Annotations journal "Polytrauma" 4/2019

Original researches

THE EFFECTIVENESS OF SODIUM DEOXYRIBONUCLEATE IN THE COMPLEX TREATMENT OF VICTIMS WITH SEVERE ASSOCIATED INJURY: A PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED STUDY

Tulupov A.N., Dulaev A.K., Gromov M.I., Pivovarova L.P., Lapshin V.N., Sinenchenko G.I., Nikitin A.V., Fedorov A.V., Markelova E.V., Osipova I.V., Razumova N.K.

Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine,

Saint Petersburg, Russia

Objective – to estimate the effect of deoxyribonucleic acid on the incidence of complications and the duration of treatment, as well as the state of immunity and hematopoiesis in victims with severe associated injury.

Materials and methods. Design is a single-center, prospective, double-blind, placebo-controlled study. 60 patients with severe associated injury who were admitted to the first level trauma center from May, 2016 to May, 2018 were randomized. Inclusion criteria were the age of 18-70, shock of degrees 2-3 with prognosis positive for life and doubtful for surgical treatment. The study cohort included 54 patients (27 in the main group, 27 – in the comparison one). The groups did not differ by gender, age, severity of injury and shock, and treatment techniques. From 1 to 10 days, each patient was injected intramuscularly daily with 5 ml (75 mg) of sodium deoxyribonucleate or 5 ml of placebo. Randomization was carried out with random numbers for determination of the use of one or another series of the drug or placebo.

Results. Sodium deoxyribonucleate activated the leukocyte migration from bone marrow, protein synthesis and cell bactericidal activity. Patients of the main group with developed complications had a shorter duration of anemia compared to the same comparison subgroup (HB < 100 g/l: 7.1 ± 2.1, and 16.0 ± 3.1 days, p = 0.026; HB < 90 g/l: 3.2 ± 1.3, and 7.9 ± 2.1 days, p = 0.044), and hypoproteinemia (total protein < 60 g/l: 8.2 ± 2.2, and 19.5 ± 4.1 days, p = 0.034; total protein <50 g/l: 1.1 ± 0.5, and 5.4 ± 1.6 days, p = 0.009). The number of complications in the groups: the main – 1.6 ± 0.3, comparison – 3.0 ± 0.4, p = 0.014. The duration of treatment in groups: the main group – 32.8 ± 4.1 days, the comparison group – 39.6 ± 6.6 days (6.8 more). One patient died in the main group, and two patients in the comparison group. There were no complications when using the drug.

Conclusion. The use of sodium deoxyribonucleate in the treatment of patients with severe associated injury reduced the number of complications and the duration of hospitalization.

Key words: associated injury; polytrauma; anemia; hypoproteinemia; deoxyribonucleic acid; immunomodulators.

Information about authors:

Tulupov A.N., MD, PhD, professor, chief of associated injury unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Dulaev A.K., MD, PhD, professor, chief of traumatology unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Gromov M.I., MD, PhD, chief of efferent therapy unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Pivovarova L.P., MD, PhD, chief of laboratory diagnostics unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Lapshin V.N., MD, PhD, professor, chief of anesthesiology and critical care medicine unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Sinenchenko G.I., MD, PhD, professor, chief of clinical gastroenterology unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Nikitin A.V., physician of surgery unit 6, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Fedorov A.V., chief of gravitational blood surgery unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Markelova E.V., physician of clinical laboratory diagnostics, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Osipova I.V., candidate of medical science, senior researcher of immunology laboratory, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Razumova N.K., candidate of biological science, senior researcher of anesthesiology and critical care medicine unit, Saint Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia.

Address for correspondence:

Gromov M.I., Budapeshtskaya St., 3, build. A, Saint Petersburg, Russia, 192242

Tel: +7 (921) 322-72-47

E-mail: gromov@emergency.spb.ru

REFERENCES:

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LYOPHILIZED ALLOGENIC GROWTH FACTORS IN TRAUMATOLOGY AND ORTHOPEDICS AS A PROMISING DIRECTION OF REGENERATIVE MEDICINE

Samoday V.G., Starikov A.O., Kalashnikov P.I.

Voronezh State Medical University named after N.N. Burdenko,

Voronezh, Russia

In recent years, the problem of high-energy trauma in world practice has assumed an alarming scale. In a combined trauma, skeletal lesions account for 93 %; 50 % of cases are associated with delayed consolidation of fractures, and the formation of pseudoarthrosis. Therapy and rehabilitation for patients with false joints takes one year or more, which leads to significant economic costs. As a result, there is a need for the development of new technologies that allow us to normalize the regeneration of bone tissue.

Objective – to develop a technique for normalizing osteogenesis in fractures of long tubular bones using a complex of allogenic lyophilized growth factors in an experiment with laboratory rats.

Methods. To solve the tasks in this work, an experimental method was used to model the fracture of the femoral diaphysis in rats (closed osteoclasis). Morphological, radiologic (X-ray of the lesion zone) and histological (with different types of staining) methods of investigation were also used. The authors plan to further use biochemical and immunohistochemical methods. The data obtained were subjected to statistical analysis using a software package using parametric criteria.

Results. Allogenic platelet rich plasma in lyophilized form can stimulate reparative osteogenesis in bone fractures. This is indicated by the analysis of R-graphic features obtained in the experiment, the analysis of histological data, as well as the statistical processing of the obtained material. The terms of consolidation in the experimental group of animals decreased by approximately 10-12 days. Also, an experiment using an allogenic lyophilisate of growth factors did not reveal any side effects. We can state the fact that there is no reaction from the immune system in response to the introduction of allogenic lyophilized growth factors.

Conclusion. Statistical processing of the obtained results suggests that the use of a complex of autogenous lyophilized platelet factors for bone damage is effective.

Key words: growth factors; PDGF; reparative osteogenesis, platelet growth factors.

Information about authors:

Samoday V.G., MD, PhD, professor, chief of traumatology and orthopedics department, Voronezh State Medical University named after N.N. Burdenko, Voronezh, Russia.

Starikov A.O., postgraduate, traumatology and orthopedics department, Voronezh State Medical University named after N.N. Burdenko, Voronezh, Russia.

Kalashnikov P.I., candidate of medical science, assistant of traumatology and orthopedics department, Voronezh State Medical University named after N.N. Burdenko, Voronezh, Russia.

Address for correspondence:

Starikov A.O., Student St. 10, Voronezh region, Russia, 394036

Tel: +7 (906) 673-37-20

E-mail: staricov9066733720@yandex.ru

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Clinical aspects of traumatology and orthopedics

TOTAL HIP REPLACEMENT IN PATIENTS WITH FALSE JOINT OF THE FEMORAL NECK

Markov D.A., Zvereva K.P., Belonogov V.N.

Saratov State Medical University named after V.I. Razumovsky,

Saratov, Russia

False joint of the femoral neck is one of the most common pathologies of the hip joint. Treatment consists of total hip arthroplasty.

Materials and methods. From January 1, 2015 to December 31, 2017, we examined and treated 102 patients with a false joint of the femoral neck. All patients were divided into 3 groups depending on the type of implanted endoprosthesis. Results of the study were evaluated in 3, 6, 12 months after total hip replacement by clinical and radiological methods, VAS, and Harris Hip Score. Statistical data processing was carried out with Microsoft Excel AtteStat 12.0.5.

Results. Total hip replacement in patients with false joints of the femoral neck was characterized as excellent, good and fair results in 95.1 % of cases. Among the complications, early postoperative hematomas and dislocations of the endoprosthesis head were most often recorded. In analysis of the outcomes of surgical treatment with Harris scale, it was found that using of the dual mobility system (group 3) was characterized by obtaining a higher functional result compared to the cementless in the group 1 (Bicon + SL) and hybrid in the group 2 (Muller + Spotorno) types of construction (group 1 – 81 (76– 84) points, group 2 – 82 (78– 85) points, group 3 – 84 (80– 87) points). The greatest number of complications was registered in the 1st and 2nd groups of the study. In 3 rd group, were noted dislocations of the implant head.

Conclusion. Using of the dual mobility system for patients with false joints of the femoral neck allows to obtain a high functional result and to reduce complications level in the postoperative period.

Key words: false joint of the femoral neck; total hip replacement; complications.

Information about authors:

Markov D.A., candidate of medical science, docent of traumatology and orthopedics department, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Zvereva K.P., assistant of traumatology and orthopedics department, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Belonogov V.N., candidate of medical science, assistant of traumatology and orthopedics department, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Address for correspondence:

Zvereva K.P., Grigoryeva St., 23/27, app. 26, Saratov, Russia, 410002

Tel: +7 (937) 977-05-55

E-mail: ksenya.zvereva.91@mail.ru

REFERENCES:

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9. Gismalla NAM, Ivashkin AN, Zagorodniy NV. The advances of use of dual mobility method in total hip replacement. Department of Traumatology and Orthopedics. 2017; 3(29): 82-86. Russian

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Application of calculating the maximum permissible load on the femur after osteosynthesis

Yamshchikov O.N., Emelyanov S.A., Emelyanova N.V.

Derzhavin Tambov State University, Institute of Medicine, Tambov, Russia

After osteosynthesis of proximal femur fractures, the patient’s treatment lasts up to several months, which negatively affects the function of the joints and the entire limb. It is impossible to imagine the correction of the motor regime and the load on the limb without taking into account the degree of consolidation of the fracture, which means that there is a problem of individualization of the motor regime and the loads on the limb after osteosynthesis based on objective numerical data.

Objective – to conduct the analysis of time course of recovery of range of motions in the hip joint after fixation of hip fracture with use of numerical calculation of load to the femoral bone.

Materials and methods. Assessment of the dynamics of the restoration of range of motion in the joints of the lower limb after surgery was performed in two homogeneous groups of 20 patients with hip fractures each. In the main group, a method was used to calculate the load on the limb after osteosynthesis, based on computer simulation data and the degree of fracture consolidation during the period of rehabilitation treatment of interest.

Results. 180 days after surgery, the deficit of range of motion in the joint in the main group was less than in the comparison group by 6.2 %.

Conclusion. Using the method of calculating the maximum allowable load on the limb after osteosynthesis, based on data on the degree of fracture consolidation and computer simulation indicators, allows creating better conditions for patient activation and speeding up the recovery of range of motion in the joints.

Key words: load on the limb; range of motion in the joints; fractures of the femur.

Information about authors:

Yamshchikov O.N., candidate of medical science, head of department of hospital surgery with course of traumatology, Derzhavin Tambov State University, Institute of Medicine, Tambov, Russia.

Emelyanov S.A., docent of department of hospital surgery with course of traumatology, Derzhavin Tambov State University, Institute of Medicine, Tambov, Russia.

Emelyanova N.V., candidate of medical science, docent of department of hospital surgery with course of traumatology, Derzhavin Tambov State University, Institute of Medicine, Tambov, Russia.

Address for correspondence:

Emelyanov S.A., B. Vasilyeva St., 6/55, Tambov, Russia, 392000.

Tel: +7(915)884-23-63

E-mail: cep_a@mail.ru

REFERENCES:

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19. Popkov AV, Aborin SA, Gorevanov EA, Klimov OV. The analysis of the optical density of the X-ray image of the femoral distraction regenerate bone in the process of lengthening of congenitally shortened femur using the technique of bifocal distraction osteosynthesis. Genius of Orthopedics. 2003; (4): 21-24. Russian

20. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of Internal Fixation. Techniques Recommended by the AO Group, Ed. 3. New-York: Springer, 1991. P. 282-299.

Clinical aspects of neuro-surgery

RESULTS OF SURGICAL TREATMENT OF UNCOMPLICATED SUBAXIAL INJURIES USING CORPECTOMY AND TELESCOPIC PROSTHESES: A RETROSPECTIVE COHORT STUDY

Byvaltsev V.A., Sorokovikov V.A., Kalinin A.A., Aliev M.A.

Irkutsk State Medical University,

Railway Clinical Hospital at Irkutsk-Passazhirskiy Station,

Irkutsk State Medical University,

Irkutsk State Medical Academy of Postgraduate Education – the branch of Russian Medical Academy of Continuous Professional Education,

Irkutsk, Russia

Objective – to analyze the results of surgical treatment of uncomplicated subaxial injuries using corpectomy and telescopic prostheses.

Materials and methods. A retrospective study included 75 patients (43 men, 32 women) aged from 28 to 56 (mean age of 32.5 years). Unstable injuries to the lower cervical spine (5 or more criteria on the modified White and Panjabi scales) and E injury severity (ASIA / ISCSI) were diagnosed in all patients. The analysis included the technical features of surgery and the specificity of the postoperative period, clinical data (level of pain in the cervical spine on the visual analogue scale (VAS), subjective satisfaction with the operation on the Macnab scale), instrumental parameters (formation of bone-metal block according to cervical spondylography and computer tomography, degeneration of adjacent segments according to magnetic resonance imaging), the presence of adverse effects. The minimum observation period was 3 years, the maximum – 5.9 years.

Results. A single-level corpectomy was performed in 59 (78.7 %) patients, two-level – in 14 (18.7 %), three-level – in 2 (2.6 %) patients. A persistent significant decrease in pre-operative pain in the cervical spine was observed (from 76 mm to 8.5 mm on average). The percentage of excellent and good outcomes 3 years after surgery was 97 %. The effective fusion in the last postoperative period was registered in 94.7 % of cases. In 12 patients (16 %), perioperative complications were recorded, with 6 cases requiring for revision decompression-stabilizing interventions.

Conclusion. High rates of long-term clinical efficacy and incidence of bone-metal block formation were established with a minimal number of postoperative complications in patients with uncomplicated subaxial injuries after anterior decompression and installation of telescopic prostheses.

Key words: subaxial cervical spine; uncomplicated traumatic injuries; corpectomy; anterior approach; telescopic prostheses.

Information about authors:

Byvaltsev V.A., MD, PhD, professor, chief of department of neurosurgery and innovative medicine, Irkutsk State Medical University; chief surgeon of Russian Railways, chief of neurosurgery center, Railway Clinical Hospital at Irkutsk-Passazhirskiy Station; professor of traumatology, orthopedics and neurosurgery department, Irkutsk State Medical Academy of Postgraduate Education – the branch of Russian Medical Academy of Continuous Professional Education, Irkutsk, Russia.

Sorokovikov V.A., MD, PhD, professor, professor-consultant of neurosurgery center, Railway Clinical Hospital at Irkutsk-Passazhirskiy Station; director of Irkutsk Research Center of Surgery and Traumatology; chief of traumatology, orthopedics and neurosurgery department, Irkutsk State Medical Academy of Postgraduate Education – the branch of Russian Medical Academy of Continuous Professional Education, Irkutsk, Russia.

Kalinin A.A., candidate of medical science, docent of department of neurosurgery and innovative medicine, Irkutsk State Medical University; neurosurgeon, Neurosurgery Center, Railway Clinical Hospital at Irkutsk-Passazhirskiy Station, Irkutsk, Russia.

Aliev M.A., PhD student, department of neurosurgery and innovative medicine, Irkutsk State Medical University, Irkutsk, Russia.

Address for correspondence:

Byvaltsev V.A., Krasnogo Vostaniya St., 1, Irkutsk, Russia, 664003

Tel: + 7 (3952) 63-85-28; + 7 (902) 510-40-20

E-mail: byval75vadim@yandex.ru

REFERENCES:

1. Tasiou A, Giannis T, Brotis AG, Siasios I, Georgiadis I, Gatos H, et al. Anterior cervical spine surgery-associated complications in a retrospective case-control study. J Spine Surg. 2017; 3 (3): 444-459.

2. Joaquim AF, Lawrence B, Daubs M, Brodke D, Patel AA. Evaluation of the subaxial injury classification system. J Craniovertebr Junction Spine. 2011; 2(2): 67–72.

3. Jain V, Madan A, Thakur M, Thakur A. Functional outcomes of subaxial spine injuries managed with 2-level anterior cervical corpectomy and fusion: a prospective study. Neurospine. 2018; 15(4): 368-375.

4. Joaquim AF, Patel AA. Subaxial cervical spine trauma: evaluation and surgical decision-making. Global Spine J. 2014; 4 (1): 63–70.

5. Hong R, Meenan M, Prince E, Murphy R, Tambussi C, Rohrbach R, et al. Comparison of three prehospital cervical spine protocols for missed injuries. West J Emerg Med. 2014; 15 (4): 471-479.

6. Hu R, Mustard CA, Burns C. Epidemiology of incident spinal fracture in a complete population. Spine. 1996; 21(4): 492-499.

7. Harris MB, Reichmann WM, Bono CM, Bouchard K, Corbett L, Warholic N, et al. Mortality in elderly patients after cervical Spine fractures. J Bone Joint Surg Am. 2010; 92 (3): 567–574.

8. Fisher CG, Noonan VK, Dvorak MF. Changing face of spine trauma care in North America. Spine. 2006; 31(11 suppl): S2–S8.

9. Byvaltsev VA, Kalinin AA, Belykh EG. Efficiency of puncture techniques in the treatment of patients with fractures and hemangiomas of vertebral bodies. Clinical Medicine. 2015; (4): 61–66. Russian

10. Byvaltsev VA, Kalinin AA, Sorokovikov VA, Belykh EG, Panasenkov SYu, Grigor’ev EG. Analysis of results of kyphotic deformity reduction using puncture vertebroplasty and stentoplasty in in patients with traumatic compression fractures of thoracolumbar localization. Priorov Herald of Traumatology and Orthopedics. 2014; (2):12–18. Russian

11. Khorasanizadeh M, Yousefifard M, Eskian M, Lu Y, Chalangari M, Harrop JS, et al. Neurological recovery following traumatic spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine. 2019. Feb 15: 1-17.

12. Glaser J, Jaworski B, Cuddy B. Variation in surgical opinion regarding management of selected cervical spine injuries. A preliminary study. Spine. 1998; 23 (9): 975–982.

13. Allen B, Ferguson R, Lehmann T, O'Brien RP. A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine. 1982; 7 (1):1–27.

14. Vaccaro A, Hurlbert R, Fisher C. The sub-axial cervical spine injury classification system (SLIC): a novel approach to recognize the importance of morphology, neurology and integrity of the disco-ligamentous complex. Spine. 2007; 32: 2365–2374.

15. Amer M. Anterior cervical Corpectomy with cage and plating in subaxial fractures: a review of 20 cases. Egy Spine J. 2013; 8:19–25.

16. Elder BD, Lo SF, Kosztowski TA, Goodwin CR, Lina IA, Locke JE, et al. A systematic review of the use of expandable cages in the cervical spine. Neurosurgical review. 2016; 39(1):1–11.

17. Byvaltsev VA, Kalinin AA. Analysis of the reduction of kyphotic deformation by the method of minimally invasive transpedicular stabilization in patients with traumatic compression fractures of the chest-lumbar localization. Grekov Herald of Surgery. 2017; 176(5): 64–71. Russian

18. Yokota K, Maeda T, Kawano O, Mori E, Takao T, Sakai H, et al. Progression of local kyphosis after conservative treatment for compressive cervical spine fracture with spinal cord injury. J Orthop Surg Res. 2019; 14 (1): 98.

19. Wengel PV, De Witt Hamer PC, Pauptit JC, van der Gaag NA, Oner FC, Vandertop WP. Early surgical decompression improves neurological outcome after complete traumatic cervical spinal cord injury: a meta-analysis. J Neurotrauma. 2019; 36 (6): 835-844.

20. Belirgen M, Dlouhy BJ, Grossbach AJ, Torner JC, Hitchon PW. Surgical options in the treatment of subaxial cervical fractures: a retrospective cohort study. Clinical Neurology and Neurosurgery. 2013; 115(8): 1420-1428.

21. Graham JJ. Complications of cervical spine surgery. A five-year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine. 1989; 14(10):1046–1050.

22. Aarabi B, Sansur CA, Ibrahimi DM, Simard JM, Hersh DS, Le E, Diaz C, et al. Intramedullary lesion length on postoperative magnetic resonance imaging is a strong predictor of ASIA Impairment Scale grade conversion following decompressive surgery in cervical spinal cord injury. Neurosurgery. 2017; 80(4): 610-620.

Case history

A NEW APPROACH TO ARTHROSCOPIC AUTOPLASTY
OF ANTERIOR CRUCIATE LIGAMENT
AFTER TRAUMATIC INJURY

Leonova S.N., Monastyrev V.V., Ponomarenko N.S.

Irkutsk Research Center of Surgery and Traumatology, Irkutsk, Russia

Despite of the improvement in methods of arthroscopic autoplasty of anterior cruciate ligament, some postsurgical problems exist such as persistent pain syndrome, inflammation in the knee joint, residual instability, knee joint contractures and dysfunction, rupture and abruption of the autograft which require for new methods for the treatment of this pathology.

Objective – to show the clinical example of the procedure and the result of individual approach to arthroscopic autoplasty of the anterior cruciate ligament after its traumatic injury.

Materials and methods. A patient A., 35 years, applied to the clinic of Irkutsk Research Center of Surgery and Traumatology. He complained of an old injury to the left knee crucial ligament. The following surgical treatment was performed: arthroscopic plasty of the left knee anterior cruciate ligament using the autograft. The new approach included preliminary detection of necessary length and thickness of the autograft corresponding to the individual size of the patient’s anterior cruciate ligament during arthroscopy, before taking the autologic tendons. The autograft was made using specified size from the single long tendon formed by the tendons of semitendinous and gracilis muscles, connected by the common tendinous intersection.

Results. Control MRI in 3 months after the surgery showed the intact autograft, no lysis around the autograft and no changes in bony canal diameters. The patient was satisfied with the result of the treatment, with significant improvement in left knee joint functions, its ability to support active physical activity, and with full return to professional activity (the patient works as a shovel operator).

Conclusion. Our clinical case of surgical treatment of the patient with the traumatic injury to the anterior cruciate ligament using new approaches to the arthroscopic autoplasty can be useful for trauma and orthopedic surgeons since it shows the methods for solution of problems concerning the increase in the tenacity of the autograft, strength of its fixation in bone canals. Also it will promote the improvement in treatment results.

Key words: traumatic injury; anterior cruciate ligament; arthroscopic autoplasty.

Information about authors:

Leonova S.N., MD, PhD, leading researcher, scientific department of traumatology, Irkutsk Research Center of Surgery and Traumatology, Irkutsk, Russia.

Monastyrev V.V., candidate of medical science, senior researcher, scientific department of traumatology, Irkutsk Research Center of Surgery and Traumatology, Irkutsk, Russia.

Ponomarenko N.S., candidate of medical science, researcher, scientific department of traumatology, Irkutsk Research Center of Surgery and Traumatology, Irkutsk, Russia.

Address for correspondence:

Leonova S.N., Bortsov Revolyutsii St., 1, Irkutsk, Russia, 664003

Tel.: +7 (914) 880-54-23

E-mail: svetlana.leonova.1963@mail.ru

REFERENCES:

1. Slastilin VV, Fayn AM, Vaza AYu. Using transplant from popliteal muscle tendons for the arthroplasty of anterior cruciate ligament (advantages, problems and ways for their solution). Transplantology. 2017; 9 (4): 317-324. Russian

2. Rikun OV, Khominets VV, Fedotov AO. Modern trends in surgical treatment of patients with ruptures of anterior cruciate ligament (review of literature). Traumatology and Orthopedics of Russia. 2017; 23(4): 134-145. Russian

A CLINICAL REPORT OF TREATMENT OF A PATIENT WITH EXTENSIVE TRAUMATIC DETACHMENT OF SOFT TISSUES

Petrov Yu.L., KorostelevM.Yu., Shikhaleva N.G.

City Clinical Hospital No.8,

Chelyabinsk, Russia,

Russian Ilizarov Scientific Center for Traumatology and Orthopaedics,

Kurgan, Russia

Extensive soft tissue detachment is a common serious surgical pathology characterized by the separation of the skin and subcutaneous tissue from the underlying muscles and fascia, resulting from a sudden shift applied to the surface of the skin. Untimely diagnosis and improper treatment of these injuries often lead to complete necrosis of the detached tissues, suppuration of the below located crushed tissues, aggravating the general condition of the victims up to the lethal outcome.

Objective – to attract the medical community to the unresolved issues of organizing, diagnosing, and treating patients with extensive soft tissue detachments, as one of the formidable causes of extremely serious complications.

Materials and methods. The article presents a clinical example of treatment of a patient with extensive traumatic detachment of the cover tissues of the lower extremities and the body on the area of 30 % of the body surface, hemorrhagic shock of 2 degree. Incorrect management at admission, which consisted in the primary surgical treatment of detached tissues and their return to the place without special treatment, led to the development of necrosis of the detached skin, the infectious process in the wound, and the early accession of sepsis. After the involvement of a plastic surgeon from the burn center in the treatment process, the conservative wound management was changed to active. At the next surgical treatment of the wound, all wounds were examined with the identification of new areas of detachment, non-viable tissues were excised, some wounds were covered with scrap skin treated with Krasovitov, others were closed with bandages with negative pressure.

Results. Later, after eliminating the source of intoxication and creating the conditions for wound healing, the close-knit team of the traumatologists, the resuscitators and the plastic surgeon managed to stop sepsis, to heal all the wounds and, ultimately, to return the patient to normal lifestyle.

Conclusion. It is necessary to carry out a great deal of informational and organizational work in order to develop and practically implement an algorithm for managing patients with extensive soft tissue detachments.

Key words: extensive traumatic skin detachment; sepsis; skin plastics; bandages of negative pressure.

Information about authors:

Petrov Yu.L., traumatologist-orthopedist, chief of traumatology unit, City Clinical Hospital No.8, Chelyabinsk, Russia.

Korostelev M.Yu., traumatologist-orthopedist, plastic surgeon, combustiologist, Russian Ilizarov Scientific Center for Traumatology and Orthopaedics, Kurgan, Russia.

Shikhaleva N.G., MD, PhD, chief of clinic of reconstructive medicine and hand surgery, Russian Ilizarov Scientific Center for Traumatology and Orthopaedics, Kurgan, Russia.

Address for correspondence:

Shikhaleva N.G., Kareltseva St., 101-165, Kurgan, Russia, 640003

Tel: +7 (912) 528-56-50
E-mail: nshihaleva@mail.ru

REFERENCES:

1. Mikusev IE, Mikusev GI, Khabibullin RF. Traumatic detachment of the skin: diagnosis and treatment. Journal of Practical Medicine. 2013; 2(1-2 (69): 104-107. Russian

2. Morris M, Schreiber MA, Ham B. Novel management of closed degloving injuries. J Trauma Inj Inf Crit Care. 2009; 67: E121– E123.

3. Antoniou D, Kyriakidis A, Zaharopoulos A, Moskoklaidis S. Report of two cases and review of the literature. Eur J Trauma. 2005; 31: 593–596.

4. Wójcicki P, Wojtkiewicz W, Drozdowski P. Severe lower extremities degloving injuries-medical problems and treatment results. Pol Przegl Chir. 2011; 83: 276–282.

5. Loktionov PV, Gudz YuV. Experience in treatment of wounds of the lower extremities with extensive traumatic detachment of skin and subcutaneous tissue. Journal of Biomedical and Psychological Problems of Safety in Emergency Situations. 2015; (1): 22-28. Russian

6. Hakim S, Ahmed K, El-Menyar A, Jabbour G, Peralta R, Nabir S, et al. Patterns and management of degloving injuries: a single national level 1 trauma center experience. World Journal of Emergency Surgery. 2016; 11: 35.

7. Latifi R, El-Hennawy H, El-Menyar A, Peralta R, Asim M, Consunji R, et al. The therapeutic challenges of degloving soft-tissue injuries. J Emerg Trauma Shock. 2014; 7(3): 228-232.

8. Yan H, Gao W, Li Z, Wang C, Liu S, Zhang F, et al. The management of degloving injury of lower extremities: technical refinement and classification. J Trauma. 2013; 74(2): 604–610.

9. Korostelev MYu, Shikhaleva NG. The current state of the problem of treating patients with extensive detachment of integumentary soft tissues (literature review). Genius of Orthopedics. 2017; 23(1): 88-94. Russian

10. Bordakov VN, et al. Traumatic detachment of soft tissues: diagnosis and treatment tactics. Military Medicine. 2015; 4: 116-119. Russian

11. White GI, Spesivtsev AYu, the Ramada HA. Closed traumatic detachment of the skin. Priorov Herald of Traumatologyy and Orthopedics. 2004; 1-2: 38-40. Russian

12. Dini M, Quercioli F, Mori A, Romano GF, Lee AQ, Agostini T. Vacuum-assisted closure, dermal regeneration template and degloved cryopreserved skin as useful tools in subtotal degloving of the lower limb. Injury. 2012; 43(6): 957-959.

13. El-Menyar A, Consunji R, Asim M, Abdelrahman H, Zarour A, Parchani A, et al. Underutilization o f occupant restraint systems in motor vehicle injury crashes: a quantitative analysis from qatar.Traffic Inj Prev. 2016; 17(3): 284-291.

14. Wong LK, Nesbit RD, Turner LA, Sargent LA. Management of a
circumferential lower extremity degloving injury with the use of vacuumassisted closure. South Med J. 2006; 99: 628–630.

15. Martel II. The method of transosseous osteosynthesis in the system of complex treatment of patients with severe open injuries of the lower limbs: dissertation of PhD in Medicine: 14.00.22 / Place of protection: Russian Research Center of Restorative Traumatology and Orthopedics. Kurgan, 2006. 221 p. Russian

16. Martel II, Samusenko DV, Shvedov VV, Karasev AG. The Ilizarov method in the staged treatment of victims with polytrauma. In: Actual problems of traumatology and orthopedics of children. Materials All-Russian scientific and practical international conference. Kurgan, 2013; 127 p. Russian

17. Baker SP, O'Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patient with multiple injuries and evaluating emergency care. J. Trauma. 1974; 14(3): 187-196.

18. Kirkpatric JR, Youmans RL. Trauma index. An aid in the evaluation of injury victims. J. Trauma. 1971. 11(7): 711–714.

19. Arnez ZM, Khan U, Tyler MP. Classification of soft-tissue degloving in limb trauma. J PlastReconstrAesthetSurg. 2010; 63:1865–1869.

THE EXPERIENCE WITH PRESERVING THE LOWER LIMB IN A VICTIM WITH A SERIOUS MINE-BLAST WOUND

Khominets V.V., Brizhan L.K., Shchukin A.V., Mikhaylov S.V., Arbuzov Yu.V., Shakun D.A., Khominets I.V.

Kirov Military Medical Academy,

Saint Petersburg, Russia

Burdenko Main Military Clinical Hospital,

Moscow, Russia

Objective – to demonstrate the opportunity of limb salvage treatment in patients with severe combat blast injury and uncertain prognosis of limb viability.

Materials and methods. In the presented clinical case, the patient’s general condition and the severity of limb trauma indicated the appropriateness of amputation according to generally used scoring systems. Nevertheless, some additional criteria allowed considering limb reconstruction instead of amputation.

The 56-year-old patient suffered from a combat blast injury. The trauma was considered as severe due to primary gun-shot blast defects of the distal tibial metaepiphysis, of the fibula and talus bone, gun-shot tarsal and metatarsal fractures, as well as due to crashed soft tissues of the left ankle with significant contamination, damage of the posterior tibial artery and of the fibular nerve, and finally due to severe blood loss and shock. The general condition of the patient according to the Emergency Aid Battlefield Scoring System (used in Russia) was severe (27 points). The Gunshot Injuries Battlefield Scoring System gave 10 (severe). AIS was 5. Fracture was 3C grade according to Gustilo-Andersen classification. The limb had 8 points of MESS.

Despite the poor prognosis and the evident indications for limb segment amputation, limb salvage management was accepted. The main stages of the treatment were correction of shock, blood loss compensation, stabilization of patient’s general condition, treatment of infectious complications, skin plastic surgery, orthopedic correction of limb shortening and rehabilitation.

Results. Due to step-by-step surgical treatment we managed to save the patient’s limb. We ended up with tibia-calcaneal ankylosis and ankylosis of midfoot joints which allowed walking without crunches or a cane, using the regular shoes and returning to his normal life. The blood circulation of the lower limb is compensated. The patient has no pain.

Conclusion. Making a decision of limb salvage attempt in cases of severe combat trauma is a hard challenge and requires an individual approach. The authors emphasize the importance of critical view on the trauma severity scales and scoring systems when they are used to determine the indications for amputation.

Key words: gun-shot fractures; external fixation; gun-shot wounds.

Information about authors:

Khominets V.V., MD, PhD, professor, chief of department (clinic) of military traumatology and orthopedics, Kirov Military Medical Academy, Saint Petersburg, Russia.

Brizhan L.K., MD, PhD, professor, chief of traumatology and orthopedics center, chief traumatologist, Burdenko Main Military Clinical Hospital, Moscow, Russia.

Shchukin A.V., candidate of medical science, chief of traumatology and orthopedics clinic’s unit, Kirov Military Medical Academy, Saint Petersburg, Russia.

Mikhaylov S.V., candidate of medical science, lecturer of military traumatology and orthopedics department, Kirov Military Medical Academy, Saint Petersburg, Russia.

Arbuzov Yu.V., consulting physician, traumatology and orthopedics center, Burdenko Main Military Clinical Hospital, Moscow, Russia.

Shakun D.A., candidate of medical science, senior lecturer of military traumatology and orthopedics department, Kirov Military Medical Academy, Saint Petersburg, Russia.

Khominets I.V., senior resident of traumatology and orthopedics center, Burdenko Main Military Clinical Hospital, Moscow, Russia.

Address for correspondence:

Shchukin A.V., Botkinskaya St., 13, Saint Petersburg, Russia, 195009

Tel: 8-911-939-60-44

E-mail: ossa.76@mail.ru

REFERENCES:

1. Ivanov AV. Treatment of extremity fractures in patients with polytrauma. Surgery of injuries, critical states. Save and protect: collection of materials of Pirogov forum. Voronezh: Publishing office “Nauchnaya Kniga”, 2017. P.112-114. Russian

2. Shapovalov VM, Khominets VV, Averkiev DV, Kudyashev AL, Ostapchenko AA. Features of arrangement of special orthopedic and traumatologic care for patients with gun-shot fractures of long bones of extremities on the basis of experience in military operations in North Caucasus. Genius of Orthopedics. 2011; (2): 118-122. Russian

3. Owens BD, Kragh JF., Macatis J, Svoboda SJ, Wenke JC. Characterization of extremity wounds in operation Iraqi Freedom and Operation Enduring Freedom. Ortop Trauma. 2007; 21(4): 254-257.

4. Shapovalov VM, Gladkov RV. Blast injuries in peaceful time: epidemiology, pathogenesis and main clinical signs. Medicobiological and social-psychological problems of safety in critical situations. 2014; (3): 5-16. Russian

5. Brizhan LK. System of treatment for patients with gun-shot fractures of long bones of extremities: dissertation of PhD in medicine. Moscow. 2010. 336 p. Russian

6. Covery DC, Born CT. Blast injuries: mechanics and wounding patterns. Journal of surgical orthopedic advances. 2010; (1): 8-12.

7. Rybnikov ON, Smekalkina LV, Paletskaya SN. Mental status of persons with traumatic amputation of extremity, and tasks of psychotherapeutics. Social and Clinical Psychotherapeutics. 2005; (1): 28-34. Russian

8. Owens BD, Belmont PJ. Combat orthopedic surgery: lessons learned in Iraq and Afghanistan. SLACK Incorporated, 2011. 328 p.

9. Schirò SR, Sessa S, Piccioli A, Maccauro G. Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord. 2015; (16): 372.

10. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. 2001; 83(1): 3-14.

Experimental investigations

A STUDY OF SPLEEN TISSUE REACTION USING NEW SAMPLES OF POLYMERIC HEMOSTATIC MATERIALS

Lipatov V.A., Lazarenko S.V., Severinov D.A.

Kursk State Medical University, Kursk, Russia

One of the important problems of modern surgery is parenchymatous bleeding arresting, and development of new efficient hemostatic measures.

Objective – to assess the splenic tissue responses when using the new samples of polymeric hemostatic materials.

Materials and methods. As the study materials, the hemostatic measures based on sodium-carboxymethylcellulose (Na-CMC) developed by the authors (the group 3), as well as Na-CMC with aminoacetic acid (the group 4), and hemostatic collagen sponges (the group 5) were used. Using analgesia, the rabbits were exposed to midline laparotomy with modeling of the superficial splenic injury. The bleeding was arrested with application of the tested materials or by means of omentum suturing (the group 2). Autopsy for the injured part of the organ with the implanted hemostatic measure was carried out on the 14th day after the experiment. The capsule thickness, the square of lymphoid follicles, the square of reactive center, and the sizes of T-zone were measured. Mann-Whitney’s non-parametric test was used for estimation of differences (p ≤ 0.05).

Results. In response to the spleen injury, there was a significant reduction (by 64.2 %) in lymphoid follicle area relative to the control group, and an increase in reactive centers by 115 %, T-zones – by 127 %, spleen capsules – by 204 %. When implanting the hemostatic sponge based on CMC, there was a statistically significant increase in the area of lymphoid follicles of the spleen in relation to the injury model (by 280 %), and a decrease in T-zone by 29 %. Collagen sponge implantation shows a significant increase in lymphoid follicle area by 81 % and T-zone by 9 % in relation to the group 2, and a decrease in lymphoid follicle area in relation to the group 1.

Conclusion. The use of the local hemostatic agent based on Na-CMC in the simulation of spleen injury promotes the activation of elements of the immune system and the formation of an adequate local immune response compared to collagen-based samples. It is manifested by more pronounced morphological changes (increasing the thickness of the capsule and T-zone, decreasing the area of lymphoid follicles) in the case of the latter.

Key words: carboxymethylcellulose; application materials; hemostatic activity; implants; polymer sponges; spleen; bleeding.

Information about authors:

Lipatov V.A., MD, PhD, professor, professor of operative surgery and topographic anatomy department, chief of laboratory of experimental surgery and oncology of experimental medicine research institute, Kursk State Medical University, Kursk, Russia.

Lazarenko S.V., candidate of medical science, assistant of oncology department, Kursk State Medical University, oncologist-urologist, Kursk, Russia.

Severinov D.A., pediatric surgeon, assistant of pediatric surgery and pediatrics department, Kursk State Medical University, Kursk, Russia.

Address for correspondence:

Severinov D.A., K. Marksa St., 3, Kursk, Russia, 305041

Tel: +7 (920) 262-15-55

E-mail: dmitriy.severinov.93@mail.ru

REFERENCES:

1. Bazaev АV, Аleynikov АV, Korolev SK, Kokobelyan АR, Rodin АG. Injury to the liver and the spleen in victims with the combined road trauma. MediА Journal. 2014; 1(11): 17-19. Russian

2. Babak A, Samad SV, Seyedpouya P, Sarvin A. Blunt abdominal trauma and organ damage and its prognosis. Journal of Analytical Research in Clinical Medicine. 2016; 4(4): 228-232. https://doi.org/10.15171/jarcm.2016.038

3. Balaphas A, Meyer J, Harbarth S, Amzalag G, Buhler LH, Morel P. Patient management after splenectomy in 2015: state of the art and recommendations. Revue medicale suisse. 2015; 11(479): 1345-1350.

4. Pivkin IV, Peng Z, Karniadakis GE, Buffet PA, Dao M., Suresh S. Biomechanics of red blood cells in human spleen and consequences for physiology and disease. Proceedings of the National Academy of Sciences. 2016; 113(28): 7804-7809. https://doi.org/10.1073/pnas.1606751113

5. Fonouni H, Kashfi A, Majlesara A, Stahlheber O, Konstantinidis L, Gharabaghi N, et al. Hemostatic efficiency of modern topical sealants: Comparative evaluation after liver resection and splenic laceration in a swine model. Journal of biomedical materials research. 2017; 106(3): 1307-1316. https://doi.org/10.1002/jbm.b.33937

6. Semichev EV, Baykov AN, Bushlanov PS, Dambayev GTs. Comparative analisys of hemostasis methods in operations on spleen. Bulletin of Siberian Medicine. 2015; 14(2): 91-99. https://doi.org/10.20538/1682-0363-2015-2-91-99. Russian

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Reviews

ARTHRODESISIS – A KEY TO DECISION OF THE MOST DIFFICULT PROBLEMS IN RECONSTRUCTIVE SURGERY OF SHOULDER JOINT

Gerashchenko N.I., Voronkevich I.А.

Vreden Russian Research Institute of Traumatology and Orthopedics,

Saint Petersburg, Russia

Currently, one can observe the increasing interest to use of shoulder joint arthrodesis in most severe disorders of the shoulder joint. Shoulder joint endoprosthetics, especially with reverse systems, is much more popular. It results in higher volume of motions. However, if the indications for revision surgery appear, the contraindications for surgery can be found in some patients. For such patients, the modern arthrodesis of the shoulder joint showed itself as efficient revision option.

Objective – to estimate the modern state of the problem of shoulder joint arthrodesis on the basis of the literature data.

Materials and methods. The presented review of shoulder joint arthrodesis and concurrent interventions included the analysis of the studies for the last 40 years. The surgery indications, development of surgical techniques, stability of fixation, and humeroscapular spatial relationships in functionally profitable anchylosis were reviewed.

Results. The analysis of publications showed the actuality of all five techniques of shoulder joint arthrodesis and their wide use in clinics of the world. In any successful use of any technique, formation of anchylosis in functionally profitable position gives the comparable positive results consisting in correction of pain syndrome and in restoration of the strength of the upper extremity without a trend to worsening in the medium term. Their subsequent improvement resulted in a special technique and the implant which solved the problem of fixation stability and achievement of functional position for anchylosis formation.

Conclusion. Currently, shoulder joint arthrodesis is reestablishing its actuality at new technological level. Moreover, it is the method of choice in some cases. The analyzed data shows some issues, which require for clarification: intrasurgical positioning of the upper extremity, stable fixation of the shoulder to the scapula. So called disputable cases require for clarification of indications for arthrodesis: severe shoulder arthropathy at the background of unrecoverable injury to the axillary nerve, consequences of gun-shot injuries in this location, and infected periarticular pseudoarthrosis.

Key words: arthrodesis; shoulder anchylosis in functional position; shoulder joint endoprosthesis; reverse shoulder endoprosthesis; axillary nerve injury; brachial plexus paresis; fixation stability.

Information about authors:

Gerashchenko N.I., clinical research assistant, research department of treatment of injuries and their consequences, Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia.

Voronkevich I.A., MD, PhD, chief of research department of treatment of injuries and their consequences, Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia.

Address for correspondence:

Gerashchenko N.I., Akademika baykova St., 8, Saint Petersburg, Russia, 195427

Tel: +7 (911) 289-27-90

E-mail: Gerashchenko@gmail.com

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