TERRA ORTHOPAEDICA

Surgical Treatment of the Terrible Triad of the Elbow

I.M. Kurinnyi, O.S. Strafun — Wed, 20 Dec 2023 00:00:00 +0200

Summary. The so called “terrible triad” injury of the elbow, which includes a combination of posterolateral dislocation of the forearm with fractures of the radial head and coronoid process, accounts for 10%-11% of all elbow fractures in adults. This type of elbow injury remains difficult to treat and is often accompanied by a high level of complications: instability, contractures, deformable arthrosis, and pain syndrome.

Objective: to assess the effectiveness of surgical treatment of patients with the terrible triad of the elbow, depending on the duration of the injury and the features of osteosynthesis of the coronoid process using certain approaches.

Material and Methods. The surgical treatment of 87 patients with the terrible triad of the elbow was analyzed. The age of the patients was 40.9±2.6 years. The average term of admission to treatment was 5.5±4.1 months after the injury. 59 patients were admitted in less than 30 days and 28 patients were admitted after 30 days. The preoperative examination included X-ray and CT; sonographic and EMG studies were performed if necessary. Surgical treatment consisted of repositioning and osteosynthesis of the coronoid process, osteosynthesis or prosthetics of the radial head, and restoration of the damaged lateral ligaments of the elbow joint. In cases of consequences of injury, in addition, mobilization of the elbow joint was performed, osteosynthesis was supplemented with bone autograft, and damaged ligaments were restored plastically. After the surgery, the elbow joint was immobilized in the extension position of 30-20 degrees. Postoperative rehabilitation begins on the first day after surgery and involves one cycle of flexion and extension during the day from the extension position of 20-30° to flexion position of 100-120°. Immobilization in the extension position of 20-30° is basic and is used in the evening and at night.

Results. The results were evaluated according to the MEPS system in 56±6.2 months. In the group of patients who underwent surgery within 30 days, the MEPS function index was 90.3±2.1 points; when surgery was performed more than 30 days after the injury, statistically worse results were achieved (83.5±2.9 points). We also compared the outcomes of treatment depending on the access to osteosynthesis of the coronoid process. When performing an anterior approach to the coronoid process, the MEPS index was 90.1±3.2 points, which was better than in case of other approaches.

Conclusions. Thus, it has been proven that better results in the surgical treatment of the terrible triad are obtained in the group of patients who underwent surgery up to 30 days after the injury compared to later admission to treatment. The advantages of the anterior approach for grade 2-3 coronoid process fractures have been proven. Our proposed early dosed rehabilitation plays an important role in the treatment of such patients.

Surgical Treatment of Patients with Damage to the Ligaments Holding the Long Head of the Biceps (Pulley Lesion) in Combination with Contracture of the Shoulder Joint

S.V. Bohdan, L.M. Yuriichuk, V.H. Lieskov — Wed, 20 Dec 2023 00:00:00 +0200

Background. Damage to the ligaments holding the long head of the biceps, or Pulley Lesion injuries, are often accompanied by contracture of the shoulder joint.

Objective. The objective of the study was to compare the treatment outcomes of patients with Pulley Lesion injuries and secondary adhesive capsulitis.

Material and Methods. The study included 82 patients with contracture of the shoulder joint and damage to the ligaments holding the long head of the biceps. The patients were divided into 2 groups depending on the extent of surgical intervention: group 1 underwent subpectoral tenodesis and selective capsulotomy of the shoulder joint; group 2 underwent subpectoral tenodesis without selective capsulotomy of the shoulder joint. The function of the shoulder joint was assessed using the Constant Shoulder Score and VAS scales before surgery, at 3 and 6 months after the surgery.

Results. At 3 months follow-up, the average functional result according to the Constant Shoulder Score was somewhat worse in group 2 (14.5±5.2 points) than in group 1 (8.5±6.4 points), p = 0.031. At 6 months follow-up, the average functional result according to the Constant Shoulder Score was 5.1±5.6 points in group 1 and 10.1±4.1 points in group 2 (p = 0.024). At 3 months follow-up, the average VAS score was worse in group 2 than in group 1 and reached 2.81±0.7 points. At 6 months follow-up, the average VAS score in group 2 was also worse than in group 1 (p = 0.051).

Conclusions. Performing selective capsulotomy and subpectoral tenodesis in patients with secondary adhesive capsulitis and damage to the ligaments holding the long head of the biceps (Pulley Lesion injuries) allows us to achieve better functional results both according to the Constant Shoulder Score and the VAS scale at 3 and 6 months after the surgery.

Methodology of Examination of Patients with Osteoarthritis and Aseptic Necrosis of Hip and Knee Joints when Using Regenerative Interventional Technologies

S.S. Strafun, Ye.L. Holiuk — Wed, 20 Dec 2023 00:00:00 +0200

Background. Diagnosis of osteoarthritis of the hip and knee joints, as of today, would seem to be a well-studied issue. Radiography, magnetic resonance imaging, ultrasonography - each of these methods makes it possible to make a diagnosis. At the same time, the use of new methods of treatment of osteoarthritis requires new approaches to its diagnosis.

Objective: to develop a methodology for examining patients with osteoarthritis and aseptic necrosis of the hip and knee joints during treatment with regenerative technologies.

Material and Methods. The material for the study was case histories of 233 patients with osteoarthritis and 58 patients with osteoarthritis of the hip and knee joints. Clinical, laboratory, and instrumental research methods were used.

Results. The methodology of clinical examination of patients when using regenerative technologies is based on filling out quality of life questionnaires. A feature of the methodology of laboratory examination of patients with osteoarthritis and aseptic necrosis of the hip and knee joints when using regenerative technologies is oncological screening in the case of the use of biotechnological products containing MSCs, with the determination of epigenetic markers of the risk of oncogenesis in the form of miRNA.

Conclusions. The methodology of the instrumental examination of patients with osteoarthritis is as follows: the key is an X-ray examination with the establishment of the stage of osteoarthritis according to the Kellgren-Lawrence classification and the subsequent ultrasound and MRI examination in order to assess the extent of damage to the soft tissues of the hip and knee joints, subchondral bone and paraarticular structures. In patients with aseptic necrosis of the hip and knee joints, when using regenerative technologies, the key is an MRI study followed by X-ray and ultrasound examination.

Outcomes of Treatment of Pectoralis Major Muscle Injury

Yu.V. Poliachenko, S.S. Strafun, Yu.A. Kulyk, V.H. Lieskov — Wed, 20 Dec 2023 00:00:00 +0200

Background. The incidence of injuries to the pectoralis major muscle (PMM) is steadily increasing, necessitating an assessment of outcomes of surgical treatment.

Objective: to analyze the outcomes of surgical treatment for PMM injuries.

Material and Methods. The study is based on the analysis of surgical treatment outcomes of 84 patients with PMM injuries who were hospitalized in the Department of Microsurgery and Reconstructive Surgery of the Upper Extremity at the State Institution "Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine" from 2003 to 2023. The patients underwent a rehabilitation program and staged observation for up to 12 months after surgical intervention. The age of the patients ranged from 16 to 62 years; they were divided by age into three groups: up to 25 years, 25-40 years, and 41 years and older. Functional assessment of the PMM was performed using the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), The Score and Subjective Evaluation by Patients with a Pectoral Major Tear (SEPPMT), and the American Shoulder and Elbow Surgeons (ASES) scales at the time of admission, at 6 months, and at 12 months after the surgery.

Results. When comparing baseline functional parameters for acute and chronic PMM injuries using the Quick DASH, SEPPMT and ASES scales preoperatively, patients with acute injuries had worse results than those with chronic injuries (p < 0.001). At 6 months after surgical treatment, the group of patients with acute injuries showed significantly lower scores compared to the group with chronic injuries. At 12 months after surgical treatment, the group with acute injuries had significantly higher scores compared to the group with chronic injuries (p < 0.001), though still corresponding to excellent and good results.

Conclusions. When comparing baseline functional parameters for acute and chronic PMM injuries using the Quick DASH, SEPPMT, and ASES scales preoperatively and at 6 and 12 months after surgical treatment, patients who underwent surgery within two weeks after the trauma demonstrated better results. In cases of chronic injuries, the results were slightly worse, but still were close to good results.

Morphological Features of Wound Canals and Intracranial Pathology in Non-Penetrating Gunshot Craniocerebral Injuries

M.S. Altabrouri, S.A. Usatov — Wed, 20 Dec 2023 00:00:00 +0200

Background. Non-penetrating craniocerebral trauma in modern warfare, according to our data, accounts for up to a fifth of all gunshot wounds of the skull and brain in armed conflicts at the end of the last century and the beginning of the current century. It is a complex problem of military field surgery, first of all from the point of view of solving an important task of the medical services of the warring parties – restoring the maximum number of wounded. The study of pathomorphological wound channels in various types of gunshot non-penetrating craniocerebral injuries gives opportunities for the development of adequate options for access during surgical treatment.

Object: to reveal the morphological features of wound canals and internal cranial injuries in gunshot non-penetrating craniocerebral injuries for optimal planning the primary surgical treatment of the wound.

Material and Methods. Study and analysis of morphological features of wound canals and intracranial pathology in 155 non-penetrating gunshot craniocerebral injuries of the military who underwent surgical treatment in the 2nd and 3rd level healthcare institutions during the war in 2014-2020. The morphology of wound canals and intracranial injuries were studied based on the laws of wound ballistics, clinical data, and computed tomography data.

Results. The largest proportion of non-penetrating gunshot wounds is perforated and depressed fractures (39.9%); perforated fractures with penetration of a fragment to the inner plate of the bone account for 20% and incomplete (to the bone) make up 5.8%. Among blind non-penetrating wounds, single ones prevail (65.2%). More often, they have a cylindrical blind canal. Subarachnoid hemorrhage, brain congestion, and very rarely epidural hematoma (one case) are found in almost all perforated bone fractures. A more complex pathomorphological structure is present in multiple non-penetrating gunshot wounds. At the same time, only one fragment causes a depressed skull fracture. Large and small wound canals can be distinguished by width. The latter do not damage the bones and do not require surgical treatment. This type of injury is accompanied by a subarachnoid hemorrhage in 78% of cases and by brain congestion near the fracture in 43% of cases. Tangential injuries occur in 21.9% of injuries; they have a grooved elongated shape. The bottom of these wounds are linear and compressed fractures. Rarely, subdural and intracerebral hematomas are formed in the projection of the fracture. All non-penetrating injuries are accompanied by small brain congestion of the I-II degrees and subarachnoid hemorrhage. Epidural and intracerebral hematomas can rarely occur with blind non-penetrating cranial injuries.

Conclusions. Non-penetrating multiple fragmental injuries are accompanied by the greatest soft tissue damage. In case of blind wound canals, there are incomplete perforated and perforated-depressed skull fractures; linear and depressed fractures occur in tangential canals. Regardless of the type of wound canals in the brain, there are small congestions (hemorrhages) and subarachnoid hemorrhage. In rare cases, epidural and intracerebral hematomas are formed. Subdural hematomas, sometimes combined with intracerebral hematomas, are found in tangential non-penetrating wounds. Projectiles in tangential wounds do not cause molecular shock and do not lead to secondary necrosis, therefore, it is not necessary to cut the edges of the wound during the primary surgical treatment.

Modern Approaches to MRI Diagnostics of Forefoot Pathology (Literature Review)

K.A. Radchenko, O.G. Haiko, R.V. Luchko — Wed, 20 Dec 2023 00:00:00 +0200

Summary. The problem of pain in the forefoot is extremely relevant in the medical and social spheres. Diseases and injuries of the foot account for 6-12% of the total number of all injuries and diseases of the musculoskeletal system. The article is devoted to the main diagnostic capabilities of magnetic resonance imaging (MRI) for pathology of the forefoot, determining the indications for examination of the patient and protocols for examining the foot.

Why are Joint Replacement Registries Needed? Part 2. Overview of Several National Registries of Knee Arthroplasty

I.M. Zazirnyi — Wed, 20 Dec 2023 00:00:00 +0200

Summary. Joint replacement registries are well established and have an important impact on decision making and clinical practice. The objective of this article is to review orthopedic registries to examine aspects of patient demographics, implant use, and revision outcomes in relation to knee replacement surgery. Six best known national arthroplasty registries with more than 10 years of data were selected for a review. Despite the geographic diversity, the demographics of patients referred for surgery and subcategories of surgeries were remarkably similar. For a cemented total knee replacement, minimally stabilized devices have been preferred in most countries, and a revision-free result can be expected in more than 94% of cases after 10 years. Partial replacement (lateral lateral or medial unicompartmental) was used in 6% to 15% of primary cases and had higher revision rates than total replacement, but had lower postoperative mortality and fewer infectious complications. Patellofemoral replacements are used in 1% or less of cases and have a high revision rate.

Reasons for the Variability of Rehabilitation Programs and the Perspective of the Standardized Guidelines Development for Patients after Anterior Cruciate Ligament Reconstruction

Wed, 20 Dec 2023 00:00:00 +0200

Summary. The following factors influence the choice of rehabilitation program after anterior cruciate ligament (ACL) reconstruction. Surgical factors: peculiarities of the tunnels drilling, method and quality of graft fixation, presence and type of additional distal fixation, as well as the presence or absence of additional reinforcement, graft diameter, graft material and quality, graft suturing method, type of ACL repair (single- or double-bundle), and other elements of the surgery. Patient factors: compliance, psychological readiness to move on to the next phase of rehabilitation, goals and objectives set by the patient; age, type, and level of activity and physical condition of the patient; motivation, expectations of the patient, the preoperative experience of the patient in performing rehabilitation exercises, weight and height of the patient, body proportions, in particular of the lower limb segments (different lever lengths), rotational and axial allignment of the lower limb bones, posterior tibial plateau slope, intercondylar notch width and notch roof slope, condition of the anterolateral ligament and other knee joint stabilizers, muscle tone and strength in general and at the time of surgery in particular, range of motion in the knee and adjacent joints. Given the need to consider at least the above factors, there should not be a single rehabilitation protocol for ACL reconstruction. Only close cooperation between the surgeon, rehabilitologist and physical therapist allows for the fastest and safest rehabilitation of such patients. The patient's subjective feelings and their ability to perform specific exercises are not the criteria for deciding to proceed to the next rehabilitation phase. There is a certain limit, determined by the speed of biological processes in the body, which we cannot yet overcome. It is a good practice for the surgeon to fill out a patient's rehabilitation card immediately after the surgery, indicating the exercises, the time they should start, and the allowed loads.