IIntroduction The scope of examination of patients with closed intraarticular fractures of the calcaneus against the background of concomitant pathology has been discussed up to date. The aim of the study was to improve the accuracy of predicting the nature of postoperative wound healing after osteosynthesis of intra-articular fractures of the calcaneus from the extended lateral approach on the background of chronic obliterating diseases of the lower limb arteries of different etiology, smoking and a combination of these factors. Material and methods Sixty-nine patients who were smokers and/or suffered from chronic obliterating diseases with a total of 74 closed intra-articular fractures of the heel bones were analyzed. All patients received a comprehensive clinical and instrumental examination consisting of radiography and computed tomography of the calcaneus to determine the proximal-distal gradient (PDG), ankle-brachial index (ABI) and transcutaneous oximetry (TrOc). A single-factor analysis of variance was performed, after which an expert evaluation of the features was performed, as well as testing of models with different sets of signs. Results The disperse analysis of variance in respect of 74 cases for the relevant group of patients allowed us to obtain two models: the first with a level of statistical significance p0 less 0,001 (χ2 – 82,63; df = 7) and the predictive efficiency of 97.3 % in regard to possible complications after open reduction with internal fixation; the second level of statistical significance p0 less 0,001 (χ2 – 34,76; df = 7) and prognostic effectiveness of 93,24 % related to the risk of repeated surgical interventions. Conclusions The proposed method of predicting the development of complications in the immediate postoperative period after internal osteosynthesis of the calcaneus allows estimation of the risks of complications by calculating PDG, ABI and TrOc with high efficiency (97.3 %). The proposed discriminant model predicts the need for repeated surgical interventions with an efficiency of 93.24 %, and feasibility of surgical treatment with an extended lateral approach.

Introduction Patella fractures account for one percent of all fractures. Arthritis, non-union and other complications which affect the function of the lower limb may develop in the long term. The aim was to develop the most optimal osteosynthesis techniques for patella fractures. Methods We analyzed longterm treatment results of 78 patients with patella fractures treated from 2017 to 2018 using the KOOS (The Knee Injury and Osteoarthritis Outcome Score) scale, clinical examinations and knee joint X-rays. Based on the methods of surgical treatment for patella fractures, we divided the patients into 5 groups: Weber tension band wiring for two-fragment fractures; cross-like osteosynthesis and other methods of patella osteosynthesis using K-wires and wire loops for multifragmental fractures of the patella; combined osteosynthesis (tension band wiring with an additional screw or cerclage around patella); partial patellectomy and the inferior pole osteosynthesis. Results A comparative analysis of patients’ groups after surgical treatment of patella fractures using the KOOS scale showed the best results after Weber tension band wiring for transversal fractures (72 %). The results of patients with multifragmental fractures of the patella using K-wires and wire loops were positive in 64 %; after the restoration of the inferior pole in 68 %, after partial patellectomy in 57 %. Conclusion For transversal fractures of the patella, tension band wiring is the method of choice. With multifragmental patella fractures, good results are achieved by cross-like osteosynthesis and other methods using K-wires and wire bands. The use of patellectomy followed by wire loop locking should be avoided for all types of patella fractures. In fractures of the inferior pole of the patella, it is preferable to fix it to the main patella fragment.

Introduction Injuries of the proximal femur remains a significant problem of management in the elderly persons. The traditional approach comprising osteosynthesis of bone fragments is a method of choice in standard situations but showed to be insufficient in patients with an increased body mass index (BMI). Significant delay in full weight-bearing walking ability in this group of patients after fixation with dynamic systems needs to be solved with a nonstandard approach to their treatment. Therefore, arthroplasty after fractures of the proximal femur allows us to hope for an improved walking already in the early stages of rehabilitation in such a difficult group of patients. Methods Early results of hip replacement in 52 patients with fractures of the proximal femur were analyzed. They were divided into two groups: group I with obesity (28 cases, BMI ≥ 25) and group II with a normal body weight (24 cases, BMI less 25). Intraoperative and postoperative hemoglobin and blood loss counts, duration of the operation, frequency of early complications and the Harris hip score at six and 12 months after surgery were compared. Results Statistical analysis of the parameters showed a significant relationship between overweight, duration of the operation and blood loss, as well as clinical and functional treatment outcomes at six months after joint replacement measured with HHS scale (p less 0.05). Significant efficiency of arthroplasty was revealed in the rehabilitation period. Conclusion Obesity complicates hip arthroplasty but significantly affects the body response of patients with injuries in the hip area only in the early stages of treatment.

Introduction Correction of brachymetatarsia is performed by lengthening with various means. The necessity of metatarsal bone lengthening in brachymetatarsia is debatable. Material and methods From 2004 to 2018, surgical correction of brachymetatarsia was performed in 13 patients (age range, 6–18 years). Biomechanics of walking was studied in the preoperative and long-term postoperative period. Results The goal of surgical correction was achieved in all cases. AOFAS score scale was used for assessment of functional status. The mean score increased from 57.0 to 93.6 points. Time and kinematic characteristics of walking improved 18 months after reconstruction. Discussion Due to pain, discomfort and cosmetic defects the patients seek medical care even if marked functional disorders are absent in brachymetatarsia. The analysis of walking in patients with unilateral brachymetatarsia shows difference between the sides, as well as a deviation from the age norm on the side of brachymetatarsia. As far as motor skills complete to be formed by 7 years of age and close-to-adults walking by 13 years, it seems appropriate to perform surgical correction of brachymetatarsia in this period. Сonclusion Lengthening of metatarsal bones improves weight-bearing of the foot, ensuring the correct walking skills and smoothness of gait. Restoration of the fourth metatarsal bone, along with elimination of metatarsalgia, improves the esthetic appearance and allows wearing normal shoes. The compressiondistraction method enables to solve the problem of elongation of short tubular bones in brachymetatarsia.

Introduction First metatarsophalangeal joint (MTPJ) osteoarthritis hallux rigidus (HR) is the most common arthritic condition in the foot and occurs in 2.5–7.8 % of the population over 50 years. First MTPJ arthrodesis is currently considered to be the gold standard for the treatment of end-stage HR. When treating the advanced stage of HR, arthrodesis has long been established as an effective surgical procedure providing very predictable and satisfying results. Although the surgical authors prefer joint-sparing procedures first MTPJ fusion when required is the joint destructive procedure of choice in severe HR to eliminate or minimize pain, stabilize the first MTPJ and allow the hallux to bear weight. Functional outcomes achieved with fusion are also consistent with those from other surgical procedures. The purpose of this study is to evaluate long-term functional outcomes of first MTPJ arthrodesis. Material and methods Clinical and functional outcomes of MTPJ arthrodesis performed for 19 patients (25 feet) with grade 3 or 4 HR using the Coughlin and Shurnas Classification System between September 2010 and December 2017 were reviewed. The patients’ mean age was 60 years (range, 35 to 86 years). The median interval between surgery and the last follow-up was 5 years (interquartile range, 1.5 to 8 years). Ultimately, outcome assessment relied on patient satisfaction, radiographic examination, visual analogue scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) and the Foot and Ankle Ability Measure (FAAM) scores. Results AOFAS score was rated as good in 92 % of the cases (23/25), as fair in 8 % (2/25) with neither excellent nor poor results recorded. The median AOFAS score increased from preoperative 43.0 to postoperative 85.0 that was statistically significant (p less 0.05). Postoperative median FAAM Activities of Daily Living (ADL) was 99 %, median subjective ADL was 90 %, median FAAM sport was 84 %, and median subjective sport was 80 %. Patient subjective assessment was scored as “excellent” in 36 % of cases (9/25), “good” in 56 % (14/25), “fair” in 8 % (2/25) with no “poor” results recorded. The median VAS pain score decreased from 6 at baseline to 1 point postsurgery (p less 0.05). Conclusion First MTPJ arthrodesis was shown to be a very effective, reliable and lasting primary procedure for severe HR that provided 92% of good outcomes in our series. The procedure can be advocated as a predictable and excellent option for Coughlin and Shurnas grades 3 and 4 HR facilitating high success rates in pain relief and restoration of function.

Background Vitamin D-resistant rickets is a systemic disease with impaired bone remodeling that interferes with orthopaedic treatment of musculoskeletal pathologies. There is a paucity of literature focusing on the content and dynamics in vascular endothelial growth factors (VEGF) that promote the transformation of cartilage to bone. Objective Explore blood serum concentration of VEGF and VEGF-А and their receptors VEGF-R2, VEGF-R3 at stages of combined osteosynthesis in patients with vitamin D-resistant rickets during correction of multiplanar deformities of lower limbs. Material and methods The study included 24 patients with multiplanar deformities of lower limbs secondary to vitamin D-resistant rickets. Patients were treated with combined Ilizarov external fixation and intramedullary nailing using hydroxyapatite-coated wires. Serum concentration of VEGF and VEGF-А and their receptors VEGF-R2,VEGF-R3 were measured during treatment. Values obtained in the patients were compared to reference levels measured in 180 somatically healthy individuals. The quantified results were presented in a percentage of the reference values. Results Preoperative serum VEGF and VEGF-R2 concentration was significantly higher in the patients than that in normal subjects: VEGF, by 1990 % (р = 0.0033); VEGF-A, by 450 % (р = 0.00042); VEGF-R2, by 392 % (р = 0.0052) while preoperative serum VEGF-R3 concentration was lower by 68 % (p less 0.05) in the patients than that in subjectively healthy individuals. Surgical treatment resulted in greater increase in VEGF, VEGF-A levels with maximal concentration observed at the distraction phase. The oppositedynamics was observed with VEGF-R2 receptor. Specific dynamics was noted with VEGF-R3 receptor during surgical correction. Nearly preoperative serum concentration of VEGF-R3 was seen at the first stage showing the lowest level (21% of the normal) during bone distraction with external fixator and regenerate formation. It was reduced by 25 % of the preoperative level at the end of treatment. Conclusion Patients with vitamin D-resistant rickets demonstrated strong imbalance in serum concentrations of VEGFs and their receptors. Phase opposition dynamics in serum concentrations of VEGFs and their receptors was detected during surgical correction of multiplanar deformities of lower limbs.

Introduction Hoffa's disease is a common condition, and is a severe pathology of the knee joint in many cases. Ultrasound with its capabilities and advantages can be a convenient method of primary diagnosis of this pathology. However, in the literature there is almost no description of the characteristic ultrasound picture of Hoffa’s disease and an analysis of the most common and pathognomonic symptoms. Objective To study ultrasound signs of Hoffa's disease and present the characteristic sonographic complex of its symptoms. Methods Ultrasound examination of the knee joint and arthroscopy of 37 patients diagnosed with Hoffa's disease, confirmed by a comprehensive clinical and instrumental study, was conducted. Results The most characteristic signs of Hoffa's disease in terms of pathological changes are hypertrophy of the Hoffa’s fat pad and changes in its structure, which were detected by ultrasound in 62 % and 84 % of cases, respectively. A new symptom, displacement of the patellar ligament, was identified by ultrasound examination of the knee joint according to the standard protocol in 32 % of the examined. The same percentage comprised the patients who had non-specific sonographic symptoms: an increase in the amount of synovial fluid, as well as signs of infrapatellar bursitis. Ultrasound data were compared with the results of arthroscopic examination, their correspondence was determined. Conclusion It has been established that the ultrasound examination of the knee joint according to the standard method enables to identify a complex of symptoms that are pathognomonic for Hoffa’s disease. It is recommended to introduce it in the protocol of the conclusion.

Objective Explore changes in roentgenoanatomical parameters of the pediatric hip joint following multilevel reconstructive surgeries performed for CP patients in combination with derotation varus osteotomy (DVO) alone or DVO and acetabuloplasty (AP). Material and methods The study included 49 children (30 GMFCS level IV and 19 GMFCS level V patients). Either DVO (n = 28, 44 joints, mean age 6.98 ± 2.2 years) or DVO and AP (n = 21, 38 oints, mean age 7.0 ± 2.04 years) were produced in combination with multilevel reconstructive surgeries to eliminate contractures of the knee and ankle joints and correct foot deformities. The acetabular angle, the Reimers' index, the acetabular depth ratio (ADR), the Wiberg center-edge angle were measured preoperatively, straight after surgery and at 1, 2, 3 years postsurgery. Results Normal relationship between the femoral head and acetabulum persisted at a long-term follow-up. The parameters evaluating acetabular morphology (Wiberg angle, AI and ADR) were shown to improve or remain stable. The mean annual increase in the Reimers' index was not more than 3 % after DVO and not more than 2% following DVO and AP. A reverse statistically significant correlation was detected between the AI and Wiberg angle after DVO alone or DVO combined with AP throughout the observation period. This sort of correlation facilitated beneficial development of the operated hips at a long term following reconstructive interventions. Moderate correlation was observed in changed AI values after DVO at 3 years postsurgery and changes in the Wiberg angle at three-year observation comparing relative measurement changes and the age when surgery was performed. Age appeared to have a minor effect on the development of the hip following multilevel procedures produced for the cohort of patients. Conclusion Appropriate conditions should be provided for normal development of the hip to address hip dislocation using growth-remaining potential and remodeling the articular ends. Single-event multilevel surgery involving hip reconstruction and addressing knee and ankle contractures is practical for providing favorable conditions for postural management and passive verticalization of patients to maintain axial loading on the limbs.

Introduction Spastic types of cerebral palsy are around 80 % of all CP cases diagnosed. They feature early secondary orthopedic complications, for the prevention of which, within the framework of comprehensive rehabilitation treatment, technical means of rehabilitation (TMR) have been widely used, and first of all, individual and model orthoses. Currently, there are no clear indications for their application. Aim To determine the variants of orthoses and their distribution depending on the level of motor activity of patients with spastic types of cerebral palsy according to the GMFCS classification. Materials and methods A retrospective analysis of 662 patients with spastic types of cerebral palsy aged from two to 17 years for the period from 2007 to 2017 was conducted. All the patients were divided into 5 groups according to the levels of motor activity by GMFCS classification. Statistical data processing was performed using Statistica 10 and Excel software packages. Results Analysis showed that patients used 15 TMR types, of which 14 were orthoses of different designs. Intergroup differences in the spectrum of applied TMR were statistically confirmed. Statistically significant differences were found in pairwise comparison of all groups of patients with at least one type of means; maximum differences in 8 types of TMR were found in pairs of groups GMFCS 2 and 4, and GMFCS 2 and 5. Conclusion Technical means of rehabilitation are widely used by patients with spastic types of cerebral palsy for complex medical rehabilitation. The variability of the number and scope of TMR was found and depended on the level of motor activity. Given the above, it is important to further study the role of technical means in the medical rehabilitation of patients with cerebral palsy, including the development of guidelines for their application.

The objective of the study was to assess articular cartilage (AC) and subchondral bone (SCB) remodeling, expression of matrix metalloproteinase 9 (MMP-9) in tissues, vascular endothelial growth factor (VEGF) in experimental osteoarthritis (OA). Material and methods Experimental comparative study was conducted on 12 outbred guinea pigs of both sexes aged 28–30 weeks that were divided into 2 groups of 6 animals each. An injury to the knee joints of hind limbs of control and experimental animals was mechanically simulated by closed scarification using a sterile needle. No treatment was provided for controls. Experimental animals were given an intraarticular injection of betamethasone (BMZ) of 0.1 mg/kg every two weeks after two weeks of injury. Two subjects of each group were euthanized at 30, 45, 60 days and knee samples collected. Immunohistochemical expression of VEGF and MMP-9 was determined in tissues. Results A statistically significant decrease in VEGF positive chondrocytes and precipitate density, an increase in positive chondrocytes and intensity of tissue response to MMP-9 as compared to those in controls was observed in BMZ animals at 30 days of experiment. A statistically significant decrease in VEGF positive cells and precipitate density, an increase in VEGF positive chondrocytes as compared to those in controls were observed in BMZ animals at 45 days of experiment. Significant reduction in VEGF positive cells and deposit density, significantly higher density of MMP-9 positive precipitates as compared to those in controls were noted at 60 days of BMZ injections. Conclusion Intraarticular injections of BMZ demonstrated a negative effect on AC and SCB with articular tissue remodeling initiated through activation mechanisms of extracellular matrix degradation, as evidenced by high expression of MMP-9. BMZ was shown to block pathological angiogenesis via VEGF inhibition.

Purpose To compare and analyze structural changes in the vascular bed of the spine skin, paravertebral muscles in the zone of surgical intervention (at the apex of the spine deformity), as well as serum concentrations of vascular endothelial growth factors and their receptors in patients with kyphoscoliosis due to neurofibromatosis type I (NF-I). Material and methods The work is based on the results of examining a continuous cohort of patients with NF-I (n = 12). During the examination the concentrations of vascular endothelial growth factors (VEGF, VEGF-А, FGF-basic) and receptors for these factors (VEGF-R2, VEGF-R3) were determined in blood serum using the immunoenzyme analysis. Histological techniques of light and scanning electron microscopy were used for studying the biopsy material of the spine skin and paravertebral muscles obtained in the projection of the spine deformity apex during surgical correction of kyphoscoliosis. Results Concentration of VEGF and VEGF-A was 8 % (р = 0.00908) and 417 % (р = 0.00392) higher than reference values, respectively. VEGF-R2 receptor was 215 % (р = 0.00622) and exceeded the level of reference values. On the contrary, VEGF-R3 receptor concentration was 58.1 % (р = 0.00415), lower than the relative reference values. FGF-basic growth factor in blood serum was within control values (р = 0.05613). Changes in the histostructure of the vascular walls of large- and medium-size arteries and veins, fibrosis and obliteration of some vessel lumens, hyperemia of venous and capillary microvessels, formation of inflammatory infiltrates in adventitia of large- and medium-size vessels and in perivascular spaces, hemorrhages were revealed in bioptates of the spine skin. Pathological changes in muscles manifested themselves as fibrosis and constriction (up to complete obliteration) of the lumens of arterial vessels, increase in the diameter of thin-walled venous vessels, increase in their permeability leading to widespread extensive hemorrhages. Conclusion Increased concentration of vascular endothelial growth factors and their imbalance with receptors in patients with NF-I are combined with pathohistological structural changes in the vascular system of the spine skin and paravertebral muscles due to the inflammatory process present. The obtained results should be taken into account both in surgical treatment of this complex disease manifestations, and when planning treatment and rehabilitation measures in general.

The anterior cruciate ligament (ACL) is the key stabilizer of the knee joint, which prevents the anterior displacement of the tibia relative the femur and rotational instability of the knee joint. Proper understanding of its complex anatomy, function and biomechanics, mechanism and the type of ACL injury is of great importance in choosing a treatment strategy. Findings of clinical tests and imaging methods have a significant value in the diagnosis of anterior knee joint instability. Considering all the variety of currently existing techniques and implants for operative treatment of anterior knee instability, the clinicalpractitioner should make the right choice of a method or combination of methods for surgical ACL reconstruction in a specific patient, taking into account individual risks of gonarthrosis. The goal is to ensure knee joint stability with the least invasiveness to allow the patient to return to the preoperative level of physical activity as soon as possible.

Introduction Based on WHO report, in 2008, the global prevalence of overweight reached over 1.4 billion people aged 20 years and over including more than 200 million men and 300 million women who suffered from obesity in 2012. More than 34 % of U.S. adults are overweight, and more than 27 % are obese. In European countries, the prevalence of obesity is 35–40 % among adult population. More than 30 percent of the Russia’s working population is overweight, 25 percent of whom are obese. Material and methods Search engines used included MEDLINE, the primary component of Pubmed; the Electronic Library System, products from Elsevier and Springer publishing companies; open access articles of PubMed Central; BioMed Central; Free Medical Journals and open access publications using the keywords 'knee osteoarthritis', 'etiology and pathogenesis', 'knee osteoarthritis in obesity'. Results and discussion Osteoarthritis (OA) is multifactorial in origin and closely associated with genetic predisposition, sex and age, greater body mass index (BMI) and obesity. Family history, age, gender, previous injury or abnormal mechanical loading are common risk factors of knee OA. While the above risk factors can increase the chances of developing knee OA, they are not absolute. In clinical practice, in patients with new onset of knee pain 5.1 % of cases are due to previous knee injury and 24.6 % related to being overweight or obese. Such metabolic factors as obesity and dyslipidemia might be involved in the pathophysiology of knee OA. Increased free radical production associated with obesity results in degradation of articular cartilage and synovial involvement. The pathogenesis of knee OA attributable to obesity is predominantly related to unfavorable mechanical environment at the joint; chronic inflammation in adipose tissue and dyslipidemia; pro-inflammatory cytokines and adipokines secreted by the adipose tissue; cytokines secreted by infrapatellar fat pad. Conclusion Inflammatory mediators of adipose origin play a major role in the initiation and perpetuation of the obesity-induced OA. There is a significant multifactorial association between OA and obesity with central roles for LDL oxyforms, HDL synthesis and excessive activation of matrix metalloproteinases, adiponectin synthesis, the release of adipokines and excessive mechanical stress.

The ankle plays an essential role in establishing lower extremity stability that is important for such physically demanding sports as ballet. Nonphysiological movements in the joint that force the ankle into extreme positions and repetitive stress during intense practice and performances predispose to the development of pathological conditions. Radiological studies are an integral part of diagnostic algorithm for the search of the causes of pain. The aim was to conduct a literature review on diagnostic imaging of ankle pathology in ballet dancers. Methods Literature searching was performed via databases of PubMed, Cochrane library, eLibrary.ru, etc. using the following terms: ankle pathology in ballet dancers, bballet ankle imaging, ballet ankle. Conclusions Standard radiographs are usually the initial screening modality to evaluate patients, including ballet dancers with lower extremity symptoms, nonetheless, MRI provides a superb global evaluation of each joint, including deep structures and detecting possible causes of pain.

Objective Demonstrate an outcome of comprehensive treatment of an adolescent with fracture-dislocation of the thoracic spine accompanied by deep lower paraplegia and pelvic floor dysfunction using noninvasive percutaneous spinal cord stimulation and mechanical stimulation of the foot bearing surface. Case study Comprehensive treatment was performed for a 17-year-old patient who sustained a combined injury during roller ski training. The patient presented with back pain, breathing difficulty, being unable to perform active movements of lower extremities. He reported loss of sensitivity in the lower part of the body, perineum and lower limbs. The injury was classified as ASIA grade B with motor impairment scored 50 and overall sensory score of 88. Surgical intervention was produced within the first hours after injury and was followed by rehabilitation program including stimulation of the foot bearing surface with Korvit plantar support load simulator and noninvasive percutaneous spinal cord stimulation. Neurologic status of the patients was graded as ASIA level D at one-year follow-up with motor score of 85 and sensory level improved to 175. Conclusion Surgical treatment produced for the patient with spinal cord injury within the first hours after trauma using noninvasive percutaneous spinal cord stimulation and mechanical stimulation of the foot bearing surface provided regress of neurological disorders facilitating more intense lower-limb motor recovery and other important gait characteristics. The patient could regain voluntary control of muscle activity, stand unassisted and walk with a cane at one year post-injury.

Background Cervical spinal cord injury (CSCI) can result in numerous pulmonary complications and special attention to respiratory support is vital in rehabilitation of the patients. Aim To develop regimens for an implantable generator of electrical impulses to be used in phrenic nerve stimulation to liberate or wean a patient from mechanical ventilator. Material and methods Stimulation of the phrenic nerve was performed for a 9-year-old boy with a traumatic spinal cord injury and complete anatomical disruption of the spinal cord at the C2 vertebra level. Artificial and auxiliary lung ventilation was provided for the patient with the CareFusion LTV 1200 system (USA). Nerve monitor ISIS IOM (Inomed Medizintechnik GmbH, Germany) was used to control the phrenic nerve. Statistical analysis of baseline data was produced with two-tailed Student's t-test. Microsoft Excel and AtteStat program, version 13.1 were used to complete data analysis reports. Results A four-contact cylindrical electrode was inserted into the epidural space of the cervical vertebrae and placed at cervical levels C2–C4 with a minimally invasive procedure and a course of electrical stimulation was initiated. Possibility of weaning was considered with four step procedure to be involved. The first phase included the development and implementation of electric stimulation modes with breathing patterns at frequency of 12, 15 and 20 cycles per minute with auxiliary respiration breathing. The second stage consisted of electrical stimulation with audiovisual support from animated cartoon singles. No auxiliary respiration was used with the peripheral oxygen saturation monitored in the upper limb. The third stage included phrenic nerve stimulation produced four times per day for fifteen minutes each, without assisted breathing, simultaneously with audiovisual support. The fourth stage included device implantation for chronic electrical stimulation with use of program version V18.6.2. Finally, the patient could breathe independently using simultaneous stimulation produced 3 times per day for 20 minutes and develop a greater amplitude of active head turns, improved speech clarity and increased voice volume. Conclusion Electrical phrenic nerve stimulation applied to a patient with a high level of spinal cord injury using an implantable modified device, virtual environment components and appropriate exercise therapy facilitated improved range of autonomy and level of independent breathing control.

Interventional laser-induced thermal therapy (LITT) is an emerging technique to treat popliteal synovial cysts. The goal of LITT is coagulation and subsequent obliteration of inosculation and cystic cavity under local tumescent anesthesia. Ultrasound is an imaging method used for LITT. Analyzing the results of the use of laser obliteration of Baker's cyst, the authors concluded that obliteration of solely the cystic popliteal cavity can provide persistent recovery. As expected, in any invasive procedure, there are some procedure-related adverse events or complications.

Introduction The main reasons for arthroplasty of the ankle joint are osteoarthritis in the terminal stage (posttraumatic or idiopathic), purulent arthritis and oncology. Publications devoted to the problems of infectious complications after arthroplasty of the ankle are not numerous. The rate of periprosthetic ankle infection varies from 2.4 % to 4.7 % of cases; and the predisposing factors include diabetes mellitus, previous history of operations on the joint and the duration of the arthroplasty procedure. The restorative strategy for periprosthetic infection involves diagnostic measures (hematological, radiological, microbiological, radiologic, cytological) and surgical treatment. The variants of surgical treatment of periprosthetic infection of the ankle joint are revision arthroplasty (single- or two-staged), arthrodesis (using external fixation devices and intramedullary nail) and amputation. Moreover, along with surgical intervention, a long-term course of etiotropic therapy (antibacterial and/or antifungal) is mandatory. Methods The result of treatment of a patient with periprosthetic ankle infection using a two-stage arthrodesis procedure was analyzed. Results The medical measures arrested the purulent inflammatory process and enabled the weight-bearing function of the limb. Discussion Two-stage arthrodesis of the ankle may be one of the options for treating periprosthetic infection aimed at maintaining the support function of the limb and its length without the use of additional orthopedic procedures, such as osteotomy for lengthening to cover the post-resection bone defect, thereby reducing the risk of possible complications (damage to the main vessels and nerves in the area of the osteotomy) and the period of surgical rehabilitation of the patient.

Introduction Lesions of the spine due to gout are rare types of seronegative spondyloarthritis. The article provides a review of the literature of primary and secondary types of gouty spondyloaritritis and presents a clinical example of nonspecific osteomyelitis of the spine (NOS) in a patient with the primary Lesh-Nyhan syndrome (LNS). The aim of the work is to show the complexity of diagnosis and treatment of pyogenic spondylitis in a patient with a genetically predetermined primary gout LNS. Materials and methods Clinical and radiographic assessment of the patient was performed in accordance with the clinical recommendations for the treatment of infectious spondylitis (2018). The effect of surgical treatment was studied with standard scales and questionnaires: ODI, SF-36, VAS, ASIA. Results Due to pain, severe neurological manifestations and instability of the spine, the patient underwent a decompression stabilizing surgery. The final diagnosis of gout tophus lesions of the spine was established with light polarization microscopy. Conclusion Diagnosis and treatment of gout spondyloarthritis is difficult. The clinical case of NOS in a patient with LNS showed that a diagnostic errorand incorrect interpretation of the diagnosis may occur if the postoperative material is not verified histologically and bacteriologically. Since radiographic changes in the spine are usually nonspecific in gout, trepanation biopsy and examination of the histological material with polarizing light are necessary to verify the diagnosis.

Background Extraarticular deformity of the femur or tibia may be critical for the success of primary total knee arthroplasty (TKA). Recognizing an extraarticular deformity preoperatively allows a surgeon to choose between various management strategies. The surgical treatment options for correction of an extraarticular deformity include (1) primary TKA, (2) simultaneous corrective osteotomy and TKA and (3) staged corrective osteotomy and delayed TKA. Objective To substantiate differentiated approach to treatment strategies for osteoarthritic knee with extraarticular deformity based on international and our own experience. Material and methods Comparative analysis of current literature on surgical treatment of extraarticular deformities in arthritic knees was produced. The differentiated approach was illustrated by a clinical instance of a 35-year-old patient with bilateral end-stage gonarthrosis associated with extraarticular deformity of both lower limbs. Staged treatment was considered for the congenital multiplanar multilevel deformity in the shaft of the left femur with 26º valgus alignment, procurvatum, external rotation to be corrected with bifocal osteotomy addressing all components of the deformity and stabilized with interlocking intramedullary nail. Standard TKA on the left side was produced a year later with posterior cruciate ligament (PCL) retention. Acquired uniplanar varus deformity of the right femur was corrected using computer-assisted navigation TKA and the PCL substitution at 5 months after the first procedure. Results Knee score improved from 28 to 85 and from 52 to 86 in the left and right sides while functional activity score increased from 42 to 90 and from 52 to 92, respectively, as measured with American Knee Society scoring system (KSS). There is plenty of evidence in the literature that computer-assisted navigation TKA facilitates accurate limb alignment, better flexion angle and improved functional score whereas osteotomies are associated with a higher risk of complications that can result in delayed consolidation or nonunion. Conclusion Differentiated approach can be advocated for correction of an extraarticular deformity of lower limb to be addressed with TKA depending on the magnitude (in degrees), the location of the deformity in relation to the knee joint and relevant patient specific charactreristics, such as age, gender, clinical history. Computer-assisted navigation TKA is practical for mild diaphyseal deformity associated with gonarthritis. Corrective osteotomy can be useful for severe diaphyseal deformity or with the apex localized close to the joint for realignment at the first stage.