Surgical Treatment Algorithm Research Articles

Surgical treatment algorithm for thoracic and lumbar hyperkyphosis in pediatric population.

There is no standardized and universally accepted surgical treatment for thoracic and lumbar hyperkyphosis in children. A surgical treatment algorithm was developed to aid in the choice of the appropriate corrective technique. A retrospective analysis was conducted of patients younger than 18years who underwent primary correction surgery and posterior fusion for thoracic and lumbar hyperkyphosis. Patients were categorized according to the classification of Rajasekaran et al. and divided into 2 groups: a posterior column osteotomies (PCO) group and a three-column osteotomies (3CO) group. We analyzed the angularity and flexibility of the curve, global sagittal balance, and preoperative neurological status of the patient. Forty-nine patients were included. The mean age was 12.8years (1-18) and the mean preoperative kyphosis was 93.5° (40°-175°). In the PCO group (N = 30), the sagittal deformity angular ratio (DAR) was less than 16.5 in 26 patients (86.6%), while in the 3CO group (N = 19), sagittal DAR was greater than 16.5 in 17 patients (89.4%). In the PCO group (N = 28), the T1-Pelvic angle (TPA) was less than 17° in 19 patients (67.8%), while in the 3CO group (N = 15), TPA was greater than 17° in 10 patients (66.6%). Five patients (10.2%) had recent-onset or progressive neurological alteration, all of them (100%) required 3CO. An algorithm for kyphosis was developed based on the classification by Rajasekaran et al., preoperative analysis of the angularity and flexibility of the curve, global sagittal balance and neurological status of the patient, to aid in the choice of the appropriate corrective osteotomy. IV.

Staged surgical treatment of wounds of the extra-abdominal rectum

AIM: to improve the algorithm and results of surgical treatment of combat wounds of the rectum. PATIENTS AND METHODS: thirty-one patients with combat injuries of the rectum were included in the cohort. RESULTS: twenty-seven (87.1 %) patients were discharged in satisfactory condition, 4 (12,9 %) patients died. Sepsis developed in all four patients: in two of them sepsis was on the background of necrotising fasciitis and one had peritonitis. Endoscopic control revealed 10 wounds of the extraperitoneal part of the rectum undiagnosed at the 1st and 2nd stages of medical care. Surgical care included all four main components: diverting stoma, distal washout (mechanical cleansing of the rectum to clear water), suturing of the lesion through perineal access, drainage or tamponisation of the presacral space was done in 20 (64.5 %) patients. Endoluminal VAC therapy was used in 12 patients. In 11 of them, VAC treatment was successful with complete healing of rectal wall wounds. CONCLUSION: the four-component treatment approach is the optimal option for wounds of the extraperitoneal part of the rectum. Diverting stoma and distal bowel washout prevents severe infection. Endoluminal VAC therapy, in some cases, can be used as an alternative to presacral drainage and suturing of the rectal wall lesion.

Cuboid fracture: surgical treatment, midterm follow-up, and management algorithm

Objectives: Describe the epidemiology of cuboid fracture, the mechanisms of injury and associated injuries, the progression to osteoarthritis, and propose a surgical management algorithm. Methods: A retrospective and descriptive study of patients with cuboid fractures operated on between 2009 and 2014. The variables analyzed were age, sex, mechanism of injury, classification, associated fractures, and osteoarthritis changes, among others. Results: Twenty-seven patients were included: 19 men and eight women. The mean age was 41.3 years (range 25 - 62). The mean followup was 3.3 years. The mechanisms of injury were motor vehicle accidents and falls from height. Among the patients, 44.4% had lateral column shortening, and 81.5% involved calcaneal cuboid articular surface. Cuboid locking plates were used in 15 patients, and single screw fixation was used in four patients. Three patients required a bone graft. Degenerative changes were observed in calcaneocuboid and cuboid-metatarsal joints. Conclusions: Cuboid fracture is an uncommon injury. In general, the injuries are caused by high-energy accidents. In our study, 40.7% of patients had an injury to the medial column. It is recommended the use of a cuboid locking plate for comminuted fractures, screw fixation for simple fractures, and a bridging plate or external fixation can be considered for most complex cases. Level of Evidence IV; Retrospective Case Series.

Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

Surgical treatment algorithm for breast cancer lymphedema—a systematic review

Surgical treatment algorithm for breast cancer lymphedema—a systematic review

Avascular necrosis of the femoral head in combination with septic arthritis of the hip joint

BACKGROUND: The combined course of avascular necrosis of the femoral head and septic arthritis of the hip joint is extremely rare and not always timely diagnosed. Analysis of specialized foreign literature revealed only single descriptions of clinical cases of combined lesions of the hip joint (avascular necrosis of the femoral head and septic arthritis). However, these studies do not describe the surgical treatment algorithms of patients. While analyzing the sources of domestic literature for the last 10 years, we did not encounter descriptions of such clinical cases. CLINICAL CASE DESCRIPTION: A 38-year-old patient was diagnosed with avascular necrosis of the femoral head with concomitant septic arthritis of the hip joint. During the preoperative period, a diagnostic puncture of the hip joint with subsequent cytologic and microbiological examination of synovial fluid was performed. Growth of the Staphylococcus aureus strain was observed. Because primary hip arthroplasty was contraindicated and isolated conservative treatment of bacterial arthritis aggravated the course of avascular necrosis, the patient underwent two-stage surgical treatment. The first stage was femoral head resection with installation of a spherical cement spacer impregnated with antibiotics, and the second stage was total hip arthroplasty after the inflammatory process had subsided. The postoperative period of each surgical stage proceeded without complications. It was possible to achieve microorganism eradication; eliminate the chronic inflammatory process, which was confirmed clinically and laboratory; ensure the possibility of total hip arthroplasty; and restore the limb-bearing capacity, extent of motion in the joint, and quality of life of the patient. CONCLUSION: The clinical observation confirms the need for detailed diagnosis in patients with an atypical course of avascular necrosis of the femoral head and demonstrates a successful treatment option in such cases.

Fracture-dislocations of the subaxial cervical spine

Fracture-dislocations of the subaxial cervical spine are rare yet potentially devastating injuries often associated with high-energy trauma. These inherently unstable injuries frequently lead to neurologic compromise, necessitating urgent operative intervention. This review provides a comprehensive overview of subaxial cervical spine fracture-dislocations, addressing their epidemiology, anatomy, and classification systems. Classification schemes including Allen and Ferguson, Cervical Spine Injury Severity Score (CSISS), Subaxial Cervical Spine Injury Classification System (SLIC), and AO Spine Subaxial Cervical Spine Injury Classification System are discussed. Prompt recognition and management of these injuries is critical in optimizing long-term functional and neurologic outcomes. Rates of neurologic injury can exceed 50 %, with distractive flexion injuries and bilateral facet injuries often presenting with higher ASIA grades and lower neurologic recovery potential. Minimizing time to reduction is the most important factor in optimizing neurologic outcomes in these injury patterns. We discuss both closed and open reduction methods, timing considerations, technical pearls, and potential complications associated with each strategy. We also discuss the diagnosis and management of concurrent acute disk herniations, the role of advanced imaging, and the debated utility of pre-reduction MRI. Many subaxial cervical fracture-dislocations necessitate surgical intervention, which can be approached from an anterior, posterior, or combined approach. Although no standard surgical treatment algorithm exists, we discuss surgical options and situations where a preferred approach may exist. Selection of the approach depends on injury characteristics and surgeon preference, and there are no clearly defined surgical recommendations based on injury pattern.

The algorithm of diagnosis and surgical treatment of Brown’s syndrome

Introduction. Brown’s syndrome (BS) is a rare type of unconcomitant strabismus, which is often interpreted by practicing ophthalmologists as a paralytic form. The difficulty of diagnosis is due to the similarity of clinical manifestations with a number of other oculomotor disorders. This leads to a late, and most importantly, tactically incorrect choice of surgical treatment method. Purpose: Development of an algorithms for differential diagnosis and surgical treatment of Brown syndrome. Materials and methods. The authors analyzed the experience of diagnosing and treating 99 patients with Brown’s syndrome. The follow-up period was 13 years, from May 2010 to May 2023. Among the examined patients, 35 (35 %) were male and 64 (65 %) were female. The median age was 7.19 ± 0.87 years, the oldest at the time of the study was 45 years old, and the youngest was 1.5 years old. All patients underwent standard ophthalmologic and strabismal examinations. In patients of verbal age, the nature of vision was examined (Worth test, Bagolini test, double Maddox test). All operated patients underwent a cyclotorsion test intraoperatively under general anesthesia to confirm the diagnosis and choose a surgical method. Surgical treatment was carried out in 60 cases of unilateral and 5 cases of bilateral BS (a total of 65 patients aged 2 to 45 years; 69 eyes). Tenotomy and tenectomy of the superior oblique muscle (ECM) were performed in 53 cases, prolongation and recession with prolongation of the ECM in 16 cases. Results. Clinical signs have been systematized, algorithms for differential diagnosis and surgical treatment have been developed, which make it possible to timely identify Brown’s syndrome and carry out stage-by-stage pathogenetically based surgical treatment. The results are presented in the form of sequential action schemes (algorithms) that will help practitioners in making a diagnosis and determining the correct tactics of surgical treatment. Conclusions. Brown syndrome has characteristic differential features and requires staged surgical treatment. Developed algorithms to obtain high functional and cosmetic results.

Acute Colonic Diverticulitis.

Acute colonic diverticulitis is a gastrointestinal condition that is frequently encountered by primary care and emergency department practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It is often diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, the presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.

Role of GLP-1 PET for the localisation of insulinomas and application of a surgical insulinoma treatment algorithm for personalised surgical management

Role of GLP-1 PET for the localisation of insulinomas and application of a surgical insulinoma treatment algorithm for personalised surgical management

An algorithm for surgical treatment of children with bone sarcomas of the extremities.

Limb salvage surgery in children following bone sarcoma resection is a challenging problem because of the small size of the bones, the lack of appropriate size-matched implants, and the risk of limb-length discrepancy once skeletal growth is complete, secondary to the loss of the epiphyseal plate. Although several reconstruction options are available in children with bone sarcomas, such as vascularized fibula, massive bone allograft, extracorporeal devitalized autograft, endoprosthesis, and allograft-prosthesis composite, a consensus has not been reached on the best reconstruction method. The purpose of the present study is to propose an algorithm for reconstruction after resection of bone sarcomas in children. In this review, we analyzed reports on limb reconstruction in children following treatment for bone sarcoma, to provide a comprehensive overview of the different reconstruction options in children with bone sarcomas, the outcomes, and the risks and benefits of the different surgical approaches. Despite a high risk of complications and the necessity for limb-lengthening procedures, prosthetic or biological reconstructions seem to achieve good functional outcomes in children with bone sarcoma. The use of massive bone graft seems to be recommended for intercalary reconstructions, with a free vascularized fibular graft for long defects, while for osteoarticular reconstruction a modular or expandable prosthesis or an allograft-prosthesis composite seems to have good results. For reconstruction of the proximal humerus, modular prosthesis or allograft-prosthesis composite are more commonly used than expandable prosthesis since there are fewer functional constraints related to possible limb-length discrepancy on the upper limb compared to the lower limb. We discuss the advantages and limitations of the different available surgical options for bone reconstruction following tumor resection in children and propose an algorithm of potential surgical treatments for children with bone sarcomas of the extremities.

Algorithm for surgical treatment of gastroduodenal ulcer with multiple combined complications

Surgical management of gastroduodenal ulcers (GDU) and multiple combined complications (MCC) remains a relevant, complex and unresolved issue. There are currently no well‑defined algorithms, strategies, or surgical procedures for the treatment of gastroduodenal ulcers accompanied by a variety of complications. Objective — to improve the results of surgical treatment and reduce the mortality of patients with GDU and MCC by implementing a surgical treatment algorithm. Materials and methods. The results of surgical treatment of patients with complicated GDU for the period 2000—2022 are presented. A total of 395 (100.0%) patients with GDU accompanied by MCC (a combination of two or more complications) were operated on. There were 52 (13.16%) patients with gastric ulcer perforation and 301 (76.2%) patients with duodenal perforation. A combination of two complications was noted in 299 (75.69%) patients, three — in 88 (22.28%) patients, and four — in 8 (2.03%) patients. Results. A total of 352 (89.11%) operative interventions were performed in an emergency, 43 (10.88%) were performed in the early delayed period (EDP). The implementation of a new algorithm of surgical treatment in the main group and the use of modern measures of endoscopic hemostasis made it possible to increase the rate of operated patients in EDP by 2.6 times, and reduce the mortality rate from 10.14% to 6.45%. The highest rate of mortality is associated with gastric resection in patients with GDU and MCC — 3 (42.87%) out of 7 patients. The lowest mortality rate was among patients who underwent one of the types of organ‑saving surgery — 7 (2.86%) patients out of 245 operated on in this group. Conclusions. The implementation of the algorithm for providing surgical care to patients with GDU accompanied by MCC made it possible to reduce intraoperative mortality from 10.14% to 6.45%. The use of modern means of endoscopic hemostasis made it possible to stabilise, adequately prepare, and operate patients in EDP, which is confirmed by the increase of this indicator in the main group by 2.6 times. The highest mortality rate was in patients who underwent gastric resection and was 42.87%.

Optimization of the treatment system for victims with long-bone gunshot fractures

Background. The full-scale war with the russian federation on the territory of Ukraine revealed a number of problematic issues regarding medical and evacuation measures for victims with gunshot injuries to the extremities, requiring the search for ways to solve them and substantiate proposals for optimizing the adjusted system of treating victims. Over a 3-month period, the number of patients with gunshot wounds to the limbs and the severity of injuries increased significantly, which is primarily due to the use of weapons with high kinetic energy (Grad, Smerch MLRS systems, air bombs, including cluster munitions, artillery and tanks (large caliber)), which led to an increase in the number of patients with severe gunshot injuries. Given these features, the question arose not only regarding the training of specialists in the treatment of modern combat injuries, but also optimizing the therapeutic process, which made this topic relevant. The aim: to analyze the system of surgical treatment for victims with gunshot wounds to the extremities by optimizing the algorithm of surgical treatment at the levels of medical evacuation. Materials and methods. Statistical materials for the period from February 24 to May 2022 and ATO/JFO data for 2014–2021. Research methods: descriptive, comparative analysis, systematic approach, statistical. Based on study results, a number of debatable issues on organizing a system for the treatment of victims with gunshot wounds were identified: analysis of the distribution of patients by a type of damaging factor; optimization of triage of victims with gunshot wounds to the extremities; general characteristics of the basic principles of treatment at the hospital stage; the presence of errors in the treatment of victims with long-bone gunshot fractures. Conclusions. The widespread use of weapons with high kinetic energy during the full-scale war with the russian federation in Ukraine determined an increase in the proportion of limb lesions and the severity of these injuries. At the same time, there was an increase in the number of victims with amputated limbs, defects in long bones and polystructural trauma. Rational medical triage in the mass admission of patients with limb injuries, which we carried out, made it possible to create conditions for the full implementation of medical and diagnostic measures with the subsequent determination of priority areas.

The Lymphatic System—A Surgeon’s Point of View

Lymphedema is a chronic and debilitating disease that affects up to 250 million patients worldwide. Recent advances in understanding its pathophysiology, along with improved diagnosis and microsurgical techniques, have enhanced our ability to cope with the challenging task of treating this disease. This review provides an overview of the disease from a surgeon’s point of view, including existing imaging modalities used for preoperative assessment, as well as surgical procedures used in its treatment. The advantages and drawbacks of various existing modalities used for the pre- or intraoperative assessment of lymphatic vessels are discussed. Lymphedema treatment has shifted from palliative debulking procedures (liposuction and direct excision) to those aimed at restoring lymphatic flow and countering the pathophysiology of the disease (lymphaticovenous anastomosis and vascularized lymph node transfer). A combination of both approaches can result in a synergistic benefit for patients and is discussed in this review. Despite recent advances, some controversies persist, and further studies are needed to better define surgical treatment algorithms.

Results of surgical treatment of patients of fertile age planning pregnancy with hernias of the anterior abdominal wall

BACKGROUND: Currently, there is no consensus and approved tactics for choosing the method of hernioplasty in the surgical treatment of patients of fertile age planning pregnancy with hernias of the anterior abdominal wall. The study is devoted to the comparative analysis of surgical treatment of these patients.
 AIM: To determine the algorithm of surgical treatment of hernias of the anterior abdominal wall in the patients of fertile age planning pregnancy.
 MATERIALS AND METHODS: The analysis of the treatment results of fertile age patients with hernias of the anterior abdominal wall in the period from 2010 to 2019 has been carried out. The inclusion criteria were as follows: patients of fertile age who underwent surgical treatment of hernias of the anterior abdominal wall, who did not have a relapse before pregnancy. Thus, 252 patients have been included in the study.
 RESULTS: The surgical tactics and optimal timing of the operation in patients of fertile age with hernias of the anterior abdominal wall have been determined.
 CONCLUSIONS: When planning surgical treatment of hernias of the anterior abdominal wall in patients of fertile age, it is necessary to clarify information about pregnancy planning. The most favorable period for planning pregnancy and childbirth is 3 years or more after hernioplasty. When planning a pregnancy in the next 12 years after surgical treatment of a ventral hernia, it is necessary to give preference to hernioplasty with local tissues, which has fewer complications in the long-term postoperative period as well as fewer relapses after childbirth compared with open prosthetic surgery. When planning a pregnancy 3 or more years after surgical treatment, preference should be given to prosthetic hernioplasty. When analyzing the results of treatment of the patients of fertile age with inguinal and femoral hernias, planning pregnancy, clinical experience has shown that there are no contraindications to performing laparoscopic transabdominal preperitoneal prosthetic hernioplasty.

Experience in a Standardized Algorithm for Surgical Treatment of Patients with Mandibular Fractures

Background. In recent decades, new surgical technologies for the treatment of patients with mandibular fractures have been introduced into clinical practice. However, the incidence of complications still remains high, practically not differing from the values 30 years ago. According to the Russian Dental Association, the incidence of complications is 1519%. Probably, the introduction of rules governing the use of new methods of treatment can change the current situation for general clinical practice. Aims to evaluate the effectiveness of the algorithm for the surgical treatment of patients with mandibular fractures, developed on the basis of clinical observations and biomechanical studies, based on significant clinical material. Methods. A retrospective study over a 3-year period of medical records of inpatients with mandibular fractures and their complications was carried out, in the surgical treatment of which, in the conditions of the basic clinic, the surgical algorithm developed by the authors was used. Results. Case histories of 442 patients who met the search criteria were examined. In terms of the composition of the patients included in the study group, it reflects a typical picture for this type of injury, which is typical for domestic clinical practice. The incidence of postoperative complications was 4.1% (of which accompanied by a prolongation of treatment 2% of cases). Conclusion. The results of this work showed that the real percentage of complications in patients with injuries of the lower jaw can be significantly reduced due to strict compliance with the requirements of the algorithm, which was shown by a retrospective analysis of medical records of inpatients over a three-year period, reflecting the results of treatment of a significant number of patients. The data obtained can serve as the basis for appropriate multicenter clinical trials.

Features of preoperative preparation in the treatment of the knee joint in patients with hemophilia

Hemophilia is considered a hematological-orthopedic disease that develops as a result of damage to various anatomical structures of the musculoskeletal system, among which the synovial joints (so-called "target joints") dominate in almost all patients with hemophilia. The purpose of the study was to develop and implement a modern preoperative preparation algorithm for surgical treatment of knee joint pathology in patients with hemophilia. In order to carry out our research, we analyzed 61 cases of hemophilia that were under inpatient and outpatient treatment at the "Kyiv City Clinical Hospital No.9" in the period from 2008 to 2022. Open or arthroscopic knee synovectomy was performed in 22 (36.1%) examined patients of our study. Indications for synovectomy were the presence of hemarthrosis 4–5 times a year or more, presence of deformity and pain syndrome. Total knee arthroplasty was performed in 39 (63.9%) patients. The indication for this operation was the presence of deforming arthrosis of the knee joint with impaired walking and standing function.The expanded algorithm of preoperative preparation included additional instrumental methods of research and calculation of the deficiency of blood coagulation factors, which made it possible to prevent hemorrhagic complications in this category of patients. Operations on patients with hereditary coagulation disorders should be performed under the supervision of hematologists specializing in coagulation disorders and preferably working in specialized centers that have all the necessary resources for the proper diagnosis and treatment of hemophilia. In order to minimize the risks of hemorrhagic complications, we strongly recommend treating such patients with the participation of a multidisciplinary team of specialists, drawing up an individual therapy plan before the operation, and conducting the operation in centers specializing in the treatment of patients with hemophilia. Keywords: orthopedics, hematological and orthopedic diseases, preoperative preparation algorithms.

The effectiveness of two-stage surgical treatment of children with complicated Crohn’s disease

Introduction. Crohn’s disease (CD) is an inflammatory disease of the digestive tract of unknown etiology with segmental transmural inflammation of various parts of the gastrointestinal tract. The annual increase in the number of children with newly diagnosed CD, late diagnosis and untimely surgical treatment is one of the urgent problems due to the lack of a single algorithm of surgical treatment.
 The aim: to determine the effectiveness of surgical treatment of CD in children.
 Materials and methods. The study included thirty six patients with complicated CD Over the period from 2018 to 2022, a re­trospective and prospective analysis of children who received medical care for CD with two-stage surgical treatment (resection of the affected area with enterostomy and subsequent restoration of gastrointestinal continuity) was carried out. 
 Results. Clinical activity according to Pediatric Crohn’s Disease Activity Index (PCDAI) in 23 (63.8%) children before treatment was recorded as high (30.0–75.2 points), in 15 (36.2%) children had average activity (11–29 points). After the staged surgical treatment, there was a change in the indicators — the onset of remission in 2 (5.5%) children and in 34 (94.5%) mild course 
 (p < 0.05). Statistical analysis of anthropometric indicators revealed positive changes (HAZ p < 0.05 and BAZ p < 0.001) with increase in weight and height criteria. Assessment of laboratory dynamics revealed positive changes (p < 0.001) — the absence of anemia, hypoalbuminemia and relief of bacterial inflammation. CD debuted before the age of 10 years in 7 children (19.4%), aged 10 to 16 years — in 29 (80.5%). In 24 (66.7%) children, genetic engineering biological therapy (GEBT) at the time of the development of surgical complications was not performed, from them 15 (62.5%) received hormonal and immunomodulatory therapy while it was not effective, while for 9 (37.5%) patients the timely verification was diagnosed at the stage of development of CD complications. However, the development of surgical complications was noted in 12 (33.3%) children, despite the timely verification and appointment of treatment for genetic engineering biologic therapy (GEBT). Biological therapy was continued for 7 (58.3%) children who received GEBT before surgery, and in 5 (41.7%) patients, treatment was continued with a change of GEBT. The period of stay with a stoma was found to be from 7 to 31 months (Me = 8).
 Conclusions. In complicated forms of CD in children, despite drug therapy, including GEBT, the development of complications requiring surgical treatment was noted, which indicates an aggressive and progressive course of CD. However, the use of stage-by-stage surgical treatment showed efficiency due to the positive dynamics of anthropometric indicators, laboratory markers, the potency of surgical treatment, and made it possible to achieve stable remission against the background of specific therapy and improve the quality of life in CD children.

Anteromedial coronoid facet fractures and associated ligament lesions: A case series

IntroductionVarus posteromedial rotational injury mechanisms lead to fractures of the coronoids process' anteromedial facet. As these fractures are often unstable, rapid fracture treatment is vital to prevent progressive osteoarthritis. Materials and methodsTwelve patients with a fracture of the anteromedial facet treated surgically were enrolled in the study. Computed tomography images were used to classify the fractures according to the system by O'Driscoll et al. Clinical follow-up included each patient's medical record, surgical treatment algorithm, all complications encountered during the follow-up period, Disabilities of the arm, shoulder, and hand score, subjective elbow value, and pain. ResultsA total of 8 men (66.7%) and 4 women (33.3%) were treated surgically and followed-up after a mean period of 45 ± 23 months. The mean DASH score was 11.9 ± 12.9 points. One patient complained of transient neuropathy in the innervation area of the ulnar nerve, however, this existed already pre-operatively and resolved after less than three months. ConclusionsThe presented patient cohort shows that AMF fracture of the coronoid process are unstable lesions according to the bony instability and the frequently ruptured collateral ligament complexes which need to be addressed. The MCL seems to be affected more frequently than previously appreciated. Level of evidenceLevel IV; Case Series; Treatment Study.

Preoperative flexion contracture does not affect outcome in total knee arthroplasty: A case-control study of 2,634 TKAs

BackgroundOne issue in total knee arthroplasty (TKA) is management of preoperative flexion contracture, which may be associated with poor functional outcome. AimThe aim of this study was to compare functional results in TKA with or without preoperative flexion contracture, treated according to a standardized algorithm of tissue release and bone cut. Patients and methodA single-center retrospective case-control study was performed on prospectively collected data for the period 1987–2016. Patients with >10̊ flexion contracture were assigned to the “contracture” group and associated to a selected control group at a ratio of 1:4. Clinical analysis used pre and post-operative International Knee Society (IKS) scores. The significance threshold was set at p<0.05. ResultsEight hundred and forty-nine cases and 3,304 controls were included, comprising a total of 2,838 male and 1,315 female participants. Mean preoperative extension deficit was 13̊±6̊ in the contracture group and 1̊±2̊ in controls. Preoperative IKS total and functional scores were significantly poorer in the contracture group (38±18 and 54±20) than in controls (52±16 and 59±19) (p<0.001). Postoperatively, the two groups did not significantly differ in IKS functional score (77±22 vs. 79±21, p=0.143). There were differences in IKS knee score (87±12 vs. 88±13, p=0.006) and maximal flexion (114̊±14̊ vs. 119̊±13̊, p<0.0001) that were statistically, but not clinically, significant. DiscussionA systematic standardized algorithm for surgical treatment of flexion contracture during primary total knee arthroplasty provided clinical outcomes similar to those of patients without preoperative flexion contracture. Level of evidenceIII; case-control study.