АНАЛИЗ ОКАЗАНИЯ СПЕЦИАЛИЗИРОВАННОЙ МЕДИЦИНСКОЙ ПОМОЩИ ПОСТРАДАВШИМ С ПОЗВОНОЧНО-СПИННОМОЗГОВОЙ ТРАВМОЙ ГРУДНОЙ И ПОЯСНИЧНОЙ ЛОКАЛИЗАЦИИ В УСЛОВИЯХ ГОРОДСКОГО ЦЕНТРА НЕОТЛОЖНОЙ ХИРУРГИЧЕСКОЙ ВЕРТЕБРОЛОГИИ

Background. Foundation of specialised centres or units of acute spinal surgery in general acute hospitals is to be considered a tendency of much importance in development of metropolitan systems for management of trauma victims with spinal injuries.Objective. To analyse size and structure of the patient inflow, contents and outcomes of treatment of trauma victims with thoracic and lumbar spine injuries in a setting of a specialised centre for acute spinal surgery located in a major city in our country.Material and methods. 1,760 trauma victims with thoracic and lumbar spine injuries admitted to an urban centre for acute spinal surgery of St. Petersburg in 2010 through 2016: 1,204 (68.4%) – isolated neurologically intact, 410 (23.3%) – isolated with spinal cord injury, 146 (8.3%) – spinal injuries in polytraumatised patients. An analysis of health administrative and clinical data was performed using non-parametric statistics.Results. During the period the centre worked, the number of annually admitted trauma victims increased 3.44 times, while notably, in the annual structure of the inflow, of which a fraction of isolated neurologically intact injuries decreased from 75.4% to 64.5%, there was an increase in fractions of persons with isolated spine and cord injuries (from 20.2 to 25.0%; р=0.2878) and with spinal injuries and polytrauma (from 4.4 to 10.5%; р=0.0718). The surgical rate was observed to increase from 69.3% to 81.9% (р = 0.0036), especially in trauma victims with unstable isolated neurologically intact injuries. In the annual structure of surgical work, a fraction of early procedures constantly increased (from 27.8 to 91.6%; р=0.0001), the increase rate appearing most stable in neurologically intact patients with isolated injuries. The treatment outcomes showed high values by all measures.Conclusion. The setting of a specialised secondary care centre for acute spinal surgery of a major city delivers high effectiveness and favourable outcomes of treatment of trauma victims with spinal injuries owing to the centralisation of their inflow, broad use of modern medical technology, and the tactic of early surgery. Введение. Создание специализированных центров или отделений неотложной спинальной хирургии на базе многопрофильных стационаров скорой медицинской помощи считается важнейшей тенденцией развития системы лечения пострадавших с травмами позвоночника в мегаполисах.Цель – проанализировать величину и структуру входящего потока, содержание специализированной медицинской помощи и результаты лечения пострадавших с позвоночно-спинномозговой травмой грудной и поясничной локализации в условиях профильного центра неотложной хирургии крупного города нашей страны.Материал и методы. 1760 пострадавших с позвоночно-спинномозговой травмой грудной и поясничной локализации, госпитализированных в городской центр неотложной хирургии позвоночника Санкт-Петербурга в 2010–2016 гг.: 1204 (68,4 %) – с изолированной неосложненной, 410 (23,3 %) – с изолированной осложненной травмой, 146 (8,3 %) – с повреждениями позвоночника в структуре политравмы. Проведен анализ медико-статистических и клинических показателей с использованием методов непараметрической статистики.Результаты. За период работы центра число ежегодно поступающих пострадавших возросло в 3,44 раза, причем в годовой структуре входящего потока на фоне снижения доли пациентов с изолированными неосложненными повреждениями с 75,4 до 64,5 % возросла доля лиц с изолированной осложненной спинальной травмой (с 20,2 до 25,0 %; р=0,2878) и с пнеотложных операций (рис. 1). При анализе этой ситуации в процентном отношении обращает на себя внимание тот факт, что после небольшого снижения их доли в общей структуре операций на протяжении первых 3 лет работы Центра (с 27,8 % в 2010 г. до 22,0 % в 2012 г.; р=0,435, критерий χ2 ) в 2013 г. она значительно увеличилась (до 68,4 %; р=0,0001, критерий χ2 ) и в последующем также постоянно повышалась, достигнув в 2016 г. величины 91,6 % (р=0,0001, критерий χ2 ). Применительно к каждому из трех вариантов ПСМТ (соответствующих ранее выделенным трем группам пострадавших) динамика изменения числа выполненных хирургических вмешательств и структуры методов лечения в целом была сходной (рис. 2–4). Так, для изолированных неосложненных повреждений доля неотложных операций возросла с 31,4 до 90,7 % (р=0,0001, критерий χ2 ), для аналогичных осложненных травм – с 26,1 до 100,0 % (р=0,0001, критерий χ2 ), для ПСМТ в структуре политравмы – с 0,0 до 75,6 % (р=0,0022, двусторонний точный критерий Фишера). При этом наиболее стабильная динамика ежегодного прироста числа таких операций была характерна именно для пострадавших с изолированными неосложненными повреждениями. Действительно, при изолированной осложненной ПСМТ необходимость оказания хирургического пособия в максимально короткие сроки после травмы является несомненной [7, 8], овреждениями позвоночника, являющимися компонентом политравмы (с 4,4 до 10,5 %; р=0,0718). Имело место повышение уровня хирургической активности с 69,3 до 81,9 % (р=0,0036), особенно в отношении пострадавших с нестабильными изолированными неосложненными повреждениями. В годовой структуре хирургических вмешательств происходило постоянное увеличение доли неотложных операций (с 27,8 до 91,6 %; р=0,0001), при этом наиболее стабильная динамика этого прироста была характерна для пациентов с изолированными неосложненными повреждениями. Результаты лечения пострадавших характеризовались высокими значениями всех показателей.Выводы. Условия профильного специализированного центра неотложной спинальной хирургии крупного города обеспечивают высокую эффективность и благоприятные результаты лечения пострадавших с травмой позвоночника за счет централизации их потока, широкого применения современных медицинских технологий и тактики раннего хирургического лечения.

Current principles and trends of using axial pattern flaps in reconstructive surgery of the extremities

On the basis of published data, we identified and analyzed current principles and trends of using axial pattern tissue complexes in patients with limb defects, depending on the nature and localization of the defect, and also objectives of reconstructive surgery. Today, there are three closely related trends. The most important one is to reduce injury caused by intervention; this results in using non-free island flaps instead of the widespread use of free perfused tissue complexes. The second trend is aimed at obtaining the most favorable functional results in treating defects of the covering structures relative to similar defects of bones and muscle-tendon units. The third trend is minimizing the negative aesthetic results

Evolution of «the problem of soft tissues» in the field of knee arthroplasty: role and function of flap surgery

The authors have analyzed scientific works on various aspects of the problem of knee arthroplasty connected with the pathology of periarticular soft tissues. One of the main goals was to trace the evolution of flap surgery principles in the treatment of patients with this pathology. It has been stated that today we can trace two sides in «the problem of soft tissues». The first one in the historical perspective is an operative management of complex wounds following knee arthroplasty, and this side has been studied well enough. The second one is the prophylaxis of skin necrosis and wound infection via flap surgery. This problem is still far from solving. Although in the tradition of world orthopedic surgery pedicled flap transfer and free tissue transfer in the complex cases of knee arthroplasty is not an exclusive practice, the methodology of flap surgery demands further development and scientific foundation

CURRENT STATUS OF INTERNAL OSTEOSYNTHESIS IN TREATMENT OF PATIENTS WITH LONG-BONE FRACTURES IN MUNICIPAL MULTI-FIELD EMERGENCY HOSPITAL OF THE RUSSIAN MEGALOPOLIS

Objective: Determine the changes in the structure of methods of internal osteosynthesis in treatment of patients with long-bone fractures in municipal multi-field emergency hospital of the modern Russian megalopolis. Carry out comparative analysis of effectiveness of use of minimally invasive osteosynthesis and conventional plating of long-bone fractures. Material and methods. We have studied the results of 1249 surgical operations of internal fixation of long-bone fractures performed in one of a municipal multi-field emergency hospitals of Saint Petersburg (Russia). We have studied the statistics of 1999-2000 and 2010. Results and conclusions. Minimally invasive osteosynthesis has occupied a leading position in the structure of internal fixation of long-bone fractures within the current 10 years period. Although such operations demand precise following surgical techniques, ability to use expensive implants and equipment as well as comparatively higher and longer training of orthopedic surgeons. These circumstances seriously limit effective use of minimally invasive osteosynthesis for the current moment. But at the same time conventional plating techniques haven’t lost their importance for treatment of patients with long-bone fractures. These techniques still occupy an important part among the methods of osteosynthesis used in the Russian multi-field hospitals. It reveals the need for continuous improvement of tactics used by orthopedic surgeons as well as the technique of performing such operations

PREVENTIVE MAINTENANCE OF ISCHEMIC CONTRACTURES AT PATIENTS WITH SEVERE HAND INJURIES

Results of surgical treatment of 35 victims who had received serious blunt open and closed injuries of hand were analyzed. All injuries of hand were divided into three types, depending on mechanism and circumstances of trauma. On the basis of the data received at direct measurement of compartment pressure, indirect signs of a menacing ischemia of intrinsic muscles have been defined, and the technique of preventive maintenance of an ischemic lesion of own hand muscles were developed. High efficiency of the offered medical approaches at the expense of the maximum restoration of function of the injured extremity was proved

TREATMENT OF POSTTRAUMATIC ISCHEMIC CONTRACTURES OF THE THUMB

Results of surgical treatment of 21 patients with posttraumatic ischemic contractures of the first finger of a hand were analyzed. The working classification in which there are three degrees of a contracture depending on size of deficiency of a dermal cord of the first interdigital interval was offered. Advanced tactics of surgical treatment of such pathology was developed. Thus, during the first stage we carried out abduction of the first finger by the elimination of cicatrical, muscle and arthrogenic contracture components. At the second stage of treatment, if it was necessary, active opposition of the first finger was restored

EXTENSIVE BONY DEFECTS OF ELBOW: CONSIDERATIONS ON SURGICAL STRATEGY AND CLINICAL CASE REPORT

The result of treatment of female patient with extensive bony defect of elbow, who was made elbow arthrodesis with the use of radial bone pedicle flap is shown. The treatment led to good result. We have made an analysis of scientific works observing the current status of this problem

MODERN STRUCTURE OF SEVERE BLUNT HAND TRAUMAS

The authors have studied the modern structure of severe blunt hand traumas in 123 patients. The size, type and localization of traumas were considerably determined by the reasons and circumstances of traumas. We have emphasized three main types of severe blunt hand traumas: traumas caused by immediate pressure of considerable traumatizing force (impaction); traumas caused by prolonged pressure of considerable traumatizing force (compression); explosive hand injuries. It has been proved that though the modern severe blunt hand traumas have mainly open character, the existence of various injuries of fascias does not provide complete decompression of compartments of hand and wrist. In the conditions of inadequate surgical treatment it may later lead to development of posttraumatic ischemic contractures of hand

Development of management of emergency surgical care for patients with acute traumatic and nontraumatic spinal pathologies in conditions of megapolis

OBJECTIVE. The authors developed the management strategy of emergency care for patients with acute spinal surgical pathology in conditions of megapolis. MATERIAL AND METHODS. A comparative statistical analysis was made in 2627 patients. The patients (n =777) underwent treatment in multicenter hospitals of emergency care of the spine (decentralized system). The other patients (n = 1850) were treated in Municipal Center of Emergency Surgery of the Spine (centralized system). RESULTS. It is appropriate to establish departments of emergency surgery of the spine on the base of separate multicenter hospitals in megapolis. These hospitals should be properly equipped and they should have specially trained doctors and nurses, stable financing, effective management on admission to hospital. CONCLUSIONS. The efficacy of proposed measures allowed authors to recommend them to wide practical application

ANALYSIS OF SECONDARY CARE PROVIDED TO TRAUMA VICTIMS WITH THORACIC AND LUMBAR SPINE INJURIES IN A SETTING OF AN URBAN CENTRE FOR ACUTE SPINAL SURGERY

Background. Foundation of specialised centres or units of acute spinal surgery in general acute hospitals is to be considered a tendency of much importance in development of metropolitan systems for management of trauma victims with spinal injuries.Objective. To analyse size and structure of the patient inflow, contents and outcomes of treatment of trauma victims with thoracic and lumbar spine injuries in a setting of a specialised centre for acute spinal surgery located in a major city in our country.Material and methods. 1,760 trauma victims with thoracic and lumbar spine injuries admitted to an urban centre for acute spinal surgery of St. Petersburg in 2010 through 2016: 1,204 (68.4%) – isolated neurologically intact, 410 (23.3%) – isolated with spinal cord injury, 146 (8.3%) – spinal injuries in polytraumatised patients. An analysis of health administrative and clinical data was performed using non-parametric statistics.Results. During the period the centre worked, the number of annually admitted trauma victims increased 3.44 times, while notably, in the annual structure of the inflow, of which a fraction of isolated neurologically intact injuries decreased from 75.4% to 64.5%, there was an increase in fractions of persons with isolated spine and cord injuries (from 20.2 to 25.0%; р=0.2878) and with spinal injuries and polytrauma (from 4.4 to 10.5%; р=0.0718). The surgical rate was observed to increase from 69.3% to 81.9% (р = 0.0036), especially in trauma victims with unstable isolated neurologically intact injuries. In the annual structure of surgical work, a fraction of early procedures constantly increased (from 27.8 to 91.6%; р=0.0001), the increase rate appearing most stable in neurologically intact patients with isolated injuries. The treatment outcomes showed high values by all measures.Conclusion. The setting of a specialised secondary care centre for acute spinal surgery of a major city delivers high effectiveness and favourable outcomes of treatment of trauma victims with spinal injuries owing to the centralisation of their inflow, broad use of modern medical technology, and the tactic of early surgery