Vol 30, No 4 (2024)

Background. Diagnostics of infectious complications in joint replacement surgery remains a significant challenge, particularly when microbiological analysis of biological material fails to reveal pathogen growth.

The aim of the study was to determine threshold values for C-reactive protein, interleukin-6, and presepsin levels, and to assess their diagnostic value in detecting periprosthetic joint infection.

Methods. A prospective cohort single-center blinded study was conducted involving cases of revision arthroplasty for periprosthetic joint infection (PJI) and aseptic prosthetic loosening. The study included 66 patients divided into two groups: Group I (n = 17), with confirmed PJI using the 2018 ICM criteria, and Group II (n = 49), with aseptic prosthetic loosening. Synovial fluid samples were subjected to bacteriological and cytological analysis, measuring levels of C-reactive protein (CRP), presepsin, and interleukin-6 (IL-6). ROC analysis, sensitivity, specificity, accuracy, and threshold values were determined for laboratory data.

Results. The highest diagnostic accuracy in distinguishing between PJI and aseptic loosening was observed in the leukocyte count in synovial fluid (AUC 0.928; 95% CI: 0.837-0.977, p<0.0001). Elevated synovial CRP levels were associated with infection, with an AUC of 0.776 (95% CI: 0.656-0.870, p = 0.0004), and IL-6 had an AUC of 0.712 (95% CI: 0.583-0.820; p = 0.0048). Presepsin levels, however, showed no significant difference between groups (AUC 0.582; 95% CI: 0.453-0.703; p = 0.3344). Threshold values were set at 5.6 mg/l for CRP, 1212.0 pg/ml for presepsin, and 988.5 pg/ml for IL-6. Sensitivity, specificity, and accuracy for PJI diagnosis were determined for CRP at 62.5%, 85.7%, and 80.0%; for IL-6 at 87.5%, 63.0%, and 69.4%; and for presepsin at 43.8%, 79.6%, and 70.8%, respectively.

Conclusion. In cases where synovial leukocyte counts are at borderline levels, the additional assessment of synovial fluid cellular composition and simple, cost-effective markers such as synovial CRP and IL-6 may be recommended to confirm PJI.

Background. Hemiarthroplasty as a surgical choice for elderly patients with femoral neck fractures is still a matter of scientific controversy.

The aim of the study is to analyse unsatisfactory outcomes of hemiarthroplasty and compare them with the similar outcomes of total hip arthroplasty in elderly patients with femoral neck fractures.

Methods. We conducted a retrospective randomized study, which enrolled 36 patients who underwent revision endoprosthetics after various types of arthroplasty for a femoral neck fracture. The patients were divided into 3 groups. Group 1 included 10 patients who underwent arthroplasty with the use of hemiendoprostheses; Group 2 — 15 patients with cemented acetabular components; Group 3 — 11 patients who had cementless acetabular components.

Results. The average age of patients in Group 1 at the time of revision arthroplasty was 79 years and was statistically significantly different from the age of patients in Groups 2 and 3 (74.4 and 74.9 years, respectively). The average time for revision interventions after hemiarthroplasty was 40.2 months and significantly differed from the time for the revisions after total cemented (82.7) as well as total cementless (86.6) arthroplasties. The average time for the onset of pain among patients in Group 2 was 68.2 months, and among patients in Group 3 — 71.2 months. The most common bone defects were types 2C and 3A (total of 41.6% in all groups). There were errors in choice of the size of the acetabular bipolar or monopolar component in all 100% of hemiarthroplasty cases. The use of a larger hemiendoprosthesis cup compared to the femoral head led to early erosion of cartilage tissue. Smaller hemiendoprosthesis cups were complicated by early protrusions of the acetabulum floor. The main errors in total arthroplasty were malposition of the acetabular component (33.3-54.5%) and inadequate cement mantle (20%). It should be noted that infections among patients from Groups 2 and 3 developed up to 24.7 months after primary arthroplasty.

Conclusions. Errors associated with incorrect choice of the acetabular endoprosthesis component size during primary hemiarthroplasty lead to early complications: erosion and protrusion of the acetabulum. Severe pain syndrome due to incorrect selection of the acetabular hemiendoprosthesis component size develops on average after 13.9 months, and the time period for revision endoprosthetics is 40.2 months after the primary operation. With erosions of the acetabulum, there are no bone defects; with protrusions — bone defects of type 2C and 3A more often occur. In comparison with the outcomes of total hip arthroplasty, the use of hemiendoprostheses shows a low survival rate of 40.2 months.

Background. Minimally invasive surgical techniques can reduce the degree of surgical injury during osteosynthesis in peri- and intraarticular pilon fractures. However, these techniques do not always achieve anatomical reduction of the articular component and stable fixation of all columns of the distal tibia.

Aim of the study — to test the hypothesis regarding the clinical advantages of multicolumn fixation for comminuted pilon fractures over traditional single-column fixation.

Methods. The study enrolled 55 patients with extra- and intraarticular fractures of the distal tibia and fibula, all of whom underwent minimally invasive osteosynthesis. Patients were divided into two groups based on the number of fixed columns. These groups were comparable in terms of gender and age. The first group consisted of 28 patients who underwent osteosynthesis with one anatomically precontoured plate. The second group consisted of 27 patients who underwent osteosynthesis with two or more plates placed on different tibial columns. The quality of bone fragment reduction was analyzed using control X-rays performed the day after the operation. Functional outcomes were evaluated according to the AOFAS scale at 6 and 12 months post-operation. The incidence of early and delayed complications of osteosynthesis was also determined.

Results. No statistically significant difference was found between the two study groups in terms of quality of reduction (p = 0.23). The median functional outcome score in the first group at 6 months was 63 points [IQR 50.00-73.00] and at 12 months was 74 points [IQR 65.00-83.25]. In the second group, the median scores were 75 points [IQR 67.50-81.00] and 85 points [IQR 71.00-94.50], respectively. Multicolumn fixation of the pilon fracture resulted in statistically significantly higher functional outcome scores at both follow-up periods: at 6 months (p = 0.015) and at 12 months (p = 0.028). The probability of complications in the first group was 4.4 times higher than in the second group: OR = 4.444 (95% CI 1.066-18.528).

Conclusion. Multicolumn fixation of complete periarticular and intraarticular pilon fractures leads to better functional results compared to single-column fixation. It also reduces the risk of complications due to increased stability of the fragment fixation and the resistance of the implant-bone system to physiological stress.

Background. Anterior cruciate ligament (ACL) tear is a common ligament injury of the knee joint. Anterior cruciate ligament reconstruction (ACLR) using autografts or allografts is the standard of treatment for complete ACL tear. Anatomical tunnel positioning provides a better rotational as well as anteroposterior stability following ACLR. Nevertheless, a well-performed anatomical ACLR does fail due to various reasons. Graft selection may be one of the contributing factors.

The aim of the study is to compare the outcome of anatomical anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft and hamstring tendon autograft at a mean follow-up of 8 years.

Methods. The study enrolled 150 patients who underwent primary anatomical anterior cruciate ligament reconstruction using either bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autograft. Plain radiography was used to differentiate anatomical and nonanatomical reconstruction. Eighty patients (BPTB — 36, HT — 44) with anatomical reconstruction were then compared for their clinico-radiological outcome at a mean follow-up of 8 years.

Results. The BPTB group showed better outcome over the HT group in terms of increased rotational and anteroposterior stability at long-term follow-up (pivot-shift test, p = 0.001; anterior drawer test, p = 0.001; the Lachman’s test, p = 0.001; radiological Lachman’s test, p = 0.001). There was no difference between the groups in terms of objective and subjective IKDC forms (p = 0.363 and p = 0.154, relatively), the Lysholm score (p = 0.894), anterior knee pain (p = 0.678), single-leg hop testing (p = 0.248) and osteoarthritic change (p = 0.550) at a mean follow-up of 8 years.

Conclusions. Bone-patellar tendon-bone autograft resulted in superior clinical outcome over hamstring tendon autograft in terms of increased knee stability. No difference was observed between the grafts in other clinical outcomes and osteoarthritic change at a mean follow-up of 8 years.

Background. Number of injuries of the hand and wrist is constantly growing from year to year. Inpatient treatment of these patients increases both time and financial costs for healthcare organizations. Thus, analysing the structure of patients who applied to the emergency department would make it possible to take more objective decisions on the organization of healthcare delivery.

The aim — to analyse outpatient visits and treatment methods of patients with hand and wrist injuries who applied to the emergency department of the Vreden National Medical Research Center of Traumatology and Orthopedics.

Methods. A sample of 18.848 patients who applied to the emergency department with hand and wrist injury in the period from 2020 to 2023 was drawn in the database of the Medialog medical information system of the Center.

Results. The most common types of hand and wrist injuries were: metacarpal and phalangeal fractures, damage to the skin and subcutaneous tissue, damage to the finger flexor tendons and nerves. Of the operations performed, K-wire osteosynthesis and primary suture of the extensor or flexor tendons of the fingers were most often used. Significantly less common were the following operations: primary surgical debridement, suture of nerves and blood vessels, replantation and revascularization. About 20% of patients with hand injuries can receive emergency medical care in emergency rooms of Saint Petersburg, thereby reducing the queue for surgical service in the Center’s emergency department.

Conclusion. Treatment of patients with hand and wrist injuries requires comprehensive approach involving doctors of various specialties at each stage of the treatment. Proper organization of such patients’ treatment will significantly improve the quality of medical care and the treatment outcomes.

Background. The leading role in long-term survival of the prosthesis installed using impaction bone grafting is given to the mechanical properties of the graft.

The aim of the study is to explore the mechanical properties of osteoplastic material and determine the potential impact of cyclic loads on dynamic changes in the position of the acetabular component after revision hip arthroplasty using impaction bone grafting.

Methods. We conducted an experiment evaluating the impact of cyclic loads on the mechanical properties of osteoplastic material. At the first stage, a single-cycle tension-compression testing was carried out. Cyclic tests were carried out at the second stage of the experiment. Taking into account the presence of blood in the wound, we provided for a model with an aqueous solution of 45% glycerin. Clinical interpretation of biomechanics was carried out basing on the dynamic radiography data of two patients who underwent revision hip arthroplasty with the use of impaction bone grafting (IBG). The changes in the position of the rotation center and acetabular component were assessed.

Results. During a single-cycle loading, we observed stress-strain dependences and instantaneous elastic moduli for each specimen. During cyclic tests, we obtained the increase of the instantaneous elastic modulus by 2.6 times for a “dry” specimen and from 3.9 to 4.7 times for the ones with liquid. X-rays of both patients showed the shift of the center rotation cranially and laterally: 2.4 and 1.5 mm in the first case and 14.9 and 9.5 mm in the second one, respectively. In the first case the change in the inclination was 18.7º, in the second case — 19.8º. The Hip Harris Score (HHS) was 97 points for the first patient, 53 points — for the second one.

Conclusions. The material used for IBG is subject to deformation both in the intraoperative and postoperative period. Compression tests have suggested that the deformation of morselized impacted bone graft gradually tends to reach a plateau in the postoperative period, and with the completion of the deformation, migration of the acetabular component stops. The change in the position of the rotation center and acetabular component in the absence of a radiolucent line is not an absolute sign of loosening.

Background. Total knee arthroplasty in patients in the residual stage of poliomyelitis is a technically difficult job. The reasons for this are anatomical features and therefore difficulties in an implant choice and conflicting results. In the present case report, we describe a unique method of a computer-navigated installation of a rotating-hinge implant in a non-standard position for a patient with residual poliomyelitis.

The aim of the study is to demonstrate a method of a computer-navigated installation of rotating-hinge knee implants in a patient with severe hyperextension and valgus deformity in the residual stage of poliomyelitis.

Case description. The clinical case presents a 55-year-old man with lower peripheral paraparesis as a consequence of poliomyelitis and bilateral valgus knee arthritis with severe hyperextension. The patient moved on crutches at a distance no more than 300 meters. Two-stage total knee arthroplasty was performed using a navigation system and second-generation rotating-hinge implants. At the 4-year follow-up period, we note a good clinical result, and the patient is satisfied with the total knee arthroplasty outcomes.

Conclusion. The clinical case demonstrates good results of performing total knee arthroplasty in a patient with bilateral severe hyperextension and knee valgus deformity in residual poliomyelitis. Having analyzed available topic-related literature, we developed an original method of a computer-navigated installation of a second-generation rotating-hinge implant. The method can be an effective treatment solution for patients with knee arthritis deformity in the residual stage of poliomyelitis.

Background. Fractures of the bones that form the knee joint in children are quite rare, accounting for up to 6% of all bone fractures. These include avulsion fractures of the patellar apex as well as tibial tuberosity avulsion fractures, which may result in patellar tendon ossification. Based on literature, the ossification may also occur in cases of primary or chronic (complete or partial) patellar tendon tears. Such a complication is quite rare in pediatric traumatology; it requires differential diagnosis and various surgical tactics.

The aim of the study is to present a clinical and radiological picture of post-traumatic patellar tendon ossification in children and its surgical treatment outcomes using a case series as an example.

Methods. We present a monocenter retrospective series of 4 male patients. Anamnestic, clinical, radiological and histological data were analyzed.

Results. The patients’ mean age was 14 (range, 11-16) years. In all cases, there was a history of trauma. Initially, after getting injured, the patients were treated for a knee injury. In one patient, as a result of his falling on 2 limbs, a bilateral pathology was observed; in other three cases, the pathology was unilateral. Flexion contracture and pain syndrome prevailed in the clinical picture. All patients underwent surgery ranging from excision of ossifications to excision of ossifications with reconstruction of tendon defects and refixation of the tibial tuberosity with osteosynthesis. In all cases, knee joint contracture was eliminated and the volume of movement was fully restored. Histology showed fragments of mature bone tissue represented by thinned bone beams with focal osteoclastic reaction and areas of endochondral ossification.

Conclusions. The clinical picture of pediatric patients with patellar tendon ossification manifests in the form of a chronic cascade of symptoms and functional and topographic disorders: patellar tendon ossification, patella alta, anterior knee pain, flexion contracture and rectus femoris muscle hypotrophy. X-ray and MRI data determine a formation of bone density with uneven clear contours in the projection of the patellar tendon, along with patella alta and the Caton-Deschamps index increasing more than 1.3. The primary treatment method of the developed complication is the surgical one, which leads to the restoration of the full amplitude of movements in the knee joint.

Background. Avascular necrosis of the femoral head (ANFH) is a disabling disease that often leads to hip replacement. Due to the increasing incidence among the young population, various methods of organ-preserving treatment aimed at slowing down the progression of ANFH and preserving the functions of the hip joint have been proposed. Today, there is a lot of controversy and disagreement over the procedure of introducing bone marrow-derived multipotent mesenchymal stromal cells (MMSCs) into the site of osteonecrosis.

The aim of the study — a systematic analysis of the accumulated literature data on the effectiveness, safety, advantages and disadvantages of treating patients with aseptic necrosis of the femoral head by the tunneling method using bone marrow-derived MMSCs, as well as their impact on reducing the risk of disease progression and long-term treatment results.

Methods. A 10-year literature search (2013-2023) was performed in the PubMed, Scopus and eLIBRARY databases. According to our inclusion criteria, the review included 8 high-quality studies that examined the use of MMSCs as part of bone marrow concentrate for the treatment of ANFH.

Results. The surgical outcomes of 368 patients (548 hips) from 8 studies were analyzed. The mean follow-up period was from 24 to 360 months. In most cases, functional indicators improved. In the main group, where mesenchymal stromal cells were used, X-ray progression to the next stage occurred in 31.25% of cases and the need for endoprosthetics was 30.6%; in the comparison group, the progression occurred in 68.75% of cases and the need for endoprosthetics was 69.4 %.

Conclusion. The use of multipotent mesenchymal stromal cells in the complex treatment of ANFH in the early (ARCO I, II, IIIA) stages of the disease can improve the hip joint function, slow down the progression of the disease and reduce the need for endoprosthetics.

Background. One of the main and most costly problems in large joint arthroplasty associated with socially significant losses is periprosthetic infection. Of particular importance is periprosthetic joint infection (PJI) caused by antibiotic-resistant pathogens and followed by the worst treatment results. Currently, when antibiotic-resistant pathogens are spreading rapidly, particularly in health facilities, researchers are constantly looking for alternative treatments for severe cases of PJI. Phage therapy can be one of these methods.

The aim of the review was to analyse the application of personalized bacteriophages in the management of periprosthetic infection caused by multidrug-resistant pathogens during arthroplasty of large joints of the lower extremities.

Methods. A 20-year literature search (2003-2023) was performed in the eLIBRARY, PubMed, Google Scholar, and Scopus electronic databases.

Results. During the search, 1.482 publications meeting the objectives of this review were found. Taking into account the inclusion/non-inclusion criteria adopted by the authors, the review included 12 studies describing 45 cases of the use of bacteriophages in the management of hip and knee PJI caused by multidrug-resistant pathogens. The infection was eradicated without recurrence in 42 cases (89.4%), recurrence was recorded only in 5 cases (10.6%).

Conclusions. The analysis of the literature confirms that a combination therapy of personalized phages and antibiotics as adjuvant therapy is safe and effective. Bacteriophage treatment is a promising direction in the fight against resistant pathogens of periprosthetic infection. Its combination with antibiotics seems to be the most promising, as it can significantly increase the effectiveness of therapy for infections caused by multidrug-resistant pathogens due to the synergy of these drug classes.