Objective — to develop and implement improved approaches to the diagnosis and tactics of surgical treatment in patients with fractures of the distal tibia metaepiphysis.Material and methods. The study included 126 patients with fractures of distal tibia metaepiphysis of «B» and «C» types who underwent internal fixation with plates in 2005–2012. The authors analyzed surgical treatment outcomes within the period from 2.5 to 9 years (average of 5.7–2.3 years) of postoperative follow up. Average age of patients was 23.4±2.1 years. Patients were divided into the main group (64 patients) and the comparison group (62 patients). In the comparison group, traditional approaches to diagnosis and surgical treatment were used, including standard clinical examination and X-rays of the affected ankle in two views and the median access to the distal tibia metaepiphysis. In the main group, a specially elaborated algorithm for selection of optimal surgical tactics was utilized basing on the improved diagnostics program. Clinical and functional data were assessed by Foot and Ankle Outcome Score (FAOS) and SF-36 Health Survey. Roentgenological assessment was done by X-rays and CT scans. Statistical significance of the differences was evaluated by Wald-Wolfowitz and Fisher tests.Results. Improved approaches to the tactics of surgical treatment in patients with pylon fractures of «B» and «C» types allowed to reduce the incidence of unsatisfactory anatomical and functional outcomes from 43.5% to 28.1%. The number of satisfactory and good outcomes increased by 4.7% and 10.7% respectively after application of improved therapeutic and diagnostic approaches.Conclusion. Proposed improved approaches to verification of severe intraarticular fractures of the distal tibia metabiphysis allowed to increase the informative value of the diagnostic procedures and to avoid discrepancies between preand intraoperative assessment of fracture type by classifications of M. Mueller-AS (1989) and X. Tang, P. Tang (2012) as well as to avoid diagnostic errors in detecting the facet impression of the distal tibia metaepiphysis.

The analysis of foreign and domestic scientific publications of recent years, devoted to the problem of revision reconstructions of the anterior cruciate ligament of the knee joint in young and middle-aged patients with high functional demands. The key directions for improving the treatment of this category of patients have been determined. It was found that the main trend in the improvement of revision reconstructions of the anterior cruciate ligament of the knee in patients with high functional demands, which primarily include professional athletes and military personnel, is the desire for enhanced stabilization of the joint by eliminating residual, primarily rotational instability and increasing protection the main graft from high stress overload. Of particular importance is a strictly individual approach to the choice of the method of revision reconstruction of the anterior cruciate ligament, which makes it possible to implement the principles underlying the primary plastic of the ligament. The solution of these two problems requires, firstly, a more detailed examination of patients in order to identify factors of increased risk for the development of recurrent joint instability, which must be eliminated during surgical treatment. Secondly, the strict anatomical nature of restoration, and more often reconstruction, of the main and auxiliary functionally incompetent stabilizing structures of the joint against an unfavorable anatomical background caused by previous operations in the form of bone defects and deformities of the condyles with destruction of hyaline cartilage and previously resected menisci. Third, the use of reinforced grafts of increased strength for the reconstruction of the anterior cruciate ligament, as the main structure that stabilizes the joint. Moreover, such reinforcement can be direct, by strengthening the cruciate ligament graft directly, or indirectly, by strengthening the anterolateral part of the joint. The most appropriate is a combination of these two directions in order to obtain the maximum positive effect. Promising options for extra-articular reinforcement today are anatomical reconstruction of the anterolateral ligament and lateral extra-articular tenodesis of the iliotibial tract as part of the anterolateral joint complex. This makes it possible to compensate for the forced resections of the menisci and, without correction, at least at the first revision, the increased posterior inclination of the articular surface of the tibial condyles. The main advantages of these operations in combination with the reconstruction of the anterior cruciate ligament are their proven efficiency, versatility, technical simplicity and availability, which are of particular importance for the introduction into wide clinical practice of trauma departments of military hospitals.

The authors conducted an analysis of national and foreign scientific publications dedicated to the problems in treatment of patients with ruptures of the anterior cruciate ligament of the knee joint. The results of the analysis demonstrated that such lesions still remain the key knee pathology resulting from sports injuries that significantly affect knee function and require timely reconstructive surgical correction. Based on the study the key areas of improvement in treatment for mentioned category of patients have been identified. This is the biomechanically justified single bundle anatomical ACL reconstruction which is currently widely applied in the clinical practice by using of an isometrically located autograft. Such technique represents a radically new stage in the development of treatment methods for young and middle-aged patients with high functional demands.