On the base of experience in treatment of 646 patients with polytrauma (1995—2004) the necessity to use damage control was for the treatment of long bone fractures was proved. The principle of damage control assumes subdivision of surgical treatment of patients with severe polytrauma into two steps. At the I st step only minimum traumatic procedures were performed. At the 2 nd step major surgical interventions were performed. According to trauma severity and individual response all patients were divided into four groups: stable, borderline, unstable and critical. In patients with stable and borderline conditions major surgical procedures did not result in aggravation of patient's state, therefore one-step surgical treatment was used. In patients with unstable and critical conditions no surgical methods of fixation of long bone fractures were applied at the I st step. In the last two groups definitive fracture fixation were performed at the 2' d step within 4—14 days after injury. The application of damage control allows improving the results of treatment, reducing the rate of complication and lethal outcomes in patients with severe polytrauma.
The aim of the study was to elaborate complex therapy for correction of intraoperative blood loss and posthemorrhagic anemia following trauma and orthopaedic surgery in children. Seventy-six patients with orthopaedic pathology, 1—18 aged, were operated on. Blood loss volume was over10% of CBV. In 46 patients (main group) reinfusion of washed erythrocytes was performed when planning operative blood loss exceeded 25% of CBV. In patients over 7(34 patients) preoperative stimulation of erythropoiesis by erythropoietin in combination with peroral ferric drugs as well as pre- and intraoperative blood intake with subsequent it utilization were carried out. At postoperative period all patients of main group took Venifor i.v. to correct ferric deficit. In control group (30 patients) intraoperative blood loss and postoperative anemia were corrected by infusion of donor blood. Use of complex measures directed to support the hemopoietic function and correct the number of functionally active erythrocytes (main group) allowed to stabilize oxygenous blood volume and decrease the hemolysis degree in patients after surgical intervention.
Total knee arthroplasty in destructive sequelae of tuberculosis and nonspecific gonitis was performed in 51 patients. Indications to total knee arthroplasty were presented. Scheme of pre- and postoperative antibacterial therapy was elaborated. At 4.5 year follow up good and satisfactory results were achieved in 91.9% of cases.
During the period from 2002 to 2004 fifty six patients with tibial condyles fractures (57 fractures) were operated on. In 41 (71.9%) cases osteosynthesis was performed after arthroscopic diagnosis. In 38 (66.7%) patients with fractures of types B2, ВЗ, C2 and C3 by AO classification bone defect plasty using porous nikelide-titanum implant was performed. In 8 (14.0%) patients with fractures of type B2 porous implant was used to fix the lifted tibial plato without additional metal fixative. Depending on the type of fracture cannulated screws (17 fractures, 29.8%), AO supportive plates (31 fractures, 54.4%), staple (1 fractures, 1.8%) were applied. Postoperative immobilization was performed by hinged orthesis with adjustable angle of movements and plaster splint. Treatment results were observed at terms from 6 months to 2 years in 47 patients (48 fractures). Excellent result was achieved in 43.8%, good — in 47.9%, satisfactory — in 8.3% of cases.
The experience in surgical treatment of 36 children with various forms of congenital malformation of the tibia (38 extremities) is presented. Use of complex surgical treatment enabled to create the optimum static and dynamic conditions for the extremity function with preservation of all its segments. In all forms of tibia malformation manifestation the foot deformities and flexion contractures have been corrected in early age (conservatively after 1 month, surgically — from 6—10 months).
The experience in surgical treatment of 33 patients with patella dislocation of various etiology and severity degree (38 dislocations) has been summarized. The methods of preoperative examination and indications for the application of various treatment methods has been described. Two methods of patella dislocation elimination were used, i.e. myofascioplasty and reconstruction of the knee joint extension apparatus with transposition of the patellar ligament medially. When indicated those methods were combined with correcting osteotomy, closed elimination of knee joint flexion contracture and shin subluxation using Ilizarov device. Postoperative fixation was performed with plaster bandage and various arrangments of Ilizarov apparatus. In the second case the possibility of early knee joint movements was provided and markedly faster restoration of joint functions was noted. Good results were achieved in 36cases, satisfactory results — in 2 cases.
Biomechanic and innervation structure of gait in patients with sequelae of cervical spine and spinal cord injury was considered. It was shown that the main indices of gait (mean speed of movement, rate, step length) had deteriorated, stability during the gait (increased duration of bearing and double-bearing phase) was decreased, amplitude of angular movements in leg joints was decrease, reduction and deformity of the components of main vector of bearing reaction took place. Electric activity of the majority of lower extremity muscles was decreased and its maximum was translated to the right along the time axis. It was shown that the shift of muscle activity maximum was caused by translation of vertical load into the middle part of bearing phase on account of use of an additional support (stick, crutches). It was noted that deterioration of all gait indices especially the decrease of mean speed of movement depended on aggravation of the pathology. Biomechanic and neurophysiologic interpretation of data obtained was presented.
In 11 patients with femoral neck fractures closed compressive osteosynthesis was performed using the device designed by N. V. Belinov. Elaborated operative technique provides for insertion of pins, which branched off conically between the bone fragments under compression. Device design and technique of its application are described. At 1 year follow up 6 patients had good results (complete restoration of hip function), 4 patients — satisfactory and 1 patient — unsatisfactory.
Ultrasound examination of 897 patients with injuries and pathology of striated muscles was performed. Ultrasound criteria of muscle diseases and injuries were detected. The evaluation of diagnostic efficacy of ultrasound data relative to data of invasive methods (surgical interventions and diagnostic puncture) was performed. Ultrasound examination of striated muscles is showed to be a highly specific and sensitive method for diagnosis of traumatic muscle tissue lesions. Ultrasound allows to assess the hematoma volume, injury degree of muscle and diastasis length between muscle fibers; regeneration stage and developed scar of injured muscle as well as to detect cystic changes, ossificans myositis, hernia and tumor-like diseases.
Analysis of natural causes of knee arthrofibrosis development after arthroscopic ACL reconstruction and its prevention is presented. Classification of arthrofibrosis basing on the arthroscopic, clinical and MRT examination results is given. Clinical-arthroscopic manifestations and morphologic picture of various forms of arthrofibrosis, particularly "infrapatellar contracture" and «cyclops» syndromes, are considered in details. Preventive recommendations are worked out.
A protocol for gradual use of nonsteroid anti-inflammatory drugs with mainly analgetic action (Ketorol) and mainly anti-inflammatory action (Nise) are suggested for complex treatment after operations on loco-motor system. It is shown that the protocol (applied in 38 patients) allows to cup off both pain syndrome and local inflammatory reaction in the operation zone more effective as compared with the routine drug therapy (40 patients — control group).
Method of the wrist joint «folk» reconstruction using microsurgical grafting of 2 nd metatarsal bone has been suggested for the reconstruction of distal forearm in children with malformation or absence of the radius and talipomanus which has developed as a result of the abovementioned pathology. The graft includes the growth zone and this prevents the deformity recurrence.
In treatment of 87 patients (main group) with diaphysial shin fractures new techniques and devices for optimization of transosseous extrafocal osteosynthesis by Ilizarov were applied. All techniques and devices, i.e. devices for the perfection of Ilizarov apparatus stability, for bone fragment reposition, console compression arrangement for extrafocal osteosynthesis in comminuted fractures, devices for damper compression of bone fragments, for prevention of lower extremity edema at extrafocal osteosynthesis, for provision of early axial loading in Ilizarov apparatus, for activization of osteogenesis using asymmetrical dynamic compression were elaborated by the author. Control group (108 patients) was treated by traditional Ilizarov technique. Treatment results were assessed at terms from 4 months to 2 years. Data of clinical, X-ray and functional examinations as well as terms of fracture healing, duration of hospitalization and terms of working ability restoration were better in the main group as compared to the control one. In the main group good results were achieved in 47.1%c, satisfactory — in 49.4%, poor — in 3.5% of cases, in control group — 30.6%, 63.0%, 6.4%, respectively. Author believes that further perfection of Ilizarov technique is reasonable.
Congenital vertical position of the talus is the main component of congenital flat-valgus foot deformity in children that determines the clinical manifestation of this pathology. The earlier the patient is hospitalized the better correction result is achieved. In spite of the diagnosis simplicity the patients are not timely referred for surgical correction. During the period from 1994 to 2003 eighteen patients, aged from 8 month to 14 years, with congenital flat-valgus foot were operated on (25 surgical intervention) at Russian Pediatric Clinical Hospital (Traumatologic and Orthopaedic Department). Kumar-Cowell-Ramsey operation was performed in children under 5 years. In children aged 5-12 Coleman operation was used and in children over 12 triarticular arthrodesis was performed. Long-term results were assessed in 15 patients (22 operations) at terms from 1 to 5 years. Good results were achieved in 68% of cases, satisfactory — in 28% and unsatisfactory — in 4% of cases.
Correlation between clinical radiologic manifestations and changes of stabilometric data and mineral density of bone tissue in proximal femur was studied. It was detected that displacement of median position of gravity center in frontal plane took place in healthy side and depended on the stage of coxarthrosis. DEXA showed that decrease of mineral density of bone tissue in femoral neck was more significant at the injured side.
Treatment results of 76 patients with combined femur and shin fractures are presented. All patients were treated with transosseous osteosynthesis technique by Ilizarov. It has been shown that the technique enables to perform closed precise reposition of bone fragments, achieve the stable fixation for the whole period of treatment and mobilize patients on 2-3 day after operation. For proper formation of bone regenerate and rigid fragment consolidation it is neces- sary to disassemble the device gradually during the treatment process.