Surgical orthopaedic management of cerebral palsy in adults: literature review and preliminary analysis of our treatment experience

Introduction Improving the quality of care has led to an increase in the life expectancy of patients with cerebral palsy and in the number of adult patients suffering from cerebral palsy. However, functional motor limitations aggravate after their physiological growth completion and the risk of pain increases. The aim of this work was to study the literature on the problem of surgical orthopedic treatment in adolescents and adults with cerebral palsy belonging to GMFCS levels I-IV of motor disorders as well as to make a preliminary analysis of the surgical orthopedic treatment performed in this category of patients at our institution. Materials and methods The results of multi-level single-event interventions were studied in 165 patients older than 16 years. The sample for analysis included cases that met the following criteria: age of 16 years and older, spastic types of cerebral palsy, GMFCS levels I–IV. In addition, some patients underwent botulinum therapy during the stages of surgical treatment. Results The maximum functional effect was manifested 12–24 months after the surgery if proper early and subsequent rehabilitation was provided. According to the Gillette Functional Assessment Questionaire, motor abilities improved in 81.3 %. Multilevel interventions included 2.3–3.5 elements on average during one surgical session. Current literature postulates the implementation of multi-level single-event interventions and indications for surgery and follow-up control are studied at a motion analysis laboratory. Conclusion Multi-level orthopedic interventions are indicated for patients who have completed physiological growth. Techniques of such interventions should provide early functional activity. Surgical orthopedic treatment in adult patients with cerebral palsy should be performed by the staff and at an institution that specialize in neuro-orthopedic

Commodity and Financial Networks in Regional Economics

The article discusses the relationship between commodity-production and financial network structures in the regional economy as dual conjugate systems. Material flows (raw materials, goods and so on) circulate in the commodity network as shown by Leontiev’s input-output balance model. Nonmaterial flows of property rights, money, and so on circulate in the financial network and reflect the movement of material objects in commodity networks. A network structure comprises closed and open circuits, which have fundamentally different characteristics: locally closed circuits meet local demand by supplying locally produced goods, thus ensuring self-reproduction of the local economy; open (or transit) circuits provide export-import flows. The article describes the mechanism of ‘internal’ money generation in closed circuits of commodity-production networks. The results of the theoretical study are illustrated by the calculations of closed and open circuit flows in the municipal economy model. Mutual settlements between the population and manufacturing enterprises are given in matrix form. It was found that the volume of the turnover in closed circuits of the municipal economic network model is about 28.5 % of the total turnover and can be provided by ‘internal’ non-inflationary money. The remaining 71.5 % of the total turnover correspond to the flows in the network’s open circuits providing export and import. The conclusion is made that in the innovation-driven economy, main attention should be given to the projects oriented towards domestic consumption rather than export supplies. The economy is based on internal production cycles in closed circuits. Thus, it is necessary to find the chains in the inter-industrial and inter-production relations which could become the basis of the production cycle. Money investments will complete such commodity chains and ‘launch’ the production cycle

Magneto-optic properties of ultrathin nanocrystalline ferrite garnet films in the 8K to 300K temperature interval

A study of the initial stages of crystallization in RF magnetron-sputtered ferrite garnet films is reported, in which a series of ultrathin Bi2Dy1Fe4Ga1O12 layers is fabricated and characterized. The spectral and temperature dependencies of magnetic circular dichroism (MCD) of these films are studied in the temperature range from 300 K down to 8 K. Measured magneto-optical properties are reported in the spectral range between 300 and 600 nm. In ultrathin garnets at temperatures below 160 K, we found that between 360 and 520 nm, the spectral MCD dependencies were typical of bismuth-substituted garnets with high levels of gallium dilution in the tetrahedral sublattice. The MCD signal strength measured at its 440 nm peak grows linearly with reducing temperature between 160 K and 8 K. This observed temperature dependency of MCD differed dramatically from these measured in thicker (3.7 nm) nanocrystalline garnet films. The peak MCD signal at 440 nm in these 3.7 nm-thick samples grows linearly from 215 K down to 100 K, resembling the same dependency seen in 1.7 nm films. In thinnest layers of thickness 0.6 nm, no MCD signals were observed at any temperature in the range between 8 and 300 K

Operative treatment of orthopedic complications in upper limb in children and adults with cerebral palsy

Introduction The benefits of surgical treatment of orthopaedic complications in the upper limb caused by cerebral palsy have been debated by some researchers. Secondary complications developed due to muscle spasticity and retraction are a serious obstacle to a significant improvement in healthrelated quality of life of CP patients. Objective To explore outcomes of CP patients who underwent surgical treatment at the Russian Ilizarov Scientific Centre “Restorative Traumatology and Orthopaedics” between 2014 and 2016. Material and methods Total 23 operative interventions were produced for 21 patients aged from 11 to 36 years (mean age of 16.6 years) using an authors’ technique. We used integral scales of the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS). Classification systems intended for differential evaluation of upper extremity motor and functional impairment included Van Heest’s deformity assessment test, the House upper extremity assessment test and Gshwind and Tonkin classification. Results Spastic diplegia was diagnosed in 6 cases including 4 GMFCS III and 2 GMFCS IV. Manual ability was assessed as MACS IV in 3 cases and MACS V in 3. Fifteen patients with hemiparethic spastic CP underwent surgical treatment of upper limbs. Manual ability was assessed as MACS III in 4 cases, MACS IV in 8 and MACS V in 3. The use of the limb by the House’s scale showed level 1 in 2, level 2 in 5, level 3 in 10 and level 4 in 6 cases. The Gschwind and Tonkin classification for pronated forearm revealed level 1 in1, level 2 in 8, level 3 in 10 and level 4 in 4 cases. There was correlation between an extent of pronation contracture and impaired function of the thumb. Improved functional abilities of the upper limb, the cosmetic appearance and comfort with the use were recorded in all the cases. Conclusion Results of multilevel interventions on upper limbs in CP patients allow us to conclude that differential approach to the choice of technique and extent of surgery to ensure efficacious surgical treatment

Intrauterine bone fractures in fetuses with osteogenesis imperfecta: a literature review and a case report

The article presents a literature review on intrauterine bone fractures in fetuses suffering from osteogenesis imperfecta. Prenatal ultrasound investigation of the condition is made to identify pathologically changed bone tissue including shortened and deformed limb segments and ribs, bone fractures and callus formation and widened intracranial sutures. Comprehensive clinical, paraclinical and radiological evaluations are produced after the birth to determine treatment strategy. Skeletal fractures in newborns are treated conservatively. With diagnosis of osteogenesis imperfect established medical treatment with bisphosphonates is administered to inhibit osteoclast-mediated bone resorption, facilitate bone mineralization and lower fracture incidence. The case report describes fractures of both femurs and left tibia in a female newborn suffering from osteogenesis imperfecta type III diagnosed in utero with ultrasonographic screening. The case presented highlights infant’s trauma-focused status, radiological findings and the treatment performed

Orthopaedic and somatic status in patients with osteogenesis imperfecta

Introduction Osteogenesis imperfecta (OI) is a group of rare and relatively diverse genetic disorders, characterized by frequent fractures, bone deformities, low bone mineral density and osteopenia. Frequent fractures, bone deformities, and nonunion are among orthopedic problems in OI patients. Varus deformity of the femoral neck, scoliosis, protrusion of the acetabulum, static deformities of the feet are considered separately. The main goal of surgical treatment of the limb deformities and fractures in OI patients is restoration and maintenance of their motor activity, autonomy and preservation of quality of life in severe OI types. The purpose of this study was to assess the deformities in the lower extremities and other accompanying orthopedic disorders, as well as the somatic status of patients with severe OI types (Sillence’s types III and IV) at the point of admission to operative orthopedic treatment. Material and methods Between 2003 and 2016, we examined 43 patients with severe OI (types III and IV) which were admitted for operative correction of deformities of the lower and upper extremities, nonunion, and varus deformity of the femoral neck. The average age at the time of admission was 14.4 ± 9.74 years (from 2 years 9 months to 46 years). Results Treatment of fractures was conservative in most cases; however, osteosynthesis with wires or flexible nails was used, followed by their removal in 4 patients; bone plates were applied in 4 patients; osteosynthesis with the Ilizarov apparatus was used in 3 cases, and intramedullary osteosynthesis with rigid rods in 4 patients. Regular administration of bisphosphonate preparations was conducted in 9 patients. Last dose of the drug was introduced at least 4 months before admission to surgical treatment. Thirteen patients had undergone reconstructive surgeries on the bones of lower extremities to correct the deformities. Conclusion Deformities of the lower limbs in patients with severe OI types are complex and multilevel, which implies the need for multilevel orthopedic interventions to correct them. High incidence of fractures and a complex nature of severe bone deformities result in the loss of the skills to move independently, or even its initial absence. Inadequate surgical interventions, untimely performed, non-telescopic nature of osteosynthesis, and absent bisphosphonate therapy contribute to the formation of additional orthopedic problems and aggravation of the loss of autonomy in such patients, which may complicate subsequent specific orthopedic surgical treatment

Bioactivity and osteointegration of hydroxyapatite-coated stainless steel and titanium wires used for intramedullary osteosynthesis

Abstract A lot of research was conducted on the use of various biomaterials in orthopedic surgery. Our study investigated the effects of nanostructured calcium–phosphate coating on metallic implants introduced into the bone marrow canal. Stainless steel or titanium 2-mm wires (groups 1 and 2, respectively), and hydroxyapatite-coated stainless steel or titanium wires of the same diameter (groups 3 and 4, respectively) were introduced into the tibial bone marrow canal of 20 dogs (each group = 5 dogs). Hydroxyapatite coating was deposited on the wires with the method of microarc oxidation. Light microscopy to study histological diaphyseal transverse sections, scanning electron microscopy to study the bone marrow area around the implant and an X-ray electron probe analyzer to study the content of calcium and phosphorus were used to investigate bioactivity and osteointegration after a four weeks period. Osteointegration was also assessed by measuring wires’ pull-off strength with a sensor dynamometer. Bone formation was observed round the wires in the bone marrow canal in all the groups. Its intensity depended upon the features of wire surfaces and implant materials. Maximum percentage volume of trabecular bone was present in the bone marrow canals of group 4 dogs that corresponded to a mean of 27.1 ± 0.14%, while it was only 6.7% in group 1. The coating in groups 3 and 4 provided better bioactivity and osteointegration. Hydroxyapatite-coated titanium wires showed the highest degree of bone formation around them and greater pull-off strength. Nanostructured hydroxyapatite coating of metallic wires induces an expressed bone formation and provides osteointegration. Hydroxyapatite-coated wires could be used along with external fixation for bone repair enhancement in diaphyseal fractures, management of osteogenesis imperfecta and correction of bone deformities in phosphate diabetes

Assessment of the state of patients with spastic cerebral palsy at transition to adult medical institutions: a cross-sectional study

Introduction The purpose of this cross-sectional study was anamnestic evaluation of the treatment performed in patients with GMFCS levels I, II, III spastic cerebral palsy and to assess their motor status, quality of life and anatomical disorders in the lower extremities in the age range from 17 to18.5 years. Material and methods A cross-sectional study was conducted in patients with spastic types of cerebral palsy at the age of 17‑18.5 years. The completeness and consistency of previous treatment (according to medical documentation), motor abilities, quality of life, radiographic anatomy of the lower extremities were studied. Results We selected 73 patients meeting the inclusion criteria out of 201 cases. Insufficient systematic implementation of complex therapeutic measures was revealed, which was reflected in a high rate of orthopedic interventions (93.1 %). Fibromyotomies, triceps lengthening surgeries performed at an early age (6-7 years) contribute to the development of an iatrogenic crouch gait pattern, a decrease in motor abilities and quality of life by the age of 17-18 years. The probability of maintaining a positive result and improving motor ability by the end of the childhood period is significantly higher in the subgroup of multilevel orthopedic interventions than in patients after fibromyotomies or who did not undergo orthopedic treatment; the differences are significant as the chi-square test for binary samples shows (p = 0.012). Conclusions The severity of impairment of motor abilities, quality of life, incidence of the crouch gait pattern in patients with spastic types of cerebral palsy are close between subgroups at the time of transition to adult medical and diagnostic institutions. The quality of life and motor status after multi-level intervention improves and remains stable by the end of the childhood. Early surgical interventions for lengthening the triceps, fibromyotomy reduce motor potential in the long term, cause the development of the iatrogenic crouch gait pattern, and decrease the quality of life of adolescents with mild neurological disorders

Limb lengthening and deformity correction in patients with severe fibular hemimelia: experience of the children's university hospital in Belgrade

Background Fibular hemimelia (FH) is a congenital disease manifested by valgus deformity and instability of the knee joint, shortening and deformity of the tibia, hypoplasia and deformities of the foot and ankle. The aim of this paper was to determine the efficacy of the strategy of separate reconstruction of the foot along with correction of tibia deformity, and then tibial lengthening in patients with FH of types 3 and 4 according to Paley. Methods This retrospective study is based on an analysis of the treatment of 12 children with severe FH. The patients, aged no older than 24 months, were treated for foot reconstruction along with correction of tibial deformity followed by a separate stage of tibial lengthening. Tibial lengthening was performed in the age 4.6 ± 1.2 years. The long-term result of treatment was evaluated at least 1 year after the end of tibial lengthening. Evaluation criteria after tibia lengthening were external osteosynthesis index, amount of lengthening, assessment of outcomes according to Lascombes. Walking ability was assessed using Gillette questionnaire. Results The approach we used gave excellent and good results in 83 % of cases after the first reconstructive stage. Complications and recurrences of deformities encountered during the first stage were eliminated during subsequent planned limb lengthening. The average magnitude of lengthening was 6.4 ± 2.4 cm (37.2 ± 12.4 % of the initial segment length). The index of external osteosynthesis was 22.9 ± 12.2 days/cm. Monofocal distraction osteosynthesis was used in 9 cases and bifocal osteosynthesis in three cases. The results of lengthening were classified by Lascombes as IA in 7 cases, IB in four cases, 2B in one case. Discussion In severe FH, the question of reconstruction or early amputation remains open. There are two opinions on the staging of reconstructive orthopedic surgery and tibial lengthening in young children with severe FH. Conclusion The strategy of reconstruction of the foot and ankle joint at an early age (16-24 months) in children with severe FH followed by lengthening of the lower leg (at the age of 4-6 years) proved to be effective and can be used when it is chosen by the patient's parents. In 3C type cases, the use of external fixation to correct the deformity and simultaneously lengthen the tibia at the first stage is an alternative reasonable strategy option