ORTHOPAEDICS, TRAUMATOLOGY and PROSTHETICS

Report on the results of the 18th International Symposium «Minimally Invasive and Instrumental Spine Surgery», held on the basis of «Sytenko Institute of Spine and Joint pathology, NАS of Ukraine» under the auspices of NASS and SICOT

Inga Fedotova — 2021-12-28

The article summarizes the results of the 18th International Symposium "Minimally Invasive and Instrumental Spine Surgery", held on the basis of the Institute of Spine and Joint Pathology. prof. MI Sytenko NAMS of Ukraine "under the auspices of ISMISS with the assistance of NASS and SICOT December 5, 2020.

Bohdan Ilyich Simenach

Staff of "ORTHOPAEDICS, TRAUMATOLOGY AND PROSTHETICS" — 2021-12-28

On October 7, 2020, at the age of 100, life ceased to beat the heart of an outstanding scientist, a wonderful man, laureate of the State Prize of Ukraine, doctor of medicalSciences of Professor Bohdan Ilyich Simenach.

Friedrich Paul Magerl

Staff of "ORTHOPAEDICS, TRAUMATOLOGY AND PROSTHETICS" — 2021-12-28

On November 14, 2020, Professor Dr. Friedrich Paul Magerl, a pioneer in spinal surgery and orthopedics, passed away.

Anatomical features for the development of patellar instability and methods for its determination

Оlexandr Kostrub — 2021-12-28

Anterior knee joint pain is one of the common complaints, mainly in young people. Patellar instability is more likely to occur without a history of direct injury. Anatomical variants of the patellofemoral joint (PFJ) are of great importance in the development of arthritis, and could affect the appearance of complications after surgical treatment. The pathology of the patellofemoral joint continues to be a common and unsolved problem associated with the features of the anatomy and biomechanics of the knee joint. It has been found that the shape and ratio of the bones in patellofemoral joint have a crucial role in the development of patellar instability and arthrosis. Objective. To analyze the scientific database as for methods for determining the shape, the relationship of bones and patellofemoral joint dysplasia. Results. We studied the bone anatomy of the patellofemoral joint and current methods for determining the normal variants of the form of patella, dysplasia of the femoral facet and the rotational relationship of patella to the femur; or relationship of femoral facet to the tibial tuberosity. In clinical practice one needs to identify intercondylar angle, Laurin angle, the patellar slope, condylar dysplasia, the relationship of intercondylar notch to tibial tuberosity. Conclusions. The development of diagnostic methods such as MRI or CT provides expanded opportunities for identifying the features of patellofemoral joint. Increased lateralization of tibial tuberosity, dysplasia of femoral condyles, and patellar shape play a critical role in the development of patellar instability or development of patellofemoral joint arthritis.

Particularities of hip arthroplasty and restoration of its function in patients with low bone mass (literature review)

Volodymyr Filipenko — 2021-12-28

Objective. Basing on the analysis of the scientific literature to study the prevalence of osteoporosis and osteopenia among patients with hip osteoarthritis undergoing THA and to establish the influence of osteoporosis/osteopenia on the choice of implants and on the restoration of the joint function after the surgery. Osteoporosis and osteopenia are manifested in 21–32 % patients undergoing hip arthroplasty. Low bone mass may be a cause of intraoperative (periprosthetic hip fractures) and postoperative complications. In patients with low bone mass bone remodeling with an increased resorption and inhibition of bone formation around hip components can lead to increasing of its micro-movements, the formation of fibrous tissues, and diminution of implants survivorship. In patients with normal bone mineral density (BMD) also the loss of bone tissue around the acetabular cup can occur; it can occur up to 20–60 % in the first three years post operation, which can lead to the cup instability. But the dynamics of changes in bone tissue around the acetabular component in patients with osteoporosis/osteopenia is nowadays poorly understood. We suppose that porous acetabular components have advantages in patients with low BMD. Due to the elastic modulus which is closely similar to cancellous bone, as well as the corresponding porosity, which facilitates osteointegration and gives a reliable secondary biological fixation of the acetabulum. Rehabilitation and restoration of kinematic and support function of the hip joint after arthroplasty is an important issue for patients with low BMD. Gait disturbance can persist 12 months after surgery. One of the reasons is the weakness of the muscles of the femur. Rehabilitation after total hip arthroplasty leads to faster recovery, but particularities of rehabilitation in patients with low bone mass are not fully studied.

Awareness of postmenopausal women about the risk of osteoporosis (literature review)

Olena Vyrva — 2021-12-28

Osteoporosis is a systemic disease of the skeleton, characterized by a decrease in bone mass and qualitative changes in bone structure, which lead to increased fragility and increased risk of fractures. Objective. To analyze the published information on the awareness of women in the United States, Europe and Ukraine about the risk of osteoporosis in the postmenopausal period. It is estimated that in general, about 50 % of postmenopausal women in most countries do not receive osteoporosis drug therapy and are unaware of the different treatment options for disease, 25 % associate it only with femur and spine fractures. Surveys have found that most respondents without a diagnosis of osteoporosis have had one or more risk factors for developing it, but osteoporosis is often not diagnosed until one or more fractures have occurred. That is why orthopedists-traumatologists, who most often face pathological fractures on the background of osteoporosis, have proposed special protocols for the timely diagnosis and treatment of fragile fractures. Treatment standards require women aged 65–85 who have suffered a fracture to be screened and receive osteotropic therapy for 6 months. However, the diagnosis and treatment of osteoporosis for 6 and 12 months after femoral neck fractures received only 17–23 % of respondents. Misconceptions about the causes and consequences of postmenopausal women fractures, combined with insufficient information from health professionals, point to the low level of attention of the population and the health care system in general to osteoporosis in all countries. The incidence of fractures in women was 3.1 higher than in men and progressively increased the age 50+. For high risk fractures women due to osteoporosis ensuring their osteoporosis awareness is a critical preventive point. This is essentialy can influence positive changes in the fight against osteoporosis around the world. Osteoporosis is a systemic disease of the skeleton, characterized by a decrease in bone mass and qualitative changes in bone structure, which lead to increased fragility and increased risk of fractures. Objective. To analyze the published information on the awareness of women in the United States, Europe and Ukraine about the risk of osteoporosis in the postmenopausal period. It is estimated that in general, about 50 % of postmenopausal women in most countries do not receive osteoporosis drug therapy and are unaware of the different treatment options for disease, 25 % associate it only with femur and spine fractures. Surveys have found that most respondents without a diagnosis of osteoporosis have had one or more risk factors for developing it, but osteoporosis is often not diagnosed until one or more fractures have occurred. That is why orthopedists-traumatologists, who most often face pathological fractures on the background of osteoporosis, have proposed special protocols for the timely diagnosis and treatment of fragile fractures. Treatment standards require women aged 65–85 who have suffered a fracture to be screened and receive osteotropic therapy for 6 months. However, the diagnosis and treatment of osteoporosis for 6 and 12 months after femoral neck fractures received only 17–23 % of respondents. Misconceptions about the causes and consequences of postmenopausal women fractures, combined with insufficient information from health professionals, point to the low level of attention of the population and the health care system in general to osteoporosis in all countries. The incidence of fractures in women was 3.1 higher than in men and progressively increased the age 50+. For high risk fractures women due to osteoporosis ensuring their osteoporosis awareness is a critical preventive point. This is essentialy can influence positive changes in the fight against osteoporosis around the world.

Allograftinf in the case of revision hip arthroplasty at aseptic loosening of the acetabular component

Volodymyr Filipenko — 2021-12-28

Bone loss and significant acetabular defects remain one of the major problems in revision hip arthroplasty. A promising material for grafting of bone defects can be materials based on allogeneic bone after various types of processing, combining optimal properties for osteoregeneration. Objective. To analyze the results of acetabular reconstruction with bone implants «OMS-A» in the case of revision arthroplasty. Methods. The results of examination and treatment of 57 patients (33 women and 24 men) were analyzed. The patients’ age at the time of hospitalization ranged from 24 to 81 years. Patients were diagnosed on the basis of a combination of clinical manifestations of the disease, laboratory data, radiography, computed tomography with 3D reconstruction. According to the classification of W. G. Paprosky, the largest group consisted of type I defects — 25 patients (44 %), II — 13 (23 %), III — 19 (33 %). For the reconstruction of the acetabulum, 21 patients (37%) we used fragmented cortical-cancellous pieces (CGP), 28 (49 %) — volumetric bone implants (OCI), 8 (14 %) — a combination of CGP and OCI. All patients underwent revision hip arthroplasty with an anterolateral approach according to Harding. The resulting acetabular defect was tightly filled with an allografts. Results. X-ray and G. A. Gie results were assessed as good in 36 patients (63 %), satisfactory — in 14 (25 %). The manifestations of infection associated with the use of bone implants «OMS-A» have not been determined. The necessity for repeated surgery in order to restore the acetabulum occurred in 7 patients (12 %). Conclusions. Тhe clinical efficiency of bone implants «OMS-A» for the reconstruction of the acetabulum according to the classification of W. G. Paprosky was: with type I defect — 92 %; with type I and type defect — 92.3 %; with type II and type defect — 78.9 %.

Experimental study of the strength of hip endoprosthesis elementsmade by 3D printing

Mykola Korzh — 2021-12-28

Тhree-dimensional printing of porous titanium implants is a promising area of additive production in orthopedic surgery. The question remains relevant mechanical strength and durability of such device. Objective. Determine in the experiment the strength of the stem, the neck of the stem and the cups of hip endoprosthes made by 3D-printing from titanium alloy, and compare with a similar rate of serial implants. Methods. The strength of the stem and cups of hip endoprostheses made by 3D-printing on an Arcam printer from titanium alloy TI6AL4V was studied. Serials hip implants made form titanium alloy. There were 3 samples of hip endoprostheses for each test. Stems of endoprostheses were examined on the TIRATEST-2300 machine under the conditions of loading on a three-point bend, the necks of stems were examined under the influence of combined load on the bend with a shift, the cups were examined on compression. Results. Tensile strength in the case of three-point bending of the stems of implants made by mechanical processing and 3D printing did not have any differences significantly (p = 0.146) and was (1480.62 ± 62.50) MPa and (1396.88 ± 50.90) MPa, respectively. The necks of stems of serial endoprostheses and made by 3D-printing had a comparable limit of strength — (408.61 ± 1.25) MPa and (403.49 ± 8.99) MPa, respectively (p = 0.384). Under the conditions of compression tests of cups of endoprostheses all the samples withstood a load of 98.0 kN without any signs of destruction. Conclusions. The values of the tensile strength of the components of serial implants and those made by 3D-printing did not differ statistically significantly. Thus, 3D-porous structures have significant potential for creation of elements of hip endoprostheses.

X-ray examination of bone density in allograft-prosthesis composite (іn vivo experiment)

Oleg Vyrva — 2021-12-28

Objective. To determine the most effective method of segmental bone allograft fixation during allograft — prosthesis composite based on searching the x-ray density of bone tissue at experimental animals. Methods. The work was performed on 28 laboratory white male rats (age 5 months, weight 350–400 g), which were divided into 2 groups, 14 animals in each group. All animals underwent allograft-prosthesis composite hip replacement: after transverse osteotomy of the femur in the 1st group of animals, after step cut osteotomy in the 2nd group. Animals were withdrawn from the experiment after 3 and 6 months after operation. The optical bone regenerate density in the contact of allograft and the recipient’s bone areas and the cortical layer of the recipient’s bone below the distal end of endoprosthesis were measured on Х-ray images. Results. Optical bone regenerate density after 3 and 6 months after operation had significant difference between recipient’s bone in both groups (p < 0.05). There was no statistically significant difference (р = 0.373) of recipient’s bone density depending on using different osteotomy types on the cutoff date of the study (6 months). But bone regenerate got more density after step-cut osteotomy ((216 ± 26) units) which was significantly (p = 0.001) compare to transverse osteotomy ((161 ± 19) units). Conclusions. The using of long bone allograft-prosthesis composite with implementation a step cut osteotomy contributes to the most rapid increase in bone regenerate density than transverse osteotomy. This is due to the achievement of better stability during fixation of the bone allograft and the bone of the recipient due to the step cut osteotomy, which contributes to fast regenerative process.

Algoritm for surgical method of treatment at spine tumors

Volodymyr Radchenko — 2021-12-28

The main goal of the primary and metastatic spinal tumors treatment are local control, preservation of weight bearing and protective function of the spine with improvement patients quality of life. Objective. To develop mathematical algorithm for selection of surgical treatment volume in spinal tumor cases. Methods. Spinal instability neoplastic score supplemented with additional signs such as ASIA scale, tumor type, epidural spinal cord compression scale by Bilsky, local kyphosis, adjacent vertebras lesions was used for the model developing. Point system that takes 9 signs has been tested in 237 metastatic spinal tumor patients. Cluster analysis for the decision tree development was applied. Results. It has been confirmed the hypothesis about decreasing surgical volume with higher SINS score. But, it was not defined which boundary indicator to define specific volume of the surgery is precise. Two patients clusters were defined, that have differences in the surgical volume, degree of tumor lesion, epidural compression and local kyphosis, neurological symptoms. Cluster I included 115 patients with higher score (severe condition, higher volume of the surgical intervention) in comparison with 122 patients from the cluster II. Decision tree for the surgical volume selection in spinal tumor patients has been developed. Conclusions. The most important signes that affect the choice of the surgical volume selection are: neurological symptoms, type of vertebra lesion, spinal stenosis and type of the surgery (radical vs palliative). Application of the developed decision tree in the clinical practise gives the opportunity to select appropriate volume of the surgical intervention in spinal tumor patient with the high significance level that provides satisfactory treatment outcome.

Mechanical and structural peculiarities of tibia shaft nonunion and its influence for treatment

Olexii Popsuishapka — 2021-12-28

Objective. To study internal tensions in bone and soft tissues of shin at normal condition and at isolated tibia nonunion, the range of fragments displacement, callous structure and to sustain the conception of treatment. Methods. Due to finite element method we created three models: I — anatomic norm; II — transverse defect of 5 mm height on the middle-lower 1/3 border filled with collagen, III — as the second model with empty fibula defect of 10 mm height on the same level 2/3–1/3 border. In 45 patients with tibia shaft nonunion (term 4–18 months) we made resection of fibula fragment 10–15 mm on the same level of tibia nonunion with apparatus of external fixation. We studied the linear bone fragments displacement and callous structure. Results. At the axial loading in normal condition (I model) there was asymmetry of tensions in the lower part of shin bones on the lateral and medial sides. At the II model vertical tensions in the lower part of tibia decreased on the medial side up to 69 % and on the lateral side — up to 44 %, tensions increased in 5 times on the lateral side of fibula. The tangential stresses increased 3 times, their resulting force vector changed the outward direction and increased 7 times. In the III model tension distribution on the tibia surface became close to normal situation. In case of tibia nonunion there was fibrous-cartilages tissues, appeared because of transverse tensions. Patients walked with weight bearing from the first days after surgery, in 95.6 % bone fragments consolidation happened in 3.5–4 months. Conclusion. Excluding of fibula from bearing function due to its 10–15 mm resection on the level of nonunion will normalize the vector of loading in the tibia fragments and fibrous-cartilage regenerate and leads to it ossification.

Efficiency of concentrated bone marrow aspirate combination with temporary fixation of the scaphoid-trapezius-trapezoidal joint in Kienbeck’s disease

Sergey Tymochenko — 2021-12-28

Method of concentrated bone marrow aspirate (BMAC) injection into aseptic bone necrosis of different localizations are described in the literature, however, without demonstrating structural and functional results for Kienbeck’s disease. Objective. To establish functional and radiological changes at injection of concentrated bone marrow aspirate into lunate bone in combination with scaphoid-trapezoid-trapezius joint temporary fixation in patients with idiopathic lunate bone necrosis. Methods. The procedure was performed in 11 patients. Age 18–46 years (28,9 ± 9,5) 6 women, 5 males. Kienbeck's disease stage II — 4 patients, IIIa — in 2, IIIb in 5 patients. Bone marrow aspirate concentration from the iliac bone was obtained using Arthrex-Angel technique, injection of 2–3 ml of the concentrate with intraosseous needle under X-ray control into the focus of aseptic necrosis of the lunate bone, STT-fixation of the wrist joint in the position of rotational correction of the scaphoid. Immobilization followed for 2 months, than removal of the K-wires and rehabilitation. X-ray, CT control and DASH testing before the procedure and in a year. Results. Five patients (45 %) had a distinct positive clinical and radiological dynamics, definite positive changes on CT (pathological fracture consolidation, lunate bone remodeling), as well as DASH scale improvement, maintenance of wrist joint radiometric parameters and an increase in strength and range of motions in the wrist. Four patients had no significant dynamics, and in two patients there was a distinct decline in function, advance lunate bone destruction, and an increased wrist joint instability. Conclusions. The technique requires advance revision of the conditions under which it demonstrates its effectiveness. Today it can be recommended in addition to other surgical procedures (shortening of the radius, STT arthrodesis), which have more predicted effectiveness.

The results of polypropylene mesh application at anterior cruciate ligament reconstruction

Maxim Golovakha — 2021-12-28

Anterior cruciate ligament (ACL) repair remains one of the most common surgeries in orthopedics and traumatology. The evolution of the ACL repair technique continues, new fixators appear, and the position of the graft, its shape and size are modified. Semi-tendon and gracilis muscle (STG) grafts are the most common used due to low-trauma and technically simple method of obtaining. Its disadvantage is a long period of intratunnel incorporation, one of the ways of this acceleration is the implantation of a polypropylene mesh. In an experiment on rabbits, we proved its positive effect. Objective. To develop a method of improving the intratunnel incorporation of STG-graft at ACL repair of the knee joint using polypropylene mesh. Methods. Results of 75 patients were analyzed. The study group consisted of 35 patients who underwent surgery during 2018–2019 using polypropylene mesh, comparative group — 40 patients who had surgical treatment in 2017. Evaluated demographic data, pre-operation period, recovery functions, complications rate, data of KOOS and IKDC scales. Results. Non-specific data of the inflammatory process (CRP and ESR) did not change significantly in patients with inserted polypropylene mesh. They did not have more pronounced pain after surgery, there were less cases of reactive synovitis with significantly minimized the number of the knee joint punctures. Restorationof knee function was faster, and early weight bearing of the leg allowed up to 6 months. Better results by the KOOS and IKDC scales received after surgery. Conclusions. Implantation of polypropylene mesh around the intratunnel part of STG-graft at ACL repair surgery did not increase the complications rate and allowed to improve the dynamics of limb function recovery up to 6 months after surgery.

Helal and Weil osteotomy in the treatment of metatarsalgia in the conditions of the transverse deformity forefoot

Dmytro Prozorovskiy — 2021-12-28

Transverse-spread deformity of the forefoot with hallux valgus is found in 75 % of women in the population. At the same time, structural and functional changes in the foot lead to redistribution of load during walking between the heads of the metatarsal bones and the occurrence of metatarsalgia. Objective. To conduct a comparative analysis of the results of surgical treatment of metatarsalgia in patients with transverse-spread deformity of the forefoot after performing corrective osteotomies Helal and Weil. Methods. The study is based on the surgical treatment of 42 (64 feet) patients with metatarsalgia due to transverse deformity of the forefoot. Patients were divided into two groups depending on the surgical method of eliminating metatarsalgia: in the first performed an osteotomy Helal (32 cases), in the second — Weil (32). The mean follow-up of patients in the first group was 19.8 months, the second — 21.5 months. Results. According to the assessment of AOFAS scale, the result of treatment of metatarsalgia and transverse deformity of the forefoot in patients of the first group was 89.4 points, the second — 83.1 points. Regression of metatarsalgia in patients of the first group was recorded in 29 (90.6 %) cases, the second — in 26 (81.3 %) (criterion χ2 = 1.16; p = 0.28). Recurrences of metatarsalgia were observed in patients after the use of both Helal and Weil osteotomies and accounted for 6.3 and 9.4 % of cases, respectively. The occurrence of transfer metatarsalgia of the anterior foot was registered in 3.1 % of cases after Helal osteotomy, in 9.4 % — Weil osteotomy. Conclusions. Surgical treatment of metatarsalgia caused by transverse deformity of the forefoot with the use of corrective osteotomies Helal and Weil allowed to achieve positive results in 90.6 and 81.3 % of cases, respectively. These surgical techniques can be successfully used for the treatment of metatarsalgia of the forefoot with a violation of the metatarsal parabola.

Principles of pharmacological therapy of comorbid diseases in patients with orthopedic pathology

Nataliya Prytula — 2021-12-28

Comorbidity is one of the leading problems in clinical practice. Interaction of diseases, involutive processes of natural aging and pathomorphosis of drugs significantly change clinical picture and course of the disease, the nature and severity of complications, limit or complicate the treatment and diagnostic process. Objective. To analyze current information on available recommendations for the treatment of comorbid diseases in patients with orthopedic pathology. Materials. An overview of the recommendations of the European Society of Cardiology, European Society of Hypertension, European Society for Vascular Surgery, Ukrainian Gastroenterological Association and American Diabetes Association for the period 2017–2019 is presented. Results. The first stage in the treatment of arterial hypertension is the lifestyle optimization, and the initial therapy of most patients with hypertension should be a combination of two drugs. Management of patients with lower extremity artery disease is associated with an increased risk of any cardiovascular events. Therefore, preventive measures are of particular importance. Gastropathies induced by non-steroidal anti-inflammatory drugs are widespread in orthopedic practice. In the prevention of their occurrence, a well-chosen gastroprotective therapy is important. Once the diagnosis of diabetes is made, lifestyle modification should be started immediately along with the start of pharmacotherapy. Metformin remains the first-line drug for treatment, drugs of other groups can be prescribed when there are contraindications to metformin. In the treatment of neuropathic pain in diabetes or pre-diabetes, only pharmacological treatment strategies are effective. Conclusions. In most cases, a number of comorbidities with timely diagnosis and compliance with the algorithms of medical care can be corrected and treated. Properly selected conservative therapy can reduce the risk of peri- and postoperative complications.

The clinical significance of posttraumatic malunions of lower extremities long bones

Kostiantyn Romanenko — 2021-12-28

The treatment of patients with long bones fractures, despite the development and improvement of treatment methods and fixing devices in certain cases can lead to unwanted results such as a formation of posttraumatic deformity — malunion. Objrctive. To provide modern approach regarding clinical significance and necessity of correction of secondary changes in moving segment that appeared as a result of formation of lower extremity malunion. Methods. The results of treatment of 196 patients were analyzed (89 men, 107 women; age from 19 to 76 years). All the patients had the malunion of the long bones of lower extremities and have been treated from 2004 to 2019 years. Analysis of special literature and own experience was performed to identify the effects of malunions. Results. It was shown that formed malunion lead to tangible shortening of injured extremity, joints overloading and muscle function violation. Malunions are compensated by the means of changing in movement arch and gait pattern. While it is noted that unphysiological load on joints, that predispose the development of degenerative changes, and muscle fatigue and pain are the results of muscle work to support inadequate position of the joints. Malunions on the level of femur and tibia became clinically significant on condition of severe restriction of extremity function, thus its restoration is the goal of treatment. Different cases of malunion development were considered: varus, valgus, antecurvatio, recurvatio, translation, torsion malalignment. Clinical examples are given. Conclusions. Clinical significance of different malunions depend upon their localization, presence and severity of secondary changes, status of injured extremity and physical condition of the patient, his or her individual demands. Secondary changes can play the role of compensation and spread on injured extremity, sacro-iliac joints, lumbar spine, contralateral extremity. The assessment of secondary changes of musculoskeletal system is mandatory for the patients with malunions during the planning of treatments measures. The indication for surgical correction should be defined with taking into consideration possible development of malunion complications in future.

Mykhailo Ivanovych Sytenko (to the 135th anniversary of his birth)

Inna Golubeva — 2021-12-28

The article is dedicated to the 135th anniversary of the birth of prof. MI Sitenko. November 2020 marked the 135th anniversary of the birth of the outstanding orthopedic traumatologist and health care organizer, corresponding member of the Academy of Sciences of the Ukrainian SSR, Professor Mykhailo Ivanovych Sytenko. The merits of Professor MI Sytenko are difficult to overestimate. His name is associated with the formation and development of orthopedics, traumatology, prosthetics and rehabilitation care in our country. With his assistance, a wide state network of institutions was created, which provided the population with highly qualified orthopedic-traumatological and prosthetic-orthopedic care, and carried out rehabilitation measures.