to be improved. Objective. Build an innovative methodological strategy that requires a combination: high quality of theoretical medical knowledge and practical skills. Results. Among modern pedagogical techniques, the most profitable is the method of Peyton, which became the base of «Professor’s Sulyma training». Detailed instruction of the author's teaching strategy is suggested in the report. This way of education is based on neurobiological research and divided into 10 stages, which are theoretically and methodically described. The authors approbated training and paid attention to its effectiveness. Conclusions. «Professor’s Sulyma training» is a method that allows practicing any valuable skills in different medical areas

Letter to editor of the journal «Orthopedics, Traumatology and Prosthetics»

S. A. Goloborodko — 2022-02-03

Letter to editor of the journal «Orthopedics, Traumatology and Prosthetics»

Answer of article’s authors «Peculiarities of surgical correction of different forms hand syndactylly in children. Retrospective study of own experience»

I. M. Harbuzniak — 2022-02-03

Answer of article’s authors «Peculiarities of surgical correction of different forms hand syndactylly in children.
Retrospective study of own experience»

ANESTHESIA PECULIARITIES IN BEACH CHAIR POSITION (LITERATURE REVIEW)

Mykola Lyzohub — 2022-02-03

Beach chair position (BCP) that is applied for shoulder surgery has a number of advantages for surgeons, but it may lead to intraoperative hypotension, bradycardia and postoperative neurologic complications. Objective of the publication is to review up-to-date literature to emphasize complications related to BCP and methods of their monitoring and prophylaxis. Methods. We have analyzed publications from Google Scholar, PubMed, and specialized scientific
journals databases. Results. In orthopedic practice the main types of surgical positions that are used for shoulder surgery are the next: semi-BCP — 30°, BCP — 60°, Semi-upright sitting position — 90°. In spite of its correlations with hemodynamic changes the tilt angle is rarely measured in clinical practice. The etiology of nervous system impairment is thought to be hypotension and subsequent brain hypoperfusion that is induced by BCP under general
anesthesia. Blood pressure at the standard brachial level is significantly higher than at the meatus acoustic level. That is why today the safety level of blood pressure for BCP surgery is not clearly estimated. The majority of clinical investigations have shown that BCP leads to decreasing of regional cerebral blood flow and brain oxygenation. The high incidence of cerebral desaturation events in BCP (more than 50 %) require its accurate monitoring. The most widely used method is NIRS (near-infrared spectroscopy). Other methods including Doppler scanning of brain vessels and jugular saturation has limited clinical using. In majority of trials of cerebral desaturation events has shown to have controversial impact on postoperative cognitive dysfunction. Serum neurospecific proteins examination may be a perspective method of further investigations for neurologic impairment after surgeries in BCP.

REVERSE SHOULDER ARTHROPLASTY. HISTORY AND DEVELOPMENT PROSPECTS

Mykola Korzh — 2022-02-03

In elderly patients with a low bone mineral density primary endoprosthesis shoulder joint is one of the methods of surgical treatment. Goal. Perform a historical review of the development of reverse shoulder arthroplasty (RSA) with analysis of biomechanical features of existing implants, their advantages and disadvantages to identify possible areas for further ways of improvement. Methods. Search for scientific information was performed in electronic databases PubMed, ScienceDirect, Google Scholar with a search depth of 30 years. There were selected 68 sources. Results. Unsatisfactory results after shoulder hemiarthroplasty caused in patients with severe damage to the rotator cuff and multifragmental fractures of the proximal humerus using RSA. Endoprosthesis design C. Neer replaced the implants of P. Grammont design, built on the principles: spherical glenoid component, concave support part on the humerus, the center of rotation at the level or medially of the scapular neck, proximal humerus fractures is displaced medially and distally. Medialization of the center of rotation is an
unfavorable factor that leads to loss of tension of the deltoid muscle. To eliminate this disadvantages, lateralized hemispheres have been developed, with the help of which stability is achieved, the formation of a defect of the lower edge of the scapular neck is prevented. Their size affects on the volume of movements: the smallest diameters should be used for prevention of soft tissue strain. Note that the use of RSA with a lateralized center of rotation and varus shoulder component brings biomechanics closer shoulder joint to normal anatomical features. Conclusions. The main directions of RSA improvement: conducting biomechanical research to evaluate structures endoprostheses in order to choose the optimal design; introduction of modern additive technologies that will allow to obtain porous components with increased osteointegrative properties; reduce the weight of the hemisphere; improving friction pairs