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Background. Recent scientific literature only has a few studies highlighting the factors affecting the development of recurrent infection after surgical treatment of chronic osteomyelitis. Aim of the study: to determine significant risk factors of infection recurrence during one- and two-stage treatment of a cavity defect with synthetic materials in patients with chronic osteomyelitis and to create an assessment scale for prediction of the treatment outcome based on this data. Material and Methods. The retrospective study comprised 131 patients with chronic osteomyelitis of the long bones. The patients were divided into two groups based on the treatment outcome: group 1 (n=90) - successful elimination of infection; group 2 (n=41) - recurrent osteomyelitis after one-stage or during two-stage treatment. Differences between the groups were assessed to identify factors that affect the risk of recurrence. Multivariate analysis was performed using the classification tree method ​​to develop a scale for the comprehensive risk assessment of osteomyelitis recurrence (CRAOR). Results. The following factors affecting the treatment outcome were assessed: location (r=0.205, p=0.019); duration of osteomyelitis (r=0.23, p=0.007); history of debridement operations (r=0.264, p=0.002); bone defect volume (r=0.175, p=0.045); physiological class according to Cierny-Mader (r=0.188, p=0.004); anatomical type of osteomyelitis according to Cierny-Mader (r=0.15, p=0.086); nature of the pathogen (r=0.123, p=0.162). The degree of the osteomyelitis recurrence risk, threshold values ​​for quantitative factors and the total score the scale were established. In patients with a score 5, the risk of osteomyelitis recurrence increased by 8.1 times in one-stage treatment compared to patients with a score ≤5 (OR 8.143, CI 1.008-65.882). In two-stage treatment, patients with a score 5 had the risk of osteomyelitis recurrence increased by 4.1 times compared to patients with a score ≤5 (OR 4.059, CI 0.461-35.714). Based on the scale, an algorithm of treatment for these patients was developed.

Introduction Periprosthetic infection (PPI) is one of the most serious complications of primary arthroplasty. Its rates range between 1.1 and 2 %. This study presents a comparative analysis of the results of the sanitizing stage of two-stage treatment of patients with chronic PPI of the hip joint (HJ) using an antimicrobial spacer impregnated with highly dispersed silver and without its impregnation. Purpose To conduct a comparative analysis of the clinical efficacy of using HD-Ag for impregnation of an antimicrobial spacer in patients with chronic PPI HJ during the sanitizing stage. Materials and methods A retrospective study is based on the analysis of the treatment outcomes of 223 patients with PPI HJ with antimicrobial spacers implanted during the sanitizing stage. Two groups of patients were formed based on the impregnation of bone cement with only an antibiotic or its combination with HD-Ag, group 1 (n = 112) and group 2 (n = 111), respectively. The evaluation of the treatment outcomes at a follow-up period of at least 2 years was carried out in accordance with the modified Delphi criteria. The reliability of differences in quantitative parameters between the groups was analyzed using nonparametric Mann – Whitney test, whereas Fisher test was used to analyze relative indicators. The differences were considered significant at p < 0.05. Results The spectrum of pathogens was comparable in both groups. The recurrence rate in groups 1 and 2 was 23.2 % and 17.1 %, respectively (p > 0.05), while for monobacterial infection caused by gram-positive bacteria it was significantly lower in group 2 (p = 0.012). Discussion As reported, the recurrence rate of periprosthetic infection varies from 8 to 40 %, depending on the nature of the infectious process and the type of pathogen. In the group with the use of HD-Ag as part of an antimicrobial spacer, the effectiveness of the sanitizing stage was 82.9 % and in the comparison group it was 76.8 %. However, a subanalysis of the effect of the etiology of PPIs on treatment results showed that the use of AM-spacer with a combination of silver and vancomycin led to a statistically significant reduction in the risk of recurrence in patients with monobacterial infection caused by gram-positive pathogens and provided arrest of infection in 89.7 % of cases. Conclusion In the sanitizing stage of two-stage treatment of chronic peri-implant hip infection caused by gram-positive bacteria, the antimicrobial cement spacer impregnated with highly dispersed silver showed high efficiency. However, further development of new combinations for bone cement impregnation is required to expand the spectrum of antimicrobial activity of the spacers.

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 (p0.001). 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. 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 2023. 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.

Background. It is known that the outcomes of patients treatment with periprosthetic joint infection (PJI) are significantly influenced by the state of the patient’s body, the nature of the pathogen, the state of tissues in the area of the infectious focus and the treatment tactics. However, topographic and anatomical features of the blood supply to the knee and hip joints, as well as the volume of soft tissues, can affect the spectrum of pathogens, manifestations of the infectious process and, as a consequence, the effectiveness of treatment. The aim of the study was to conduct a comparative analysis of the somatic status of patients, the etiology of the infectious process and the effectiveness of treatment of PJI depending on its localization. Methods. A single-center retrospective study was conducted. The cases of 337 patients were studied — 119 patients with knee and 218 patients with hip PJI who underwent treatment with a two-stage technique during the period from 2007 to 2017. A comparative analysis of the PJI pathogens structure and concomitant pathology between patients with hip and knee PJI was carried out. The frequency of infection relief in the groups following the first stage was counted. Results. Recurrence was diagnosed four times more frequently in patients with hip PJI compared to knee PJI. Risk factors for recurrence were gram-negative pathogens, microbial associations, and fistulous forms of the infectious process. Localization of the infectious process in the hip area was associated with a statistically significant greater volume of blood loss during the prolonged debridement surgery. Conclusion. Recurrences of PJI occur more frequently in the hip area compared to the knee joint. Further analysis of critical factors in recurrence development is necessary for potential intervention.

Introduction Mycobacterium abscessus species belongs to the group of non-tuberculosis mycobacteria responsible for chronic infections in people with weakened immunity. M. abscessus exist in various ecological niches and are able to colonize artificial surfaces, including medical and surgical instruments/ devices. Due to the low incidence of M. abscessus as a causative agent of orthopedic infection, a rare clinical case of periprosthetic infection caused by M. abscessus would interest practitioners. The aim is to present a clinical case of periprosthetic infection caused by M. abscessus. Materials and methods From the medical records and discharge documents, it was known that female patient X. underwent total hip replacement at her residence hospital. Signs of acute infection of the postoperative wound appeared in the early postoperative period. Results Three months later, the patient was hospitalized in a specialized institution with a diagnosis of chronic deep periprosthetic infection. During the examination, the mycobacterial etiology of the process was established. During two hospitalizations, the patient underwent 4 consecutive revision surgeries (including muscle plastic surgery and installation of an antimicrobial spacer) and massive parenteral antibiotic therapy for 8 months, including at the outpatient stage, using at least 3 antibacterial agents. After 4 years, the patient does not complain of the infectious process. Postoperative scar is 45 cm. The residual shortening of the right lower limb of 3 cm was compensated by orthopedic shoes. Discussion Treatment of infection caused by M. abscessus is challenging due to the natural resistance of the pathogen to a wide range of antibacterial drugs. The literature describes separate cases of orthopedic infections caused by this pathogen. All authors agree that the key to successful treatment is a combination of radical surgical debridement and antibacterial therapy using at least three antimicrobial drugs. Conclusion A rare clinical case of periprosthetic infection caused by Mycobacterium abscessus after primary hip replacement is presented. This infectious agent is a rare pathogen, for which there is no proven therapeutic algorithm. Long-term aggressive antibiotic therapy in combination with stage-by-stage surgical treatment was successful.

Background. Resection arthroplasty with non-free muscle flap transfer allows to quickly eliminate the infection, but resulting in functional impairment of hip joint. To date, there are only a few publications with a small number of observations, where the proportion of patients who underwent the second stage of the revision hip arthroplasty (rTHA) is extremely small. The aim of the study was to evaluate the effect of resection arthroplasty on the functional outcomes and incidence of adverse outcomes in patients with difficult-to-treat (DTT) periprosthetic infection who had previously undergone resection arthroplasty with a non-free transfer of the axial flap fom the vastus lateralis muscle. Methods. The prospective study included 24 patients. During the period 20112021, at the first stage of the treatment for chronic recurrent DTT PJI of the hip, resection arthroplasty was performed with a non-free transfer of an island flap from the vastus lateralis muscle. Subsequent reimplantation of the endoprosthesis was performed in at least 1 year after the infection remission. The functional outcomes, degree of the lower limb shortening immediately before and in two or more years after revision arthroplasty (rTHA), the results of the microbiological cultures at the first and second stages of PJI treatment, technical aspects of the surgery as well as the postoperative period and long-term PJI remission were studied. Results. Revision arthroplasty resulted in a statistically significant improvement of the postoperative functional outcome and quality of life in patients. The average Harris score agter rTHA increased from 53 to 83 points after surgery, EQ-5D degree of the quality of life increased from 50 points to 80, the overall score from 0.61 to 0.74 and average intensity of pain via VAS decreased from 3 points to 1 point in 3.1 years after rTHA (p0.05). After reEP, complete restoration of the limb length was achieved in 29.1% of cases (n = 7) with an average compensation of the limb length for 4.5 cm. In 66.7% of patients (n = 16), the results of the intraoperative tissue biopsy microbiological analysis during reEP were culture negative. The recurrence rate of PJI was 12.5% (n = 3) up to 30 days after rTHA and 4.2% (n = 1) with a follow-up period of 3.1 years (IQR 2.14.1). With a single revision surgery performed without a delay, stable remission of DTT PJI was 95.8%. Conclusion. Complex two-stage surgical treatment using resection arthroplasty with a non-free muscle flap transfer at the stage of debridement and subsequent revision has demonstrated high efficiency in eliminating the infectious process as well as restoring weight-bearing capacity and extremity function. It could be recommended as a method of choice in the treatment of patients with DTT PJI of hip joint.

Background. Protein-energy malnutrition (PEM) is an established risk factor of postoperative complications in orthopedic disorders, including arthroplasty of the large joints. The study aimed to evaluate PEM prevalence and its association with the early postoperative revision in patients with the difficult-to-treat (DTT) prosthetic joint infection (PJI) of the hip. Methods. The retrospective study included 132 patients with chronic DTT PJI of the hip. The patients underwent orthopedic implant removal, radical debridement of the infected tissues, and resection arthroplasty with non-free transplantation of an axial vastus lateralis muscle flap (n = 57) or installation of an antimicrobial spacer (n = 75). DTT PJI was defined as an infection caused by rifampicin-resistant staphylococcal strains, ciprofloxacin-resistant gram-negative bacteria, fungi of the genus Candida, and their associations. The assessment of the patients protein-energy status included the evaluation of reference laboratory parameters, such as levels of hemoglobin, total protein, and albumin and number of lymphocytes. The degree of PEM was determined by the number of laboratory markers below the threshold values. The statistical comparison was performed using Fishers test. The odds ratio (OR, 95% confidence interval [CI]) was calculated to assess the risk of PJI recurrence. Differences were considered significant at p0.05. Results. More than 70% of patients with chronic DTT PJI included in the study were diagnosed with preoperative PEM of varying degrees of severity. Hypoalbuminemia and decreased hemoglobin levels were diagnosed more often: 64.3% and 57.1% in the muscle flap plasty and 57.3% and 31.1% in the antimicrobial spacer group, respectively. In muscle plasty and antimicrobial spacer groups, a decrease in the values of three or more reference PEM markers was detected in 28.5% and 16.0% of patients, and this advanced impairment of the nutritional status increased the risk of early revision intervention by two (OR 2.0; CI 95% 0.478.56; p = 0.35) and six times (OR 6.11; 95% CI 1.0635.35; p0.04), respectively. Conclusion. In general, the analysis of publications and results of our study show that PEM is associated with the development of surgical site infection and recurrence of PJI after revision surgery. A decrease in the values of three or more reference PEM markers is a significant predictor of repeated revisions after debridement surgery with the installation of an antimicrobial spacer. PEM complicates the postoperative course in patients with resection arthroplasty. Given the high incidence of PEM in patients with DTT PJI of the hip joint, further research is needed to develop methods for nutritional status correction and assessment of their effect on the outcomes of debridement surgery.