Vol 27, No 2 (2021)

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Background. Chronic periprosthetic joint infection (PJI) remains the one among the most severe complications of total hip arthroplasty. Presence of sinus tract assosiated with polymicrobial infection development, complexity of bacteriological diagnostics  and  damage  of  soft  tissues  lead  to  constrictions  of  one-stage  revision  hip  arthroplasty  (RHA). The  aim of this studywas to assess the influence of draining sinus tract on the outcomes of one-stage RHA in patients with chronic hip PJI.

Materials and Methods.A prospective cohort comparative study included 78 patients who underwent one-stage RHA in 2017-2020. Two groups were formed: 48 (61.54%) patients without sinus tract (WST) and 30 (38.45%) patients with sinus tract (ST).

Results. The presence of a sinus tract significantly increased the duration of a one-stage RHA in groups of ST and WST (230 and 197.5 min respectively, p = 0.02), as well as blood loss (850 ml and 700 ml, respectively, p = 0.046). Sinus tract was a reliable symptom of soft tissue local infectious inflammation (86.67%, p = 0.00031), fasciitis (36.67%, p = 0.012), purulent cavity (66.67%, p = 0.00027). The structure of the pathogens was comparable. Monobacterial infections predominated in the WST group (82.98%) and in the ST group (77.78%, p = 0.08). In most cases staphylococci were isolated. The median follow-up was 20 months for both groups. The PJI was healed in 93.0% (n = 28) patients in WST group and 82.2% (n = 43) in ST PJI (p>0.05). Postoperative evaluation in the WST and ST groups: HHS 92 and 90 points (p = 0.79), EQ-5D-5L – 0.82 and 0.78 points (p = 0.84) respectively. The proportion of patients who were indicated revision surgery with no PJI association in the ST group exceeded this indicator more than twice according to the WST group — 25 and 11.62%, respectively (p>0.05).

Conclusion.As a result of the study, there was no statistically significant difference between the outcomes of one-stage RHA in patients with and without sinus tract. Factors such as the anamnesis morbi, the soft tissues condition at the surgical site and the pathogenic microflora characteristics should be taken into account in order to achieve favourable outcomes of surgical treatment.

Background. Despite the success in the treatment of children with mucopolysaccharidoses (MPS) as a result of the widespread of  enzyme  replacement  therapy  and  hematopoietic  stem  cells  transplantation,  orthopedic  manifestations  continue  to  be a  significant  problem,  while  the  pathology  of  the  upper  limbs  in  children  with  MPS  is  not  sufficiently  represented  in  the literature. The aim of this studywas to analyze orthopedic and neurological manifestations in the upper extremities of children with  mucopolysaccharidosis  based  on  a  sequential  case  series. Materials  and  Methods. We  carried  out  a  comprehensive analysis of clinical and radiological involvement of the upper extremities in 49 patients with MPS. Results. The most common complaints reated to the upper extremities were difficulties in the daily activities (dressing, self-care, playing), impairment of the fine motor skills, and muscle weakness. The most frequent clinical manifestations related to the upper extremities were limited active shoulder abduction, impaired hand grip, flexion contractures of the elbow joint, ulnar deviation of the hand. All patients with MPS types I, II, and VI had limited active and passive extension and flexion of the metacarpophalangeal and interphalangeal joints. In patients with MPS IV, hypermobility of the hand joints prevailed. We noticed minimal presence of typical clinical manifestations related to compression of the median nerve secific for carpal tunnel syndrome. The majority of patients showed a decrease in tendon and periosteal reflexes. The most pronounced decrease in muscle strength was observed in to extensors (elbow, fingers) and shoulder abductors, which may contribute to the predominant formation of a flexion pattern of contractures. On radiographs of the hand, the “melting sugar” symptom and shortening of the metacarpal bones were observed in most patients. Conclusion.Clinical and radiological manifestations related to the upper extremities take  place  in  all  types  of  the  mPS,  and  lead  to  functional  disorders  that  complicate  daily  life  and  self-care.  Upper  limb pathology in children with MPS requires earlier detection and more active treatment after comprehensive risk assessment.

Background.Local prevention of periprosthetic infection and treatment of infectious complications after various joints arthroplasties includes the use of polymethylmethacrylate-based spacers impregnated with antimicrobial agents. At the same time, the added components are able to change the bone cement characteristics and have variable antimicrobial effect duration. The aim of the studywas to evaluate the duration of antimicrobial activity and the effect on the MRSA ATCC 43300 biofilm formation on bone cement samples with gentamycin impregnated with vancomycin and/or highly dispersed silver.

Materials and Methods.Samples were made from bone cement DePuy CMW 1 Gentamicin and mixed with vancomycin and/or highly dispersed silver. The elemental composition was studied by scanning electron microscopy and  micro-x-ray  spectral  analysis.  The  study  of  the  antimicrobial  activity  duration  was  performed  by  daily  applying an  incubation  solution  with  samples  to  the  bacterial  lawn  surface.  The  effect  on  biofilm  formation  was  evaluated  by immersing the test samples in LB-broth with MRSA.

Results.The control samples did not have antimicrobial activity (AMA) against MRSA ATCC 43300. Test samples, additionally containing 10 wt.% of vancomycin was effective for 9 days. When adding highly dispersed silver, the lengthening of the samples activity time was recorded. So, when applying 2.5 wt.% of highly dispersed silver, the duration of AMA was 21 days, and when increased to 10 wt.% — 34 days. Energydispersion analysis of the sample surface with 10 wt.% of vancomycin and highly dispersed silver showed that the skeletal structure type contains matrix component based on barium sulfate with silver inclusions. During the study of the samples effect  on  a  typical  strain  biofilm  formation,  no  statistically  significant  differences  were  found  between  the  optical density of gentian violet extracts in the negative control and in the medium with MRSA.

Conclusion. The vancomycin with highly dispersed silver combination prolonged the antimicrobial activity of the samples against MRSA ATCC 43300 and effectively prevented the formation of microbial biofilms on its surface. Despite the fact that the conditions of the conducted experiment in vitro are not identical to the conditions of bone cement antimicrobial spacers clinical use, our results indicate the need to use spacers with a known duration of antimicrobial activity and to comply with the terms of temporary structures replacement.

Background. Achieving  a  durable  connection  between  the  lacerated  tendon  ends  is  difficult.  The  outcome  of  treatment depends on many factors. Several authors consider the properties of the surgical needle used for suturing the tendon to be important. The aim of the study— to compare the strength of the tendon suture applied with the conventional cutting edge and reverse cutting edge surgical needles in the experiment.

Materials and Methods.We used porcine tendons for the experiment. The tendon fragments were divided into 2 groups of 20 tendons each. On all 40 tendons, the same type of “injury” of the tendon was simulated — using a scalpel. In the first group, the interrupted suture of the tendon was applied with a cutting edge surgical needle, in the second group — reverse cutting edge. Laboratory tests of the tendon sutures strength were performed on the improvised stand.

Results.In the first (suture made with a cutting needle edge), diastasis of 2 mm was determined at an average load of 1219.5 g (m = ±76.56, where «m» is the representativeness error). Complete suture failure occurred at an average load of 1770.8 g (m = ±100.02). In this group, the thread rupture was not recorded. In the second group (a suture made with a reverse cutting edge needle), diastasis occurs with an average load of 1754.75 g (m = ±77.32). Complete suture failure occurred at an average load of 2571.25 (at m= ± 103.78). In three cases, the thread ruptured. In the second group (reverse cutting edge needle), the tendon suture strength was statistically significantly higher than in the first group.

 Conclusion. The tendon suture strength depends on the surgical needle properties. In tendons  reconstruction  the  reverse  cutting  edge  needle  use  is  more  preferable  compared  to  the  conventional  cutting  edge needle use.

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Background. The rarity of the disease and, in this regard, the lack of doctors awareness about the pathology, late diagnosis and severe complications of the musculoskeletal system emphasize the relevance of clinical case demonstrating. The uniqueness of  the  case  lies  in  the  fact  that  hypophosphatemia,  noted  3  years  after  the  disease  debut,  was  not  taken  into  account.

Case description. A 45-year-old patient with complaints of muscle weakness, gait disorders, torso deformity and multiple vertebral body fractures that appeared against the background of any somatic diseases absence, a differential diagnosis of metastatic vertebral bodies lesions and secondary osteoporosis complicated by vertebral body fractures was carried out for four years in various hospitals, and was even treated with bisphosphonates. Against this background, the chest deformity increased,  kyphosis  and  remodeling  fractures  of  other  bones  appeared.  The  assessment  of  calcium  and  phosphorus homeostasis  was  first  performed  at  the  4th year  of  the  disease,  but  the  detected  hypophosphatemia  was  not  regarded as  a  manifestation  of  hypophosphatemic  osteomalacia.

Conclusion. Among  adult  patients  with  multiple  low-energy fractures,  severe  muscle  weakness  and  bone  pain  that  appeared  against  the  background  of  complete  health,  to  exclude hypophosphatemic osteomalacia induced by mesenchymal tumor, it is necessary to include the level of phosphorus in blood and daily urine assessment in the diagnostic algorithm.

Background. Currently, various algorithms of tactical classifications and treatment regimens for hematogenous vertebral osteomyelitis (HVO) are proposed. However, all proposed approaches are designed for the treatment of patients in specialized multidisciplinary clinics departments, although the initial treatment often occurs in municipal polyclinics, private medical centers  and  district  hospitals.  The  question  is  what  the  appropriate  scope  of  diagnostic  and  therapeutic  measures  in institutions with different material and resource bases and how to ensure continuity according to the existing three-level system of medical care remains open. The aim of this studyis to determine the probable routing and treatment options for patients with HVO on the example of the Tyumen region, depending on the existing three-level system of providing medical care to the population.

Object and Methods.The current Orders of the Ministry of Health of the Russian Federation and the Resolutions of the Government of the Tyumen Region were studied, on which basis a three-level system of providing medical care to the population was organized and organizations providing emergency and elective medical care to patients with HVO were identified. The volume of medical and diagnostic measures in patients with HVO in institutions of various levels, as well as their routing to the regional clinical hospital No. 2 in case of impossibility or inexpediency of providing specialized medical care at the place of primary treatment, is analyzed on the example of the Tyumen region. The clinical material is presented by 267 patients with HVO who were treated in the Tyumen regional clinical hospital No. 2 from 2006 to 2019, 78.7% of whom were treated in the profile of traumatology and orthopedics, 18.7% — neurosurgery and 2.6% — surgery.

 Results.The list of medical institutions that provide emergency and planned care in traumatology and orthopedics, neurosurgery in the Tyumen region is defined, depending on the level of the institution and the available material and resource base. A block diagram is proposed that determines the scope of medical and diagnostic measures in institutions of I-III levels and specialized departments of multidisciplinary clinical hospitals. The principle of determining the patient profile (surgical, orthopedic, neurosurgical) depending on the type and severity of the inflammatory lesion according to the classification E. Pola (2017) is proposed.

Conclusion. The need for effective use of medical and diagnostic resources starting from level I is determined by clear routing of the patient to ensure the continuity of medical care. A full-fledged diagnosis is possible in institutions not lower than the third level with the mandatory determination of the lesion type and the severity of the inflammatory process. HVO treatment is advisable in level III institutions, specialized departments of regional clinical hospitals and federal institutions.

Introduction. Main objective of total hip replacement (THR) is fast recovery of hip joint function and patient’s return to daily routines. Use of minimally invasive approaches (MIA) may help achieving set objective. The purpose of the study was to analyze and compare MIA in THR.

Materials and methods. Databases of PubMed, Scopus, Cochrane Systematic Reviews, Google Scholar and E-library were searched for the period since 2000 to 2020. 55 scientific articles were selected for the analysis. Publications contain results of studies of MIA, such as Direct Anterior Approach (DAA), Micro-Hip (MH), Röttinger (R), Mini-posterior (MP), Direct Superior Approach (DSA), SuperCap (SC), PATH (P), SuperPATH (SP). The initial data were combined and underwent statistical processing.

Results. A comparative analysis of MIA couldn’t identify superiority of any approach. Blood loss, length of hospital stay, functional outcomes (Harris Hip Score) at 3 and 12 months didn’t differ between the groups. Significant differences were found in the operation time between DSA and SP. Acetabular inclination was different between some approaches. Cup inclination in R and DSA, cup anteversion in DAA, MH and SP slightly exceeded Lewinnek's «safe zone». Recurrent dislocation, periprosthetic fractures, damage to the lateral cutaneous nerve are the most frequent postoperative complications.

Conclusion: THR can be done using a variety of surgical approaches. The choice of approach relies on surgeon’s experience and personal preferences. Minimally invasive approaches have the advantage of short-term recovery due to the preservation of soft tissues.

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Background.The effectiveness improvement and standardization of the methods of histological diagnosing periprosthetic infection (PPI) is an urgent task in the treatment of complications after large joint arthroplasty. Purpose of the study— Histopathological evaluation of the infection involvement of periprosthetic tissues at the stage of revision arthroplasty for deep infection of the hip using HOES scale and immunohistochemical analysis of CD15 expression.

Materials and Methods.A single-center prospective study was performed on the clinical intraoperative material obtained at the stage of revision arthroplasty of the hip in 27 patients at the age of 65 (55÷69) years. The group of examination included patients with acute and chronic forms of deep periprosthetic infection. Light-optical microscopic investigation of the samples of periprosthetic connective-tissue membrane and bone tissue from the foci of infectious involvement was made on paraffin sections stained with hematoxylin and eosin; with the immunohistochemical reaction to determine the expression of CD15 neutrophil granulocyte markers. HOES Scale for pathohistological assessment was used in order to objectify osteomyelitis signs in periprosthetic bone tissue.

Results. The signs of acute and chronic stages of periprosthetic osteomyelitis were observed in 9/16 patients with PPI chronic course within 1–30 months of postoperative period, from one to 18 months after manifestation of the symptoms. The signs of subsided osteomyelitis were determined in 12/27 patients with PPI of acute and chronic forms. Infected periprosthetic membranes were found in 19/27 clinical cases in the early and longterm  time  periods  after  arthroplasty  surgery.  A  direct  significant  correlation  was  revealed  between  histopathological signs  of  infecting  the  periprosthetic  bone  and  the  connective-tissue  periprosthetic  membrane,  especially  strong  one in  patients  with  acute  and  chronic  PPI  osteomyelitis.

Conclusion. The  use  of  HOES  Scale  and  the  analysis  of  CD15 expression  ensure  the  objectivity  of  PPI  histological  diagnosing.  The  results  obtained  indicate  an  increased  risk  of osteomyelitis development in patients with chronic periprosthetic infection after the hip arthroplasty.

Traumatic hip dislocations occupy the fourth place among dislocations of various localizations and, as a rule, are the result of  exposure  to  a  high-energy  traumatic  agent.  Such  injuries  are  more  often  observed  in  young  and  middle-aged  males. The main cause of hip dislocations is road accidents. The femoral head is more often dislocated posteriorly, but anterior dislocations  are  not  casuistic  and  account  for  approximately  10%.  Hip  dislocations  are  often  combined  with  acetabular fractures,  while  their  fairly  clear  clinical  picture  in  the  presence  of  fractures  can  be  leveled.  Traumatic  hip  dislocations require urgent diagnosis and treatment. After the clinical examination of the patient, an x-ray of the pelvis and hip joints are performed. Radiographic diagnosis of hip dislocation remains relevant, but modern imaging methods allows to study the hip joint in more detail and identify concomitant injuries. The main treatment for hip dislocation is closed reduction. Early dislocation reduction and the absence of damage to the structures forming the hip joint are important for the treatment results prognosis. The further patient management tactics after the dislocation reduction is determined by the results of stress tests and the CT data. When confirming the instability and associated injuries of the hip joint anatomical structures, surgical treatment is indicated. Among the complications of hip dislocation: sciatic nerve damage, post-traumatic coxarthrosis, the femoral head avascular necrosis, heterotopic ossification. Current literature data indicates the importance of early diagnosis of dislocation-associated injuries of the hip joint and periarticular tissues. Early and comprehensive repair of all existing injuries is crucial for favorable outcomes. A number of therapeutic and diagnostic methods, primarily arthroscopy, show optimistic results, but need further study.