In Italy, as in much of the industrialized world, the health sector is facing a double challenge. On the one hand, the economic crisis nd the urgent need to control spending and on the other there is the awareness that health care can not be separated from high quality standards. The model health future will be more and more "patientcentered" with a strong integration of services and consequently you will find more resources for such evelopment. It seems clear that to manage such complexity respecting a certain equilibrium, we must respect the sharing of values and methodologies among different rofessionals. In addition it must ensure that the understandable pressure placed on operators on cost control will not reflect negatively on the performance of he patient. It seems clear that to restore the system not just to cut costs, but you need to use all available tools and methodologies to facilitate effectiveness and linical appropriateness. And 'necessary to focus the process of planning and management of health services to the needs of the community, enhancing the role and responsibilities of hysicians and health care by promoting the culture of quality. In this regard, it seems clear that the processes of care should be studied and re-engineered with the aim to optimize spending, while maintaining as a "gold tandard" the high quality of care. The aim of this study was to analyze in this context, the activities of the Unit of Hand Surgery with particular emphasis to the Department of Rehabilitation of he principals of the group Multimedica and so, check its viability, producing a model, possibly duplicated and exportable to other similar initiatives.

Purpose. To develop the technology of manufacturing an individual full-contact receiving socket for forearm prostheses. Materials and Methods. We developed and tested a new technology of manufacturing individual full-contact receiving socket for forearm prostheses which included the stage of performing an intermediate receiving socket and its completion using the compositions based on organosilicon compounds (silicon) that allowed taking all the anatomical details of the faulty stump into account. Results. The developed technology has some advantages over the traditional technology of manufacturing receiving sockets: it allows to fix prostheses securely with minimal piston-like motions; to improve both the cosmetic quality of prosthetics and the appearance due to elimination of additional fastening elements. Conclusion. The developed technology does not require using additional equipment and production tools, it allows to make complex prosthetics in prosthetic-orthopedic enterprises, as well as it has some advantages over the traditional technologies of manufacturing receiving sockets.

Purpose. To evaluate the efficiency of the developed system of rehabilitation of patients with plegiae in the forearm and hand area. Materials and Methods. The authors presented a new conceptual algorithm of clinical orthotic support (RF Patent N 2550049) in complex treatment of patients with plegiae and “spastic hand” syndrome on the basis of low-temperature plastic properties, as well as on the conditions of using an individual set of “hospital in the hand” orthoses in the rehabilitation individual program. They demonstrated a clinical example of using the proposed rehabilitation algorithm in a patient with plegia of central origin. Results. The new method of orthotics allowed providing an increase in the amplitude of motion of all the segments of the forearm, wrist and the hand small joints. It complemented other rehabilitation technologies including surgical ones. The result of the patient’s system rehabilitation within a year consisted in the improving the hand function, perfectioning the patients’ self-service, enhancing their quality of life, reducing the time for handling the disabled by normal family members. Conclusion. The increase in the efficiency of complex treatment of the patients with “spastic hand” consists in the involvement of multidisciplinary team of specialists. Coordinated actions of the specialists should be implemented in comparing definitions when registration of medical documents.

The authors covered the problem of organization of rendering rehabilitation care for orthopedic-traumatological patients in the large federal center inpatient setting. They analyzed the foreign publications and those of our country in the given direction, as well as the legislative documents regulating the identified problem. Moreover, they proposed the staged algorithm of performing rehabilitation measures, specified the methodological approaches for the implementation of rehabilitation programs. The main units of the rehabilitation system for its successful functioning determined.

The terms dynamic and static are often used in splint classifications. This terminology leads to confusion. Immobilization and mobilization splints are more appropriate terms. Dynamic splints are often  onsidered
to be used for improving range of motion (ROM), however static splints by maintaining a joint in end range  re also efficient in increasing ROM. This chapter presents the orthoses we recommend.

Study Design. Presentation of a clinical case of weight bearing and walking function recovery in a female patient with chronic osteomyelitis of pelvic bones, myelomeningocele and stumps of both femurs. Object. The clinical example of verticalization in a young girl, 26 years old, who got over both femur amputation in childhood and moved around in a wheelchair. Multiannual sitting position and moving around in a wheelchair caused developing the contact chronic osteomyelitis of pelvic bones and, moreover, the patient suffered from myelomeningocele and Spina bifida of open form when both femur prosthetics was impossible without preliminary surgical preparing. Method. The authors made staged surgeries in order to arrest osteomyelitis, myelomeningocele elimination, as well as they performed primary prosthetics of the both femur stumps in combination with the lumbar spine orthotics (a brace of thermoplastic material) Result. The patient was verticalized for the first time in her life with walkers that was realized in the possibility of standingand ambulate. Discussion. The observation demonstrates the need for multidisciplinary approach to rehabilitation of the patients with polysegmental and complicated pathology of the locomotor system.

Purpose. To evaluate the effectiveness of using the functional correcting brace of Chenault type in treatment of patients with idiopathic scoliosis. Materials and Methods. The authors observed 53 patients (41 girls and 12 boys) who underwent scoliosis conservative treatment using the functional correcting brace of Chenault type. Age-related distribution as follows: there were 3 patients at the age from 5 to 9 years, 21 patients – at the age from 10 to 13 years, 25 – from 14 to 16 years, and 4 patients at the age from 17 to 18 years. As for the deformity type, the patients with combined scoliosis prevailed: those with right-sided thoracic arc and left-sided lumbar one – 35 patients. 4 patients suffered from right-sided thoracic scoliosis, 10 patients – from thoracolumbar scoliosis, 4 patients – from lumbar scoliosis. The patients were divided into groups depending on the deformity degree: 8 subjects – 11-25º, 30 patients – 26-40º, 15 patients – above 41º. Initially the growth of the spine bones was uncompleted in all the patients. Results. The deformity correction in children from Group 1 (11-25º according to Cobb) was 100 % in 3 patients, 70 % – in 3 patients; in Group 2 (26-40º according to Cobb) – 100% in 11 patients, 90% – in 3 patients, 70% – in 3 patients, 50% – in one patient, 40% – in one patient; in Group 3 (above 41º according to Cobb) – 70% in 2 patients, 50% – in 5 patients, 40% – in 2 patients, 30% – in one patient. Conclusion. It is possible to achieve maximum correction in children with the scoliotic deformity of 11-25º and 26-40º according to Cobb, and that evidences of the fact that treatment with the functional correcting brace of Chenault type appears to be the most favorable at the early stages of the disease. Orthotics should be individual in view of the characteristic properties of the spine deformity and its progression prospects, age, the spine growth potential and therapeutic tasks.

Purpose – to analyze сomplications after the shoulder arthroplasty in patients with inveterate fractures and fracture-dislocations of the proximal humerus. Materials and Methods. 69 patients with inveterate fractures and fracture-dislocations of the proximal humerus underwent surgery. The fractures were accompanied by posttraumatic plexopathy in 89% of cases. The following methods of studying were used: clinical, radiological, MRI, MSCT, ENMG of the shoulder girdle. Hemiarthroplasty was performed in 51 patients, bipolar arthroplasty in 10 patients, and total arthroplasty – in 8 ones. The outcomes of treatment were available in 54 patients within the periods from 6 months to 9.5 years after surgery. Results. Complications after the surgery were observed in 16 patients (29.6%). Brachial plexopathy accompanied the fractures in all these patients. The following complications were the most significant: implant head migration (16.6%) and implant instability (5.5%). Conclusion. The decrease in the number of complications after the shoulder arthroplasty for inveterate fractures in this area can be achieved by early prosthetics of the patients with fresh fractures, as well as by therapy of accompanying plexopathies simultaneously with treating the shoulder bone injuries.

Purpose. To develop the algorithms based on combining musculotendinous transpositions and osteoplastic interventions in the shoulder girdle in order to increase the active movements of abduction and supination in the shoulder in children with the consequences of the brachial plexus paralysis at birth. Materials and Methods. The authors examined 37 patients with the brachial plexus birth injury consequences. They used the methods of multispiral computed tomography (MSCT) and magnetic resonance imaging (MRI). Various-degree secondary changes in the shoulder components revealed in 26 patients. There were no changes in 11 patients according to the data of instrumented examinations. Hypoplasia, elevation and rotation of the scapula – SHEAR-deformity (Scapular Hypoplasia Elevation and Rotation) was considered as the secondary change; as well as the coracoid deformity characterized by the coracoid elongation, growth in the lateral direction; and the humeral head ovoid shape. Different variants of musculotendinous plasty surgery performed in 25 cases. Humeral derotation osteotomy performed in 6 cases. NeiSi-3M system of chronic electrical neurostimulation implanted in six patients with epineural electrode fixation to C5-C6 roots and their branches, to the inferior subscapular nerve, the suprascapular nerve, the axillary nerve, the musculocutaneous nerve. Orthoses for the shoulder used for some months in order to hold the shoulder in the predetermined position. Mallet scale used to evaluate the results of the performed treatment. Results. The best results were obtained in the group of the patients who underwent the surgery of humeral derotation osteotomy. The formation of abduction external-rotation contracture of the shoulder, the elevation and lateralization of the scapula, the combined movement of shoulder-scapula complex due to the scapula-thoracic junction – this observed in most patients who underwent surgical musculotendinous plasty. Conclusion. The efficiency of using a particular technique of treatment is determined by its reasonable selection in each specific case.

The results of long-term follow-up survival of Oxford III (Biomet) design unicompartmental implant poorly studied since this effective method had been implemented in practice. We prospectively studied and analyzed the long-term outcome of 400 Oxford III (Biomet) unicompartmental implants from 320 patients with the mean age of 69 years (48 to 82) at the time of surgery. Average follow-up was 9.3 years (5 to 15). When analyzing the fifteen-year longterm results of arthroplasty Knee Society score significantly increased from 56.2 (41 to 93) before surgery to 88.6 (61 to 97) (p = 0.036) after surgery, and the functional parameters – from 59.2 (45 to 94) to 88.2 (55 to 98) (p = 0.023), respectively; the average score of Oxford Knee score system improved from the average of 25.8 points (12 to 39) to 40.1 points (28 to 54). Revision arthroplasty was performed in 21 patients (5.25%). Five patients underwent total knee arthroplasty. Minimally invasive unicompartmental arthroplasty using Oxford III (Biomet) design showed satisfactory long-term clinical results.

Purpose. To undertake a comparative study of the efficiency of medication correction influence on remodeling processes of the bones forming the knee before and after the knee arthroplasty. Materials and Methods. Clinical and densitometric investigations performed in patients with terminal-stage gonarthrosis and mineral bone density decrease who underwent the knee arthroplasty. All the patients were females with the mean age of 57 years. X-ray densitometry (dual-energy absorptiometry) performed before surgery and 12 months after it. The patients were divided into the main group and control one depending on further treatment regimen. Results. Densitometry data analysis before and after surgery demonstrated a reliable increase in bone density after surgery in the patients of the main group who received osteotropic preparations comparing with the control group values. Bone density increase in the main group by the end of the year amounted to 60.0%, in the control group – to 18.8%. Conclusion. Osteotropic therapy in patients with marked osteoporosis should be started not later than six months before the knee total arthroplasty.

Introduction. Arthroplasty in current orthopaedics is very popular for treatment of patients with gonarthrosis. But the interest in correcting osteotomies doesn’t disappear as well. Purpose. To analyze the effectiveness of treating gonarthrosis mainly affecting the knee medial part using different types of high tibial osteotomies with biomechanical axis recovery. Materials and Methods. We considered the issues of surgical treating severe gonarthrosis with the medial knee primary involvement by performing tibial osteotomies in the proximal third and fibular osteotomies – in the distal third using the Ilizarov fixator. Treatment results analyzed in 60 patients at the age of 50-75 years (64±0.5 years) with gonarthrosis who underwent correcting subcondylar osteotomy. The absence of the knee pain was the main criterion of treatment effectiveness. Results. The achieved result maintained up to seven years. Conclusion. The proposed technique of treatment allows recovering limb biomechanical axis and thereby normalizing the load on the medial joint. This technique is used practically throughout the world including the best European clinics.

Introduction. There are no studies on vascular pathomorphological changes in persons constituting the risk group on the hand finger traumatic abjunctions and wounds in the available literature, although there is evidence suggesting a significant influence of this factor on the results of revascularizing reconstructive-and-restorative surgeries. Purpose. To reveal and analyze possible pre-existing vascular pathomorphological changes in persons with traumatic finger abjunctions and wounds with a circular saw and milling-machine. Materials and Methods. The authors investigated the operation material from 26 men with open injuries of the hand who engaged in mechanized physical labor and subjected to active or passive smoking using the methods of light microscopy of paraffin and epoxide semi-thin sections. Results. They determined the frequency (50%) and the variants of obliterating arterial involvements of the hand fingers: adaptive neointimal hyperplasia, atherosclerosis, Hammer-syndrome, vasculites. The frequency of pathomorphological changes in vessels is reliably higher in patients above 30 comparing with those at the age from 22 to 30 years. Conclusion. A variety of arterial obliterating involvements of the hand fingers in patients from the risk group on the hand finger abjunctions and wounds evidences about the need to investigate operation material histologically. This approach will allow clarifying the outcome prognosis of revascularizing surgery, as well as the protocol of postoperative management of patients.

The literature has not paid adequate attention to the problem of neural structure involvement in the patients suffered from vitamin D-resistant rickets with deformities of the lower limb bones. Purpose. To study the thermo-and-algesthesia condition in the patients suffered from vitamin D-resistant rickets with multiplanar deformities of the lower limb bones. Materials and Methods. The results of examining 15 patients with multiplanar deformities of the lower limb bones due to vitamin D-resistant rickets formed the basis of the work. The authors investigated the thermo-and-algesthesia with an electrical estesiometer in the area of L1–S2 dermatomes. All the patients underwent surgical treatment including transosseous osteosynthesis with the Ilizarov fixator combined with intramedullary osteosynthesis using wires with hydroxyapatite coating. The investigations performed before surgery, in the process of the deformity correction and in the long-term periods after treatment. Results. The authors revealed that before surgical treatment thermo-and-algesthesia disorders observed in the dermatomes from L4 to S2 where thermoesthesia thresholds were increased or there was no thermoesthesia in them at all, algesthesia threshold tended to increase in L5 dermatome. The investigation of the thermo-and-algesthesia during treatment demonstrated that acute deformity correction on the whole didn’t cause significant changes in the thermo-and-algesthesia condition. Conclusion. Thus, the authors observed the moderate disorders of the thermo-and-algesthesia in the dermatomes from L4 to S2 of the patients suffered from vitamin D-resistant rickets with deformities of the lower limb bones. The used technique of correcting multiplanar deformities of the lower limb bones doesn’t result in the failure of the compensatory mechanisms of the thermo-and-algesthesia system both at the stages of treatment and in the long-term periods of postoperative follow-up.

The authors analyzed the scientific publications related to the problems of treating the injured persons with femoral neck fractures. The main part of the sources in the literature was published within the last 10 years. As it has been revealed, despite the availability of many different surgical methods, as well as a wide range of implants, the incidence of unsatisfactory outcomes of treatment remains very significant. As it follows from the literature, there is no consensus on optimal means of fixation, indications for osteosynthesis and arthroplasty, the timing of surgery performing, rehabilitation principles up to date. Therefore, the search of new solutions in the problem of treating patients with femoral neck fractures, as well as the development of new efficient devices for reposition and fixation of bone fragments which reduce treatment time and improve treatment effectiveness is relevant.

The authors of this review evaluated the current laboratory tests reflecting early (preclinical) quantitative and dynamical pathochemical manifestations of osteoarthrosis (OA). The literature analysis allowed to reveal the fact that the increase in urine concentration of Type II collagen C-terminal telopeptide (uCTX-II), the increase in serum level of cartilage oligomeric matrix protein (sCOMP), as well as the increase in three IL-6, IL-1, TNF-α blood proinflammatory markers were the most informative tests for early diagnosis and evaluation of OA progressing. The authors presented the promising current developments of new diagnostic tests carrying out in the field of proteomics, genomics and metabolomics. As they noted, despite the success in search of laboratory criteria for early OA diagnosis it was evident the need to solve the following two problems for wide introducing the new laboratory tests in clinical practice: 1) identification of the genes, proteins and metabolites of high-degree association with OA; 2) development of the algorithms of clinical use and standardization of the tests already proved.

The authors presented a clinical case of a female patient, 29 years old, who admitted with comminuted humeral shaft fracture, concomitant iatrogenic injury of the ulnar and radial nerve after two surgeries made at the place of residence using the Ilizarov rod fixator. They performed the following surgical intervention: the fixator dismounting, re-osteosynthesis with the Ilizarov wire fixator. Epineural electrodes were fitted using punctures. Postoperatively the patient underwent a course of electrical stimulation by electrodes and skin leads for two months, vascular therapy, exercise therapy, massage, she received Group B vitamins, Prozerinum. The electrodes were removed on Day 57 after fitting. The fixation period using the fixator was 139 days. The function of the wrist, that of the first finger, and the hand sensitivity recovered.