Early outcomes of using custom-made augments in revision total hip arthroplasty.

INTRODUCTION: The continuing high demand for revision total hip arthroplasty (RTHA) requires not only additional economic costs, but also the search for new, effective methods to manage the reconstruction of acetabular bone loss. This study focuses on the assessment of the clinical and radiographic outcomes after RTHA using custom-made augments (CMA) in the short-term follow-up period. MATERIALS AND METHODS: We retrospectively analyzed the results of using CMAs in 19 patients (20 hips). The average follow-up period was 41.3 months. All surgery was performed on defect types III and IV as per the Gross and Saleh classification. RESULTS: There was a statistically significant difference when comparing the Oxford Hip Score before RTHA of 15.0 (Std. deviation-5.9) and after RTHA of 36.3 (Std. deviation-6.3) (p = 0.01). All implants were radiologically stable. CMA has demonstrated a good ability to restore position of hip centre of rotation (HCOR). In the postoperative period, two patients (2 hips) had dislocations. Only one of two patients underwent re-revision due to dislocation. CONCLUSION: Treatment of uncontained loss of bone stock in RTHA using CMA shows promising clinical and radiographic results at short-term follow-up period; however, dislocation rate is 10% in this study.

[Routine preoperative examination for diagnosis of periprosthetic joint infection and its recurrence in revision hip arthroplasty]. / Rol' rutinnogo dooperatsionnogo obsledovaniya v vyyavlenii periproteznoi infektsii i ee retsidiva pri revizionnom endoprotezirovanii tazobedrennogo sustava.

OBJECTIVE: To evaluate diagnostic value of routine preoperative laboratory tests such as erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and microbiological examination of joint aspirate in patients with periprosthetic joint infection or its recurrence in patients scheduled for revision hip arthroplasty. MATERIAL AND METHODS: There were 117 patients. Preoperative CRP and ESR, the culture of pre- and intraoperative joint aspirates and tissue biopsies were studied. We analyzed diagnostic significance of these parameters and the likelihood of periprosthetic joint infection depending on increase of CRP/ESR and previous joint infection. RESULTS: According to microbiological data, periprosthetic joint infection was diagnosed in 19.7% of patients. High CRP in this group significantly increased the chance of joint infection diagnosis (OR 6.3; 95% CI 1.491-26.615). Concomitant increase of both ESR and CRP increased this likelihood by 7.7 times (OR 7.778; 95% CI 0.931-66.296). In the 2nd group, periprosthetic joint infection was confirmed in 25% of patients. At the same time, detection of pathogen in isolated or combined increase in CRP and ESR was less likely compared to the control group. Prognostic value of negative preoperative microbiological examination of joint aspirate was only 93%. We failed to obtain aspirate in 21.4% of cases. CONCLUSION: Increase of the routine serological parameters before revision hip arthroplasty is more sensitive for prediction of periprosthetic joint infection in patients without previous infection. Previous joint infection reduces diagnostic value of ESR and CRP in detection of recurrent periprosthetic joint infection. Preoperative examination of joint aspirate is not sufficient for etiological diagnosis of periprosthetic joint infection. However, positive microbiological culture should be taken into account for the choice of further management.

[Mortality in patients with proximal femur fractures undergoing conservative and surgical treatment]. / Letal'nost' u patsientov s perelomami proksimal'nogo otdela bedrennoi kosti pri konservativnom i operativnom lechenii.

OBJECTIVE: To study the incidence of proximal femur fractures (PFF) in St. Petersburg and survival rate depending on treatment strategy. MATERIAL AND METHODS: Considering the data of long-term monitoring of traumatology and orthopedic service in St. Petersburg, we assessed the incidence of PFF in adults and various treatment options. Moreover, we have studied all patients admitted to 2 large hospitals in St. Petersburg between December 2017 and December 2018 for at least 14 months. There were 914 requests for medical care for PFF from 903 patients. RESULTS: Mean incidence of PFF in St. Petersburg is 0.88 per 1000. The discharged patients without surgical care make up 20%. About 37.5% and 42.4% of patients require hip arthroplasty or osteosynthesis, respectively. Postoperative mortality was 3.5%, in-hospital mortality after therapeutic management - 9.1% (p=0.016). Two-year mortality after osteosynthesis was 27.2%, after hip arthroplasty - 19.3%, after conservative treatment - 43.9% (p<0.001).

[Additive technologies for complete recovery of joint function in revision endoprosthesis surgery (experimental trial)]. / Additivnaia tekhnologiia v polnom vosstanovlenii funktsii sustava pri éndoprotezirovanii (éksperimental'noe issledovanie).

AIM: Experimental analysis of the strength properties of integration of muscle tissue, tendons and ligaments, bone tissue into titanium highly porous materials prepared by using of additive technologies. MATERIAL AND METHODS: The study included 9 mature rabbits of the Chinchilla breed. Both posterior paws and latissimus dorsi muscles (36 specimens) were used. Titanium models (Ti-6-Al-4-V, 'Rematitan', Germany) were made by additive technologies with preliminary prototyping, the prototypes had a highly porous mesh structure. RESULTS: It was developed experimental model of functional bone defect involving points of attachment of the muscle and ligaments. Strength of attachment of muscles to highly porous implants was 145 H vs. 31 H for standard models. Tensile strength for fixation to bone tissue was 84 H vs. 152 H in the main group. CONCLUSION: It was found integration of soft tissues and bones into highly porous titanium implants prepared with additive technologies. Fixation strength significantly exceeds that for standard models.

15 years of the histopathological synovitis score, further development and review: A diagnostic score for rheumatology and orthopaedics.

The histopathological synovitis score evaluates the immunological and inflammatory changes of synovitis in a graduated manner generally customary for diagnostic histopathological scores. The score results from semiquantitative evaluation of the width of the synovial surface cell layer, the cell density of the stroma and the density of the inflammatory infiltration into 4 semiquantitative levels (normal 0, mild 1, moderate 2, severe 3). The addition of these values results in a final score of 0-9 out of 9. On the basis of this summation the condition is divided into low-grade synovitis and high-grade synovitis: A synovitis score of 1 to≤4 is called low-grade synovitis (arthrosis-associated/OA synovitis, posttraumatic synovitis, meniscopathy-associated synovitis and synovitis with haemochromatosis). A synovitis score of≥5 to 9 is called high-grade synovitis (rheumatoid arthritis, psoriatic arthritis, Lyme arthritis, postinfection/reactive arthritis and peripheral arthritis with Bechterew's disease). By means of the synovitis score it is therefore possible to distinguish between degenerative/posttraumatic diseases (low-grade synovitis) and inflammatory rheumatic diseases (high-grade synovitis) with a sensitivity of 61.7% and a specificity of 96.1%. The diagnostic accuracy according to ROC analysis (AUC: 0.8-0.9) is good. Since the first publication (2002) and an associated subsequent publication (2006), the synovitis score has nationally and internationally been accepted for histopathological assessment of the synovitis. In a PubMed data analysis (status: 14.02.2017), the following citation rates according to Cited by PubMed Central articles resulted for the two synovitis score publications: For DOI: 10.1078/0344-0338-5710261 there were 29 Cited by PubMed Central articles and for the second extended publication DOI:10.1111/j.1365-2559.2006.02508 there were 44 Cited by PubMed Central articles. Therefore a total of 73 PubMed citations are observed over a period of 15 years, which demonstrates an international acceptance of the score. This synovitis score provides for the first time a diagnostic, standardised and reproducible histopathological evaluation method enabling a contribution to the differential diagnosis of chronic inflammatory general joint diseases. This is particularly the case by incorporation into the joint pathology algorithm. To specify the synovitis score an immunohistochemical determination of various inflammation-relevant CD antigens is proposed to enable a risk stratification of high-grade synovitis (e.g.: progression risk and sensitivity for biologicals).

[Fifteen years of the histopathological synovitis score : Review and further developments of a diagnostic score]. / 15 Jahre histopathologischer Synovialitis-Score : Rückblick und Weiterentwicklung eines diagnostischen Scores.

The histopathological synovitis score evaluates in a graded approach, as is largely usual for diagnostic histopathological scores, the immunological and inflammatory changes caused by synovitis. A synovitis score of between 1 and ≤ 4 is classified as low-grade (osteoarthritis-related synovitis, post-traumatic synovitis, meniscopathy-related synovitis and synovitis in hemochromatosis). Synovitis scores of between ≥ 5 and 9 are classified as high-grade synovitis (rheumatoid arthritis, psoriatic arthritis, Lyme's arthritis, post-infection/reactive arthritis and peripheral arthritis in Bechterew disease); sensitivity is 61.7% and sensitivity 96.1%. According to receiver operating characteristic (ROC) analysis (AUC: 0.8-0.9), diagnostic value is good. National and international acceptance of the synovitis score has grown since the first publication in 2002 and a related follow-up publication in 2006. PubMed data analysis (as of 11.01.2017) yielded the following citation values according to "cited by PubMed Central articles" for two publications relating to the synovitis score: there were 29 cited-by-PubMed articles for DOI: 10.1078/0344-0338-5710261 , and 44 cited-in-PubMed articles for the second publication, DOI: 10.1111/j.1365-2559.2006.02508 . This makes a total of 73 PubMed citations over a period of 15 years, thereby evidencing the score's international acceptance. Immunohistochemical determination of a number of CD antigens relevant to inflammation has been proposed to further specify the synovitis score for the purposes of risk stratification of high-grade synovitis (e.g., risk of progression and sensitivity to biological agents).

POSSIBILITIES OF MODERN TECHNOLOGIES OF VISUALIZATION AND MODELING IN ORTHOPEDICS AND THEIR ROLE IN DEVELOPMENT OF INDIVIDUAL CONSTRUCTIONS IN HIP ARTHROPLASTY.

The article presents the authors' experience. Medical visualization is applied in orthopedics on all stages such as diagnostics, treatment planning and control of the results. Modern approaches in instrumental diagnostics and specialized application-dependent software allowed a new qualitative level of orthopedics and medical care in different areas of medicine. Modern technologies gave a lot of opportunities to doctors in order to improve diagnostics at higher level, make an individual planning of operations and built individual implants, when it wasn't possible to use standard constructions.

[Osteocytes and the pathways of mechanical homeostasis optimization from the point of view of functional osteology].

The aim of this work was to determine, on the basis of the results of authors' own research and literature data, the main pathways of osteocyte (OC) influence on the mechanical homeostasis of the skeleton. The following pathways of reorganization of the architecture of bone structures are postulated: at the ultrastructural level without direct cell participation, through the bone matrix synthesis by osteoblasts and OC, through bone matrix resorption by osteoclasts and OC, the latter being able to resorb the surrounding mineral and organic matrix both separately, and conjointly. This reorganization results in local changes of the mechanical characteristics of bones due to changes in: porosity of interstitial spaces, transport ability of the lacunar-canalicular system, porosity of the area of osteoblastic-osteoclastic remodeling, modeling of bone structures. From the point of view of adaptation theory it is highly significant that the subtle local control of bone structures is able to induce changes in the parameters of the mechanical environment, which, on the one hand, would correspond to OC metabolic requirements and, on the other hand, would support the parameters of body mineral homeostasis.

[Osteocytic bone remodeling: history of the problem, morphological markers].

On the basis of the authors' own results and the analysis of the literature, the morphological markers of resorptive and synthetic phases of osteocytic bone remodeling under physiological conditions, are discussed. Their application by different authors is considered taking into account the history of the research of the osteocyte role in bone matrix metabolism (synthesis and resorption). Currently, there arose an urgent need for the quantitative assessment of osteocyte remodeling by combining routine histological methods of the osseous tissue study with the possibilities of modern image analysis systems.

[Hierarchy of spiral organization of skeletal structures. Interrelationship between structure and functions].

The objective of this review is to discuss the interrelationship between hierarchy of spiral organization of the structural elements of the skeleton and its mechanical characteristics with regard to functional-biological expediency. The following hierarchic levels of spiral organization of skeletal structures are defined: collagen chains, collagen molecules, microfibrils, fibrils, collagen fibers, osteon network and organization of osseous macrostructure responsible for torsion effect in weight bearing. This spiral organization creates the conditions, under which the directions of domineering forces in the bone usually do not coincide with the direction of the longitudinal crystallite axes. It causes shifting deformity between the adjacent crystallites. which should be taken into account alongside with distraction-compression deformity. These features form the basis of nano-level mechanism responsible for mechanical characteristics of bone tissue.

[Dynamic assessment of bone tissue osteocytic remodeling using a noninvasive method].

Projectional bone mineral density (PBMD) in the proximal region of both femoral bones, the distal part of the forearm bones on both sides and in the lumbar vertebrae was studied with the method of dual energy roentgen absorption (DEXA) in two male volunteers at the age of 40 and 60 years on a daily basis during one month. On the basis of the results of the estimation of each area of interest (AI) M(av), oscillation range (4(sigma)) and the greatest difference were calculated. In addition to it, a statistic mathematic modeling was conducted through smoothing out the dynamic rows of the results achieved for each AI. It was found out that the average oscillation range exceeded 9% of the average index value, which is thrice as much as the method reproducibility error. This kind of investigation in the process of treatment allows monitoring its efficiency taking into consideration both mechanisms (osteoblastic-osteoclastic remodeling and osteocytic remodeling) as well as estimating the toxic effects of medical agents on bone cells. As a result of statistic mathematic modeling, cercaseptane periodicity of PBMD changes with the average period of 5.5 days was found. The authors see the cause of these short-term changes in osteocytic remodeling and suggest to use a dynamic successive PBMD measurements during 7-10 days as a way of non-invasive monitoring of osteocyte resorption-synthetic activity in AI.

[Levels of bone mineral matrix organization and the mechanisms determining parameters of its formation].

Authors suggest to regard bone mineral matrix as the four-level structure. The first level is represented by an internal structure of a mineral, the second--by mineral morphological structure, the third--by coplanar association of minerals, and the fourth--by macroassociation of minerals in a single complex inside each bone. The most probable mechanisms determining stability of reproduction of mineral matrix parameters on each of these levels are shown. As a result of their functioning, the variants of bone mineral matrix structures are formed that are the programmed reflection of specificity of the given site of organic structures.

[Storage of autologous hemocomponents in patients before endoprosthesis of great joints].

Storage of autologous hemocomponents in patients prepared for elective surgery is the method of choice for adequate preparation before surgery. Autogenic erythrocytes and blood plasma increase infectious safety and efficacy of postoperative transfusion therapy. Up-to-date storage of autologous hemocomponents is indispensable condition for effective treatment of orthopedic patients.

[Biorhythmic characteristics of patients with total primary and revision hip replacement].

Age-dependent fluctuations of primary total and revision endoprosthesis have been found which appear to reflect changes in the activity of the inflammation process that can be regarded to be an element of periodic diseases. This seems to depend on the regulatory-metabolic shifts caused by aging.

[Aging of the osseous tissue. Theoretical basis for new directions of mechanotransduction optimization].

On the basis on literature studies and the results of personal studies, the authors describe ultra- and micro-structural changes in the osseous tissue associated with the process of aging. Functional disturbances in tissue processes causing osseous tissue loss and osteoporosis development are characterized. It is suggested that the described changes are induced by age-dependent hypermineralization of the osseous tissue with the consequent disturbances of mechano-transduction. A hypothesis is discussed concerning a novel approach to pharmacological treatment of osteoporosis. Development of a new group of drugs controlling the calcium exchange between the osseous compartment and the blood is considered. Presumed pathogenetic and clinical effects of these drugs are described.

[Chronic recurrent instability of the shoulder joint]. / Khronicheskaia retsidiviruiushchaia nestabil'nost' plechevogo sustava.

The article gives an analysis of results of conservative treatment of 503 patients with a primary traumatic dislocation of the shoulder. High frequency of the development of chronic instability of the shoulder joint was shown to be 31.2%. The using of arthroscopy, noninvasive methods of diagnosis (rentgenography, USI) allowed to diagnose the typical complex of morphological injuries following dislocations of the shoulder. General and local factors responsible for the development of chronic instability of the shoulder joint were established. Arthroscopy and early surgical stabilization of the joint are thought to be expedient in cases of a combination of these factors. Conservative treatment is indicated to patients older than 40 without high physical needs.

[Surgical methods in the treatment of patients with sequelae of hip joint injuries]. / Khirurgicheskaia taktika pri lechenii bol'nykh s posledstviiami travm tazobedrennogo sustava.

The article analyzes results of treatment of 64 patients with sequelae of traumas of the hip joint. They showed that arthrodesis of the hip joint was indicated in treatment of young patients with severe posttraumatic coxarthrosis, destruction of the cotyloid cavity or the femur head including those after fighting injuries of the joint, purulent complications after traumas or preceding operations. Intertrochanteric osteotomy of the femur is reasonable in treatment of young patients with the initial stages of coxarthrosis and preserved amplitude of movement of the joint. Endoprosthesis of the hip joint is the operation of choice in patients older than 40-45 years with posttraumatic coxarthrosis and aseptic necrosis of the femur head, as well as in patients with the recurrent pain syndrome after intertrochanteric osteotomy.

[The surgical treatment of degenerative-dystrophic diseases of the hip joint]. / Khirurgicheskoe lechenie degenerativno-distroficheskikh zabolevanii tazobedrennogo sustava.

An analysis of long-term results of surgical treatment of 609 patients with degenerative-dystrophic diseases of the hip-joint was made. Choice of the optimum methods of surgical treatment of such patients must be based on the prognosis of effectiveness of the operative intervention taking into account general regularities associated with the degree of the arthrosis alterations, dyscongruence of the articulation surfaces and duration of the disease, the degree of disturbances of the femur head blood supply, the disturbed supporting ability and severity of the trauma. When choosing the method of surgical treatment of young patients with coxarthrosis the operative interventions aimed at saving the hip joint should be considered.

[Regional arterial infusion in patients after reconstructive-restorative operations of the hip joint]. / Regionarnaia arterial'naia infuziia u bol'nykh posle rekonstruktivno-vosstanovitel'nykh operatsii na tazobedrennom sustave.

The effectiveness of the regional arterial infusion in prophylaxis of complications was studied in 14 patients after reconstructive-restorative operations upon the hip joint. The method and program of the complex infusion therapy are proposed which facilitate the correction of disturbed microcirculation and oxygen regimen in the tissues after operation (trauma) on the hip joint.

[A systemic approach to the surgical treatment of degenerative-dystrophic diseases of the hip joint]. / Sistemnyi podkhod k khirurgicheskomu lecheniiu degenerativno-distroficheskikh zabolevanii tazobedrennogo sustava.

Based on the experience gained with the surgical treatment of over 900 patients with different forms of degenerative dystrophic diseases of the hip joint the current principles of the choice of different types of surgical interventions were defined. As far as the patients with aseptic necrosis of the head of the femur are concerned, the main problem in this case lies in the early diagnosis of osteonecrosis. The surgical treatment is specified by the leading factor of the pathogenesis at every stage of the development of the process (vascular disorders, changes in the biomechanism of the joint). The planning of operations in patients with dysplastic coxarthrosis rests on the consideration of 8 basic factors that influence the disease by means of factorial analysis and determination of the prognostic estimations of the treatment efficacy.