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Coxarthrosis is a heterogeneous group of diseases with various etiologies and similar biological, morphological, clinical manifestations and outcomes, which are based on damage to all components of the joint: cartilage, subchondral bone, synovium, ligaments, capsule, and periarticular muscles. Clinical guidelines are the main working tool of a practicing physician, both a specialist and a narrow practice doctor. Conciseness, structuredness of information about a particular nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, allow to give in a short time one or another answer to a question of interest to a specialist, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the classification, clinical presentation, diagnosis, and treatment of coxarthrosis. In addition, they provide methods for the rehabilitation of patients with this pathology.

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 (p

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.

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.

Intention. To conduct a comparative analysis of the dynamics of the consolidation of intraarticular fractures of the posterolateral parts of the lateral tibial condyle, the anatomical and functional outcomes of surgical treatment of these patients after plate osteosynthesis with traditional anterolateral and posterolateral transfibular surgical approaches as well.Methodology. A comparative prospective study of the effectiveness of osteosynthesis in patients with fractures of the posterolateral part of lateral tibial condyle in two compatible clinical groups was performed in dynamics for periods of 7–10 days, 1, 3, 6 and 9 months after surgery. In the first group (25 patients), bone osteosynthesis was performed from traditional anterolateral approach (TALA), and in the second group (20 patients), from the posterolateral transfibular approach (PLTFA). The average duration of osteosynthesis operations was compared. The displacements of fragments of the articular surface of the lateral tibial condyle, the indices of the KSS and Lysholm scales, the results of measurements of the angle of flexion and valgus stress test of the knee joint were evaluated. Data processing was performed using the Data Analysis and Chart Master modules (Excel), the Basic Statistics / Tables module (Statistic for Windows) as well.Results and Discussion. In the PLTFA group, the average operation time was (81.0 ± 8.5) minutes (from 67 to 96 minutes), in the TALA group, the duration of operations was 35.8 % longer and averaged (110 ± 5.2) minutes (from 82 to 125 minutes) (p < 0.05). The values of the KSS and Lysholm scales in dynamics showed a steady and statistically significant (p < 0.01) increase with increasing time after surgery without significant differences between the groups. The angle of flexion of the knee joint increased more rapidly during the first three months, then the rate decreased from 6 to 9 months (p < 0.05) without significant differences between the groups. The frequency of displacements of fragments of the articular surface in the first group was statistically significantly (p < 0.05) higher than in the second group. Differences in the valgus-stress test indices in both groups reached a maximum after 9 months – 52 and 30 %, respectively.Conclusion. With PLTFA, surgery duration decreases, articular surface fragments are better reduced, and their subsequent displacement at the stages of treatment is less likely; therefore, this approach is preferable for osteosynthesis of fractures of the posterolateral parts of the lateral tibial condyle.

The aim of the study was to assess capability and benefits of this method, its technical feasibility and safety regarding a damage of the most essential anatomical structures.Material and methods. The study involved 15 natural humeral bones; their parameters - the length and shape of the plates – were measured for osteosynthesis. Bone osteosynthesis was further performed on 14 intact upper limbs taken from 7 non-fixed corpses of people died at the age of 63–77 using the discussed method; after that, the operated limbs were studied using preparating technique. Furthermore, after plate application on two shoulder sections, 12 transverse cuts with their epoxy plastination were made at three levels according to the original technology; this was followed by the preparation of histotopographic sections.Results. The results obtained have demonstrated that for the new method of bone osteosynthesis it is advisable to use metal plates 220–260 mm long with spiral twisting clockwise for the right humerus and counterclockwise for the left. Average distances from the fixed plate to the humerus, tendon of the long head of the biceps of the shoulder muscle, large blood vessels and peripheral nerves were determined using precision preparation and measurements; the measurements were also performed on transparent plate-shaped shoulder cuts. All the above validates safety of the discussed method regarding a damage of the most essential anatomical structures and allow to successfully use it in the clinical practice.Conclusion. The discussed technique of plastinated transverse shoulder cuts with further experimental fixation of metal implants for osteosynthesis ensures safety of the initial topographic and anatomical relationships of these structures with anatomical structures. In addition, high transparency of the tissues created by epoxy plastination allows determining distances between implants and important anatomical structures with high precision, the fact being of great significance in applied anatomical studies.

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) (p0.0001) while the share of patients with two and more recurrences was 78.9% (n = 45) and 25.3% (n = 19), respectively (p0.0001). No significant variances were observed between the groups in respect of type composition of PJI microbial infection agents. The infection in a vast majority of patients in both groups was caused by microbial association: 77.2% and 72.0% in PMF and AMS groups, respectively. In the early postoperative period secondary revision of surgical site was performed in 35% and 28% of cases in PMF group (n = 20) and AMS group (n = 21), respectively, including due to recurrent infection in 15.8% and 28% of cases, respectively. Stable remission of difficult-to-treat PJI in PMF group was 96.5% and 45.3% in AMS group. Conclusion. Despite some cases that required secondary revisions in early postoperative period the resection arthroplasty in combination with pedicle muscle flap can be considered a surgery of choice for management of recurrent difficultto-treat PJI with feasible re-implantation of prosthesis against the stable remission of infection.

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.

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.

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.

Biocompatible composite hydrogels based on polyacrylamide and reinforced with bacterial or vegetable cellulose were synthesized. In the mechanical characteristics and water content, these hydrogels are similar to knee joint cartilages with average rigidity level. The structure and chemical composition of the hydrogels after their residence for 45 days in laboratory animal joints were studied by scanning electron microscopy and energydispersive X-ray microanalysis. Prolonged contact of the hydrogels with bones results in formation of calcium phosphate spherulites similar in composition to hydroxyapatite.

To evaluate the efficacy of chronic recurrent hip periprosthetic joint infection (PJI) eradication after resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh.There were 38 patients with chronic recurrent hip PJI who underwent resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh in 2005-2016. The groups were compiled considering the absence or presence of recurrent infection in early postoperative period. Infection duration, number of operations, incidence of recurrent PJI, type of pathogen, laboratory parameters, bone defect size and presence of PJI remission within at least 2 years were investigated.Uneventful early postoperative period after resection arthroplasty with non-free transplantation of vastus lateralis muscle flap was noted in 81.6% of cases (n=31, group 1). Postoperative wound revision was required in 18.4% of cases (n=7, group 2). Stable remission of infection within 2-8 years (Me - 4 years) was achieved in 36 (94.7%) patients. Relative risk of recurrent PJI increased by more than 4 times (RR 4,364, 95% CI 0,581-32,787) in cases of polymicrobial infection involving Gram-negative bacteria and decreased in cases of monomicrobial infection (RR 0,256, 95% CI 0,034-1,916). Significantly longer duration of surgery and more pronounced laboratory changes were revealed in group 2.High efficacy of resection arthroplasty with non-free transplantation of vastus lateralis muscle flap of the thigh was established in patients with chronic recurrent hip PJI. This procedure might be considered as a stage treatment with the possibility for revision arthroplasty in case of failed initial debridement surgery due to PJI pathogens that are difficult for eradication.Цель исследования - оценка эффективности купирования рецидивирующей хронической перипротезной инфекции (ППИ) области тазобедренного сустава (ТБС) после резекционной артропластики с несвободной пересадкой островкового лоскута из латеральной широкой мышцы бедра (ЛШМБ). Материал и методы. В исследование включены 38 пациентов, которым в 2005-2016 гг. выполнили резекционную артропластику с несвободной пересадкой островкового лоскута из ЛШМБ по поводу рецидивирующей хронической ППИ области ТБС. Группы формировали в зависимости от отсутствия или наличия рецидива инфекции в раннем послеоперационном периоде. Изучали длительность инфекции, количество операций, рецидивов ППИ, вид возбудителя, динамику лабораторных показателей, величину костных дефектов, наличие ремиссии ППИ при сроке наблюдения не менее 2 лет. Результаты. В 81,6% случаев (n=31, группа 1) ранний период после резекционной артропластики ТБС с несвободной пересадкой островкового лоскута ЛШМБ протекал благополучно, в 18,4% случаев (n=7, группа 2) потребовалась ревизия послеоперационной раны. У 36 (94,7%) больных удалось достичь стойкой ремиссии инфекционного процесса в течение 2-8 лет (Ме 4 года). Относительный риск рецидива ППИ возрастал более чем в 4 раза (RR 4,364, 95% ДИ 0,581-32,787) при полимикробной инфекции с участием грамотрицательных бактерий и снижался (RR 0,256, 95% ДИ 0,034-1,916) при монобактериальной инфекции. В группе 2 выявлена статистически значимо большая (р0,049) длительность операции и более выраженные изменения лабораторных показателей. Выводы. Установлена высокая эффективность резекционной артропластики с несвободной пересадкой островкового лоскута из ЛШМБ для купирования рецидивирующей формы хронической ППИ области ТБС. Данное вмешательство может быть рассмотрено как этапное лечение с возможностью последующего реэндопротезирования сустава при неудаче первичной санирующей операции в случае ППИ, обусловленной трудно поддающимися эрадикации возбудителями.

Potentialities of reconstructive and plastic microsurgery in patients with different pathology of large joints of the extremities were studied. Results of 265 microsurgical operations with pedicle flap (65.7%) and free tissue (34.3%) grafting were assessed. It was shown that use of microsurgical techniques provided reconstruction of full value para-articular soft tissues, increased range of joint movement and created the conditions for effective arrest of local inflammatory process. Besides, they possessed potentialities for the performance and increase of the efficacy in arthroplasty and some other high technology operations on large joints. The more distally the joint is located the higher is the need in reconstructive-plastic microsurgical operations and free tissue grafting on upper and lower extremities.

Results of surgical treatment of 19 patients in whom total knee replacement was performed in combination with various reconstructive microsurgical operations were analyzed. It was shown that application of microsurgical technologies provided new potentialities in total knee arthroplasty first of all in atypical and complicated cases. Advantages of step-by-step treatment presupposing firstly the restoration of integument in the knee joint region followed by its total arthroplasty were revealed.

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.

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.

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.

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.