Traumatology and Orthopedics of Russia

Background. The widespread integration of patient-specific vertebral body prostheses in clinical practice is hindered by their high manufacturing costs. A comprehensive understanding of the long-term cost-effectiveness of additive manufacturing is required for informed decision-making in spine surgery.

The aim of the study — to evaluate the cost-effectiveness of patient-specific 3D-printed polyetheretherketone (3D PEEK) prostheses compared to off-the-shelf constructs for anterior spinal column reconstruction in patients with spinal tumors.

Methods. A retrospective cohort study included 85 patients who underwent surgery for spinal tumors between 2018 and 2025 (34 in the 3D PEEK group, 51 in the standard group). We assessed clinical characteristics, perioperative parameters, survival, complication rates, and quality of life (EQ-5D-5L). A health economic evaluation was performed using a Markov model (60-month horizon, 1-month cycle, 3% discount rate). Cost-effectiveness was determined based on the incremental cost-effectiveness ratio (ICER) against a willingness-to-pay (WTP) threshold of 2,235,202 RUB/QALY.

Results. Both cohorts were comparable in baseline demographics and clinical characteristics. The rate of revision surgery was significantly lower in the 3D PEEK group (12% vs 33%, p = 0.024). Both groups demonstrated improved quality of life, but the utility gain was more pronounced with customized implants: the final utility index reached 0.718±0.122 vs 0.611±0.155 (p = 0.004). Initial direct medical costs were predictably higher for the 3D PEEK cohort (489,361 RUB vs 269,950 RUB, p < 0.001). Markov modeling indicated that the 3D PEEK strategy required an additional 161,661 RUB while yielding an extra 0.298 QALY. The ICER was calculated at 541,873 RUB/QALY, remaining well below the established WTP threshold. Probabilistic sensitivity analysis confirmed a median ICER of 368,357 RUB/QALY.

Conclusion. The application of patient-specific 3D PEEK prostheses in spinal oncology is an economically acceptable strategy. Despite higher initial costs, reliable reconstruction and a reduced need for revision surgery provide long-term improvements in patients’ quality of life.

Background. The choice of an optimal fixation method for two-part proximal humerus fractures remains a matter of debate, despite the widespread use of locking plates and intramedullary nails.

The aims of the study: 1) to evaluate the relationship between fracture characteristics and the chosen fixation method; 2) to compare functional outcomes, complication rates, and reoperation rates between intramedullary nailing and locking plate fixation.

Methods. This retrospective cohort study included 207 patients with two-part proximal humerus fractures classified according to the Neer classification. Intramedullary fixation was performed in 115 patients, and locking plate fixation in 92 patients. At 12 months, pain intensity, functional scores (CSS, ASES, and DASH), and shoulder range of motion were assessed. Complications were assessed at 2 years postoperatively, and reoperations were recorded at 2-year and 5-year follow-up.

Results. Normal neck–shaft angle values were achieved in 89.1% of patients in the plate fixation group and in 80.0% in the intramedullary nailing group (p = 0.074). At 12 months, functional outcomes according to CSS, ASES, and DASH were higher and less variable in the plate osteosynthesis group (p < 0.001). No pain was reported by 78.0% of patients; the rest described their pain as mild. Plate fixation was associated with a longer operative time: 135 [99; 155] minutes compared with 72 [50; 103] minutes for intramedullary nailing (p < 0.001), and a higher rate of mid-term complications. Within 2 years, complications were recorded in 11 of 92 patients (12.0%) in the plate fixation group compared with 5 of 115 patients (4.3%) in the intramedullary nailing group. Within the first 2 years, reoperations were performed in 23 (11.1%) of 207 patients, including 17 hardware removals, 6 additional procedures, and 3 delayed arthroplasties. Between 2 and 5 years, only 4 reoperations were performed in the 142 patients available for follow-up, all of which were nail removals.

Conclusion. In two-part proximal humerus fractures, plate fixation provided better 12-month functional outcomes with less variability, although it was associated with longer operative time and a higher rate of complications. Intramedullary fixation offered a shorter operative time and a lower complication rate, but was more frequently associated with residual pain and resulted in slightly inferior functional outcomes.

Background. Treatment of massive irreparable rotator cuff tears remains a challenging clinical problem. Recent advances in arthroscopic techniques have improved functional outcomes and broadened the indications for musculotendinous transfers, which are no longer limited to cases with loss of active shoulder rotation.

The aim of the study — to evaluate the mid-term clinical and functional outcomes of full arthroscopic transfer of the teres major and latissimus dorsi tendons using axillary portals in patients with irreparable rotator cuff tears.

Methods. This retrospective observational cohort study included 67 patients who underwent arthroscopic transfer of the teres major and latissimus dorsi tendons. Functional status was assessed using the Constant Shoulder Score (CSS), the American Shoulder and Elbow Surgeons (ASES) score, and the Visual Analogue Scale (VAS), along with range of motion, scapular rhythm, and patient satisfaction with the treatment outcome. Radiography was performed in all patients to evaluate the acromiohumeral interval (AHI) and osteoarthritis stage, while MRI of the shoulder was used to determine the stage of arthropathy, the degree of muscle atrophy, and fatty infiltration.

Results. Of the patients, 79.1% were satisfied with the treatment outcome. No infectious or neurovascular complications were observed. The mean CSS score increased from 32.3 to 63.1 (p < 0.001), and the mean ASES score from 26.4 to 69.2, reaching the minimal clinically important difference in all cases. Pain intensity on the VAS decreased from 8.7 to 2.1 (p < 0.001). Pseudoparesis resolved in 23 of 29 (79.3%) patients, including 12 patients with preoperative loss of active external rotation of the shoulder. Symmetrical scapular rhythm was restored in 46 (68.7%) patients. A weak inverse correlation was found between the AHI, preoperative active flexion deficit, body mass index, and postoperative CSS scores. The mean postoperative CSS score was significantly lower in patients with preoperative pseudoparesis (p = 0.012). In overweight patients with a body mass index greater than 35, the CSS score was also significantly lower (p = 0.031). Factors associated with a higher risk of dissatisfaction included age over 65 years, a body mass index greater than 35, an AHI less than 6 mm, and shoulder arthropathy greater than stage II.

Conclusion. Full arthroscopic transfer of the latissimus dorsi and teres major muscles is effective in the treatment of patients with massive and irreparable posterior-superior rotator cuff defects. This procedure demonstrates clinical and functional outcomes equivalent to those of arthroscopically assisted transfer, but is associated with a lower risk of infectious complications.

Background. Knee flexion contracture (KFC) is one of the most common secondary orthopedic complications in patients with cerebral palsy (CP), with a reported prevalence of up to 50%. It is primarily caused by muscle spasticity and imbalance between knee flexors and extensors, resulting in impaired knee extension and development of crouch gait. This gait pattern is associated with increased energy expenditure and reduced capacity for independent ambulation. KFC induces compensatory changes in proximal segments of the musculoskeletal system, including the pelvis and spine. Despite the evident biomechanical interrelationship, age-related mechanisms of adaptation of sagittal spinopelvic alignment remain insufficiently understood.

The aim of the study — to evaluate the impact of knee flexion contracture on sagittal spinopelvic parameters in children with cerebral palsy.

Methods. This study included 89 children with CP and KFC aged 4-17 years, classified as Gross Motor Function Classification System (GMFCS) levels II-III. Patients were divided into two age groups: Group 1 (<12 years, n = 34) and Group 2 (≥12 years, n = 55). The age threshold of 12 years was selected based on literature indicating completion of active lower limb growth and associated changes in sagittal gait patterns in CP, which may be related to the specific formation of compensatory musculoskeletal mechanisms. All patients underwent clinical examination and standing full-spine radiography. Sagittal parameters assessed included pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA).

Results. In patients younger than 12 years, no statistically significant correlations were found between KFC severity and sagittal spinopelvic parameters, suggesting predominantly local compensation. In contrast, patients aged ≥12 years demonstrated systemic compensatory adaptations with two distinct patterns. The spinal pattern was characterized by decreased lumbar lordosis and anterior displacement of the sagittal vertical axis. The pelvic pattern involved pelvic retroversion and alterations in the mechanical axis of the lower limb, indicating progressive involvement of the musculoskeletal kinematic chain.

Conclusion. Three sequential levels of compensation were identified: local, spinal, and pelvic. Spinopelvic changes in patients with cerebral palsy and knee flexion contracture reflect progressive adaptation of the musculoskeletal system.

Background. The high level of antibacterial resistance of the leading Gram-negative pathogens causing orthopedic infection complicates the selection of antibacterial drugs at both inpatient and outpatient treatment stages.

Research questions. Does resistance of Gram-negative pathogens to orally available antibiotics affect treatment success? Should oral antibacterial therapy be prescribed when the isolated pathogen is resistant to all available oral agents? Are there differences in the efficacy and safety of different regimens used for prolonged antibacterial therapy?

Methods. This prospective study enrolled patients who had undergone surgical debridement for periprosthetic joint infection or osteomyelitis due to a Gram-negative pathogen (P. aeruginosa, K. pneumoniae, A. baumannii) at the Department of Septic Surgery of the Vreden National Medical Research Center of Traumatology and Orthopedics between November 1, 2023, and February 1, 2025. At discharge, patients were divided into 3 groups: T1 — patients with implant-associated infection (IAI) caused by strains susceptible to oral antibacterial drugs and who were prescribed etiotropic therapy with ciprofloxacin (T1-CIP) or co-trimoxazole (T1-SXT); T2 — patients with IAI caused by strains resistant to all oral antibacterial drugs, for whom prolonged antibacterial therapy was not recommended; T3 — patients with IAI caused by strains resistant to all oral antibacterial drugs, but who were recommended to take ciprofloxacin (T3-CIP) or co-trimoxazole (T3-SXT). Treatment was considered effective if no signs of infection recurrence were observed within 1 year after the index surgery.

Results. The study included 96 patients, among whom a favorable outcome was in 66.6% of cases. The isolation of a pathogen susceptible to ciprofloxacin or co-trimoxazole, followed by pathogen-directed oral antibacterial therapy, was associated with a 4.76-fold higher likelihood of treatment success (p = 0.003, 95% CI, 1.63-13.9). The treatment outcomes of patients in groups T2 and T3 had no statistically significant differences (p = 0.586), and there were no differences in the outcomes of patients in subgroups T1-CIP and T1-SXT (p = 0.161), T3-CIP and T3-SXT (p = 0.812). The administration of a specific antibacterial drug in groups T1 and T3 also had no significant effect on the outcome (p = 0.105). Adverse reactions developed in 20% of patients in groups T1 and T3 in total, dyspeptic symptoms, dizziness and headache were the most common.

Conclusion. Patients with implant-associated infection caused by Gram-negative pathogens susceptible to oral antibiotics had 4.8-fold better treatment outcomes than those with resistant strains. Prescribing ciprofloxacin or co-trimoxazole in cases where the causative pathogens were resistant to them showed no advantages over discharge without recommendations for prolonged antibacterial therapy.

Background. Studying the effect of polymeric hydrogel on surrounding tissues is essential for assessing delayed complications and preventing postoperative adverse events at the surgical site during fracture reduction and prosthetic reconstruction of bone tissue elements.

The aim of the study — to evaluate the impact of an experimental polymeric hydrogel with prolonged antimicrobial activity on the histoarchitecture of parenchymatous organs and perifocal tissues of laboratory animals following its implantation into the distal femoral epiphysis.

Methods. The experiment was performed on Soviet Chinchilla rabbits (males aged 8 months, body weight 2-3 kg). A diagonal transosseous tunnel intersecting the medullary canal was created using a surgical drill. In animals of Group 1 (n = 3), a K-wire was implanted into the defect. In animals of Group 2 (n = 3), the polymeric hydrogel (0.5 mm³) was injected into the created canal, followed by the implantation of an identical wire. Throughout the experiment, hematological parameters were monitored; upon completion, histological examination was performed.

Results. No deviations in clinical and biochemical blood parameters from reference values were observed, which is corroborated by preserved histoarchitecture of parenchymatous organs on histological examination. The analysis of the histological sections of bone and soft tissue samples from the thigh in the implantation zone of the wire with hydrogel revealed that gel fragments (456.23-34,108.29 µm²) persisted for up to one year both in the femoral region and within the medullary canal among red bone marrow cells. Over time, a connective tissue capsule (~10 µm thick) formed around the particles, with subsequent compaction and thickening to 17.5 µm, accompanied by the signs of heterotopic ossification. In the medullary canal, lymphocytes were observed around the gel particles as a thin demarcation zone, with sporadic perifocal presence of giant multinucleated foreign-body cells (1-2 cells per 3 gel particles) containing gel fragments within their cytoplasm.

Conclusion. The dynamics demonstrate progressive connective tissue formation around gel particles in the thigh soft tissues and in the medullary canal, with subsequent compaction within the medullary canal. It was also established that the gel exerts no toxic effects on bone marrow cells or parenchymatous organ structures.

Background. Artificial intelligence-based technologies are being increasingly used in the diagnosis of musculoskeletal disorders, particularly for automated detection of pathological findings, quantitative assessment of imaging features, and decision support in the interpretation of radiological examinations.

The aim — to perform a systematic review of the diagnostic accuracy of artificial intelligence-based technologies for musculoskeletal disorders, including both peer-reviewed publications and grey literature sources, with methodological quality assessment and meta-analysis for conditions with at least 3 comparable independent sources.

Methods. A systematic search was conducted in the PubMed and eLibrary databases, along with an analysis of grey literature sources for the period from 2023 to 2025. The review included peer-reviewed studies and grey literature sources with external validation and quantitative measures of diagnostic accuracy. The quality of included sources was assessed using the modified QUADAS-CAD tool. Meta-analysis for individual conditions was performed using a bivariate random-effects model in the interactive web-based tool for meta-analysis of diagnostic test accuracy studies, and in cases of model instability due to a small number of studies, a Bayesian meta-analysis tool for diagnostic test accuracy was applied to obtain pooled estimates of sensitivity and specificity. The certainty of evidence was assessed using the GRADE approach.

Results. A total of 42 sources were included in the systematic review: 24 peer-reviewed publications and 18 grey literature sources, including 13 services from the Moscow Experiment. Seventeen sources were included in the meta-analysis, of which 8 were peer-reviewed publications and 9 were grey literature sources. Meta-analysis was feasible for five conditions: knee osteoarthritis, active sacroiliitis, osteoporosis, vertebral compression fractures, and scoliosis. The inclusion of grey literature made it possible to perform meta-analysis for certain conditions, but was associated with lower certainty of evidence: low for osteoporosis and vertebral compression fractures, and very low for active sacroiliitis, knee osteoarthritis, and scoliosis.

Conclusion. The findings suggest potential diagnostic value of AI-based technologies for selected musculoskeletal conditions; however, low and very low certainty of evidence according to GRADE limits the robustness and generalizability of the pooled estimates. A key strength of this review is the inclusion of Russian services, which constituted the majority of grey literature sources.

Background. Rupture of the distal biceps brachii tendon (DBT) is a functionally significant injury resulting in reduced flexion and supination strength of the forearm. Despite the widespread use of surgical treatment, there is no consensus on the choice between single-incision and double-incision techniques. This umbrella review provides a comprehensive assessment of methodological quality, risk of bias, evidence overlap, and certainty of evidence comparing SI and DI techniques.

The aim — to perform a comparative analysis of the clinical efficacy and safety of single-incision versus double-incision refixation techniques for distal biceps tendon rupture, based on data from systematic reviews, with a comprehensive assessment of methodological quality, risk of bias, primary study overlap, and certainty of evidence.

Methods. A systematic search was conducted in PubMed, Scopus, Cochrane Library, and Google Scholar. Systematic reviews with or without meta-analysis that compared SI and DI techniques were included. Methodological quality was assessed using AMSTAR-2, risk of bias using ROBIS. Overlap of primary studies was evaluated using the Jaccard index and the Corrected Covered Area (CCA). Certainty of evidence was graded using a modified GRADE approach. The protocol was registered in PROSPERO (CRD420261397223).

Results. Seven systematic reviews (2008–2025) were included. All had critically low methodological quality (AMSTAR-2) and high risk of bias (ROBIS). The SI technique was associated with statistically significantly better functional outcomes; however, differences in DASH scores did not reach the minimal clinically important difference. SI was associated with a lower incidence of heterotopic ossification and radioulnar synostosis, but a higher incidence of injury to the lateral antebrachial cutaneous nerve and superficial branch of the radial nerve. No differences were found in rerupture or reoperation rates. The mean Jaccard index was 0.30, and the overall CCA was 14.2% (upper border of high overlap). The certainty of evidence according to GRADE was very low for all outcomes.

Conclusions. Although the certainty of evidence is very low (GRADE D), the single-incision technique may be the preferred option for patients with high functional demands who have no risk factors for neurological complications. The double-incision technique may be used in patients at increased risk of peripheral nerve injury. Ultimately, the choice of technique should be individualized based on the patient’s risk profile and the surgeon’s experience, given the very low quality of the evidence base.