Vol 31, No 4 (2024)

BACKGROUND: Surgical site infections (SSIs) are one of the most common preventable healthcare-associated infections, with a significant socioeconomic burden. Information technology, particularly clinical decision support systems, has been shown to improve patient safety. However, there have been few publications on the use of these systems for the prevention and treatment of SSIs.

AIM: To develop a multifunctional patient safety information system (PSIS) for the prevention, diagnosis, and treatment of SSIs in traumatic and orthopedic surgery.

MATERIALS AND METHODS: A PSIS for traumatic and orthopedic surgeons was developed and implemented in the N.N. Priorov National Medical Research Center of Traumatology and Orthopedics in late 2023 to early 2024. The PSIS includes two user systems: 1) an analytical and authoring system (PSIS-Manager) for subject matter experts who develop scenarios; 2) a medical system for patient data entry and access to guidelines.

RESULTS: A PSIS prevention scenario was developed based on the guidelines of the National Association of Infectious and Non-Infectious Disease Control Professionals. It includes 11 recommendations for the preoperative stage, 30 for the perioperative and intraoperative stages, 33 for SSI prevention during surgery, and 7 for the postoperative stage. A surgical antibiotic prophylaxis scenario includes 24 recommendations. Decision-making algorithms for the treatment of SSIs are based on the guidelines of the American Academy of Orthopaedic Surgeons (AAOS). Decision-making involves 6 factors providing 264 various clinical scenarios, with 9 decision options.

CONCLUSION: Scenario-based protocols can be used to support decision-making on patient management strategy, as well to control compliance with SSI prevention and treatment guidelines. Further perspectives on PSIS development in terms of SSI diagnosis and treatment include the use of artificial intelligence technologies to aid in the diagnosis of wound infections and the selection of treatment options.

BACKGROUND: Chronic deep periprosthetic infections (PPIs) of the hip joint are a major concern in modern orthopedic surgery. Numerous risk factors are being studied to reduce the recurrence rate; however, the role of functional fistulous tracts remains unclear.

AIM: To compare the physical status of patients, infection etiology, efficacy of chronic periprosthetic hip joint infection therapy, and treatment outcomes depending on the presence of a fistulous tract.

MATERIALS AND METHODS: The retrospective analysis included 218 patients, with two study groups. Group 1 had 80 PPI patients without fistulas, while Group 2 had 138 PPI patients with fistulas. Treatment outcomes were assessed in 202 patients; the median duration of follow-up was 26 months.

RESULTS: Patients with fistulas were younger than those without fistulas: 58 and 63 years, respectively (p = 0.006). There were no significant intergroup differences in the total comorbidity score, duration of surgery, and blood loss. Patients with fistulas had a three-day shorter average hospital stay than those without fistulas (p=0.03). Monobacterial PPIs were the most common in both groups, with Staphylococcus epidermidis predominating in the group without fistulas and Staphylococcus aureus in the group with fistulas (p <0.001). These findings had no significant impact on the recurrence rate. The efficacy of the first debridement was 82% and 76% in the groups without fistulas and with fistulas, respectively; the efficacy of the second debridement was 69% and 58%, respectively (p >0.05). The presence of a fistulous tracts significantly increased the risk of PPI recurrence (p=0.048).

CONCLUSION: PPIs of the hip joint with fistulas have no significant impact on the first PPI relapse; however, fistulas may significantly increase the risk of the second relapse. This must be taken into account when planning relapsing PPI treatment stages.

BACKGROUND: Gram-negative bacteria, specifically P. aeruginosa, Acinetobacter spp., Klebsiella spp., and Enterobacter spp., can cause osteomyelitis. Two-stage treatment according to the Masquelet technique is considered effective; however, single-stage surgical treatment options are also being investigated. Submerged implants with bioactive antimicrobial calcium phosphate coating may prevent infectious complications, reduce the incidence of osteomyelitis relapses, and accelerate osteogenesis.

AIM: To assess bactericidal properties of experimental titanium implants with antimicrobial calcium phosphate coating against gram-negative bacteria.

MATERIALS AND METHODS: A single-center, continuous, prospective, open-label experimental in vitro study was performed. The disk diffusion test was used. BT6 titanium disks with calcium phosphate coating, impregnated with amikacin, cefepime, and cefotaxime (2.5/5.0/7.5 µg), were tested. Reference cultures: archival strains of Pseudomonas aeruginosa (АТСС 27853), Acinetobacter baumannii (АТСС 19606), and Klebsiella pneumoniae (АТСС 700603). The results were assessed by the inhibition zone diameter around a disk.

RESULTS: The study found that impregnating a bioactive metal base with amikacin and cefotaxime at a dose of ≥2.5 µg or cefepime at a dose of ≥7.5 µg results in bactericidal activity against Klebsiella pneumoniae. Amikacin at a dose of ≥5 µg and cefepime at a dose of ≥7.5 µg provide bactericidal activity against Pseudomonas aeruginosa. Antibiotic doses used in the study had no bactericidal effect against Acinetobacter baumannii. The bactericidal effect was only investigated in relation to archival gram-negative bacteria strains, which is a limitation of this study. Using clinical strains may yield different results.

CONCLUSION: Commonly used antibiotics may provide bactericidal properties of the surface of submerged implants designed for traumatic and orthopedic surgery, notably against gram-negative bacteria. However, the efficacy of implants depends on the selected antibiotic and its concentration.

BACKGROUND: Scaphoid bone fractures are quite common. Difficulties and inaccuracies in the diagnosis of damages may significantly delay the treatment and reduce its efficacy. Routine X-ray imaging of the wrist joint is insufficiently informative, leaving some fractures undetected. The scaphoid bone has a distinctive shape and position in the wrist joint; thus, when using conventional positioning during X-ray imaging, the fracture line is not always visible, and the scaphoid bone appears shorter. W.R. Stecher, an American surgeon, proposed specific positioning options to examine the entire scaphoid bone, thus improving the diagnosis of scaphoid bone pathology.

AIM: To compare conventional positioning with three Stecher positioning options; to determine the option that best eliminates the distortion (shortening) of scaphoid bone images.

MATERIALS AND METHODS: The study included 13 volunteers aged 23 to 65 years. X-ray imaging of the wrist joint was performed in all volunteers using conventional positioning and three Stecher positioning options. The scaphoid bone length was measured. The results were processed using the MS Excel Analysis ToolPak (descriptive statistics); the Friedman test was used for repeated measurements.

RESULTS: The scaphoid bone length varied when using different positioning options. All volunteers had the shortest scaphoid bone length when using conventional positioning and the longest when using modified Stecher positioning. The difference in measurements between these positioning options was 2 to 8 mm, which is significant for a small anatomical structure.

CONCLUSION: In this study, the option “fingers clenched + elbow deviation” was found to be the best for frontal X-rays of the scaphoid bone. This approach (modified Stecher positioning) produces scaphoid bone images with minimal distortion, which is crucial for diagnosis, preoperative planning, treatment, and outcome assessment.

BACKGROUND: Benign soft tissue masses of the hand are defined by the lack of a generally accepted global classification, consistent terminology, and histological identification criteria, as well as a wide range of forms and frequent recurrences. During preoperative preparation in routine clinical practice, imaging and comprehensive clinical examinations are frequently not performed in patients with soft tissue masses of the hand. In the event of a later recurrence, the selection of treatment approach can be challenging due to limited clinical and imaging findings.

AIM: To assess the prevalence of benign soft tissue masses of the hand among all neoplasms of the hand, based on the histological structure, as well as the characteristics of clinical diagnosis and the efficacy of specialized examination methods.

MATERIALS AND METHODS: A retrospective study was performed in 1.355 patients with benign soft tissue masses of the hand and tumor-like lesions for a 10-year period between 2010 and 2020. The diagnosis was based on clinical, X-ray, and ultrasound findings, with a mandatory histological examination of the excised tumor in all patients. To clarify the diagnosis, additional magnetic resonance imaging was used in 53 patients, computed tomography in 15 patients, angiography in 13 patients, and thermographic and radionuclide studies in 28 patients.

RESULTS: Of the 1,355 cases of tumor-like lesions on the hand, 563 (41.5%) were benign soft tissue masses. The most prevalent were benign synoviomas (263 cases; 46.8%), hemangiomas (94 cases; 16.8%), lipomas (62 cases; 11.2%), fibromas (35 cases; 6.2%), glomangiomas (28 cases; 5%), and fibrolipomas (26 cases; 4.6%). Angiofibromyomas, hemangiopericytomas, and lymphangiomas had the lowest prevalence (3 cases each; 0.5%).

CONCLUSION: The study found that benign soft tissue masses of the hand accounted for 41.5% of all tumor-like lesions on the hand, with benign synoviomas being the most prevalent. The diagnostic significance of mandatory X-ray and ultrasound examinations before surgery was confirmed. Only 884 of 1,355 cases (62.5%) had a preliminary diagnosis made prior to imaging studies that matched the final diagnosis based on histomorphological examination of the excised tumor. The feasibility of widespread use of high-resolution MRI for the differential diagnosis of hand neoplasms was determined. The diagnostic significance of angiography, computed tomography, and thermographic and radionuclide studies in detecting benign hand neoplasms was confirmed. It is incorrect to perform surgery without preliminary clinical and imaging examinations. A histomorphological examination of the excised tumor is mandatory in all cases.

BACKGROUND: Intraoperative neurophysiological monitoring (IONM) in remedial spine surgery is currently a gold standard, and protecting the nervous system during surgery is a major concern for both surgeons and patients. Moreover, we use various types of preoperative halo traction in patients with severe scoliosis to reduce the risk of neurological complications. Thus, we performed a comparative study of changes in IONM findings during scoliosis surgery in patients with and without preoperative halo-gravity traction.

AIM: To compare IONM findings during scoliosis surgery with and without preoperative halo-gravity traction.

MATERIALS AND METHODS: An observational, single-center, retrospective, single-arm study of IONM findings was performed in 88 patients with severe scoliosis who underwent scoliosis surgery with halo traction between 2019 and 2023. The study included two groups. Group 1 (52 patients) had preoperative halo-gravity traction while standing or sitting. Group 2 (36 patients) had intraoperative halo traction. A comparative analysis was performed, which included the following: risk criteria for neurological deficit in the lower extremities during surgery, deformation angles, mobility parameters, postoperative deformation, blood loss, and surgery duration.

RESULTS: The intergroup comparison of changes in deformation angles and IONM findings revealed that Group 1 had more severe deformation based on primary and compensatory curve angles, more severe stiffness, and a lower number of patients with normal motor evoked potential (MEP) levels. The differences were significant (p <0.05). Risk criteria for neurological deficit were reported in 12 patients: seven in Group 1 and five in Group 2. In two patients in Group 2, MEP values of the lower extremities were not restored, resulting in permanent neurological deficit.

CONCLUSION: Preoperative halo traction prepares the nervous structures for the treatment of severe deformations and minimizes the intraoperative impact on the nervous system, reducing the risk of neurological complications in patients with severe spinal deformities compared to immediate treatment with intraoperative traction.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare but severe infectious disease, characterized by the accumulation of pus in the epidural space of the spine. This condition may cause spinal cord and spinal root compression, resulting in a persistent neurological deficit or even death in the event of a delayed or incorrect diagnosis. The prevalence of SEA has increased in the recent decade, which is attributed to increased life expectancy, extensive use of invasive procedures, and an increase in risk factors such as diabetes mellitus, obesity, and intravenous drug abuse. SEA is difficult to diagnose because of its non-specific symptoms. However, clinicians’ awareness and early use of magnetic resonance imaging (MRI) allow timely disease detection and therapy initiation.

CLINICAL CASE DESCRIPTION: Patient (55 years old), presented with complaints of weakness in all extremities and neck pain. The medical history started roughly 4 months ago, beginning with strep throat, after which the patient developed increasing weakness in the extremities. Based on the MRI and CT findings, the following diagnosis was made: SEA at the C4–C5 level, causing spinal cord compression. The following procedures were performed: C4 and C5 corporectomy, epidural abscess excision and drainage, and stabilization with a cervical plate and autograft. A significant improvement was observed in the postoperative period, with a notable decrease of neurological deficit at discharge.

CONCLUSION: This case report highlights the need to improve awareness of SEA among healthcare professionals for early diagnosis and treatment initiation, particularly in high-risk patients. Despite advances in treatment, mortality rates and the incidence of neurological complications remain high, necessitating further research to improve treatment strategies and outcomes in SAE patients.

INTRODUCTION: Surgical site infections following spinal surgery are a major concern. According to the literature, the incidence of surgical site infections is 2.0%–2.5%. These complications are sometimes accompanied by soft tissue defects, which require special treatment, including skin grafting.

CLINICAL CASE DESCRIPTION: The paper presents a clinical case of postoperative wound infection in the lumbar region. Complication management resulted in a 12×6 cm tissue defect. The wound included previously implanted metal screws and pins. To address this issue, the defect was repaired using a perforator lumbar flap. The implants were not removed. The postoperative wound healed properly, the implants were preserved, and the patient has been followed up since 2014.

CONCLUSION: Skin grafting using a perforator flap is an option in soft tissue defect repair due to infectious complications of spinal surgery.

INTRODUCTION: Idiopathic osteoarthritis of the rearfoot joints most commonly affects the talonavicular joint. Currently, talonavicular osteoarthritis is commonly treated using double and triple arthrodesis, as well as isolated talonavicular arthrodesis. However, restricting functionally significant joints of the foot results in increased load on adjacent joints, causing degenerative changes.

CLINICAL CASE DESCRIPTION: The paper presents a clinical case of surgical treatment in a patient with avascular necrosis of the talar head, deforming arthrosis, and fibrous ankylosis of the talonavicular joint by talar head replacement with an original ceramic implant. The presented case is the first to describe a novel treatment method for gross talonavicular joint pathology using a ceramic implant to replace the talar head.

CONCLUSION: Based on the medium-term outcomes of surgical treatment in a patient with stage III deforming arthrosis and fibrous ankylosis of the talonavicular joint, talar head replacement is a promising treatment option for this condition. The initial findings showed that the proposed implant and its placement method can be used as an option of choice to preserve the mobility of the talonavicular joint.

Local depot systems with high antibiotic content are an essential component of combination therapy in osteoarticular infections. These systems are effective against microbial biofilms by providing drug concentrations that surpass the requirements of planktonic bacteria. Currently, there are numerous support matrixes with various properties. Only a few of them are sufficiently studied and actively used in clinical practice. These include polymethylmethacrylate-based bone cement, calcium sulfate, collagen, allografts, etc. However, the vast majority of local systems have only been studied in vitro and in vivo. This review describes currently available depot systems, including their primary properties, advantages, and disadvantages, as well as potential for future use of a specific matrix both for the treatment and prevention of diseases.

The paper presents a literature review on chronic recurrent multifocal osteomyelitis. This orphan disease, which primarily affects children and adolescents, has a wide range of clinical manifestations and presents various diagnostic, pathological, and therapeutic problems. An analytical review was performed using medical literature databases and PubMed (MEDLINE), Google Scholar, and eLibrary search systems. The review addresses the following: epidemiology, clinical presentation, pathogenesis, diagnosis, treatment, and genetic factors in the pathophysiology of chronic recurrent multifocal osteomyelitis in humans. The review aimed to improve clinicians' understanding of this disease, allowing for timely diagnosis and appropriate treatment initiation.

As recently as the middle of the 20th century, arthroscope insertion in a ball-and-socket hip joint was thought to be almost impossible. Hip arthroscopy has evolved greatly since then, and its current development rate is closely related to the detection rate of hip joint disorders. Athletes and other young patients with hip joint injuries are increasingly being diagnosed with constantly evolving disorders. Many of these conditions were previously undiagnosed and hence remained untreated. Hip arthroscopy, like any other procedure, has its risks. This procedure is not widely available, as it requires special equipment and extensive training.