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The review examines pharmacological agents that can have potential disease-modifying osteoarthritis drugs (DMOADs) status. DMOADs prevent the progression and further structural joint damage (structure-modifying effect), leading to a decrease in symptoms severity (symptom-modifying effect), such as pain, and improvement of joint function. Approaches to potential DMOADs selection are discussed: (1) the preferred target (bone, cartilage, synovia); (2) action drug mechanism/anti-cytokine therapy (matrix metalloproteinase inhibitors, inhibitors of pro-inflammatory interleukins, etc.). The main delivery systems of drugs claiming to be of DMOADs status and possible contribution of immunological mechanisms to osteoarthritis pathogenesis are considered. Methods evaluating the effectiveness of DMOADs therapy are of great interest (cytology, microscopy, radiological research methods, blood and synovia biochemical markers). Based on research results analysis, the following substances can be considered as potential DMOADs: chondroitin sulfate, glucosamine sulfate, undenatured type II collagen, vitamin D. Each of them has symptom-modifying and structural-modifying effects.

In recent decades, there has been an increase in the prevalence and medical and social burden of osteoarthritis (OA) and nonspecific back pain in all countries of the world. The First Multidisciplinary Bilateral Russia-Uzbekistan Expert Council presented innovations in the prognosing, personalized prevention and adjuvant therapy of degenerative-dystrophic diseases of the joints and spine, the evidence base for the effectiveness and safety of the use of drugs that modify the course of OA (Disease-modifying osteoarthritis drugs, DMOADs): chondroitin sulfate, glucosamine sulfate, undenatured type II collagen for adjuvant pharmaconutraceutical support – prevention and adjuvant therapy (treatment) of OA and nonspecific lumbosacral pain. The expert counsil resolution presents an optimized algorithm for the management, prevention and adjuvant therapy of OA and non-specific back pain, maintaining the function of healthy joints after intense physical activity with the inclusion of the drug Chondroguard solution for intra-articular and intramuscular administration (INN – chondroitin sulfate) and a new pharmaconutraceutical from the DMOADs group – TRIO trademark Chondroguard® (Chondroguard®TRIO).

The need for effective drugs for the treatment of knee osteoarthritis (OA) is constantly growing. Current guidelines recommend the use of symptomatic slow acting drugs for osteoarthritis (SYSADOA) such as glucosamine (GCA) in this disease. Among various drugs containing GCA, high bioavailability and clinical efficacy have been shown only for prescription crystalline GCA sulfate (pGCAS) administration. Several meta-analyses and network meta-analyses have shown that efficacy of pGCAS 1500 mg once daily is superior to other GCA-based products (such as GCA hydrochloride with or without sodium sulfate) and the combination of GCA with chondroitin sulfate (CS) in terms of reducing the intensity of pain and improving the functional state. These studies confirmed the favorable safety profile of pGCAS, which was comparable to placebo in the incidence of adverse events. Pharmacoeconomic studies have also demonstrated greater cost-effectiveness of pGCAS compared to other GCA drugs.A group of Russian experts at a meeting of the advisory committee reviewed the evidence in favor of the use of pGCAS and evidence of its effectiveness in the treatment of knee OA in comparison with other products that include GCA, and the fixed combination of GCA with CS. Taking into account the results obtained, the use of pGCAS at a dose of 1500 mg once a day is recommended as a rational choice for the treatment of knee OA.

Osteoarthritis (OA) is the most common pathology of the musculoskeletal system and is a serious medical and social problem. OA is of particular importance in elderly and senile people due to the high frequency of comorbid pathology. Pain relief is a priority in the formation of individual therapeutic programs for patients with OA, starting from their first request for medical assistance. At the same time, due to the ambiguity of existing clinical recommendations, most experts note a number of difficulties in prescribing treatment for patients with OA.The article presents a consensus position of experts regarding a complex approach to the choice of therapy in patients with OA at the initial visit to the doctor. The article discusses: current clinical guidelines for the management of patients with OA; most common problems in the management of patients with OA in real clinical practice; goals of treatment strategies for OA taking into account the risk factors for its progression; an algorithm of pain relief during initial treatment in patients with OA; prevention of OA exacerbations with the use of basic structure-modifying drugs; recommendations for the choice of non-steroidal anti-inflammatory drugs.According to experts, a rational approach to the treatment of OA is based on the combined use of non-drug and pharmacological methods with constant monitoring of therapy regimens and side effects. These recommendations can be considered disease-modifying strategies that in many cases allow improving functional status and achieving long-term remission in patients with OA.

Aim. A meta-analysis of 8 controlled studies (n=771, age 53.6±6.2 years) of tie use of tie Chondroguard (100 mg i.m. first 3 injections, from tie 4th injection - 200 mg i.m., EOD, course 20-30 injections) in the complex therapy of osteoarthritis (OA).Materials and Methods. Tie meta-analysis according to tie fixed-effects model included all published clinical studies on tie efficacy and safety of the CG drug in OA). The effectiveness of therapy was assessed using the VAS, Lequesne, WOMAC scales/indices. For each study, information was collected on 23 features. Data analysis was carried out using the MEDSTUDY and "R" software packages.Results. Meta-analysis confirmed significant associations between the use of Chondroguard (CG. and pain reduction assessed by the visual analog scale (V)S. - CG: a decrease in pain intensity by -28.3 points, control: -11.6; p=0.042. There was a significant reduction in pain according to VAS at night (CG: -20.1; control: -9.9; p=0.05018., while sitting or lying down (CG: -15.5; control: -7.6; p=0.01656., when walking (CG: -28.2; control: -17.0; p=0.04957). The use of CG led to a significant decrease in the scores of the Lequesne index (CG: -4.3; control: -1.4; p=0.0349., and of the WOMAC index (CG: -338.4; control: -219.8; p=0.004., including WOMAC "function" (CG: -247.8; control: -96; p=0.0027., and WOMAC "stiffness" (CG: -25.4; control: -11.2; p=0.0462.. The incidence of side effects did not differ significantly from the control.Conclusion. Chondroguard is an effective treatment for osteoarthritis and has a good safety profile.

Purpose of the study — to compare management efficiency for difficult-to-treat periprosthetic hip joint infection (PJI) during resection arthroplasty with grafting by vastus lateralis pedicle island flap in comparison with insertion of an antimicrobial-loaded cement spacer. Material and Methods. 132 patients were included into the retrospective study who underwent treatment from 2012 until 2018 including removal of orthopaedic implant, radical surgical debridement of infection focus, resection arthroplasty with grafting by vastus lateralis pedicle island muscle flap (PMF group — 57 patients) or insertion of antibacterial-loaded cement spacer (AMS group — 75 patients). The authors examined medical histories, nature of infection process, infection agent type, laboratory data in respect of systemic inflammation, size of bone defects, follow up status and remission of PJI in the late period. Results. 89.4% of patients (n = 51) who underwent grafting by vastus lateralis pedicle island flap had a history of 3 and more prior surgical procedures in the same area. At the same time the share of such patients in the spacer group was only 38.6% (n = 29) (p

Purpose of the study — to provide an anatomical rationale and evaluate the clinical application of posterolateral surgical approach with osteotomy of the fibular head for internal fixation of the posterior aspect of the lateral tibial condyle. Material and Methods. Anatomical topography research was performed on 14 lower limbs of 8 fresh cadavers. In the first series of research L-shaped plate was fixed on the posterolateral surface of lateral tibial condyle from the examined approach, then preparation was performed and measuring of distances from various parts of the plates to the common peroneal nerve and anterior tibial artery. In the second series the authors prepared histological topograms by transverse sectioning of plastinated specimens from the knee joint area after implantation of L-shaped buttress plates. Prospective observation clinical study included 20 patients who underwent internal fixation with L-shaped buttress plate from the examined approach for fracture of the posterolateral column of the tibial plateau, type 41В by AO classification. KSS and Lysholm scales were used to evaluate treatment outcomes at days 7–10 and in 1, 3, 6 and 9 months postoperatively. Data of the anatomical and clinical research was compared. Results. Compliance with the technique of posterolateral transfibular surgical approach allows to avoid risk of injury to the common peroneal nerve and anterior tibial arthery which on the specimen were always located safely away from implanted plates. All 20 clinical cases demonstrated good visualization of bone fragments and articular surface of the tibial plateau which ensured reliable reduction and fixation by L-shaped buttress plate. KSS excellent and good outcome scores amounted to 50% and 45%, respectively, while satisfactory score was reported in 5% of cases; Lysholm scale demonstrated 55% of excellent outcomes, 45% of good outcomes, and 5% of satisfactory outcomes. Safety of the approach was verified: no injuries to large blood vessels or iatrogenic neuropathies were reported as well as no large hematomas or infectious complications of the surgical wound in early postoperative period. Conclusion. Results of the present study proved the feasibility and safety of the posterolateral transfibular surgical approach for internal fixation procedures in patients with intraarticular fractures of posterolateral column of the tibial plateau.

The authors present a short analysis of autoabstracts of all theses in traumatology and orthopedics speciality (14.01.15), 10 doctoral and 59 candidate theses, that were defended at 11 dedicated dissertation boards starting mid of October 2016 until mid of October 2017 and underwent expert reviews during 2017 in expert council of the Higher certifying commission on surgical science.The absolute majority of 26 papers in traumatology (16 candidate and 5 doctoral theses) were dedicated to treatment of patients with different fractures and another 5 candidate theses examined issues of arthroscopic procedures in case of a trauma. 25 dissertations in orthopedics mainly reviewed aspects of large joints replacement (6 candidate and 3 doctoral these) and treatment of periprosthetic infection (4 candidate theses). Spine pathologies (5 candidate theses) and oncology orthopedics (2 candidate theses) prevailed among dissertation topics on paediatric orthopedics. The only doctoral thesis on paediatric orthopaedics was dedicated to clubfoot.In accordance with recommended criteria of clinical Orthopaedics and Related Research journal 40 (67,8%) candidate theses and 2 (20%) doctoral theses corresponded to evidence level III, 17 (28,8%) candidate and 8 (80%) doctoral theses were classified as evidence level IV and only 2 candidate theses (3,4%) formally corresponded to evidence level II.

The authors performed an analysis of published stadies devoted to osteoporosis situation in Russian Federation including epidemiological, social, medical and economical aspects of this pathology. The analysis demonstrated that osteoporosis is reported in every third woman and every forth man of 50 years old and older. Seven vertebra fractures happen every minute and one fracture of proximal femur — every 5 minutes in Russia. An overall number of all key osteoporotic fractures will increase from 590 thousand up to 730 thousand cases by the year 2035. Osteoporosis is financially demanding for healthcare due to high treatment cost of fractures that are accompanied by life quality deterioration, high mortality and invalidization of patients. Epidemiological studies demonstrated that due to high fracture risk the osteoporosis therapy should be assigned to 31% of female and 4% of male patients over 50 years old. Such factors of osteoporosis risks are widespread in the society: smoking, low food calcium consumption, vitamin D deficit, low physical activity. The authors analyzed the problems in organization of medical care to patients with osteoporosis and osteoporotic fractures and possible solutions to existing issues. The organization of healthcare should be addressed at identification of high risk patient groups, early diagnosis and assignment of corresponding treatment aimed at decreasing potential fracture risk as well as at pathology prophylaxis.

Objective: to analyze the dynamics of quality of life (QOL) in patients with prior osteoporotic vertebral compression fracture during an 18-month follow-up study. Subjects and methods. The investigation enrolled 219 patients (mean age, 67.6 years) with vertebral fracture from seven centers of the Russian Federation. QOL was assessed four times using the EQ-5D (EuroQoL-5D) and TTO (Time Trade-Off) questionnaires during an 18-month prospective follow-up study. The work was done within the framework of the International Multicenter Study ICUROS (The International Costs and Utilities Related to Osteoporotic Fractures Study) organized by the International Osteoporosis Foundation (www.icuros.org).Results and discussion. The patients with vertebral compression fracture showed a statistically significant decrease in QOL throughout the follow-up period. Immediately after the fracture, there was a dramatic decrease in the total EQ-5D score, followed by its gradual increase. However, the emerging trend in QOL recovery proved to be unstable, and by the end of the 18th month, it was significantly lower than that before the fracture. On the contrary, the TTO questionnaire showed that QOL drastically decreased immediately after fracture, but at month 4 it reached the level that was before the fracture, and remained stable until the end of the follow-up period.Conclusion. The performed investigation enabled us to obtain data on QOL using the EQ-5D (QOL assessment from the social point of view) and TTO (individual QOL assessment) in the population of residents of the Russian Federation, in men and women aged 50 years and older with osteoporotic vertebral compression fracture.

Based on the analysis of the scientific heritage the authors presented the contribution of the great Russian surgeon N.I. Pirogov in the development of surgery of the locomotor system. Discussed in detail next lines of activity of N.I. Pirogov being of interest of trauma and orthopedic surgeons, in particular the: anatomical and physiological approach to studying the issues of surgery of extremities, development of scientific and organizational bases in the domestic military-field surgery, the Pirogov's ideas in the field of reconstructive surgery of the extremities, as well as its contribution to the reforming of surgical education in Russia and improvement of the domestic surgical instruments.

In order to justify a new method of surgical treatment of patients with recurrent and chronic Achilles tendon ruptures conducted applied topographic-anatomic study of 12 fixed and 8 fixed preparations of the lower extremities was performed. In the developed technique were carried out operations in 18 patients aged from 30 to 72 years with repeated ruptures Achilles tendon. The results of treatment were followed-up in all 18 patients in the period from 6 months to 3 years. Repeated tears of Achilles tendon were not observed. The range of motions in ankle joint reconstructed almost in its entirety. Performed topographic and anatomical studies and accumulated clinical experience allow us to recommend the proposed method for a wider clinical use.

The applied topographic-anatomic studies prepared in 14 fixed and 16 unfixed preparations of upper extremity allowed to precise the details of radius blood supply with reference to possibilities of formation of bone autografts with blood supply. Due to this fact the novel method of single-stage bone plasty for pseudoarthrosis of both forearm bones was developed and successfully approved in clinic. This method proposes the formation of two periosteal-cortical grafts with blood supply and small muscle cuff in distal and middle one-thirds of radius simultaneously.

29 women with postmenopausal osteoporosis, complicated by compression vertebral fractures were treated by infusion of zoledronic acid, 5 mg. The results were assessed using dual-energy X-ray absorptiometry. By 12 months BMD increased both in lumbar spine (mean 5,2% (σ=0,17) and in femoral neck (mean 3,9% (σ=0,20)); by 24 month the mean increase were 6,3% и 4,0% (σ=0,33) respectively. No new compression vertebral fractures were found.

Applied topographic-anatomical studies were carried out on 12 fixed lower extremities and revealed that in the anterior portion of the middle gluteus muscle 4 cm in width the upper branches of the gluteal vessels are always held supplying the area of the iliac crest. Taking into account the received data the authors proposed a new method of femoral neck osteosynthesis with non-free autoplasty by the autograft from the iliac crest, which is moved at constant muscle-vascular supply pin and fixed with screw in the fracture. Osteosynthesis using the proposed method was performed in 24 patients and provided the union of fractures in all cases in a period of 5 to 8 months. Analysis of long-term results of treatment of 22 patients performed 3 years after the operations showed good function of injured joints and no evidence of avascular necrosis of the femoral head in 18 (83.3%) cases.

Applied topographic and anatomic studies on 12 lower limbs of seven premature stillborn children have allowed to substantiate the possibility of formation and free transplantation in children of the epimethadiaphyseal fibula graft with two blood supply sources. In view of the obtained data, it has been developed and successfully tested clinically the original reconstructive microsurgical operation, which allows to replace in children simultaneously extensive (more than 50% of length) defects of the distal radius with preservation of function of the growth plate of the transplanted bone.

Relying on studies of scientific publications we have analyzed possibilities and effectiveness of using various modern techniques of replacement of major posttraumatic defects of tissues of extremities and we have worked out the main lines of improving the treatment of this category of patients.

Background. Minimally invasive surgical interventions are widely used in trauma and orthopedic surgery. Both the surgical technique and the instruments applied are being improved, which contributes to better functional results of patients’ treatment. Aim of the study — to present a new guide tool for minimally invasive surgical correction of acquired hallux valgus. Guide description. A guide tool intended to be used in minimally invasive surgical interventions for hallux valgus (HV) correction has been developed. It consists of several interconnecting components: the distal bar, the intramedullary guide, the proximal bar, and the wire guide. These components are fixed to each other. At the same time, the distal bar, the proximal bar, and the wire guide are connected with the possibility of adjusting their mutual positioning. The design of the proposed device enables to guide the first guiding wire and to place the cannulated screw in an optimal position. The presented clinical case illustrates the successful application of the described device. The patient underwent minimally invasive distal corrective osteotomy for hallux valgus of medium severity. According to the preoperative X-rays, the first intermetatarsal angle and the first toe deviation angle were 13.5° and 25°, respectively. Six months after the surgery, they were 3° and 7°, respectively. The result of the corrective surgery was considered excellent. Conclusion. Application of the proposed guide tool decreases surgery duration, reduces soft tissue damage and minimizes radiation exposure of the surgeon and the patient.

The article presents a discussion with the authors of a previously published article (Zelyanin D.A. et al. Features of the Extraction of the Anterior Tibial Vessels in the Formation of Vascularized Bone Grafts. Traumatology and Orthopedics of Russia. 2022. Vol. 28, No 1. p. 89-99), as well as on the basis of our own topographic and anatomical studies, the information about the details of the topography of the branches of the anterior tibial vascular bundle (ATVB) and the permissible levels of its proximal mobilization during island flaps transfer are justified. Topographic and anatomical study was performed on 32 non-fixed speciments of the lower extremities for substantiating plastic surgery with island skin flaps isolated on ATVB. The arterial bed of the lower leg was injected with black natural latex Revultex, followed by precision dissection and measurements of all branches of the anterior tibial artery (ATA) with a diameter of 0.3 mm or more using a binocular magnifier with a magnification of 3.3 times. All the studied branches of ATA were identified, the number of which varied from 26 to 49 (on average 38.53.2), and 88.7% of them went to the three muscles of the anterior group of the lower leg. At the same time, the average numbers of ATA branches departing in each of the 10% intervals of the length of the lower leg were determined, and the average total values of the cross-sectional area of arterial branches in these intervals were calculated. It was found that from 28% to 39% of the total cross-section of all branches of the ATA are localized in the first and second 10% intervals of the length of the lower leg, which makes it possible to justify the proximal limit of the mobilization of the ATVB. Reasonable criteria for choosing the level of proximal mobilization of the ATVB are: the location of the mobilization border is not higher than the level of the upper 20% of the length of the lower leg, the assignment of this border, at least 6 cm distal from the exit of the anterior tibial vessels into the anterior bone fascial sheath of the lower leg and the preservation of at least four feeding vascular bundles extending from the ATVB to the tibialis anterior muscle (two bundles) and to the extensor digitorum longus muscle (two bundles).

Background. Surgical treatment of malleoli injuries is performed according to the principles of articular fractures management. It is particularly true for ankle injuries involving fractures of posterior edge of the tibia. The posteromedial approach enables to improve the results of surgical treatment of patients due to the direct reduction of tibia fragments. Aim of the study to evaluate the efficacy and advisability of the modified posteromedial approach in patients with unstable fractures of malleoli and posterior edge of the tibia. Methods. Twenty two patients with unstable fractures of malleoli and posterior edge of the tibia underwent surgical treatment via the posteromedial approach. The X-ray control was performed the next day after the surgery as well as 6, 12, 24 and 48 weeks from the osteosynthesis. The functional results were evaluated in 12, 24 and 48 weeks after the surgery with the use of AOFAS and Neer scales. Results. The average duration of postoperative period (9.33.8 days) was mainly determined by the state of the soft tissues. 91% of patients had anatomical reduction of posterior edge fragment of the tibia, 17 (77%) from 22 patients demonstrated fracture consolidation in X-rays 12 weeks after the surgery and all 22 patients (100%) 24 weeks after surgery. There were no cases of postoperative complications in patients 24 weeks after the surgery. While managing patients the range of motion in the ankle joint increased from 41.16.9 12 weeks after the surgery to 57.34.6 48 weeks after the surgery, that was statistically significant (p0.01). The functional results improved as well according to both AOFAS and Neer scales and this improvement was also statistically significant (p0.01). Conclusion. The is rather effective in Patients with unstable fractures of malleoli and posterior edge of the tibia had a statistically significant improvement in function after posteromedial approach.

Background. Protein-energy malnutrition (PEM) is an established risk factor of postoperative complications in orthopedic disorders, including arthroplasty of the large joints. The study aimed to evaluate PEM prevalence and its association with the early postoperative revision in patients with the difficult-to-treat (DTT) prosthetic joint infection (PJI) of the hip. Methods. The retrospective study included 132 patients with chronic DTT PJI of the hip. The patients underwent orthopedic implant removal, radical debridement of the infected tissues, and resection arthroplasty with non-free transplantation of an axial vastus lateralis muscle flap (n = 57) or installation of an antimicrobial spacer (n = 75). DTT PJI was defined as an infection caused by rifampicin-resistant staphylococcal strains, ciprofloxacin-resistant gram-negative bacteria, fungi of the genus Candida, and their associations. The assessment of the patients protein-energy status included the evaluation of reference laboratory parameters, such as levels of hemoglobin, total protein, and albumin and number of lymphocytes. The degree of PEM was determined by the number of laboratory markers below the threshold values. The statistical comparison was performed using Fishers test. The odds ratio (OR, 95% confidence interval [CI]) was calculated to assess the risk of PJI recurrence. Differences were considered significant at p0.05. Results. More than 70% of patients with chronic DTT PJI included in the study were diagnosed with preoperative PEM of varying degrees of severity. Hypoalbuminemia and decreased hemoglobin levels were diagnosed more often: 64.3% and 57.1% in the muscle flap plasty and 57.3% and 31.1% in the antimicrobial spacer group, respectively. In muscle plasty and antimicrobial spacer groups, a decrease in the values of three or more reference PEM markers was detected in 28.5% and 16.0% of patients, and this advanced impairment of the nutritional status increased the risk of early revision intervention by two (OR 2.0; CI 95% 0.478.56; p = 0.35) and six times (OR 6.11; 95% CI 1.0635.35; p0.04), respectively. Conclusion. In general, the analysis of publications and results of our study show that PEM is associated with the development of surgical site infection and recurrence of PJI after revision surgery. A decrease in the values of three or more reference PEM markers is a significant predictor of repeated revisions after debridement surgery with the installation of an antimicrobial spacer. PEM complicates the postoperative course in patients with resection arthroplasty. Given the high incidence of PEM in patients with DTT PJI of the hip joint, further research is needed to develop methods for nutritional status correction and assessment of their effect on the outcomes of debridement surgery.

The malleoli fractures in combination with the fractures of posterior edge of the tibia are considered unstable injuries and present particular difficulties in surgical treatment. The aim of the study was to evaluate short-term and mid-term results of osteosynthesis on account of unstable fractures of malleoli and posterior edge of the tibia using posterolateral surgical approach. Materials and Methods. The analysis of short-term and mid-term results of the treatment of 29 patients with malleoli fractures types 44-B3 and 44-C1.3, C2.3 and C3.3 (according to the AO classification) with the involvement of the Volkman`s posterior tibia fragment was performed in traumatology departments of three hospitals during the period from January 2019 to September 2020. In all 29 cases the fracture of the posterior edge of the tibia was classified as type 1 according to the classification of N. Haraguchi et al. All patients underwent osteosynthesis of the posterior edge of the tibia and the lateral malleolus via posterolateral surgical approach. Combined fracture of the medial malleolus was fixed via classical medial approach. 5 patients (17.2%) with continued instability of the distal tibiofibular syndesmosis underwent fixation with positional screw. Functional results, as well as the range of motions in the ankle joint were evaluated with the use of AOFAS and Neer scales 3, 6 and 12 months after surgery. Results. Statistically significant improvement in functional outcomes over time was noted when evaluated on the AOFAS scale (p0.05) and on the Neer scale (p0.01). 12 months after the surgery these points were 83.213.4 and 87.816.8 respectively. Complications were noted in 5 patients (17.24%). Deep periimplant infection was registered just in one case, another patient had marginal necrosis of the operative wound. Three patients had clinically significant post-traumatic deforming arthritis of the ankle joint. Conclusion. Posterolateral surgical approach has advantages when performing osteosynthesis in patients of the studied profile and enables anatomical reduction and stable fixation of fragments of the Volkman`s posterior edge of the tibia, which provides the possibility of early mobilization of the ankle joint and has positive effect on the results of treatment.

Background: The study hypothesis is that the knowledge about the mechanical properties of biological tissues will help surgeons to choose a transplant. Aim: To determine the optimal type of a graft, based on the assessment of the mechanical properties of three types of grafts used for the superior capsule reconstruction of the shoulder joint with a massive rotator cuff tear. Methods: In the experimental work, 3 types of biological tissues were studied: allografts of the fascia lata and of the dura mater, and the DX Reinforcement Matrix (a dermal ECM xenograft). The experiment was divided into two parts. In the first part, the mechanical strength at rupture of the samples was evaluated and compared, in the second part the resistance of a vertical suture was studied. The tests included uniaxial stretching with the force and strain at rupture recorded. Results: The fascia lata allograft showed the highest ultimate tensile strength, while the dura mater allograft had the lowest ultimate tensile strength. All the three materials showed rather high values of the rupture strain. The lowest value of the rupture strain was detected for the dura mater allograft 15.22.6%, the highest value was obtained for the dermal ECM xenograft 63.320.8%. The largest value of the fracture stress was recorded for the DX Reinforcement Matrix 33.5 N. The minimum value was recorded for the fascia lata allograft 9.9 N. Conclusion: The fascia lata allograft and DX Reinforcement Matrix have the optimal mechanical characteristics and can be recommended as grafts for the superior capsule reconstruction of the shoulder joint with a massive rotator cuff tear.

Bisphosphonates is a first-line therapy for treatment of osteoporosis. In the last decade, the number of atypical femur fracture (AFF) cases during long-term treatment with bisphosphonates has increased. The aim of this article was to analyze the literature data on this problem, to define the diagnostic criteria of AFF and to present the case of AFF in the patient who received treatment with alendronate for 3.5 years. A 78-year-old woman, receiving oral bisphosphonate for severe postmenopausal osteoporosis for 3.5 years, suddenly started feeling pain in her right thigh while walking. Three months later, she had got a fracture in middle third of the right femur after falling from her standing height. According to instrumental diagnostics, this fracture had all criteria of AFF. Blocking intramedullary osteosynthesis with shafts was performed. A retrospective analysis of soft tissue magnetic resonance imaging in the area of right thigh, done before the fracture, showed the presence of undiagnosed incomplete right femur fracture in the middle third, which subsequently led to a complete fracture. Presented clinical case demonstrates the complexity of AFF diagnostics. The purpose of the publication is to draw attention of medical specialists to the issue of this rare side effect of bisphosphonate treatment.

Osteoporosis is considered a serious public health and social concern that catches public attention worldwide. A set of recommendations for management of patients with fragility fractures were developed on an initiative of the European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopedics and Traumatology (EFORT) in December 2016. Authors have reviewed the recommendations through provision of health care practices in the Russian Federation. A protocol of hip fracture surgery within 48 hours of admission to trauma services for fragility cases represent a needful tool for optimization of medical care system. Specific techniques and implant designs for fracture fixation in osteoporotic bone are described with the focus on subsequent fractures prevention and fracture risk assessment. Effective rehabilitation is shown to rely on patient's understanding of the pathogenesis of the pathological process. Specific drug therapies and non-pharmacological treatment can be administered for osteoporotic patients with low-energy fractures.

This article is dedicated to the problem of creating off fracture liaison services (FLS) for patients with osteoporosis including overview of the problem and some recommendations on it. The article presents there levance of the problem discussed, gives recommendations of the IOF working group,shows an international and Russian experience of FLS creation, its medical-economic effectiveness and discus the key moments that provide effectiveness of fracture liaison services for patients with osteoporosis. The recommendations part includes goals, main working directions and principles of FLS creation in the Russian Federation. They are based on the "Prometheus" program that was introduced by the Russian Osteoporosis Association and became the first national experience of organizing fracture liaison service. According to author’s point of view the information from this article can be help full in organizing FLS invarious medical institutionsin our country and can be used to reduce the negative effects of repeated osteoporosis fractures.

Травматологи-ортопеды, как правило, сталкиваются с проблемой остеопороза, когда пациент обращается уже с осложнением последнего, низкоэнергетическим переломом. У таких пациентов многократно возрастают риски повторных переломов, ухудшается прогноз по качеству и продолжительности жизни, а сам диагноз остеопороз формулируется уже как тяжелый остеопороз. Вследствие этого трудно переоценить роль травматологов-ортопедов в решении обсуждаемой проблемы и чрезвычайно важно знать в какой степени они участвуют в лечении пациентов с остеопорозом. Цель. Оценить степень информированности травматологов-ортопедов по вопросам диагностики и лечения остеопороза, вторичной профилактики остеопоротических переломов костей, а также определение степени их участия в решении указанных проблем. Материал и методы. Нами проведено анкетирование 153 травматолого-ортопедов из всех федеральных округов РФ, принявших участие в научно-практической конференции с международным участием «Вреденовские чтения» в октябре 2015 года. Средний возраст опрошенных составил 37 лет (от 22 до 68 лет), средний стаж работы 13 лет (от 1 до 40 лет), 93% работали в стационаре, 84% выполняли не менее 25 операций ежемесячно. Результаты. 77% врачей не шифруют в медицинской документации диагноз остеопороз согласно кодов МКБ. 75% указали на наличие в их регионе центра профилактики и лечения остеопороза. Наличие денситометра в регионе подтвердил 91% опрошенных, но направляют на него только 71%. При этом средняя доля направленных на денситометрию по отношению ко всем пациентам, которым был поставлен диагноз остеопороз составила лишь 34%. Основным методом диагностики остеопороза врачи считают рентгенографию (78%), а рентгеновскую денситометрию только 61%. Всего 20% используют FRAX. Чаще всего для лечения остеопороза доктора назначают комбинированные препараты кальция и витамина Д3 (70% опрошенных) и препараты кальция (56%). Все остальные варианты медикаментозной терапии набрали по результатам анкетирования менее 50% ответов. Несущественной оказалась разница между парантеральной и пероральной формами назначаемых фисфосфонатов (41% и 39% соответственно). 18% респондентов назначают кальцитонин лосося в виде назального спрея и 21% стронция ранелат, несмотря на существенные ограничения в использовании этих препаратов. 27% опрошенных назначают активные метаболиты витамина Д. На вопросы о сроках назначения медикаментозной терапии 44% ответили, что назначают терапии как можно раньше после перелома, 25% - больше одного года, 22% - сразу после активизации пациента, 13% - на один год. 56% травматологов-ортопедов, из числа назначающих терапию, проводят контроль ее эффективности. 60% с этой целью используют рентгеновскую денситометрию. Только 10% повторно рассчитывают индекс FRAX. Травматологи-ортопеды широко использую немедикаментозные методы лечения остеопороза: лечебную физкультуру 89%, физиотерапию 52%, лечебное питание 42%, пищевые добавки 21% опрошенных. Только 31% респондентов указали на проведение в их учреждении мероприятий по вторичной профилактике переломов костей, среди которых чаще всего были отмечены: 26% - информирование пациентов по вопросам остеопороза, 23% - консультация пациента в специализированном центре или кабинете. Контроль эффективности антиостеопоротического лечения через год и выполнение повторной рентгеновской денситометрии реализуются в 15% и в 16% учреждений соответственно. В тоже время, 95% опрошенных специалистов отметили необходимость таких мероприятий, 73% для всех пациентов с переломами костей и 24% для части из них. Заключение. Впервые в Российской Федерации удалось провести анкетирование столь значительной группы травматологов-ортопедов по вопросам диагностики и лечения остеопороза, представлявших все регионы страны. Полученные данные свидетельствую о недостаточной информированности респондентов в вопросах как диагностики, так и лечения остеопороза, наличии собственных схем и приоритетов в лечении. Однако понимание травматологами и ортопедами важности вопроса вторичной профилактики остеопоротических переломов дает надежду на комплексное решение этой проблемы в ближайшие годы.

Медико-социальную и экономическую значимость остеопороза определяют его неуклонно нарастающая распространенность, а также затраты на лечение собственно остеопороза и его прямых осложнений - переломов, приводящих к развитию хронической боли, деформации скелета и потере трудоспособности. В Российской Федерации данные об экономических и социальных последствиях остеопоротических переломов практически отсутствуют, и имеют ограниченную ценность для применения в экономике здравоохранения. Исследование проведено в рамках международного многоцентрового исследования ICUROS. Целью исследования являлось единообразное (с использованием единой методологии сбора и анализа данных) изучение странах экономических и социальных последствий остеопоротических переломов. В Российской Федерации в исследовании участвовали 9 центров. В тезисах впервые использована окончательная версия базы данных. Материал и методы. Всего включено 1143 пациента от 50 лет и старше, перенесших низкоэнергетический перелом, из них 251 (21,96%) - с переломами шейки бедра, 255 (22,33%) - с переломами запястья, 219 (19,16%) - с переломами позвонков, 182 (15,92%) - с переломами плечевой кости, и 236 (20,65%) - с переломами лодыжки. Опрос пациентов проводился непосредственно после перелома и касался информации о качестве жизни (КЖ) до перелома и непосредственно после перелома (Фаза I). Далее сбор информации осуществлялся через 4 (Фаза II), 12 (Фаза III) и 18 месяцев (Фаза IV) после перелома. Средний возраст включенных пациентов составил 65,2 года (95% доверительный интервал (ДИ) от 64.65 до 65,72). Одним из интегральных параметров КЖ исследовании был опросник EQ-5D, включающий данные по подвижности, самообслуживанию, повседневной активности, боли и дискомфорту, выраженности тревоги и депрессии. Отдельные шкалы данного опросника были преобразованы в общий балл, стандартизованный к шкале от нуля до единицы. Результаты. Ретроспективные данные о КЖ по стандартизованному суммарному баллу EQ-5D составили 0,824 (95% ДИ: 0,812-0,836). На момент перелома у пациентов значимо падало КЖ - 0,290 (95% ДИ: 0,273-0,307) (р0,05). Выводы. Таким образом, если общая субъективная оценка здоровья по ВАШ возвращается к значениям «до перелома» уже к 4 месяцам после перелома, то суммарный балл по EQ-5D) достигает значений, близких к исходным, только к 12 месяцам, и продолжает улучшаться и через 18 месяцев. Эти данные свидетельствуют о важности изучения отдельных компонентов качества жизни пациентов, входящих в EQ-5D, а не только суммарных результатов.

Современный взгляд на организацию служб вторичной профилактики переломов (FLS - Fracture Liaison Service) является определенным и подтвердил свою эффективность. Такие службы должны решать задачи организации помощи больным, получившим малоэнергетические переломы костей, с целью предупреждения повторных переломов. Организация и функционирование таких служб оптимально на базе стандартов разработанных под эгидой Международной организации по остеопорозу (IOF) в рамках программы «Capture the Fracture», включающих 13 стандартов, разделенных на 3 уровня. В нашей стране первым проектом FLS для амбулаторных пациентов стала программа «ПРОМЕТЕЙ» в Санкт-Петербурге. С 2015 года работает программа FLS для стационарных больных, созданная в РНИИТО им. Р.Р. Вредена. Цель. Разработать и внедрить в РНИИТО им. Р.Р. Вредена систему учета, дополнительного обследования, анти-остеопоротической терапии и диспансерного наблюдения за пациентами в возрасте старше 50 лет с малоэнергетическими переломами костей. Задачи. 1. Отработать маршрутизацию пациентов с малоэнергетическими переломами костей старше 50 лет в рамках института. 2. Организовать выбор и учет пациентов, нуждающихся во вторичной профилактике повторных остеопоротических переломов костей, создать регистр на бумажном и электронном носителях. 3. Определить и провести у отобранных пациентов необходимый объем диагностических мероприятий с целью выявления системного остеопороза, его дифференциальной диагностики и оценки риска повторных переломов. 4. Назначить и провести по соответствующим показаниям адекватную антиостеопоротическую фармакотерапию. 5. Организовать систему диспансерного наблюдения за пациентами указанного профиля на протяжении года после травмы. 6. Определить у них анатомические и функциональные исходы после оперативного лечения. 7. Оценить приверженность и эффективность проведенной у отобранных больных вторичной профилактики остеопоротических переломов костей. Материал и методы. В институте была разработана схема маршрутизации профильных больных старше 50 лет с малоэнергетическими переломами костей, в соответствии с которой такие больные на следующий день после поступления в стационар осматриваются исследователями, им рассчитывается индекс FRAX, назначается рентгеновская денситометрия, данные заносятся в регистрационную карту и электронную базу. Затем по итогам обследования больному рекомендуется соответствующее антиостеопоротическое медикаментозное лечение. В дальнейшем посредством телефонных контактов через 3,6 и 12 месяцев проводиться контроль приверженности лечению. Результаты. В настоящее время в исследовании под наблюдением находятся 154 пациента средний возраст которых 65 лет (от 50 до 87 лет), среди которых преобладают женщины - 112 (72,7%). Локализация зарегистрированных переломов представлена преимущественно дистальным метаэпифизом лучевой кости у 63 (40,9%) пациентов, проксимальным отделом бедренной кости у 24 (15,6%) пациентов и проксимальным отделом плечевой кости у 23 (14,9%) пациентов. Иные локализации малоэнергетических переломов составили 28,6%. У 75 (48,7%) пациентов в анамнезе уже имелись малоэнергетические переломы. 93 (60,4%) пациента прошли денситометрическое обследование, которое выявило у 67 (72% от обследованных) значения соответствующие остеопорозу (от -2,5 до -4,3 стандартных отклонений в поясничном отделе и от -2,5 до -3,5 стандартных отклонений в проксимальном отделе бедра). У 26 (28%) обследованных пациентов показатели соответствовали остеопении. Всем пациентам было назначено соответствующее медикаментозное лечение, тем кто не выполнил денситометрию на основании расчета индекса FRAX. При телефонных опросах через 3 месяца рекомендаций по лечению придерживались 98 (63,6%) пациентов, через 6 месяцев 64 (41,6%), через 12 месяцев 48 (31,2%). 12 (7,8%) пациентов сообщили о повторных переломах, из них 10 лечения не получали. Заключение. Первые результаты функционирования программы FLS в крупном травматолого-ортопедическом стационаре - РНИИТО им. РР Вредена показали высокую медицинскую и социальную значимость этой работы и полностью подтвердили необходимость создания подобных служб в нашей стране.