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. Reinfection and recurrence of periprosthetic infection rates during the second stage of revision hip arthroplasty (RHA) remain quite high. Performing preoperative diagnostic aspiration in patients with the installed hip spacer is a controversial issue.

Aims of the study: 1) to compare the diagnostic accuracy, specificity and sensitivity of the used infection markers as a part of preoperative diagnostic protocols in order to exclude reinfection in patients with installed hip spacer before the second stage of RHA; 2) to analyze and compare the microbiological spectrum obtained at the stages of RHA.

Methods. Diagnostic accuracy parameters of the used infection markers were assessed in order to exclude reinfection/recurrence in 107 patients with installed hip spacer. All patients were divided into two groups. In Group 1 (prospective), blood tests as well as diagnostic aspiration of synovial fluid were performed within the extended diagnostic protocol. In Group 2 (retrospective), the examination was performed according to the screening preoperative diagnostic protocol including blood tests. The used reference range of inflammatory biomarkers was based on the “small criteria” of ICM 2018. According to the results of the intraoperative microbiological examination of peri-implant tissue samples at the first and second stages of RHA, the analysis of detected microflora was conducted in order to assess probable reinfection/recurrence.

Results. According to the results of the intraoperative microbiologic examination during the second stage of RHA, reinfection was detected in 40% of cases: in Group 1 — 9 cases, in Group 2 — 31 case. Synovial fluid was obtained from 85% of cases when preoperative diagnostic aspiration was performed. Synovial fluid could not be obtained in 15% cases (dry joint).

Conclusion. Performing preoperative diagnostic aspiration before the second stage of RHA in patients with the installed spacer allowed choosing correct treatment tactics in 9% of cases. The parameters of diagnostic accuracy accounted for 82,6%. In the structure of detected pathogens in case of recurrence and reinfection, the representatives of Gram-positive coagulase-negative flora were the most frequent.

Background. Unstable fractures of the posterior pelvic ring represent a pressing concern in trauma surgery. Minimally invasive osteosynthesis techniques have gained widespread acceptance in contemporary practice. Accurate radiographic visualization is a critical component for the precise and successful placement of iliosacral and transsacral screws. Obtaining and accurately interpreting X-ray images can pose challenges in specific clinical situations, particularly those involving age-related skeletal changes.

The aim of the study is to assess the influence of the patient’s age on the measures of pelvic radiographic inlet and outlet views angles for performing a sacral fracture fixation using cannulated screws.

Methods. A retrospective analysis of CT data was conducted on 106 patients with posterior pelvic ring injuries requiring cannulated screw fixation. Preoperative CT scans were reconstructed into sagittal projections. We performed construction and measurement of the true inlet angle, super-inlet angle, pelvic outlet angle, sacral concavity angle, promontory angle, S1 and S2 outlet view angles. Statistical correlation between sacral tilt angle and the patient’s age was assessed.

Results. A two-step cluster analysis divided the patient cohort into two groups with significant differences in pelvic outlet angles and age (N1 = 64, N2 = 42). Statistically significant differences were found between the two clusters in all the studied parameters: median values of true pelvic inlet angles were 27.2° [23.2-32.2] and 18.2° [11.4-26.6] respectively (p<0.001); super-inlet angles were 42.5° [39.3-47.8] and 36.2° [28.7-42.8] respectively (p<0.001); promontory angles were 128.1° [123.3-133.2] and 122.1° [115.6-129.3] respectively (p = 0.003); pelvic outlet angles were 62.6° [58.4-69.6] and 50.3° [45.9-53.5] respectively (p<0.001); S1 outlet angles were 51.8° [48.9-56.5] and 46.8° [43.1-50.2] respectively (p<0.001); S2 outlet angles were 40.8° [37.3-44.6] and 35.7° [30.9-38.6] respectively (p<0.001); the mean of the sacral concavity angles was 174.8°±10.5 and 152.1°±38.2 respectively (p<0.001); and the main age was 41.6±18.7 and 69.2±16.1 years respectively (p<0.001). A statistically significant inverse correlation between age and pelvic tilt angle (ρ = 0.534; p<0.001) was found. A novel diagnostic method for identifying sacral dysmorphism using angle measurement within the S1 bone corridor is presented. The sacrum was considered dysmorphic if the angle was equal to or less than 5°.

Conclusions. As the patient’s age increases by one year, pelvic outlet angle decreases by 26°. If pelvic inlet angles are equal to or less than 14.45°, the difficulties in visualizing S1 and S2 outlet views during surgery are to be expected. The median of angles difference before and after anterior sacral tilt correction using a coccyx pad was 9.4° with interquartile range from 7.8° to 11°. Significant anatomical variations in posterior pelvic ring structure were observed among the study cohort. Preoperative CT sagittal reconstructions allow appropriate planning of intraoperative visualization considering expected intraoperative radiographic inlet and outlet views.

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. Single Assessment Numeric Evaluation (SANE) Score is a single-answer scale widely used within the global medical community. However, to date, it has not been adapted and validated into Russian, particularly as a tool to assess orthopedic shoulder conditions.

The aim of the study is to conduct a cross-cultural adaptation and validation of the Russian version of the SANE score as an assessment tool of orthopedic shoulder conditions.

Methods. The study included a total of 160 patients with various shoulder pathologies, of which 101 (63%) males and 59 (37%) females. The median age was 45 (37-52) years. At the first stage of the study, we performed cross-cultural adaptation of the SANE score into Russian. The second stage was the validation of the obtained score. Its reliability, validity and responsiveness were evaluated. Reliability was assessed by “test-retest” method. It allowed to measure an intra-class correlation coefficient (ICC) between the SANE score results obtained at the time of the first appointment and again in 14 days. The validity assessment was based on the comparison of the SANE and ASES (have already been adapted into Russian) score results. Responsiveness was assessed using statistical analysis for two dependent samples and calculation of the Guyatt’s Responsivity Index (GRI). Floor and ceiling effects were evaluated as the percentage of patients who reported either minimum or maximum scores.

Results. The psychometric properties assessment has revealed good indicators of reliability (ICC = 0.77), validity (a strong direct correlation between SANE and ASES scores = 0.707; a moderate strength inverse correlation with ASES “Intensity of pain” subsection = 0.542) and responsiveness (GRI = 1.861). Floor and ceiling effects accounted for <1% and 3%, respectively, (all below 15%).

Conclusions. Adapted to assess the shoulder conditions, the Russian version of the SANE score has good psychometric properties. Its advantage is the combination of completion speed and ease of use with a high-quality integrated subjective assessment of the patients’ set of complaints.

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 2003. 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.