Traumatology and Orthopedics of Russia

Background. Antibacterial agents are used in orthopedic practice to prevent surgical site infections, as well as for empirical and etiotropic antibacterial therapy. Each of the groups of antibacterial agents has specific indications for use and limitations that determine their role in empirical and etiotropic treatment regimens for musculoskeletal infections.

The aim of the study — to substantiate the choice of a drug for empirical antibacterial therapy based on the analysis of antimicrobial resistance dynamics in leading Gram-positive bacteria isolated from patients with orthopedic infection from 2011 to 2022.

Methods. We performed a retrospective study of data on the antimicrobial susceptibility in leading Gram-positive bacteria isolated from patients who were treated at the purulent osteology department from 01.01.2022 to 31.12.2022. Based on the data obtained, we investigated the dynamics and determined the prognosis of resistance in leading Gram-positive pathogens. This article analyzes 5 groups of antibiotics active against Gram(+) microorganisms: ß-lactams, glycopeptides, oxazolidinones, rifampicin, fusidic acid.

Results. The cumulative proportion of Gram(+) bacteria sensitive to ß-lactams accounted for 60.8%. During the study time period, vancomycin was active against 99.65% of Gram(+) bacteria and only 2 linezolid-resistant E. faecium strains were isolated. The average proportion of fusidic acid-resistant MRSA strains over the 12-year follow-up period was 0.7%; MSSE — 14.1%; MRSE — 10%; MSSA — 0%. The proportion of rifampicin-resistant MSSA and MSSE strains did not exceed 3% throughout the follow-up. MRSA and MRSE resistance to rifampicin averaged 25 and 16.3%, respectively.

Conclusions. In this article, we have considered groups of antibiotics that are predominantly active against Gram(+) microorganisms. The study showed that ß-lactam antibiotics, despite their widespread use in all fields of medicine, remain active against a significant proportion of Gram(+) bacteria. The maximum activity against the studied pathogens is demonstrated by vancomycin and linezolid. The obtained results could help to improve the empirical antibacterial therapy, taking into account resistance and availability of the drugs. The second part of the study will be devoted to broad-spectrum antibiotics.

Background. Replacement of bone defects in the surgical treatment of chronic osteomyelitis is a key step to prevent recurrence of infection and potential fractures at the site of rehabilitation. Bone cement, biodegradable synthetic materials, as well as autologous, allogeneic, and xenogeneic bone tissue have become widespread in surgical practice. Giving these materials antibacterial properties will expand their use in the treatment of bone and joint infections, shorten the treatment time, and improve the patients’ quality of life.

The aim of the study — to analyze the mid-term results of the second stage of surgical treatment for chronic osteomyelitis in long bones, depending on the type of used vancomycin-impregnated bone graft material: an original biodegradable mineralized material based on allogeneic bone or a commercially available biocomposite material consisting of β-tricalcium phosphate and hydroxyapatite.

Methods. The study included 25 patients who underwent the second stage of surgical treatment for chronic osteomyelitis. After removal of the cement spacer, the defect was replaced in Group 1 (n = 14) with a biocomposite material ReproBone® Granules with the addition of vancomycin, while in Group 2 (n = 11) — with an original mineralized allograft impregnated with vancomycin. Laboratory tests, vancomycin concentration in the drainage fluid, and the presence of infection recurrence within 1-3 years after surgery were evaluated.

Results. The groups did not differ in gender, age, and duration of the disease. The volume of the cavity defect was significantly higher in Group 2 (50 ml vs 14 ml; p = 0.0004). The vancomycin concentration in the drainage fluid from the first day after surgery in Group 2 was more than 10 times higher than in Group 1 (p = 0.0300) and remained at a high level until the 5^th day. Osteomyelitis recurrence was observed in 14% of patients in Group 1 and was absent in Group 2.

Conclusions. Standard approach to the treatment of chronic osteomyelitis using antimicrobial spacers does not ensure complete eradication of microbial pathogens that continue to persist in bone tissue. The original biodegradable mineralized bone graft material based on allogeneic bone creates significantly higher local vancomycin concentrations and demonstrates clinical efficacy in all applications.

Background. Periacetabular osteotomy (PAO) is an effective method to prevent or delay the need for hip replacement surgery in young adults, though it carries a certain risk of complications. It is essential to study the factors influencing the complications rate in order to optimize surgical techniques and improve the outcomes.

The aim of the study — to identify the incidence of postoperative complications and risk factors for their development in patients undergoing periacetabular osteotomy.

Methods. The study included 82 patients (89 joints) with hip dysplasia (Crowe I-II grades, Hartofilakidis A and B types), operated between 2007 and 2023. The mean age of the participants was 30.90±8.71 years (95% CI: 29.02-32.79). We analyzed 178 X-rays and 58 CT scans performed one day before surgery and on day 1 after PAO. Radiographic parameters assessed included Wiberg angle, Tönnis angle, Sharp angle, femoral head extrusion index, index of sphericity of femoral head, and retroversion index. The CT scans were used to evaluate the values of AASA (anterior acetabular sector angle), PASA (posterior acetabular sector angle), HASA (horizontal acetabular sector angle), and AcetAV (acetabular anteversion angle).

Results. Identified complications included acetabular overcorrection leading to pincer-type femoroacetabular impingement (24.72%), acetabular undercorrection (13.48%), stress fractures (16.85%), neurological impairments (8.99%), and infectious complications (3.37%). Patients with signs of overcorrection were 2.67 times more likely to require hip replacement (95% CI: 1.41-5.08). Undercorrection was associated with a 4.4-fold increase in arthroplasty risk (95% CI: 1.42-13.70; p = 0.013). An inverse relationship was found between the femoral head sphericity index and the likelihood of hip replacement following PAO: a 1% increase in this index reduced the odds of arthroplasty by 1.28 times (95% CI: 1.09-1.49).

Conclusions. The key factors influencing hip joint survival after periacetabular osteotomy are the accuracy of acetabular correction and the degree of femoral head sphericity. To reduce the rate of complications, it is necessary to develop preoperative criteria for assessing joint congruity, as well as tools for precisely positioning of the acetabular fragment.

Background. Patient-reported outcomes (PRO) play a significant role in interpreting treatment results. The HOOS is a popular patient-completed questionnaire used to assess hip joint function and quality of life. To date, there is no official Russian version of HOOS that has undergone all the language adaptation and validation procedures.

The aim of the study — to perform the cross-cultural and linguistic adaptation of the HOOS questionnaire for assessing quality of life in patients with hip joint pathology, as well as to validate the Russian version of the questionnaire, and test it in patients with hip osteoarthritis undergoing surgical treatment.

Methods. The study included 125 patients with hip osteoarthritis requiring surgical treatment. The first stage involved translating the questionnaire into Russian. The second stage involved validating the Russian version of HOOS to assess its reliability, validity, and sensitivity. Statistical analysis included calculation of Cronbach’s alpha, ICC correlations, application of the Wilcoxon signed-rank test for paired comparisons in related groups, and the Spearman’s rank correlation coefficient. Results. The values of Cronbach’s alpha for certain domains of HOOS ranged from 0.92 to 0.98, indicating good internal consistency of the questionnaire. The reproducibility of the questionnaire was evidenced by a significant correlation between domain scores upon retesting (ICC>0.7; p<0.001). Acceptable convergent and content validity of the questionnaire, as well as its sensitivity to changes in hip joint function post-surgery were demonstrated. The results of the HOOS questionnaire testing showed its informative value for assessing hip joint function before and after surgery.

Conclusion. The findings indicate the reliability, validity, and sensitivity of the Russian-language version of HOOS, as well as its suitability for assessing the hip joint condition in patients undergoing surgical treatment.

Background. Unsatisfactory clinical outcomes and patient dissatisfaction with the functional and aesthetic results of treating a mallet finger remain a significant challenge, as there is a lack of consensus among specialists regarding the optimal treatment approach, depending on the specific injury type.

The aim of the study — to retrospectively evaluate the efficacy of external immobilization, trans-articular fixation and percutaneous extension block pinning for different types of mallet finger injuries, and to identify factors that influence functional outcomes.

Methods. In a retrospective single-center study, functional results of 120 patients treated for acute mallet finger injuries were analyzed according to the Crawford classification. Patient satisfaction with the treatment was also assessed, and factors influencing treatment outcomes were identified.

Results. Depending on the type of injury among the study participants, excellent and good outcomes were achieved in 22 (25%) and 30 (34%) patients with type I injuries, while satisfactory and poor outcomes were observed in 26 (29.5%) and 10 (11.4%), respectively. Patients with IVB and IVC injuries mostly experienced poor outcomes in 13 (48.1%) and 2 (40%) cases with satisfactory outcomes in 11 (40.7%) and 3 (60%), respectively. The type of injury according to the Doyle classification system, treatment method, and initial nail phalanx extension deficiency had a significant impact on treatment outcomes. Most patients with type I injury received conservative treatment, whereas patients with an initial phalanx extension defect of 30 degrees or more often experienced satisfactory and poor outcomes with a residual extension defect of 15±5 degrees. In patients with type IVB and type IVC injuries, 40% underwent percutaneous extension block pinning. These patients were more likely to have residual deficit in extension more than 20±6°, a higher incidence of pain syndrome and flexion insufficiency in the distal interphalangeal joint.

Conclusion. In the management of type I injuries, the most significant factor influencing the functional outcome is the degree of initial deformity. Surgical intervention for type I injuries using trans-articular fixation can improve clinical outcomes, but it is associated with a significant risk of infection-related complications. When performing percutaneous extension block pinning for IVB and IVC type injuries, it is essential to achieve adequate repositioning to prevent improper fusion and the development of deformity-related osteoarthritis in the distal interphalangeal joints.

Background. Local therapy aimed to suppress infection of the osteoarticular apparatus is based on the use of coated spacers. As a rule, the coating surfaces are composed of bone cement supplemented with bioactive substances, e.g., antibiotics. However, current approaches aimed to stimulate the release of antibiotics from bone cement are not always effective and may even decrease their properties and biological activities.

The aim of the study — to examine the effect of the lattice structures of base implants on the dynamics and amount of antibiotics released from bone cement in vitro.

Methods. A novel type of implants with a lattice structure and traditional reinforced spacer filled with bone cement and antibiotic were used in present study. The release of vancomycin and cefazolin was measured spectrophotometrically for up to 30 days. Calibration curves were made according to the regression lines based on the values of the stock solutions with the well-known concentrations of the antibiotics.

Results. For all tested samples, the elution profile of antibiotics was determined and illustrated the significant release of the drugs during the initial time-period followed by the decrease (day 7) and reaching a uniform elution plateau (day 15). In all samples, the amount of released antibiotic did not exceed 1% of total amount of the drug present in the implant. Notably, the higher release of the antibiotics was found for the samples with lattice structure when compared with control group, despite the relatively higher initial amount of bone cement and antibiotics in control samples. A difference in the amount of antibiotics was also detected between the tested samples of two types of lattice structures.

Conclusion. The lattice structure of the implants increases the amount of antibiotic release from the bone cement and also facilitates the antibiotic dynamics release when compared to the traditional bone cement used as the reinforced spacers.

The paper analyzes the local total hip arthroplasty (THA) registry database over 18 years, from 2007 to 2024.

The following questions were posed. Are there any changes in the structure of revision THA? What are the current trends in revision THA in recent years? What revision technologies are being utilized?

A total of 11.201 cases of revision procedures were analyzed, which accounted for 12.4% of all registered THAs. Compared to previous analyses, the share of early revisions has increased — 42.2% of initial revisions and 87.6% of subsequent re-revisions are performed within the first five years after the previous surgery.

This analysis revealed several important trends:

1. The significant increase in both the absolute number and proportion of infection-related revisions (40.7%). This share is significantly higher for re-revisions (72.5%) compared to 20.2% for initial revisions.
2. Rejuvenation of revision — the average age is 60.7 years for aseptic revisions and 58.5 for infection-related ones.
3. The increase in proportion of trabecular metal constructs and other revision acetabular components, as well as a significant increase (up to 11.9%) of custom-made acetabular implants produced via 3D printing.
4. For femoral component revision, there is a steady trend towards using Wagner-type tapered fluted titanium components. Their share increased from 39.4% in 2019 to 61.7% in 2024.

There is a sharp increase in the number of revision procedures, a growing proportion of complex revisions requiring advanced and costly implants, and an exceptionally rapid rise in the number of infection-related revisions. It is therefore clear that the challenges of revision arthroplasty may soon affect all surgeons performing primary total hip arthroplasty — initially through the need to manage infectious complications, and later due to the gradual accumulation of patients requiring other types of revisions, including repeat procedures.

Background. Infected nonunion of long bone fractures poses a dilemma for trauma surgeons, especially when accompanied by bone defects. The main goals for management are curing infection, reconstructing the bone defect, achieving union at the fracture site, and eventually obtaining acceptable functional outcomes. In these situations, the surgeon could manage the infected nonunion through single-stage surgery. However, some surgeons prefer two-stage surgical intervention, wherein in the first stage, all attention is paid to curing the infection and providing temporary stabilization till the second stage, which is the definitive fixation. Temporary fixation during the first stage after thorough debridement could be obtained by various methods, including intramedullary nails coated by bone cement or external fixators.

The aim — to describe a modification while using a locked plate impregnated with antibiotic-loaded bone cement during

the first stage of two-stage revision for managing infected nonunited distal femoral fracture.

Technique description. The method described in the current technical note is a locking plate impregnated with antibiotic-loaded bone cement. This technique provides optimal local antibiotic delivery through the bone cement and proper stability owing to the fixation using the locking plate, which could be applied as close to the bone as possible due to its function as an internal-external fixator.

Conclusion. The technique is easy and efficient and can be applied using ordinary tools without needing complex instruments.

Background. Treatment of post-traumatic and post-operative soft tissue edema is especially relevant due to the high incidence of these conditions. They have a profound effect on patients´ quality of life and recovery process, as edema contributes to microcirculation impairment, pain exacerbation, fibrosis development, and limitation of motion. Escin, a promising treatment for edema, is a naturally derived compound with anti-edematous, angio- and endothelioprotective, anti-inflammatory, analgesic, and other effects.

The aim of the review — to summarize the clinical trial data on the efficacy and safety of systemically administered escin medications in the treatment of post-traumatic or post-operative soft tissue edema.

Methods. The review was conducted following the PRISMA-2020, ROBIS, and AMSTAR-2 guidelines and included clinical trials (CTs) that met the PICO(S) criteria. The search was carried out on January 8, 2025 in the PubMed, eLIBRARY, SciELO, Cochrane Library databases, and in the US, EU, and UK clinical trial registers. Qualitative evidence synthesis was performed in a narrative approach with confidence assessment by the GRADE-CERQual method. Risk of bias in individual CT was assessed using the RoB 2 tool.

Results. The review included three open-label, randomized, parallel-group CTs devoted to the anti-edematous effect of escin for managing post-operative edema in chronic venous disease (1 CT, n = 87), trauma-related skin flap transplantation (1 CT, n = 90), and surgical treatment for blunt limb trauma (1 CT, n = 102). In all trials reviewed, systemic administration of escin was effective in correcting local edema, did not significantly differ from comparison groups in terms of safety and tolerability, and had a positive effect on several pathogenetic laboratory markers of edema. All included CTs raised some concerns regarding the overall risk of bias, mainly due to the absence of blinding and randomization protection. The outcome reporting and publication bias for the evidence synthesis was deemed low.

Conclusions. The review has shown that systemic (oral or parenteral) administration of escin in the acute post-traumatic and post-operative periods effectively reduced the severity of edema (moderate confidence by GRADE-CERQual) and was well-tolerated. The incidence of adverse events did not significantly differ from the negative control, the active comparator (mannitol) (moderate confidence by GRADE-CERQual). The findings of this review may find further application as a basis for novel, more advanced approaches to the drug correction of edema of various etiologies.