Vol 29, No 3 (2023)

Background. According to the analysis of large arthroplasty registers we have noted the increase in the use of non-cemented implants, because the latter shows the same results of implant survival as well as cemented implants. On the other hand, they can affect the quality of the bone around the implant in different ways. These components differ in shape, length, and surface properties. According to the analysis of the arthroplasty register of the Vreden National Medical Research Center of Traumatology and Orthopedics, a significant decrease of the Alloclassic femoral stem using can be noted. In parallel the use of its SL-PLUS MIA modification has increased significantly.

Aims of the study: 1) to determine the influence of changes in the design of the Zweymüller-type femoral stem on midterm and long-term outcomes and its survival; 2) to identify the characteristics of adaptive remodeling of periprosthetic bone tissue around these femoral stems; 3) to determine risk factors for aseptic loosening of these femoral stems.

Methods. 492 cases of hip arthroplasty using the Alloclassic and SL-PLUS MIA femoral stems were observed, with an average follow-up 78.6 months. The patients were divided into 2 groups according to the type of femoral stem. The assessment the hip articulation condition was carried out using the HHS and OHS. The intensity of the pain syndrome was assessed by VAS, and the level of patient’s satisfaction. The dynamic analysis of X-rays was also performed visually.

Results. A significant improvement in clinical and functional results was observed according to the HHS and OHS in both groups of patients, regardless of the type of femoral stem. Analysis of X-rays over time showed differences in the behavior of these two femoral component models. The radiolucent lines around the femoral stem are absent in SL-PLUS MIA group, in Alloclassic stem group radiolucent lines are present even at a minimal period (12 months). We also found that a tight fit of Zweymüller femoral stems in the distal shaft is a risk factor for severe stress-shielding syndrome, especially in the funnel channels. But ceteris paribus, a distal tight fit of SL-PLUS MIA stems despite similar geometry of the distal part does not lead to such frequent manifestation of severe stress shielding.

Conclusion. The change in Zweymüller stem design from Alloclassic to SL-PLUS MIA improved the nature of adaptive remodeling in the periprosthetic area of the femur. It may improve the long-term results of primary hip arthroplasty, but these differences require closer observation.

Background. The choice of the method and options for surgical treatment of degenerative pathology of the lumbar spine is difficult due to the lack of clear clinical and radiological criteria for diagnosis and a direct correlation between the severity of the radiological manifestations of the disease and clinical symptoms.

The aim of this study was to analyze the clinical and neurological characteristics of elderly patients with degenerative disorders of the lumbar spine and to identify the dominant clinical and radiologic syndromes.

Methods. Сohort of 1013 patients were operated using MIS technologies (decompression alone, TLIF, LLIF, ALIF) in the period 2013–2017 (367 male/646 female). The age range is 60-89 years (mean 66 years). The criteria for identifying the leading syndromes: leg pain/back pain with a threshold value of 5 points according to VAS, X-ray criteria for clinical instability by A.A. White and M.M. Panjabi (value >5 points), Cobb angle >10°, markers of sagittal imbalance: Index Barrey (II and III), PT increase above target values, L4-S1 and LL deficiency.

Results. Symptoms of compression were identified in 97% of patients. Radiculopathy syndrome was detected in 665 (66%) patients with mean leg pain 7 points, neurogenic intermittent claudication — in 319 (31%) patients. Degenerative spondylolisthesis according to radiological criteria was detected in 428 (42%) patients. Degenerative scoliotic deformity had 91 (9%) patients. In accordance with the proposed criteria, the dominant compression syndrome was determined in 624 patients (62%), clinical instability syndrome — in 338 (33%), deformity syndrome with sagittal imbalance — in 51 (5%).

Conclusion. Syndromic assessment of clinical, neurological and radiological manifestations of degenerative disorders provides the possibility of identifying the dominant syndrome requiring operative surgical treatment and a differentiated approach to choosing the optimal surgical option.

The failure of ACL reconstruction may occur not only due to repeated injury but also technical errors or biological reasons. The individual patterns of knee morphology addressed in the study of M.S. Ryasantsev et al., particularly tibial slope. Statistically significant difference does not necessarily mean that it leads to clinical impact on the patient. Therefore, all findings should be discussed from the point of minimal clinically relevant difference, especially if the study is underpowered.

Background. The number of primary anterior cruciate ligament (ACL) reconstructions increases every year, which causes an increase in revision interventions due to ACL graft failure. When studying the literature, we identify many factors that together influence the outcome of revision ACL reconstruction, but are not always taken into account by surgeons.

Aim of the review — is to perform a systematic review of studies that evaluated the outcomes of revision anterior cruciate ligament reconstructions and to identify optimal solutions to the most common problems encountered in preoperative planning.

Methods. Information search was performed in the eLIBRARY, PubMed, and Scopus databases for the period from 2013 to 2022. Studies describing the main aspects of revision ACL reconstruction were selected for analysis. Inclusion criteria were the following: mean patient follow-up period of no less than 12 months, number of observations of no less than 10 cases. After evaluation of 898 articles, 22 articles were included in the systematic review.

Results. Five main factors that should be taken into account in preoperative planning of revision ACL reconstruction have been identified: choice of the graft, necessity of reconstruction of the anterolateral complex, correction of tibial plateau deformity in the sagittal plane, determination of indications for one- or two-stage intervention, method of bone defect replacement in two-stage surgical treatment.

Conclusion. The patient’s autogenous tissues should be preferred when choosing a graft. Correction of excessive anteroposterior tibial plateau inclination angle is performed only at the second revision intervention if the inclination angle exceeds 12º. Reconstruction of the anterolateral complex should be performed in young, active patients who are involved in pivot sports and in case of severe anterior instability. When determining the possibility of performing revision ACL reconstruction in one or two stages, the canal diameter is not a crucial parameter, as it is necessary to take into account the possibility of fusion of the canals from the previous surgery with the newly created ones. If the canals have correct entry points, one-stage revision reconstruction can be performed with the canal width not exceeding 10 mm and depending on the expected diameter and type of the prepared tendon graft. Bone grafting of the secondary dilated canals in two-stage intervention can be carried out using any material, but allogenous bone or synthetic grafts have certain advantages.

Background. Previous research has shown that neurectomy of the sciatic nerve leads to a reduction in bone density in the femur and tibia of laboratory mice and rats. However, the impact of surgeries aimed at restoring nerve innervation on the bones of distal limb parts has not been studied.

Aim of the study — to identify structural changes in the shaft of the third metatarsal bone after primary autogenous plasty of the resection defect of the tibial portion of the sciatic nerve in rats.

Methods. Autologous neuroplasty of the tibial portion of the sciatic nerve was performed on 16 Wistar rats (aged 8-10 months). The animals were euthanized at 4 and 6 months after the surgery, and a control group of 7 intact rats of similar age was included. Histomorphometric analysis was conducted on a dissected fragment of the forefoot at the level of the metatarsal bones. The ratio of fuchsinophilic and anilinophilic structures of the cortical plate was determined using point-count volumetry on Masson-stained images of transverse sections of the third metatarsal bone shaft. The thickness of the cortical plate, numerical density, area, and diameter of osteons and Haversian canals were measured.

Results. After 4 months, compared to the control group, a 15% decrease (p = 0.0001) in the proportion of mineralized structures of the cortical plate and a 12.7% reduction (p = 0.0184) in its thickness were observed. Osteolysis signs were present in the osteonal layer, along with decreased numerical density and dimensional characteristics of osteons, and the presence of osteons with dilated Haversian canals. At 6 months, the thickness of the cortical plate did not significantly differ from the norm (p = 0.2067), but there was a progressive 33.6% decrease (p = 0.0001) in the proportion of mineralized structures. Reduced values of numerical density, area, and diameter of osteons persisted in the osteonal layer, while the diameters of Haversian canals in osteons increased over time.

Conclusion. From 4 to 6 months, the thickness of the cortical layer in the compact bone of the third metatarsal bone shaft was restored. However, changes in the numerical and dimensional composition of osteons, along with decreased mineralization of the extracellular matrix and erosion of the subperiosteal bone layer, continued to progress. The developed experimental 2D model can be used to assess denervation osteopenia in distal limb parts and further explore rehabilitation interventions that enhance and improve reinnervation.

Background. Minimally invasive surgical interventions are widely used in trauma and orthopedic surgery. Both the surgical technique and the instruments applied are being improved, which contributes to better functional results of patients’ treatment.

Aim of the study — to present a new guide tool for minimally invasive surgical correction of acquired hallux valgus.

Guide description. A guide tool intended to be used in minimally invasive surgical interventions for hallux valgus (HV) correction has been developed. It consists of several interconnecting components: the distal bar, the intramedullary guide, the proximal bar, and the wire guide. These components are fixed to each other. At the same time, the distal bar, the proximal bar, and the wire guide are connected with the possibility of adjusting their mutual positioning. The design of the proposed device enables to guide the first guiding wire and to place the cannulated screw in an optimal position. The presented clinical case illustrates the successful application of the described device. The patient underwent minimally invasive distal corrective osteotomy for hallux valgus of medium severity. According to the preoperative X-rays, the first intermetatarsal angle and the first toe deviation angle were 13.5° and 25°, respectively. Six months after the surgery, they were 3° and 7°, respectively. The result of the corrective surgery was considered excellent.

Conclusion. Application of the proposed guide tool decreases surgery duration, reduces soft tissue damage and minimizes radiation exposure of the surgeon and the patient.

Background. Nowadays the knee arthroplasty register of the Vreden National Medical Research Center of Traumatology and Orthopedics (hereinafter referred to as the Vreden Center) contains clinical and statistical data on more than 39,000 primary and revision knee replacements, that mimics current state of this kind of surgery in Russia.

Aim of the study — to analyze the last decade trends in primary knee arthroplasty in largest Russian arthroplasty center.

Methods. Data were obtained from the register of the Vreden Center for the period from 2011 to 2022. Information on knee arthroplasty included epidemiologic and numerous peri-operative data including type of surgery and implant, degree of constrain, primary patella resurfacing etc.

Results and discussion. From 2011 to 2022, 36,350 (92.3%) primary arthroplasties performed at the Vreden Center.

The number of interventions increased more than twice: from 1,678 in 2011 to 3,924 in 2022. Similar trends observed in Australia and Sweden, where the number of knee arthroplasties increased by 8.2% and 8% in 2021 compared to 2020, respectively. The frequency of primary patellar resurfacing at the Vreden Center was 2.2% over the entire period of observation. On the contrary, the rate of patella replacement increased from 41% in 2005 to 76.1% in 2021 in Australia and from 24.4% in 2015 to 31.9% in 2020 in Switzerland. The partial knee arthroplasty showed enormous growth — more than 14 times: from 0.3% in 2011 to 4.3% in 2022 at the Vreden Center. Worldwide unicompartmental knee replacement is still less popular than total and its number widely varies: 4.2% in the USA, 6.9% in Australia, 9.2% in Canada, 11.9% in Norway, 12.8% in Sweden, and 18.4% in Switzerland. Posterior cruciate ligament (PCL) retaining total knee arthroplasties (TKA) prevailed at the Vreden Center: 68.3%, while in other countries it utilize even more widely: 70.5% in Norway, 75% in New Zealand and 93.5% in Sweden.

The total length of hospital stay (LOS) decreased dramatically from 19.6 in 2011 to 8.6 in 2022 at the Vreden Center. Nevertheless, there are still opportunities to improve it: by the way in Canada the average LOS for TKA is 2.3 and the USA — 0.8 and 1.7 for partial and total arthroplasty, respectively.

Conclusion. The main current trends of knee arthroplasty in Russia are the following: increase the number of surgeries, reduced LOS, TKA without patella resurfacing and with PCL retention, finally the growth of partial knee arthroplasties.

Background. Osteonecrosis of the femoral head is significantly more common in HIV-positive patients than in the general population. The etiology and pathogenesis of this process are not fully understood. In some studies, suggestions have been made about the possible direct pathological action of the virus on bone tissue cells. No studies dedicated to the identification of the virus directly in the foci of osteonecrosis were found in available literature sources.

The aim of the study — to present the first clinical cases of patients with aseptic osteonecrosis of the femoral head in whom HIV RNA was found in the focus of bone necrosis.

Cases presentation. Patients aged 54 and 38 years, suffering from HIV infection, were admitted to the clinic due to aseptic osteonecrosis of the femoral head. For diagnostic purposes, the patients underwent trephine biopsy of the osteonecrosis sites in the femoral head and unaltered bone tissue of the greater trochanter. The biological material was studied using PCR, microbiological, and histological methods. As a result of the PCR study, HIV RNA was detected in the foci of osteonecrosis in the femoral head. In the blood plasma of both patients, viral load was undetectable. In the bone tissue of the greater trochanter in the 54-year-old patient, the viral load was not determined, while in the 38-year-old patient, the viral load in the greater trochanter was significantly lower than in the necrosis focus of the femoral head.

Conclusion. The obtained data may indicate the possibility of direct involvement of the virus in the pathogenesis of arthropathy and cast doubt on the aseptic nature of osteonecrosis in HIV-positive patients.

Background. Iatrogenic neuropathies of the radial nerve following intramedullary nailing of the humerus are observed in 2.9% of patients. In 30% of cases, iatrogenic nerve injury is associated with distal nail locking. Questions about the timing and volume of diagnostic measures to determine the nature of nerve damage, methods of conservative and surgical treatment, and their effectiveness remain relevant.

Aim of the study — to illustrate the causes, prevention methods, diagnosis, and treatment of iatrogenic radial nerve injuries in humeral shaft fractures through a clinical example.

Case presentation. A 30-year-old female patient was admitted with a nonunion fracture of the left humerus and iatrogenic radial nerve injury three months after the fracture was fixed with a locking nail. A revision operation was performed: removal of the nail from the left humerus; re-fixation of the left humerus with a plate; revision, neurolysis, and plastic repair of the left radial nerve using autografts from the right sural nerve. Postoperative courses of medication therapy, physiotherapy, and therapeutic exercises were conducted. At 26 months after the surgery, complete range of motion and restoration of strength in active extension of the left wrist and three phalanges, abduction of the first finger, partial extension of the first finger, and restoration of sensitivity on the outer surface of the left forearm and the back of the hand were observed.

Conclusion. Iatrogenic radial nerve injury primarily occurs as a result of incorrect technique when introducing locking screws during intramedullary nailing of humeral shaft fractures. Delayed examination and surgical treatment of patients with injured radial nerve lead to a lack of full functional recovery, potential muscle atrophy, and impairment of their motor function. Surgical treatment aimed at restoring the radial nerve at an early stage after injury, combined with a full range of postoperative rehabilitation for a year, is the only correct treatment approach.

High incidence of injuries, diseases of musculoskeletal system and connective tissue leads to a high demand for modern high-tech materials in the area of orthopedics and traumatology. Development of russian materials is an extremely relevant issue, especially under conditions of restricted supply of foreign products to the Russian Federation. Creation of new products and their subsequent launch to the market require comprehensive protection of unique information about the design, composition or production/manufacturing technology of the product. Analysis of patenting domestic solutions for trauma and orthopedic surgery in the Russian Federation has shown that there are various risks associated with the commercialization of national products. For example, russian developers in a number of cases neglect patent protection of their developments, which puts successful developments at risk of unauthorized copying or claims from other market players. On the other hand, patenting strategy of domestic developers for their products in most cases contains a number of errors, such as narrow bounds of patent protection due to incorrectly drafted patent claims. For example, these can be in formulations that can be easily bypassed in case of commercial interest in the product, preferential patenting of technological processes, lack of comprehensive patent protection of the product. Such patenting errors make the development unattractive for investors and manufacturers, which leads to low commercializability of russian inventions. Thus, russian developers, who have significant scientific potential and competencies to create highly effective national products, do not proceed with technology transfer and cannot bring their promising and in-demand products to the market.

14 августа 2023 г. на 76-м году жизни после не продолжительной болезни скоропостижно скончался выдающийся ученый, отличный организатор, прекрасный клиницист, эрудированный педагог, общественный деятель, доктор медицинских наук, профессор, академик РАН Сергей Павлович Миронов.