Vol 26, No 4 (2020)

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Background. Nowadays, according to the foreign and native registers data, the number of patients with periprosthetic infection (PJI) tends to increase. The early PJI diagnostics allows to provide timely effective treatment. Several widely used PJI diagnostic algorithms PJI exist. The objective of the study is comparative analysis of diagnostic value, accuracy and specificity of contemporary diagnostic algorithms. Materials and methods. A post-hoc analysis of 242 patients undergoing revision arthroplasty in 2018, held at FSFI FCTOE, was carried out. According to the study design, 127 patients were included in this study. PJI was diagnosed according to three known algorithms: ICM (International Consensus Meeting 2018), WAIOT (The World Association against Infection in Orthopedics and Trauma), EBJIS (The European Bone and Joint Infection Society 2018). Diagnostic sensitivity, specificity and total accuracy of each algorithm was carried out. The evaluation of ICM diagnostic algorithm was made with 2 variants: “not convincing = no infection”, “not convincing = infection”. The presence of infection was confirmed by bacteriological examination of synovial fluid aspirate, intraoperative biopsy of materials and sonification of explanted components. Results. The highest value of common accuracy was achieved in ICM 2018 algorithm — “not convincing = infection” was 91.3%, with sensibility and specificity — 89.3% and 93.0% respectively. The best specificity was shown by the algorithms WAIOT and ICM (“not convincing = no infection) – 95.8%, with sensibility and common accuracy — 80.4% and 89.0% respectively. The sensibility and specificity of EBJIS algorithm was 87.5% and 84.5%, respectively, the common accuracy — 85.8%. Conclusion. All included in investigation diagnostic algorithms showed high specificity values in diagnostics of hip and knee PJI without significant differences. Patients with subclinical PJI and low virulent pathogens have the biggest difficulties in PJI diagnostics. It seems that the selection of analyzed algorithms doesn’t play an important role, however PJI diagnostics requires complex approach with the use of different clinical and laboratory values.

Background. In recent years, there has been an increase in the number of the patients with multiligament knee injuries. A significant proportion of unsatisfactory outcomes of such injuries treatment is associated with this injury features and the objective difficulties of its surgical correction. This determines the need for searching the optimal methods of diagnosis and treatment of such an injury. The purpose of this study was to compare the results of surgical treatment of the patients with multiligament knee injury, including the injury of the ligament-tendon complex of the knee posterolateral angle with two different techniques. Materials and Methods. The study included 51 patients with multiligament knee injury undergone the surgical treatment from 2007 to 2019. The average age of the patients was 32.1±9.2 years. The patients were divided into two groups. The patients of the main group (24 patients) underwent reconstruction of the cruciate ligaments and the main structures of the posterolateral angle: the fibular collateral ligament, the popliteofibular ligament, and the popliteus tendon. The patients of the comparison group (27 patients) underwent the reconstruction of the cruciate ligaments supplemented with isolated fibular collateral ligament grafting. The results obtained were evaluated clinically using the Lysholm scale (1982), by determining the subjective assessment of treatment outcomes, and by functional X-ray and MRI. The results of the treatment were studied in all injures: in the main group in 9 months, in the comparison group on average in 16 months after the surgery (from 9 to 43 months). Results. The use of the developed diagnostic and surgical methods made it possible to improve the clinical and functional results by the Lysholm scale: the main group 82 [70; 86] points vs the control group 68 [64; 76] points (p = 0.003). The II degree residual lateral instability was observed in 2 patients of the main group and in 7 patients of the control. 19 (79.2%) patients in the main group and 18 (66.7%) in the control were satisfied with treatment outcomes according to the scale of subjective assessment. There were no patients who rated the result of their treatment as “good” in the both groups. Conclusion. The practical employment of the proposed modification of the fibular collateral ligament grafting by the LaPrade in the patients with multiligament knee injury makes it possible the statistically significant improvement of the treatment functional results after the reconstructive surgery in the medium term (9 months) compared with the patients undergone isolated fibular collateral ligament grafting. The unsatisfactory results of the treatment caused by the severity and morphological features of the injuries. They require further study, as well as the improvement of the surgical techniques.

Background. In acetabular fractures, the correct choice of the surgical approach is mandatory to achieve accurate reduction and to avoid complications. Anterior approaches include the ilioinguinal, the Stoppa, the iliofemoral and the pararectal exposures. The ilioinguinal and the Stoppa approaches are the most ones nowadays. The purpose of the study was to compare the efficacy of modified Stoppa and ilioinguinal approach in the management of acetabular fractures in terms of quality of reduction achieved, complication rates, functional outcomes, operative time, intraoperative blood loss, view angle of the surgical wound, the applicability of the forceps. Materials and Methods. The study enrolled 53 adult patients. We evaluated 53 cases of treatment of patients underwent acetabular fractures osteosynthesis. The patients were divided into two groups. We used the Letournel approach in group 1 (n = 27), the Stoppa/iliac approach — in group 2 (n = 26). The group 2 was split into two subgroups: in subgroup 2A, osteotomy of the anterior superior spine was performed (n = 13), in subgroup 2B, we did not perform it (n = 13). The following parameters were compared: the quality of reposition of fragments, operation time, intraoperative blood loss, damage to neural structures, viewing angle, and ease of use of pelvic instruments for reduction. The functional outcome was assessed by the Majeed scale. Results. Comparison of the two approaches showed that the indices of reduction of fragments, total blood loss and operation time did not differ significantly and were not statistically significant (p>0.05). However, there were more neurological complications in group 1, but they did not affect the treatment outcome. The angle of the sector of view during the operation with osteotomy of the anterior superior spine of the pelvic wing is about 90°, which contributes to a more efficient use of repositioning instruments. The functional results of treatment were the same in both groups in 12 months after surgery. Conclusion. The Letournel and the Stoppa/iliac approach are equivalent in terms of the degree of reduction, operation time and blood loss during the operation. Application the Stoppa/iliac approach helps to avoid iatrogenic meralgia paresthetica unlike Letournel approach. The Stoppa/iliac approach and osteotomy of the anterior superior spine provides better visualization and provides a greater degree of freedom for the surgeon during manipulation tools for reposition.

Background. The modern principles of reconstruction of the anterior cruciate ligament (ACL) and well-known surgical techniques do not take into account the peculiarities of the anatomical structure of the female knee. This happens due to insufficient substantiation that these peculiarities could influence the results of the treatment. The purpose of this study was to obtain new data on the structure of the areas of the ACL attachment, taking into consideration patient’s gender and the surgical anatomy. Material and Methods. 40 unpaired “fresh” anatomical preparations of the human female and male knees were studied. After preparation of the knee joints, the morphometry of the distal femoral epiphysis and the proximal tibial epiphysis was carried out by a digital sliding caliper according to 16 parameters. The shape, size, area, and the distance of the ACL attachment center from individual bone structures were assessed. The obtained data were correlated with the gender type of the knee structure. Results. The distal femoral epiphysis of the “female” type knee joint compared with the “male” type revealed the significant differences (p<0.05) in the following parameters: the width of the condyles at the level of the transepicondylar line, the width of the intercondylar fossa, the length and height of the lateral condyle, and the ratio of the condyles width at the level of the transepicondylar line to the height of the lateral condyle. The tibial proximal epiphysis showed the gender differences in the articular surface frontal and sagittal dimensions, the width of the intercondylar eminence and the posterior slope of the tibial epiphysis articular surface. These features determined the different proportions of the female knee structure. The area of the anterior cruciate ligament femoral attachment and its center in the “female” type of structure were located 3 mm distal and 1.5 mm posteriorly (anteriorly and downwardly in arthroscopic imaging). The area of the tibial attachment of the same ligament and its center were localized 2 mm anteriorly in comparison with the “male” type structure. Conclusion. The discovered anatomical differences made it possible to distinguish the “female” and “male” types of the knee structure. The topography of the anterior cruciate ligament attachment areas is gender specific. This should be taken into account in the anatomical reconstruction of the ligament.

Background. Periprosthetic joint infection in the early postoperative period is a severe infectious complication. Its development, as a rule, is associated with the exogenous surgical wound infection, with the iatrogenic factor at the forefront. Clinical case description. A 73-years-old female with left-sided idiopathic 3^rd stage hip osteoarthritis and concomitant pathology with a high degree of comorbidity underwent left hip arthroplasty with a cement-fixed “Endoservice” endoprosthesis. In the early postoperative period (4^th to 6^th days), against the background of chronic calculous cholecystitis exacerbation and gastrointestinal dysfunction, clostridial septicemia developed as a result of bacterial translocation. The timely diagnosis of the endogenous nature of this infection and the targeted antibiotic therapy prevented the surgical wound and endoprosthesis infection. The Harris score for the function of the left hip at discharge was 78 points. Conclusion. The presented clinical case demonstrates the importance of careful preoperative planning, especially in the patient with identifying somatic pathology of infectious nature, the need to detail the organ-specific microbiota as a mandatory procedure, as well as the prevention of periprosthetic joint infection during orthopedic operations, taking into account the data obtained.

Background. The lack of a system for evaluating the feasibility of new trauma and orthopedic departments in outpatient clinics under construction creating is one of the main reasons for the imbalance in their territorial location. Therefore, one of the most urgent modern tasks in the megalopolis healthcare organization — is to develop a system for effective regulation of the trauma and orthopedic outpatient departments network construction. The purpose of the study is to improve the effectiveness of outpatient trauma and orthopedic care for megalopolis residents. Materials and Methods. In the research process, theoretical (formalization, synthesis, deduction) and empirical (observation, comparison, modeling, measurement) methods were used. A total of 67 emergency trauma outpatient departments in Moscow were sampled and data on their attendance for April 2019 were collected. Results. Creation of a mathematical model of the network of outpatient primary trauma care and a basic algorithm for estimating the average time from the moment a patient received injuries to the time of primary care in one of the emergency outpatient trauma units of the medical organizations of the capital, which can be used by the executive bodies of the healthcare organization cities in solving administrative and economic problems. Conclusion. The developed specialized mathematical algorithm for assessing the existing effectiveness of the already existing emergency outpatient trauma units network and the distribution of new units allows you to create an “ideal” model for the location of these deparments in a megapolis. In the future, this model can be developed taking into account the development of the transport network, the financing of emergency rooms, etc.

Background. Current evidence based research data lead to reassessment of traditional approaches for treatment of patients with bone and joint disorders especially knee osteoarthritis (OA). The purpose of the study was to review randomized clinical trials (RCT) and meta-analyses of RCT as well as recent guidelines of professional societies for application of arthroscopic lavage, debridement and meniscectomy in knee OA. Materials and Methods. Databases PubMed, e-LIBRARY, EMBASE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL) were searched for the period from 2000 till 2019. From 138 heats irrelevant and poor quality studies were excluded. In total there were 1614 patients aged 48,9–62,8 in RCT and 20 770 patients aged 42–62,4 in meta-analyses of RCT. Results. Both arthroscopic lavage and debridement do not lead to significant pain relief as well as functional improvement in long term therefore are not recommended. Nonsurgical treatment should be the first line strategy in patients with early and moderate knee OA even with degenerative meniscal tears irrespective of mechanical symptoms like painful locking, catching or sudden giving way. Arthroscopy might be performed only if complex non-surgical treatment including non-steroidal anti-inflammatory drugs, structured exercises program and intra-articular injections failed after 3 months in patients without ‘bone on bone’ cartilage erosions and frontal malalignment or if the knee is mechanically locked due to bucked handle type meniscus tear or loose body. Conclusion. Evidence based medicine approach let us to conclude that arthroscopy in knee OA is non-efficient and rarely indicated therefore if proper non-surgical treatment is failed around the knee osteotomies and partial or total arthroplasty should be considered.

Background. The shoulder MRI is one of the main methods for the rotator cuff injuries diagnostics and determination of the further treatment tactics. The agreement in the MRI data interpretation among specialists regarding different types of shoulder ruptures is an integral part of diagnostic test validity evaluation. The purpose of this study was to assess the agreement in the MRI data interpretation in the patients with shoulder rotator cuff pathology among trauma surgeons, as well as between trauma surgeons and a radiologist. Materials and Methods. The study was a retrospective analysis of the MRI data and surgical reports regarding 57 patients with various shoulder pathologies undergone the shoulder MRI and arthroscopic shoulder revisions in the period from 2017 to 2019. There were 38 (67%) men and 19 (33%) women among the patients. The average age of the patients was 52.7±13.6 years. The sensitivity and specificity, as well as the shoulder MRI inter-rater reliability were assessed in the course of the study. Results. The rotator cuff pathology was revealed in 52 patients: supraspinatus tendon injury in 98% of cases, supraspinatus and infraspinatus tendon — in 26%, isolated subscapularis tendon injury — in 2%, supraspinatus and subscapularis tendon — in 39%. The maximal concordance in the MRI data interpretation was achieved in the patients with full-thickness supraspinatus tendon rupture, as well as with the supraspinatus tendon calcifications. However, significant disagreement was found between orthopedists with different work experience in determination of the presence and type of infraspinatus and subscapularis tendons pathology and supraspinatus tendon incomplete ruptures and tendinitis. Conclusion. The high agreement in the MRI data interpretation in determining the pathology of the shoulder rotator cuff among trauma surgeons, as well as between trauma surgeons and radiologists, was observed only regarding the supraspinatus tendon, calcifying tendonitis and full-thickness injury. The diagnosis of tendinitis and incomplete tendon rupture remains difficult. Their interpretation results vary greatly. It is also worth noting the heterogeneity of the results of diagnostics of the infraspinatus and subscapularis tendon pathology.

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