Vol 30, No 2 (2024)

Background. The most common method of treatment of chronic periprosthetic joint infection (PJI) is considered to be a two-stage revision arthroplasty. The efficacy of this technique is largely determined by the results of infection management after the first (debridement) stage, which may depend on many factors. At the same time, the widespread tendency to reduce the duration of patients’ hospital stay brings to the forefront the problem of long wait for the results of preoperative microbiological examination.

Aims of the study: 1) to retrospectively evaluate the efficacy of the debridement stage of chronic periprosthetic hip joint infection in 2021 depending on the availability of preoperative microbiological examination results; 2) to determine the factors influencing the treatment outcome.

Methods. Patients (n = 86) with chronic PJI of the hip were allocated into two groups depending on the presence or absence of results of the microbiological examination of preoperative biomaterials (aspirate and/or tissue biopsy) at the time of performing the first stage of the two-stage revision arthroplasty.

Results. The availability of final results of the microbiological examination (MBE) of joint aspirate at the time of surgery had no significant effect on the efficacy of infection management (p = 0.536; OR = 1.53, 95% CI 0.43-5.45). There was a significant reduction of the risk when the results of preoperative and intraoperative MBE coincided (p = 0.024; OR = 0.121, 95% CI 0.015-0.990). An increased risk of adverse outcome of the debridement stage of treatment was observed in the case of types 2C (p = 0.042; OR = 6.66; 95% CI 1.26-35.2) and 3B (p = 0.078; OR = 8.1, 95% CI 1.015-64.8) acetabular defects, type 3A femoral defects (p = 0.021; OR = 6.57, 95% CI 1.49-29.01), and connective tissue diseases (p = 0.062; OR = 5.25, 95% CI 1.05-26.2). The presence of microbial associations (p=0.02; OR = 6.75, 95% CI 1.36-33.44) and the presence of Gram-negative bacteria in them (p = 0.058; OR = 4.2, 95% CI 1.02-17.20) significantly worsened the treatment prognosis. As the number of patient’s risk factors increased, the probability of an unfavorable outcome increased significantly (p<0.001).

Conclusion. Polymicrobial infection, presence of Gram-negative bacteria in microbial associations, connective tissue diseases, types 2C and 3B acetabular defects, type 3A femoral bone defects, and total number of risk factors in one patient had a significant negative impact on the outcome of debridement surgery. Apparently, the results of the microbiological examination of preoperatively sampled biomaterials are much more important as a diagnostic criterion for suspected periprosthetic infection than as a criterion for the drug choice for etiotropic antibacterial therapy. However, this assumption should be studied on a larger sample of patients.

Background. The outcome of complex treatment of implant-associated infection (IAI) depends on various factors, but one of the most important is the etiology of the inflammatory process. Treatment of orthopedic infection caused by Gram-negative microorganisms in general and representatives of the family Enterobacteriaceae in particular causes many difficulties, one of which is the rapid growth of antibiotic resistance.

Aim of the study — to evaluate the factors affecting the course and prognosis of implant-associated infection caused by Klebsiella spp.

Methods. We performed a retrospective analysis of case histories of 85 patients who underwent treatment of IAI caused by Klebsiella spp. in the clinical departments of the center from January 1, 2017 to December 31, 2021. According to the results of the telephone survey, the patients were divided into 2 main groups depending on the outcome of the 2-year follow-up period determined in accordance with the Delphi criteria.

Results. It was found that the prognosis was significantly worsened by the number of sanitizing surgical interventions in the anamnesis (p = 0.022), the need for sanitizing intervention in the early postoperative period (p<0.001) and the presence of Klebsiella spp. growth in postoperative culture tests (p = 0.002), hypoalbuminemia on 7-14 days after the surgery (p = 0.008). The administration of trimethoprim-sulfamethoxazole for the outpatient treament stage significantly improved the outcome (p = 0.038), which is most likely due to a high proportion of polymicrobial associations — 69.5%.

Conclusions. There is a statistically significant direct relationship between the probability of an unfavorable treatment outcome of patients with IAI caused by Klebsiella spp. and the number of sanitizing surgical interventions in the anamnesis, low serum albumin (g/l) on 7-14 days after the operation, revision intervention in the early postoperative period, positive growth of Klebsiella spp. in postoperative culture tests. The probability of a favorable outcome was increased by the prescription of trimethoprim-sulfamethoxazole for oral administration at the outpatient stage.

Background. The results of revision anterior cruciate ligament reconstruction (ACLR) are usually worse than the primary ACLR. The positive outcome of the revision ACLR is significantly influenced by the following factors: anatomical position of bone tunnels, correct choice of graft, its preparation and fixation method. Equally important is to choose the accurate indications for additional extraarticular interventions.

The aim of the study is to evaluate the role of a peroneus longus tendon (PLT) autograft in one-stage revision ACL reconstruction and to compare the obtained data with the results of primary ACLR.

Methods. The comparison was carried out between the RACL-PLT group (n = 29) and the PACL-HT group (n = 82), which underwent single-stage revision ACLR with a PLT autograft and primary ACLR with a hamstring tendons (HT) autograft, respectively. Subjective and objective evaluation was performed on the KOOS, IKDC, and Lysholm Knee scales. Also, in the RACL-PLT group, the position of the central entry points into the primary and revision tunnels was determined.

Results. We observed no statistically significant differences during the objective assessment of knee joint stability between the groups (p>0.999). During the subjective assessment on the KOOS, IKDC and Lysholm Knee scales, significantly higher results were obtained in the PACL-HT group (p<0.001). The position of the central entry points into the revision tunnels corresponded to the normative values in all cases.

Conclusions. The analysis of the use of a PLT autograft in revision ACLR, as well as the achievement of the anatomical position of the revision tunnels showed: 12 months after surgery, the results of an objective assessment between the revision and primary ACLR are comparable; the results of a subjective assessment are statistically significantly different. However, the differences in indicators do not reach a minimal clinically important difference.

Background. Massive rotator cuff tears are up to 40% and can progress to the stage of irreparable ones. Nowadays, there are many treatment options available for irreparable rotator cuff injuries, from conservative treatment and arthroscopic reconstructions to reverse shoulder arthroplasty. Currently, the comparative effectiveness of various treatment methods remains uncertain, and therefore there is no clear algorithm for choosing treatment tactics of such orthopedic shoulder pathologies.

The aim of the study is to compare short-term treatment outcomes of patients with irreparable rotator cuff tears using arthroscopic partial rotator cuff repair, latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty.

Methods. The study enrolled 75 patients who underwent the following types of surgical interventions: partial arthroscopic repair, posterior and anterior arthroscopically assisted latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Treatment results were assessed using measurements of the range of active movements in the shoulder joint, the ASES and Constant-Murley Score (CMS) questionnaires, the Visual Analog Scale (VAS), assessment of radiographs and MRI. The assessments were performed preoperatively and at 6 and 12 months after surgery.

Results. In all groups, there was a statistically significant improvement by all indicators (p<0.05). Clinical and functional results at the short-term follow-up after partial rotator cuff repair and various options of latissimus dorsi tendon transfer are largely comparable, while at the same time superior to the results of reverse shoulder arthroplasty and pectoralis major tendon transfer.

Conclusions. The use of partial rotator cuff repair and musculotendinous transfers at the short-term follow-up gives comparable and better results in comparison with the use of reverse shoulder arthroplasty, which allows to consider “joint-preserving” interventions as an option in patients with massive irreparable rotator cuff tears.

Background. Open reconstructive plastic surgeries are the most radical method of treating patients with elbow contractures caused by ossification. However, these surgeries pose a serious problem due to the large number of unsatisfactory results.

The aim of the study is a comparative assessment of the effectiveness between standard techniques and 3D visualization technologies in the surgical treatment of patients with elbow contractures caused by ossification.

Methods. Using random number generation, all patients (n = 71) were randomized into two groups. The first group included 34 patients with elbow contractures caused by ossification that underwent surgical intervention using 3D technologies to assess the ossification process. The second group enrolled 37 patients with a similar nosology that underwent standard examination and surgical treatment. The results were evaluated intraoperatively and 180 days after the surgery. The data were obtained from primary medical records and further survey.

Results. The application of new planning technology and tactics for onstructive plastic surgeries made it possible to reduce the surgery time by 1.2 times (p<0.05), reduce blood loss by 1.3 times (p<0.05) and increase the relative number of patients with sufficient movement volume by 10.6% (p<0.05). The assessment of various performance parameters (range of motion, pain syndrome, quality of life etc.) showed that after 6 months in the main group, the relative number of patients with problems related to the operated joint was significantly lower than in the control group: 20.5% vs 84.7% (p<0.05).

Conclusions. The data obtained indicate that the use of the new technique for planning and performing reconstructive plastic surgery in patients with elbow contractures caused by ossification contributes to a less invasive intervention and achievement of better intraoperative and medium-term treatment results.

Background. New implantation methods are of great importance due to the development of endoprostheses in traumatology and orthopedics, restorative medicine and dentistry. Equally important is the early detection and description of the implant-associated complications.

The aim of the study is to find and describe thrombi and emboli in the heart and lungs formed after experimental implantation of metallic devices in the peripheral part of limb using extracellular vesicles of mesenchymal stromal cells.

Methods. Outbred rabbits of both genders at the age from 4 to 6 months and of weight from 3 to 4 kg underwent experimental implantation. The study enrolled 57 species in total. They were divided into two groups: 30 animals underwent implantation of metallic devices using extracellular vesicles of mesenchymal stromal cells (EV MSCs), 27 — without their use. The rabbits’ hearts and lungs were studied by light microscopy methods at different stages after integration of screw titanium implants into the proximal condyle of the tibia using EV MSCs.

Results. After implantation of metallic devices into the proximal condyle of the tibia, we detected fibrin, detritus and even the red bone marrow structures (various blast forms of hematopoietic cells: megakaryocytes, cells of the erythroid and myeloid lineages) in the right cavities of the heart. In the pulmonary arteries, we also found thrombi and emboli, which either led to the obliteration of the involved vessel or to gradual lysis, not disappearing completely within 10 days of follow-up.

Conclusions. After intraosseous implantation of the metallic devices, there is an embolism risk in the right atria and ventricle of the heart and the pulmonary arteries and veins due to the debris migration with the bloodstream from the surgery site. At the same time, one cannot exclude a thrombotic risk in the heart and pulmonary arteries as a reaction to the presence of detritus. It is advisable to take measures aimed at preventing both debris releasing into the bloodstream and pulmonary embolism during any implantations into the bone tissues, even of relatively small devices. Using EV MSCs to affect the implant engraftment processes has no significant effect on the severity and frequency of thromboembolic complications.

Background. Central third of the patellar tendon is a well know graft for anterior cruciate ligament (ACL) reconstruction. However, it’s usage can be difficult in case of long patella tendon, which causes graft length discrepancy.

The aim of this article is to evaluate the results of arthroscopic anterior cruciate ligament reconstruction with a help of original method of bone patella tendon bone graft preparation.

Methods. 26 males operated for ACL tear have been included in the study. On the preoperative MRI scans the approximate length of ACL, tibial tunnel, patella tendon length and tibial bone plug length have been measured. The technique of tibial bone plug cut was optimized based on preoperative MRI assessment.

Results. In all cases, MRI-based assessments were consistent with intraoperative measurements, hence there was possible to avoid graft length discrepancy. In a period of 12 weeks the average score on the step-and-holds test was 23.8±1.1, the single-leg squat test was 6.7±0.9 and the Y-balance test was 83.2±1.4. The average IKDS score was 64.9±5.7.

Conclusion. The proposed method is appropriate for anterior cruciate ligament reconstruction in patients with long patella tendon.

Introduction. Deep infection after open osteosynthesis of tibial plateau fractures occurs in 9.9%. This rate is significantly higher than in surgical treatment of closed injuries of other localizations. Many authors consider it necessary to improve management protocols for patients with complex plateau fractures in order to minimize or prevent the development of infectious complications.

Aims of the study: 1) to discuss the treatment tactics of a patient with an intraarticular fracture of the tibial plateau after osteosynthesis complicated by the development of early deep surgical site infection (SSI), using clinical case as an example; 2) to carry out the analysis of medical care defects.

Case description. A 71-year-old patient with compromised somatic status underwent osteosynthesis with a buttress plate and allogeneic bone grafting of the metaphyseal defect on the 12^th day after injury. In 7 days after the occurrence of signs of infection, a revision surgery was performed. Later, a number of consecutive revisions were performed due to recurrences of the infectious process. The complex of measures against SSI included the use of vacuum drainage systems and antibacterial spacers. As a result, the wounds had healed. Two years after the injury, the patient had a good functional result.

Conclusion. The presented clinical case has shown that even if the treatment tactic for early peri-implant infection is chosen correctly, there are several defects in our routine practice. First of all, inaccurate sampling of material for bacteriological study and inadequate duration of antibacterial therapy are to be mentioned. To successfully treat infectious complications of osteosynthesis, a team of like-minded specialists including traumatologists as well as physicians, microbiologists and clinical pharmacologists is needed. Undoubtedly, surgical treatment of fractures might develop into infectious complications. Their diagnosis and treatment are often accompanied by a number of various mistakes. The most important points are early radical revision of the postoperative wound, etiotropic antibacterial therapy, maintaining stability of fixation after primary osteosynthesis. If these standards are complied with, the outcome of surgical treatment might be satisfying even with such a severe complication as peri-implant infection. At the same time, we are planning further researches aimed at improving algorithms and tactics for surgical treatment of infectious complications, reducing surgery trauma level and upgrading quality of primary osteosynthesis.

Background. In recent years, the topic of artificial intelligence (AI) in medicine has been actively discussed not just as a promising solution but the one that can help to improve some results. A significant growth of interest in AI systems all over the world began in the early-mid 2010s, which allowed us to consider the practical application of such systems.

The aim of the study is to analyze all the software products (SP) registered in our country as a medical device, including those with AI technology, and to evaluate their applicability in traumatology and orthopedics.

Methods. The study included all the SP having a registration certificate of a medical device according to the OKPD2 code 58.29.XX.XXX (services for publishing other software). In the state register of medical devices and organizations (individual entrepreneurs), which is engaged in the production and manufacturing of medical devices, we found 111 registered SP according to the inclusion criterion, as at February 14, 2024.

Results. We proposed to categorize all registered SP as follows: systems working with the DICOM standard images (47 pcs, 42%), laboratory data (20 pcs, 18%), microscopy images (7 pcs, 6%), photographic images (5 pcs, 5%), medical information systems (4 pcs, 4%), text data mining systems (3 pcs, 3%), clinical decision support systems (3 pcs, 3%), Holter ECG analysis (2 pcs, 2%), other systems (16 pcs, 14%). Systems applicable to traumatology and orthopedics accounted for 4 pcs (4%).

Conclusions. Unfortunately, the real-world applicability of existing solutions in the field of traumatology and orthopedics can be regarded as minimal in comparison with pulmonology, oncology, and laboratory diagnostics, where AI programs have already achieved significant success.

Background. One of the little-studied but long-known problems is determining the optimal treatment regimen for patients with infectious arthritis of the hip joint. Existing studies offer various methods of conservative and surgical treatment, which, however, do not have a fundamental evidence base. The polyetiology and variability of the clinical manifestations of infectious arthritis of the hip joint and the severity of the consequences in case of incorrectly chosen tactics require a differentiated approach to treatment and development of certain diagnostic and treatment algorithms.

The aim of the review – to identify pathogenesis factors that are significant for the choice of treatment tactics and to analyze modern methods of treating infectious arthritis of the hip joint based on the data from available medical literature.

Methods. For analysis, we selected 90 foreign and domestic sources published between 1997 and 2023. Inclusion criteria were: clinical studies, analytical reviews and meta-analyses of the literature. The search was performed in eLIBRARY, PubMed and Google Scholar databases.

Results. The analysis showed that, despite the comparable effectiveness and advantages of individual treatment methods, their use is limited to certain indications, and the choice of the optimal one for a particular patient should take into account many etiopathogenetic factors, clinical, laboratory and instrumental data, the role of which is still insufficiently studied. Currently, throughout the world the “gold standard” for radical surgical treatment remains the technique of two-stage hip arthroplasty using an antibacterial spacer. However, encouraging results of alternative treatment methods require continued search for ways to optimize diagnostic and therapeutic tactics.

Kristaps Juris Keggi was born on August 9, 1934 in Riga in the family of surgeon Janis Keggi. In 1944, the family moved to Germany and then to the United States, where Kristaps received his medical education at Yale University. In 1966, he became an associate professor at the University’s Orthopaedic school and focused on hip and knee arthroplasty. In the 70s of the twentieth century, Kristaps Keggi developed direct anterior approach to the hip joint and started to do arthroplasty using a minimally invasive technique. Over the years, he performed more than 10,000 total hip replacements with his technology at hospitals in New Haven and Waterbury, Connecticut, and authored 135 scientific papers and monographs. In 1989, Kristaps became a Clinical professor of Orthopaedics and Rehabilitation at Yale Medical School and in 2008 was elected a Full professor. During this time, he trained hundreds of residents and became the founder of his own orthopedic school. Keggi was known for a variety of innovative technologies that were widely used all over the world. In 1988, Keggi organized a non-profit Orthopedic Foundation to provide educational programs for official academic exchanges between the United States and the republics of the USSR. For 10 years, more than 300 doctors from Russia, Belarus, Ukraine, the Baltic States, Central Asia, Vietnam and East Germany have received scholarships and the opportunity to learn the basics of the hip and knee arthroplasties In parallel, he traveled to the clinics with lectures, seminars and demonstration surgeries. For outstanding services to national healthcare, in 1993 he was elected a Foreign Member of the Russian Academy of Medical Sciences and, subsequently, the Russian Academy of Sciences. In 2012, Professor Keggi was awarded the silver medal “For Medical Dignity and Service to Russian Medicine”.

A brilliant surgeon, inventor, scientist and teacher, successful athlete, philanthropist, Kristaps Juris Keggi died on July 4, 2023, leaving in our hearts a feeling of deep respect and vivid impressions from communicating with him.

The article presents a preliminary version accepted at the V Congress Orthobiologics 2024 «Consensus in clinical practice» (19-20 Apr 2024). The final version will be published as soon as the reviewers’ and expert group’s comments are implemented. The consensus paper on the use of hyaluronic acid-based injectants has been created. The paper is aimed to optimize their use regulations in various musculoskeletal disorders. The mechanisms of action, biological effects, clinical efficiency and safety of use of hyaluronic acid in various pathological conditions are described. Legal fundamentals, scientific and clinical perspectives of using hyaluronic acid therapy in clinical practice are presented.