Vreden National Medical Research Center of Traumatology and Orthopedics
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Choice of antibiotics for the treatment of orthopedic infection caused by gram-positive pathogens, based on a 12-year follow-up. Part 2: fluoroquinolones, sulfonamides, tetracyclines, lincosamides, fosfomycin
The aim of the study — to substantiate the choice of a drug for empirical antibacterial therapy based on the analysis of antimicrobial resistance dynamics in leading Gram(+) bacteria isolated from patients with orthopedic infection from 2011 to 2022. Methods. We performed a retrospective study of data on the antimicrobial susceptibility in leading Gram(+) bacteria isolated from patients who were treated from 01.01.2022 to 31.12.2022. Based on the data obtained, we investigated the dynamics and determined the prognosis of resistance in leading Gram(+) pathogens. This article analyzes 5 groups of antibiotics active against Gram(+) microorganisms: fluoroquinolones, sulfonamides, tetracyclines, lincosamides, fosfomycin. Results. More than 75% of MRSA strains and more than 50% of MRSE strains demonstrated resistance to fluoroquinolones. Methicillin-sensitive strains have a lower resistance profile; the proportion of moxifloxacin-resistant MSSA during the entire follow-up period was 2.3%, MSSE — 14.7%. The proportion of ciprofloxacin-resistant E. faecalis strains decreased during the 12-year follow-up from 61.3% in 2011 to 40.4% in 2022. Over the 12-year follow-up period, our center has seen a decrease in the proportion of Staphylococcus spp. strains resistant to co-trimoxazole. At the same time, the drug is more active against S. aureus and methicillin-sensitive strains than against S. epidermidis and MR strains, respectively. The local monitoring data in our center demonstrate the activity of fosfomycin against more than 90% of staphylococci. In general, the average proportion of MRSA strains resistant to this drug was 5.8%, MRSE — 7.7%, and MSSE — 7%. The proportion of clindamycin-resistant MSSA increased from 1.5 to 12% and averaged 4.4%. At the same time, the incidence of clindamycin-resistant MRSA varied between 39-60% with a tendency to decrease to 48% by the end of the follow-up period. Conclusions. None of the broad-spectrum antibiotics can be recommended for use in the initial empirical therapy of orthopedic infection. Fluoroquinolones and co-trimoxazole are active against 30-33%, tetracyclines — against 39% (mainly due to the continued activity of minocycline and tigecycline), clindamycin — against 64% of gram-positive pathogens. Fosfomycin remains active against about 90% of staphylococci. However, to date, there are no criteria for assessing the sensitivity of enterococci to it, and therefore the sensitivity of enterococci to fosfomycin has not been determined.
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Revision and complex primary total hip arthroplasty with impaction bone grafting for acetabular defects: medium-term results
Background. Impaction bone grafting remains an alternative method for managing bone deficiency. Cyclic loads on the allograft may cause its further compaction and deformation, leading to migration of the acetabular component. The aim of this study — to evaluate the effectiveness and refine the indications for the use of impaction bone grafting for acetabular defects in revision and complex primary total hip arthroplasty by assessing the mid-term survival of implanted cemented acetabular components. Methods. We performed a retrospective analysis of the results of impaction bone grafting in 48 patients whose data were available for the assessment of acetabular component survival. Radiographic data were analyzed in 42 cases, clinical outcomes were assessed in 44 cases. Structure of operations was represented by 37 revisions and 5 cases of complex primary hip arthroplasty. The average follow-up period was 60 months. We assessed radiographic signs of cup migration, loosening and bone allograft remodeling. Kaplan-Meier survival analysis with 95% confidence intervals was performed. Results. The general survival of acetabular components was 97.9% (95% CI: 97.86-97.94) for 60 months and 84.3% (95% CI: 84.15-84.43) for 90 months. In 4 (7.4%) cases, we recorded an unsatisfactory result. In 7 cases, radiolucent lines without clinical signs of loosening were detected. In 22 (52.3%) cases a simultaneous change in inclination and cranial displacement of the rotation center were noted. In isolated assessment of inclination, changes were noted in 24 (57.1%) cases. We found a direct correlation between the acetabular component migration, defect severity and the use of a containment device (p = 0.006), as well as between the displacement of the rotation center by more than 5 mm and the inclination by more than 10° in 91.7% of cases (p < 0.0001). The median functional assessment according to the Hip Harris Score showed 85.50 [70.5; 95.0] points and 6.5 [2.0; 21.0] points according to the WOMAC questionnaire. Conclusions. Impaction bone grafting is a method of choice for limited bone defects replacement. Migration of the cup, displacement of the rotation center by more than 5 mm and an increase in its inclination by more than 10° can be regarded as a conditional norm due to natural biomechanical processes, which is confirmed by high medium-term survival rates of the implant according to clinical data.
Predictors of early aseptic loosening of prosthetic components following primary total knee arthroplasty
Background. Aseptic loosening of the knee prosthesis components is one of the most common causes of revision surgery. The acceptable range of angular values for postoperative alignment of the lower limb and the frontal positioning of the prosthetic components remains a subject of debate. The aim of the study — to identify the predictors of the early aseptic loosening of prosthetic components following primary total knee arthroplasty. Methods. The study group included 31 patients with aseptic loosening of prosthetic components. The comparison group consisted of 55 patients with no signs of loosening over a follow-up period of at least 8 years. Baseline characteristics (sex, age, body mass index, and operated side) were compared, along with preoperative and postoperative angular alignment of the lower limbs, specifically, the anatomical femorotibial angle (aFTA) and the hip-knee-ankle angle (HKA), as well as reference angles for prosthetic component positioning. Results. Patient age over 60.5 years and BMI over 27.5 were associated with a 2.9-fold and 2.6-fold increased risk of prosthetic loosening, respectively. Preoperative varus deformity, with an HKA angle exceeding 9.5° and an aFTA over 6.5°, increased the risk of loosening by 9.6 and 23.1 times, respectively. Postoperative residual deformity exceeding 0.5° in either direction, as measured by the aFTA, increased the risk of loosening by 8.7 times. Valgus positioning of the tibial component was associated with a 2.8-fold increased risk of component loosening. Conclusions. In elderly and overweight patients with pronounced varus deformity of the lower limb, personalized preoperative planning should be prioritized to prevent early aseptic loosening of prosthetic components. In cases where postoperative residual deformity or valgus positioning of the tibial component is detected, enhanced clinical follow-up with radiographic monitoring every 6 months is recommended. If radiolucent lines progress and pain is present, early consideration of revision surgery is advisable, as it may increase the likelihood of a successful conservative revision.
Outcomes of anterior cruciate ligament reconstruction using detached and non-detached autografts: comparative analysis
Background. Despite the widespread use of autograft techniques for anterior cruciate ligament (ACL) reconstruction, there remains a need to improve surgical methods aimed at enhancing graft osseointegration, reducing inflammatory responses, and preventing bone tunnel widening. Particular attention has been drawn to techniques that preserve the tibial insertion and ACL remnant. A systematic comparison of these approaches based on objective functional and morphological parameters is necessary. The aim of the study — to conduct a comparative analysis of short-term and early outcomes of different anterior cruciate ligament reconstruction techniques. Methods. The study included 112 patients stratified into four groups based on the type of ACL reconstruction performed: D — detached graft; N — non-detached graft; D+S — detached graft with remnant preservation; N+S — non-detached graft with remnant preservation. Clinical outcomes were evaluated at 6 and 12 months using the Lysholm score, IKDC, and KOOS, as well as MRI-based Signal-to-Noise Quotient (SNQ) and CT-based bone tunnel widening. Statistical analysis included one-way and multivariate ANOVA (MANOVA), as well as Principal Component Analysis (PCA). Results. The comparative analysis revealed statistically significant differences between the groups across all evaluated parameters (p < 0.05), according to the ANOVA test. The best functional outcomes (Lysholm, KOOS, IKDC) and morphological indicators (SNQ ratio, bone tunnel widening) were observed in the N+S group. MANOVA and PCA confirmed spatial separation of groups, with a distinct cluster formed by N+S patients, indicating the superiority of this technique. All intergroup differences were statistically significant (p < 0.05). Conclusion. The results suggest that the use of non-detached autografts in combination with preservation of anterior cruciate ligament remnant offers substantial potential for improving surgical outcomes in knee joint instability. However, large-scale randomized trials with long-term follow-up are needed to confirm these findings.
Impact of using an original guiding device on operative time and radiation exposure in minimally invasive Hallux Valgus correction
Background. Minimally invasive Chevron and Akin osteotomy (MICA) for hallux valgus is a high-tech procedure, with certain stages potentially being time-consuming and requiring intraoperative fluoroscopic guidance. The aim of the study – to evaluate the impact of the original guide device on the operative time, fluoroscopy time, and radiation exposure during minimally invasive Chevron and Akin osteotomy of the first metatarsal bone. Methods. The study included 42 patients with hallux valgus, divided into two groups. All patients underwent surgery using a minimally invasive technique. The Guiding Device Group consisted of 21 patients who underwent osteotomy with the use of the original guide. The Freehand Group included 21 patients who underwent osteotomy without the guide. At the end of the procedure, the duration of the surgery and the radiation dose – measured using the image intensifier sensors – were recorded. Results. The median duration of surgery in the Guiding Device Group was 25.00 minutes [25.00; 30.00], while in the Freehand Group it was 45.00 minutes [40.00; 57.50]. The observed differences were statistically significant (p < 0.001). The mean radiation dose was 0.30±0.06mGy in the group where the guide was used, and 0.79±0.20mGy in the group where guidewires for screws were inserted freehand. The mean difference between the groups for this parameter was 0.49mGy (95% CI 0.39-0.58mGy; p < 0.001). Pain intensity assessed by the VAS at 2, 4, and 8 weeks, and at 6 months postoperatively, was lower in patients who underwent surgery with the guide (p < 0.05 for all time points). Conclusion. The use of the original guiding device in minimally invasive corrective osteotomies for hallux valgus deformity significantly reduced operative time and radiation exposure for both the patient and the surgeon.
Classification of midfoot deformities in Charcot neuroarthropathy
Background. Midfoot pathology accounts for 60-70% of all deformities in diabetic Charcot neuroarthropathy. However, the available classifications of this pathology are few and have certain disadvantages. The aim of the study — to analyze X-rays of patients to investigate the displacement patterns of the midfoot bone and joint structures in Charcot neuroarthropathy, and, based on the identified displacement trends, to develop an anatomical and radiological classification of midfoot deformities. Methods. A retrospective analysis was performed on the foot X-rays of 416 patients (436 feet) with midfoot pathology in Charcot neuroarthropathy. Of these, 233 X-rays were provided by inpatient hospitals, and 203 — on an outpatient basis. Only X-rays taken in anteroposterior and lateral views were included in the analysis. We assessed the alignment of bones within the foot joints, the extent of destruction, and the direction of the displacement of bony structures. Results. The following types of lesions are identified. 1A — involvement of the navicular bone and talar head with the preservation of the lateral column anatomy. 1B — simultaneous involvement of the talonavicular and calcaneocuboid joints. 1C — subluxation or dislocation of the talonavicular joint with transition to the lateral parts of the tarsometatarsal joint with plantar dislocation of the cuboid bone and preservation of anatomical integrity in the calcaneocuboid joint. 1D — complete displacement of the navicular bone with the dislocation of the talonavicular, naviculocuneiform and tarsometatarsal joints. 2 — deformation (subluxation, dislocation, fracture-dislocation) of the naviculocuneiform joint, with involvement of the lateral column in the metatarsocuboid joint and flattening of the medial column. 3 — isolated involvement of the Lisfranc joint. 4A — isolated involvement (subluxation or dislocation) of the first cuneometatarsal joint without visible deformity in the affected area. 4B — dislocation of the medial naviculocuneiform and medial cuneometatarsal joints with the displacement of the medial cuneiform bone relative to the other foot bones. 5 — varus deformity of the foot with fractures of the metatarsal bones. Conclusion. A new classification of Charcot midfoot lesions is intended to guide the selection of key reconstructive surgical interventions for this pathology.
Results of the use of modified bipolar radiofrequency ablation in patients with proximal plantar fasciopathy
Background. Among the many causes of plantar heel pain, the most common is proximal plantar fasciopathy (PF), second only to ligamentous injuries of the foot. The disease reduces the quality of life and is difficult to treat, as its pathogenesis remains unexplored. The aim of the study — to conduct a comparative evaluation of treatment outcomes in patients with proximal plantar fasciopathy using extracorporeal shock wave therapy, as well as minimally invasive bipolar radiofrequency ablation, both with and without the described modification. Methods. We analyzed the treatment outcomes of 36 patients who sought medical care for chronic heel pain caused by proximal PF in the period from 2018 to 2023. Among the patients, there were 14 (38.8%) women and 22 (61.2%) men, with a median age of 55.4 [46.7; 61.7] years. All patients were randomly assigned to three groups of 12 patients each. In Group 1 (control), extracorporeal shock wave therapy (ESWT), which had not been used at previous stages, was used for treatment; in Group 2 (comparison) — minimally invasive bipolar radiofrequency ablation (BRFA); in Group 3 (main) — minimally invasive BRFA using a method modified by the authors. Comparative evaluation of the results was carried out at 1, 3, 6 and 12 months after surgery in Groups 2 and 3 and after the completion of ESWT course in Group 1. Results. The median plantar fascia thickness of the affected limb did not differ between the groups at 3 months after the completion of treatment. At 6 months, these indicators were significantly different between the control and main groups (p = 0.001). In the intergroup analysis of the dynamics of pain syndrome and foot functionality, the treatment results in the main group showed a statistically significant advantage compared with control and comparison groups after 1, 3 and 6 months of follow-up (p < 0.05). Conclusions. The modified minimally invasive radiofrequency ablation method for the treatment of patients with proximal plantar fasciopathy demonstrated superior early clinical outcomes compared to the standard ablation technique and a course of extracorporeal shock wave therapy. The results obtained appear promising and suggest that the modified technique may be considered a preferred treatment option in cases where all types of conservative therapy fail within a six-month period.
Cross-cultural adaptation and validation of the Russian-language version of the Manchester-Oxford Foot Questionnaire (MOxFQ) in patients with foot and ankle disorders
Background. The Manchester-Oxford Foot Questionnaire (MOxFQ) is one of the most validated and widely used tools assessing foot and ankle disorders based on patient-reported outcomes. To date, there has been no Russian-language version of the MOxFQ that has been adapted according to international methodological standards. The aim of the study — to perform the cross-cultural adaptation and to assess the psychometric validity of the Russian-language version of the MOxFQ among patients with foot and ankle pathology. Methods. The study enrolled 50 patients who were in the preoperative stage of treatment for foot and ankle joint disorders. The MOxFQ was translated and adapted following the ISPOR guidelines. All patients completed both the MOxFQ and EQ-5D-5L questionnaires. Test-retest reliability was assessed 7-14 days later in 38 patients who had not undergone surgery or other interventions during this period. Internal consistency (Cronbach’s α), test-retest reliability (ICC), standard error of measurement (SEM), minimal detectable change (MDC), floor and ceiling effects, and construct validity were evaluated. Results. The Russian-language version of the MOxFQ showed high internal consistency (α = 0.878) and good test-retest reliability (ICC = 0.758). SEM accounted for 3.09 points; MDC — 8.55 points. No floor or ceiling effects were observed. Significant correlations were found between the total MOxFQ score and EQ-5D-5L domains (ρ = 0.599-0.745; p < 0.001), as well as with the VAS (ρ = -0.564; p < 0.001). Conclusion. The Russian-language version of the Manchester-Oxford Foot Questionnaire demonstrated strong psychometric properties and is recommended for use in clinical and research practice.
Psychological implications in percutaneous Hallux Valgus surgery
Background. Despite the evolution of the surgical technique, sometimes patients complain of dissatisfaction even though the objective post-operative parameters do not demonstrate obvious complications. The aim of the study — to evaluate psychological implications for post-operative pain perception after hallux valgus surgery in patients who had already undergone contralateral foot surgery. Methods. The study included 42 patients treated with percutaneous surgery for bilateral hallux valgus in two different time periods (40 females and 2 males; mean-age at the 1st surgery — 55.7 years; mean-age at the 2nd surgery — 56.7 years). All patients were administered a visual analog scale (VAS) one week after surgery to judge post-operative pain. Each of them was evaluated clinically to assess post-operative convalescence. The patients were randomly divided into 2 groups: in group A, patients have not received further indications about post-operative pain in contralateral surgery; in group B, patients have been informed that post-operative pain would have been worse in contralateral surgery. Both groups received the same anesthesiological and pharmacological support in the peri-operative period. Results. The VAS pain score was 1.03 and 1.55 after first surgery; 4.57 and 0.5 after second surgery for group A and group B, respectively. All patients reported no pain 7 days after surgery. No significant clinical variation was reported. Conclusion. We observed the great importance of psychological implications for pain perception in patients undergoing foot surgery. The role of a surgeon is related not only to technical skills, but it is also conditioned by their ability to drive patients’ individual perception of post-operative outcome.
Histological Features of Fascial Fibromatosis in Patients with Rapidly Progressive Dupuytren’s Contracture
Background. Research into the etiology and pathogenesis of palmar fascial fibromatosis remains relevant to this day. However, the data on the histogenetic nature of its rapid progression and histological predictors of its recurrence are absent in the literature. The aim of the study — to perform a comparative analysis of the tissue composition and perforating arteries of the palmar aponeurosis in patients with rapid and typical progression of Dupuytren’s contracture. Methods. A total of 222 medical records of patients operated on in the period from 2014 to 2019 were analyzed. The development period of Dupuytren’s contracture (DC) in the largest group (n = 88) — from 3 to 8 years — was defined as typical; the development of DC in two years or less (n = 41) was interpreted as rapid. Histomorphometry of the surgical material was performed in cases of rapid (n = 20, Group 1) and typical (n = 25, Group 2) progression of DC. We used the fragments of palmar aponeurosis from conditionally healthy people (n = 5) as control samples. These were excised during surgical treatment of the hand wounds. Results. The median content of hyperplastic connective tissue was statistically significantly higher in Group 1 (p < 0.05), though the indicator varied widely in both groups. Group 1 showed a statistically significantly higher proportion of microvasculature vessels, including pathologically altered and newly formed ones (CD34+). Histomorphometry of the perforating arteries of the palmar aponeurosis showed that, compared with the control samples, the outer diameter in medium-sized arteries in patients of Groups 1 and 2 is larger by 4% (p < 0.05) and 12.5% (p < 0.01), respectively. The lumen diameter is 30% smaller in Group 1 (p < 0.01) and 31% larger in Group 2 (p > 0.05). In large-caliber arteries in Groups 1 and 2, the outer diameter is smaller by 18% (p < 0.01) and 17% (p > 0.05) compared to the control, and the lumen diameter is smaller by 52% (p = 0.00) and 18% (p > 0.05), respectively. Conclusion. Despite the shorter duration of the disease, patients with rapidly progressive Dupuytren’s contracture showed an increase in the number of pathologically altered microcirculatory vessels, as well as more pronounced stenotic remodeling of the perforating arteries of the palmar aponeurosis, which verifies early vascular aging. Histologic predictors of postoperative recurrence should be assessed individually.
A New Surgical Approach for Reconstruction of the Achilles Tendon
Background. The limited skin mobility on the posterior surface of the lower third of the leg, along with a small amount of subcutaneous fat and the close proximity of the Achilles tendon, predisposes this area to tissue defects following surgery. Numerous surgical approaches have been proposed; however, none of them completely address the problem of tissue defect elimination when correcting persistent equinus foot deformity. The aim of the study — to demonstrate a new surgical approach for Achilles tendon reconstruction. Surgical technique description. The surgical approach for Achilles tendon lengthening involved creating an arched incision and sequentially isolating the skin and fascial flaps. Achilles tendon shortening was corrected using Z-plasty. After that, the tendon was covered first with a fascial flap, and then the skin was partially sutured without tension. The remaining soft tissue defect was covered with a skin graft. Patients underwent 6 weeks of plaster immobilization, after which full weight-bearing on the operated leg and physical therapy was allowed. Conclusion. The described surgical approach is simple to perform and allows for the simultaneous replacement of tissue defects following the correction of equinus foot deformity.
Assessment of the accuracy of pedicle screw fixation in thoracolumbar vertebrae using freehand technique in resource-limited settings: insights from a prospective analysis
Background. Thoracolumbar fractures and diseases represent a significant healthcare problem. Pedicle fixation is a cornerstone in the surgical stabilization of spinal disorders, where spinal stability is crucial for maintaining proper biomechanical function and preventing neurological compromise. The aims: 1) to reassess the accuracy of freehand pedicle screw fixation in thoracolumbar vertebrae, particularly within the context of resource-limited settings where image-guidance technologies are not feasible; 2) to explore how surgical ergonomics, particularly surgeon handedness, affects screw placement accuracy. Methods. A prospective study was conducted, recruiting 90 patients with thoracolumbar lesions who underwent pedicle screw fixation by freehand technique in 2024. We excluded patients with congenital spine deformities and revision surgery. The accuracy and incidence of cortical breach of screws were determined by postoperative CT. Results. Six hundred eighty-one screws were inserted in the lumbar and thoracic spine of 90 patients using a freehand approach. Out of them, 579 (85%) screws were installed within the pedicle without cortical breach, 78 (11.4%) screws — with a cortical breach less than 2 mm, and 24 (3.5%) screws — a with a cortical breach more than 2 mm. Six hundred fifty-seven (96.4%) screws were considered a safe breach, and 24 (3.6%) screws were considered a dangerous breach. Conclusions. The use of freehand technique in pedicle screw fixation appears to be reliable and safe. It remains a valuable method, particularly in a resource-limited environment, providing a cost-effective and radiation-free alternative to navigation-assisted systems. This study reveals that surgical ergonomics, specifically surgeon handedness, do not significantly impact a breach when proper technique is maintained.
Isolated Head and Liner Exchange for Polyethylene Wear and Periprosthetic Osteolysis in Revision Hip Arthroplasty: A Review
Background. The growing number of primary total hip arthroplasties (THAs) and the associated long-term complications — such as polyethylene wear and periprosthetic osteolysis — underscore the importance of this technique. Although isolated head-liner exchange offers clinical advantages, including reduced surgical morbidity, shorter operative time, and expedited postoperative recovery, there remains a lack of clearly defined indications and patient selection criteria for its optimal application. The aim of the study — to synthesize current perspectives on isolated head and liner exchange in patients presenting with polyethylene wear and osteolysis surrounding stable hip prosthesis components, based on a comprehensive review of the international literature. Methods. A systematic literature search was conducted in PubMed/MEDLINE (English), eLIBRARY (Russian), and Google Scholar (English and Russian) databases. Search terms included: osteolysis acetabular, revision total hip arthroplasty, polyethylene liner wear, isolated head and liner exchange. Titles and abstracts were screened for relevance, followed by full-text evaluation. Articles without accessible full-text versions were excluded from the analysis. Results. The most frequent complications following isolated head-liner exchange are prosthetic dislocation and aseptic loosening. Identified risk factors include suboptimal component positioning, small femoral head diameter, extensive osteolytic lesions, and questionable stability of the acetabular component. Bone grafting of osteolytic defects may help mitigate these risks, though its efficacy remains under investigation. Advances in preoperative imaging, including CT and 3D reconstruction, have significantly improved surgical planning accuracy. Current evidence suggests comparable implant survivorship between cemented and press-fit liner fixation techniques. Conclusion. Isolated head and liner exchange, provided that the implants are well-fixed and positioned correctly, represents a viable and less invasive alternative to complete component revision. However, further high-quality studies are warranted to refine patient selection criteria and to establish standardized indications for this approach.