Rationale for the use of the original classification of posttraumatic acetabular deformities in primary total hip replacement

Introduction Analysis of publications on primary hip replacement shows lower survival rates in patients with acetabular injuries. With the lack of a unified system for assessing post-traumatic acetabular deformities, authors tend to use the available classifications of acute pelvic trauma (AO/ ASIF, Young & Burgess, Tile, etc.) and acetabular osteolysis (AAOS, DGOT, Gross and Saleh, Paprosky), which we think can be inappropriate with the classifying systems meant for different patterns of acetabular deficiency. Material and methods CT scans of 117 patients with posttraumatic acetabular deformities were reviewed prior to total hip replacement (THR) performed for posttraumatic grade III coxarthrosis. The displacement of acetabular walls was determined with the measurements tabulated and analyzed. Results An original "ASPID" classification of post-traumatic deformities based on the findings obtained was offered with use of three assessment criteria: localization of the deformity, extent of displacement and the integrity of the pelvic ring. The ASPID classification can be used for the localization of the deformity with anterior (A), superior (S), posterior (P) and inner acetabular walls (I) to be identified. Measurements of displacement ranging 0-5 mm suggests grade 0 displacement; 6-15 mm, grade 1 displacement and greater than 15 mm, grade 2 displacement. The integrity of the pelvic ring evaluated from the involvement side as D0 suggests maintained pelvic integrity and D1, broken pelvic integrity. An acetabular hardware would be marked with 'H'. Conclusion ASPID classification is easy to use and has shown to be practical for planning of primary THR after acetabular fracture.

Pathogenetic features of chronic osteomyelitis treatment

Over the past decades, there has been a steady increase in the incidence of osteomyelitis. It is associated with an increased use of implants in traumatology and orthopedics. The social aspects of osteomyelitis are, on the one hand, significant financial costs for the healthcare system, and on the other hand, high recurrence and re-infection in the treatment of joint pathology associated with long-term loss of work ability and a high risk of patient’s disability. Purpose To conduct a search and analysis of publications in Russian and English, devoted to the problem of osteomyelitis and periprosthetic infection, on the basis of which to summarize the main current notions about the etiology, pathogenesis, diagnosis and treatment of osteomyelitis. Materials and methods The search was carried out in the Pubmed and CyberLeninka databases of literature sources over the past 10 years. The data were analyzed and compared with the materials from earlier publications. Only publications from peer-reviewed journals were considered for analysis. Results and discussion Success in the treatment of peri-implant infection with prosthesis re-implantation and satisfactory joint function has been achieved in only just more than a half of patients. Recent studies have significantly changed the understanding of the etiology and pathogenesis of osteomyelitis. It has been proven that in osteomyelitis and implant-associated infection, four reservoirs of infection are formed in the patient's body: abscesses in soft tissues and bone marrow canal, biofilms on the surface of implants and necrotic tissues, intracellular colonization with bacteria of the macroorganism and lacunar-canalicular system. Understanding the mechanisms of osteomyelitis development and its course forces the specialists to take a fresh look at the causes of failures in the fight against such a severe pathology and change approaches to its prevention, diagnosis and treatment.

Treatment of pertrochanteric fractures in elderly patients: is dynamic fixation so important?

Introduction The problem of complications after surgical treatment of pertrochanteric fractures in elderly patients is relevant and far from a solution. Materials and methods The retrospective study was based on the analysis of the results of treatment of 129 patients with pertrochanteric femoral fractures (average age 76 years). All fractures in the early time from trauma were fixed with two types of cephalomedullary nails, either dynamic or static. All patients could not limit the load on the operated limb after surgery because of different reasons. Results The results of treatment were evaluated in 109 patients after one year. In dynamic cephalomedullary fixator group (59 patients), there were 7 orthopedic complications with a functional Harris scale result of 68 points (range, 26 to 94 points). In static cephalomedullary fixator group (50 patients), there were 14 orthopedic complications with a functional Harris score of 56.5 points (range, 15 to 92 points). Discussion Higher results of treatment in the group of dynamic fixator in the condition of full-weight bearing on the operated limb may be associated with the possibility of dynamization of the part of fixator in response to bone resorption in the contact area of bone fragments. The use of dynamic cephalomedullary fixators instead of static ones for treatment of pertrochanteric femoral fractures in elderly patients exercising full weight-bearing leads to a decrease in orthopedic complications (from 28 to 11.9 %) and improves the functional results of treatment.

Possibilities of latent PJI detection in revision knee arthroplasty

Introduction The paper presents a comparative analysis of routine screening methods and the EBJIS 2021 algorithm in detection of latent periprosthetic joint infection in patients admitted for revision knee arthroplasty due to aseptic loosening and after spacer implantation. Materials and methods Group 1 included 49 patients who underwent revision knee arthroplasty due to aseptic loosening, group 2 were 47 patients with PJI after spacer implantation. Results and discussion There were no significant differences between patient groups in terms of age, gender, and preoperative ESR and CRP levels. In 62.2 % of all cases, the aspirate was inappropriate for cytological examination; this fact limited its diagnostic value. The most frequently intraoperatively isolated pathogen in both groups was coagulase-negative staphylococci. However, in 70 % of cases these results were not diagnostically significant, and infection was diagnosed only in 8.2 % of cases in group 1 and 12.8 % in group 2. Moreover, the chances of isolating the pathogen from tissue biopsies were 5.6 times higher than from intraoperative aspirate (OR = 5.6, 95 % CI = 1.2-26.4). In case of negative preoperative aspirate, in almost 25 % of cases, pathogens were isolated from intraoperative tissues, 40.9 % of them were diagnostically significant. The chances of its detection increased 4.7 times in combined increase in ESR and CRP blood level (OR = 4.686, 95 % CI = 0.765-28.700). Using EBJIS 2021 criteria, infection was confirmed in more than 10 % of cases in each group, and the diagnostic significance of the criteria exceeded the significance of using routine screening methods. At a follow-up period of more than 2 years, the effectiveness of treatment was 95.3 %, while signs of infection were detected in 4.7 % of cases, regardless of the group. Conclusion EBJIS 2021 criteria are characterized by high diagnostic sensitivity and specificity and enable to identify periprosthetic joint infection in knee revision cases even in its latent form and to correct treatment tactics in patients without a history of PJI.

Two-stage treatment of hip periprosthetic joint infection complicated with retroperitoneal urinary bladder defect

emphasize the importance of preoperative preparation and well-coordinated work of related specialists using a specific clinical instance. Case report Reported is a successful experience of two-stage treatment of the patient with hip PJI complicated with urinary bladder defect. A 40-year old male patient diagnosed with left-sided deep hip PJI Tsukayama type 3 was treated at department of infection surgery, Rostov Regional Clinical Hospital No. 2 in January 2019. Total hip arthroplasty performed in 2008 was complicated by migration of acetabulum component. A retroperitoneal bladder defect (pressure ulcer) was detected during the first stage of resection arthroplasty and placement of an antibacterial spacer. Urological procedure was performed in a delayed manner due to technical difficulties of implant removal, prolonged and traumatic procedure, and high blood loss. With the patient's condition stabilized cystoscopy and bilateral ultrasound guided percutaneous nephroureterostomy were performed. Prolonged antibacterial aetiotropic treatment was administered. The second stage of surgical treatment included revision hip arthroplasty using a tailored acetabular component and a standard revision femoral component performed at 6 months of debridement. Results Short- and long-term results were good with sustained remission achieved. Patient could walk unassisted using a cane and had a satisfactory ROM in the left hip with HHS scored 76.255. Conclusion Multiple disciplinary teamwork is appropriate for treatment of deep PJI with much coherence, coordinated efforts and expertise from diverse professionals.

The choice of a spacer at the first stage of treatment for late deep periprosthetic hip joint infection

Introduction Periprosthetic infection in hip arthroplasty is a social and economic problem. Its main reason is multidrug resistance of microorganisms. Purpose To evaluate the effectiveness of the first stage in two-stage revision arthroplasty for the treatment of deep periprosthetic infection of the hip joint by improving the constructive and antibacterial features of spacers. Materials and methods The treatment results of 127 patients with late deep periprosthetic hip joint infection who underwent two-stage revision arthroplasty in the period from 2015 to 2019 were analyzed. In the first group, 42 patients were fitted with a two-component (total) spacer based on the developed antimicrobial composition of bone cement with gentamicin, antiseptics and polymer (patent RU 191236). In the second group, a two-component spacer (patent RU 174697) based on conventional bone cement with gentamicin was implanted in 43 patients; the third group of 42 patients had a preformed spacer. Results A bactericidal and antiadhesive, nontoxic composition based on bone cement with gentamicin with antiseptics poviargol, dioxidine and high molecular weight polyvinylpyrrolidone with a prolonged action for 348 days against gentamicin-resistant staphylococci has been developed. All patients underwent the first stage of hip arthroplasty with removal of the implant and installation of a spacer. Recurrence of periprosthetic infection was observed in 1 (2.3 %) patient of the first group, in 5 (11.6 %) in the second and in 6 (14.2 %) patients of the third group. Non-infectious complications such as spacer dislocation and instability were observed in 12 cases, one case (2.3 %) in the first, 2 (4.6 %) in the second and 9 (21.4 %) in the third group. The average time from the first stage of treatment to the second stage of re-implantation was 7.5 months (range, 4–13 months). Discussion According to the literature, the introduction of new antibiotics into the bone cement with gentamicin does not increase the antimicrobial action of the spacer, especially against antibiotic-resistant isolates, and the use of a preformed spacer contributes to an increase in the number of non-infectious complications. Antiseptics with different mechanisms of action are able to act on antibiotic-resistant bacteria, and the polymer can prolong this effect. Conclusions Creation of two-component spacers based on bone cement with gentamicin using antiseptics with different mechanisms of action and polymer promotes long-term bactericidal action of the spacer, which leads to effective sanation of the joint area, reducing non-infectious complications.

Perioperative prognosis of infectious complications after total hip and knee arthroplasties. Part I

Introduction The number of total joint arthroplasties performed globally has increased over time, and the projected growth for total knee arthroplasty (TKA) and total hip arthroplasty (THA) in 2030-2050 is associated with an increase in the number of surgical complications, such as periprosthetic joint infection (PJI). Perioperative modifiable risk factors can be altered to help improve rates of the devastating scenario. The purpose of the review was to systematize information on modifiable risk factors for PJI after THA and TKA and the ways to improve them. Material and methods Scientific literature search was performed via web-based services of PubMed, eLibrary, Scopus, Dimensions. The search depth was 30 years. Results Modifiable risk factors were shown to be associated with the patient's condition, medical history, current status, intraoperative and postoperative surgical options. Well-established modifiable risk factors include tobacco use, alcohol consumption, excess body weight, obesity, malnutrition, duration of surgery, postoperative wound hematoma. Discussion Timely diagnosed modifiable risk factors for PJI can be improved at the preparation stage, perioperatively and postoperatively. The interaction of inpatient and outpatient hospital services in the perioperative period is essential for reducing the risk of PJI after THA and TKA.

Current approaches to treatment of patients with closed fractures of the patella

Introduction Treatment of patients with acute fractures of the patella is the task of the trauma and orthopedic service and should provide restoration of the integrity of the bone tissue and the extensor apparatus of the knee joint for its early mobilization. There is an opinion that conservative treatment cannot meet requirements of patients’ quality of life, and therefore, most traumatologists are inclined to surgically treat patellar fractures. Purpose Based on the available literature data, to determine the most rational way to treat patients with patellar fractures Materials and methods Available studies published in the last 10 years were analyzed. The databases NCBI Pubmed, Healio Orthopedics, Medline were searched. Results Such osteosynthesis methods as patella suture, osteosynthesis with plates, special internal devices, external fixation devices, Kirschner wires and wire cerclage, various screws were covered. The question of clinical application of patellectomy was touched upon; the contribution of the Department of Traumatology, Orthopedics and Urgent Surgery of the Krasnov Samara State Medical University to the development of operative techniques of osteosynthesis of the patella, the basic concepts of scientific research, and also the most optimal ways of treating patients with patellar fractures were described. Conclusion The conservative method of treating patients with patellar fractures is most relevant if there are contraindications to surgery. It inevitably leads to persistent arthrogenic contracture. The best functional results of treatment have been achieved with surgical treatment due to the possibility of early mobilization of the knee joint. According to the data of available studies, plates and screws as well as osteosynthesis with Kirschner wires and wiring cerclage show maximum stability. There is evidence of a direct correlation between the risk of developing infectious complications and pain in the postoperative period and the number of elements of subcutaneous metal implants. Thus, the most optimal way to treat closed fractures of the patella is osteosynthesis with the use of wires and wire cerclage according to the tension band principle.

Risk factors for lethal outcomes after surgical treatment of patients with chronic periprosthetic hip joint infection

Introduction Periprosthetic joint infections (PJI) are serious complications of total hip arthroplasty (THA) and affect the patient's life expectancy. The aim of the study was to identify independent factors influencing the risk of death in patients with PJI after revision THA. Materials and methods The study included 51 lethal outcomes in patients with chronic PJI of the hip. Results and discussion In our cohort of 434 patients, 13 (2.99 %) patients died within the first year after surgery (p > 0.05), which is 2.2 times less than similar published data. The result of gender analysis showed no statistically significant differences in the risk of death between men and women (OR1.05 CI 0.59–1.89, p = 0.87). It was found that in patients over 70 years old, the risk of death was significantly higher (OR 2.05 CI 1.09–3.87, p = 0.031). Additional independent risk factors of death are diseases of the cardiovascular system. It was not possible to find a statistically significant effect of the nature of infection on the risk of death: no growth (OR 2.23, CI 0.52–9.61), monomicrobial infection (OR 1.98, CI 0.45–8, 73), polymicrobial infection (OR 3.2, CI 0.71–14.45, p > 0.05). Conclusion The mortality rate during the first year after revision THA in patients with PJI was 2.99 %, which is lower than the results of other researchers. In the next 2–3 years, the rate of death increases 3.9 times. The main independent risk factors are the age of patients and concomitant diseases of the cardiovascular system.

Hematological parameters of rheumatoid arthritis patients undergoing total hip replacement

(THR). Inflammation in RA is the main factor manifesting anaemia, neutropenia, thrombocytosis and eosinophilia. The changes in blood components are important for the outcomes of major orthopaedic surgery. The purpose was to identify hematological parameters in RA patients undergoing THR and assess the effect on intraoperative blood loss. Material and methods Outcomes of 44 THR patients treated for grade III degenerative coxarthrosis (n = 21, OA group) and RA coxarthrosis (n = 23, RA group) in Ekaterinburg regional hospital № 1 between 2018 and 2019 were reviewed. The patients' age ranged from 41 to 70 years. Clinical, radiological, laboratory examinations, computed tomography and statistical analysis were used for the study. Cell counting was produced with the Sysmex XT-4000i automated hematology system. Statistical analysis was performed using the tools of Statistica software. Nonparametric Mann-Whitney test was used to compare cell counts between the groups. The Spearman Rank correlation was used to analyse the correlation between the the cell counts in the groups. For calculations, a significance level of р < 0.05 was adopted. Results There were no significant differences in the preoperative white blood cell (WBC), neutrophil, lymphocyte, monocyte, eosinophil counts between RA and OA groups. The RA group showed an evident decrease in red blood cell (RBC) count and haemoglobin level as compared to OA group. The RA group demonstrated the higher platelet count with mean platelet volume (MPV) being significantly lower than that in the OA group. WBC count, neutrophils, in particular, was shown to increase with lymphocyte, RBC, platelet count and hemoglobin, plateletcrit levels decreased at 24 hours postoperatively. There were no significant differences in WBC and RBC counts in the groups postoperatively. The differences in the MPV were leveled up in the groups with the platelet count being higher in the RA group as compared to the OA group. Conclusions Hematological parameters of RA patients who had undergone specific preoperative preparation were not shown to be associated with greater blood loss during hip replacement surgery. The leukocyte count leveled up in the preoperative and early postoperative periods can be indicative of the absence of a significant effect of RA on the postoperative inflammation.