Two-stage Treatment Research Articles

Среднесрочные результаты применения метода аутопластики медиального дефекта большеберцовой кости при первичном эндопротезировании коленного сустава

Introduction Repair of a bone defect in primary total knee arthroplasty remains one of the most common tasks that must be addressed intraoperatively. Autologous bone grafting is a good biological option to preserve the bone tissue for conservative revision. The objective of the study was to analyze the results of autologous bone grafting of the medial tibial defect in primary total knee arthroplasty. Material and methods Results of autografting a bone defect with cancellous bone obtained when forming a groove for the intercondylar box of the femoral component of the tibia during primary total knee arthroplasty were retrospectively analyzed (main group, n = 31). The control group (n = 31) was formed by leveling the heterogeneous clinical parameters identified in the initial data using the PSM method. The mean follow-up period was 72 months. The Mann-Whitney and Wilcoxon tests were used for statistical data analysis. Lower limb realignment and bone graft reconstruction were evaluated radiographically, and KSS and WOMAC questionnaires were used for physical evaluation. Results There were no significant differences in the baseline and postoperative clinical conditions of the realigned lower limbs and the number of identified non-progressive radiolucent lines no greater than 2 mm in the groups. There were significant differences in the severity of varus deformity at baseline. Each group had one case of aseptic loosening of the tibial component. One patient of the comparison group had a late periprosthetic joint infection that was arrested with two-stage revision treatment. Discussion There were significant differences in the size of the varus deformity with no significant differences in the scores at the baseline between the groups. There were no differences in the realigned lower limbs and in the scores reported in the groups postoperatively. Conclusion The method developed was shown to be safe, affordable and effective. The result obtained was confirmed by absent differences in clinical and radiological outcomes between groups.

Reverse Shoulder Arthroplasty After Communited Humerus Fracture: А Case Report

Background. Fractures of the proximal humerus are common injury, especially among older age group patients. For the treatment of most cases, conservative tactics are required, some require surgery: osteosynthesis, arthroplasty. Proximal humerus fractures with extension to the metadiaphyseal and diaphyseal zones uncommon, and treatment of this type of injuries is complex for trauma surgeons.
 The aim of the study is to demonstrate successful experience of two-stage treatment of the proximal humerus fracture with extension to the diaphysis middle third in an older age group patient.
 Case presentation. The clinical case presents successful two-stage treatment of the proximal humerus fracture with extension to the middle third of the diaphysis in an older age group patient. The first stage was performed osteosynthesis of the humerus with the PHILOS Long plate, the second stage reverse shoulder arthroplasty.
 Conclusion. Consistent performing of osteosynthesis and total reverse shoulder arthroplasty allows to achieve satisfactory treatment results with restoration of the injured limb function and relief of pain syndrome.

Dark fermentation as an environmentally sustainable WIN-WIN solution for bioenergy production

The current energy and environmental crisis, linked to increasing industrialisation, has progressively driven the adoption of solutions focused on circular life cycle thinking, such as waste management with resource recovery and decarbonization of technologies. In this context, this study was built to quantify the environmental performance of a two-stage wastewater treatment process (dark fermentation with anaerobic digestion) in which three feedstocks (sugar beet molasses, cheese whey and wine vinasses mixed with wastewater treatment plant sludge) from the food industry were valorized as hydrogen. In this regard, several environmental profiles were created using the Life Cycle Assessment methodology with two system boundaries (cradle-to-gate and gate-to-gate) and two methods (ReCiPe Midpoint and Endpoint). Furthermore, this research was synergistically complemented with an energy analysis including indicators and input-output flow balances to provide a win-win solution for food waste utilization. The results have taken different directions depending on the methodological assumptions considered but, in general terms, the sugar beet molasses scenario can be claimed in all cases as the energetically sustainable process with the best environmental profile. With an energy surplus of 155%, the cradle-to-gate scenario recorded the best environmental impact in 4/8 midpoint categories and an overall reduction of 67% and 94% (excluding co-products) for the ReCiPe damage single score compared to the wine vinasses and wastewater treatment plant sludge and cheese whey scenarios, respectively. In this sense, the viability and competitiveness of these two scenarios is compromised by the lack of energy self-sufficiency (there is a 53% deficiency in the wine vinasses and wastewater treatment sludge scenario) and the lack of climate-neutral outcomes (a result of 5510 mPt/Nm3 H2 shows that the cheese whey scenario is far from being a zero-emission process).

Understanding the role of faster emergency medical service response in the survival time of pedestrians

Fatalities and severe injuries among vulnerable road users, particularly pedestrians, are rising. In addition to the loss of life, about 6,000 annual pedestrian deaths in the U.S. cost society about $6 billion. Contrary to the assumption that all fatal pedestrian-involved crashes are similar, instantaneous death is substantially more severe than death that occurs several days after the crash. Instead of homogenizing all fatal pedestrian crashes, this study takes into account the severity of fatal injury crashes as a timeline based on the survival time of pedestrians. This study extracts valuable information from fatal crashes by examining pedestrians' survival time ranging from early death to death within 30 days of the crash. The Fatality Analysis Reporting System dataset is utilized from 2015 to 2018. The emergency medical service (EMS) response time is the key post-crash measure, while controlling for pedestrian, driver, roadway, and environmental characteristics. Notably, the response time and survival time can cause endogeneity, i.e., the response times may be shorter for more severe crashes. Due to the spatial and temporal nature of traffic crashes, to extract the association of different variables with pedestrians' survival time, a geographically and temporally weighted truncated regression with a two-stage residual inclusion treatment (local model) is estimated. The local model can overcome the endogeneity limitation (between EMS response time and survival time) and uncover the potentially spatially and temporally varying correlates of pedestrians’ survival time with associated factors to account for unobserved heterogeneity. Moreover, to verify the variations are noticeable, a truncated regression with the two-stage residual inclusion treatment is developed (global model). The modeling results indicate that while capturing the unobserved heterogeneity, the local model outperformed the global model. The empirical results show that EMS response time, speeding, and some pedestrian behaviors are the most important factors that affect pedestrians’ survival time in fatal injury crashes. However, the effect of factors on pedestrians’ survival time is noticeably varied spatially and temporally. The results and their implications are discussed in detail in the paper.

Single-Stage Surgical Treatment of Multi-ligament Knee Injuries Results in Lower Cost and Fewer Complications and Unplanned Reoperations Compared With Staged Treatment

PurposeTo compare complications, unplanned reoperations, and costs between single-stage and 2-stage treatment of multi-ligament knee injuries.MethodsThe MarketScan database was queried (2007-2016), identifying patients undergoing surgery for a multi-ligament knee injury. The single-stage cohort was defined as having at least 2 Current Procedural Terminology codes for ligament reconstruction at the index procedure without a Current Procedural Terminology code for ligament reconstruction appearing in the database for the following 12 months. The 2-stage cohort was defined as undergoing multiple ligament reconstruction procedures within a 12-month period with subsequent ligament procedure codes that differed from the index ligament reconstruction codes. Propensity score matching was performed using a greedy nearest-neighbor algorithm to match specific injury patterns between the 2 cohorts. Baseline demographic characteristics, medical comorbidities, and the Charlson Comorbidity Index were recorded. Complications, unplanned reoperations, and total health care expenditures were recorded for up to 5-year follow-up. Two-sample t tests, χ2 tests, and Fisher exact tests were used with an α level of .05 set as significant.ResultsWe identified 1,150 patients who underwent surgery for multi-ligament knee injuries (1,080 with single-stage approach and 270 with 2-stage approach). No significant differences in baseline characteristics or medical comorbidities were found between the cohorts. After propensity score matching, the single-stage group had fewer complications at 30, 90, 180, and 365 days (P < .05). Two-stage treatment increased the risk of reoperation at 1 year (5.5 times) and 2 years (4.9 times) after the index procedure. Health care expenditures were lower in the first 9 months for the staged cohort, but from 9 months ($31,210 vs $22,252, P < .0001) through 5 years, total costs were higher in this group.ConclusionsSingle-stage surgical treatment of multi-ligament knee injuries results in fewer complications and reoperations and lower total costs compared with 2-stage treatment, even after controlling for the number and combination of ligaments injured.Level of EvidenceLevel III, retrospective cohort study.

Combination of high-speed softening heat treatment and aluminizing blanks for the manufacture of steam heater tubes in a single technological process

Problem. At domestic metallurgical plants, recrystallization annealing in hood furnaces is used to weaken cold-rolled sheet steel from low-gauge steels, which does not allow obtaining the required level of properties in blanks for electrically welded tubes of steam heaters. Goal. The purpose of this work is to provide 08kp steel blanks with sufficient strength while increasing technological plasticity and preventing deformation aging for defect-free production of tubes. Solving this issue is relevant and has an undeniable practical significance. Methodology. Cold-rolled 08kp sheet steel with a thickness of 0.6 mm was studied, which had a textured structure with a grain size of 70–80 μm and the following mechanical properties: ϬВ = 810 MPa, ϬТ = 640 MPa, δ = 2 %. To ensure technological plasticity, the tube blanks were subjected to high-speed (80 ºС/s) one-time and cyclic two-time recrystallization annealing by means of contact electric heating. During single heating, the temperature varied from 650 to 750 °C with a holding time of 10, 15, and 20s, and during cyclic heating it was equal to 680, 700, and 720°C with the same holding time. Cooling after one-time heating was in air, between cycles and final cooling to 400°C in air and then in water. After annealing, the steel was subjected to aging at a temperature of 400 °C with periods from 2s to 2 min. The effectiveness of the results was evaluated by the microstructure. Results. Recrystallization annealing at 700ºC with a holding time of 20s provided a complex of mechanical properties, which in terms of level practically corresponds to the values after cap annealing. Natural aging within 5 days leads to a significant drop in plasticity. Two-stage heat treatment: annealing at 680 ºС with a holding time of 10s and cooling between cycles and final in air to 400ºС, and further in water, and aging at 400ºС for 2 min. significantly improved the level of properties: Ϭв = 350 MPa, Ϭт = 250 MPa, δ = 34.5% and ensured the absence of natural aging within a month. The technology of high-speed alitization of the sheet surface, which is combined in a single cycle with weakening heat treatment, has also been developed. Originality. For the first time, high-speed cyclic annealing was used as a softening heat treatment of a cold-rolled sheet. Practical value. The obtained results satisfy thecustomer's requirements for high-quality defect-free production of steam heater tubes that work in conditions of high temperatures, aggressive environment and significant pressure. The tubes have passed 100 % industrial control for stretching, flattening and corrosion resistance.

FEATURES OF REPLACEMENT OF EXTENSIVE POST-RESECTION BONE DEFECTS IN PELVIC AND SACRAL TUMORS

Purpose of the study . To represent the results of a two-stage surgical treatment in patients with extensive pelvic bone defects. Materials and methods . Data on 7 patients who underwent surgery for pelvic and sacrum tumors at the National Medical Research Centre for Oncology from 2016 up to 2020 are presented. The average age of the patients was 36 years. Patients with massive tumors that required a major resection of the posterior pelvis and the formation of an extensive bone defect requiring reconstruction with massive allografts and implants were selected for the study. 5 patients underwent different variations of sacrectomies with the resection of the iliac bones; 2 patients – interiliac-abdominal resections. For all these patients, surgical treatment was split into 2 stages. Results . At the first stage we performed: 5 surgical interventions (total or extended sacrectomy at L5–S1 with lumbar-iliac bilateral stabilization with an 8‑screw pedicle system) in patients with sacral tumors. In 2 cases, an interilio-abdominal resection with the defect replacement with cement articulating spacer. Intraoperative blood loss on average was 1.8L. We used autohemotransfusion to compensate the intraoperative blood loss. The 2nd (reconstructive) stage was completed on average after 3 months. The reconstructive stage was not accompanied by major trauma in all patients. The average blood loss was approximately 800 ml. There were no complications after the reconstructive surgical stage. Conclusion . The described two-stage technique allowed to avoid severe infectious complications requiring removal of implants and grafts in all patients. Adequate spinal pelvic stabilization and/or spacing of the defect contributed to early functional rehabilitation of patients and the continuation of adequate adjuvant therapy in the interstage period. The delaying of the reconstruction allowed to reduce the duration and invasiveness of the main intervention without affecting the final result of treatment.

Оценка функциональных результатов лечения пациентов с различными хирургическими подходами удаления хрусталика при регматогенной отслойке сетчатки

Currently, the most popular treatment for retinal detachment is microinvasive vitrectomy with vitreous cavity tamponade. Often, surgical intervention in the posterior segment is preceded by the removal of the lens with intraocular lens implantation. However, when there is the absence of opacities in the lens in a young patient, another surgical tactic – the preservation of the native lens and the implementation of delayed phacoemulsification can be used. In the present study, we compared two groups of patients who were treated for rhegmatogenous retinal detachment with simultaneous removal of the lens and two-stage treatment with preservation of the native lens at the first stage of treatment. The comparison was carried out on quantitative and qualitative features. Quantitative features included: age of the patient; value of the anterior-posterior axis of the eye (APO); BCVA value before surgery and in the early postoperative period (from 1 to 3 months after surgery). Qualitative features included: detachment age (up to a month; 1–3 months; more than 3 months); macula capture (presence, absence); tactics of lens surgery (combined operation (single-stage) or combined (two-stage treatment). According to the results of the retrospective analysis, it was found that patients of the compared groups differed significantly only in the value of BCVA before surgery. However, despite the absence of significant differences between the compared groups in terms of qualitative features, it should be assumed that the decrease in the value of BCVA in patients of the second group is more related to the age of retinal detachment. Concerning the lack of a statistically significant relationship between the dynamics of BCVA and the tactics of cataract surgery, it should be assumed that both approaches to patient management take place in practical ophthalmology. Keywords: retinal detachment, cataract, combined operations.

Application of one-stage surgical tactics treatment of acute cholecystitis in combination with choledocholithiasis

Introduction: Concrements of the common bile duct (choledocholithiasis) occur from 8% to 20% in patients with acute cholecystitis. This pathology requires simultaneous correction of the pathology of the gallbladder and the common bile duct. Methods: We retrospectively analyzed the case histories of 135 patients who underwent endoscopic retrograde cholangio pancreatography, endoscopic papillosphincterotomy, choledocholithoextraction followed by laparoscopic cholecystectomy + CHEST + LCE) for acute cholecystitis in combination with choledocholithiasis in the period from January 2016 to March 2021. Patients who underwent simultaneous treatment (ERCP + EPST + CLE + LCE under one anesthesia) were assigned to the OS group (n = 63), patients who underwent two-stage treatment (ERCP + EPST + CLE and LCE on the 3-4th day during one hospitalization) were assigned to the TS group (n = 72). All endoscopic procedures in both groups were performed by the same endoscopist using the same technique. Result: There were significant differences between the groups in terms of the duration of anesthesia, the dynamics of the decrease in the blood serum of the total bilirubin and the leukocytes range at the postoperative period, the frequency of postoperative complications and the duration of the average hospitalization in favor of one-stage treatment. &#x0D;

Fractionation of Lignocellulosic Fibrous Straw Digestate by Combined Hydrothermal and Enzymatic Treatment

In industrial-scale biogas production from cereal straw, large quantities of solid fiber-rich digestate are produced as residual material. These residues usually contain high amounts of cellulose, hemicellulose and lignin and thus have potential for further utilization. However, they also contain impurities such as ammonia and minerals, which could negatively affect further utilization. Against this background, the present study investigates how this fibrous straw digestate can be fractionated by a combined hydrothermal and enzymatic treatment and what influence the impurities have in this process. Therefore, it is analyzed how the fractions cellulose, hemicellulose and lignin are modified by this two-stage treatment, using either raw digestate (including all impurities) or washed digestate (containing only purified fibers) as the substrate. For both substrates, around 50% of the hemicellulose is solubilized to xylans after 50 min of hydrothermal treatment using steam at 180 ∘C. Furthermore, by subsequent enzymatic treatment, around 90% and 92% of the cellulose and hemicellulose still contained in the solids are hydrolyzed to glucose and xylose, respectively. Lignin accumulates in the remaining solid but structurally degrades during the hydrothermal treatment, which is indicated by decreasing ether and ester bond contents with increasing treatment times. Impurities contained within the raw digestate do not hinder this fractionation; they even seem to positively affect hemicellulose and cellulose valorization, but apparently lead to a slightly higher lignin degradation.

One-stage approach to cholecystocholedocholithiasis treatment: a feasible surgical strategy for emergency settings and frail patients.

Cholecystocholedocholithiasis (CCL) occurs in up to 18% of patients undergoing laparoscopic cholecystectomy (LC). The two-stage treatment using endoscopic retrograde cholangiopancreatography (ERCP) followed by LC is the treatment of choice for CCL. However, only 10 to 60% of patients have common bile duct (CBD) stones at the time of ERCP, thus exposing patients to unnecessary ERCPs, causing 3 to 15% of post-interventional pancreatitis. One-stage laparoscopic-endoscopic rendezvous (LERV) is an alternative for the treatment of CCL. Given the selective top-to-bottom CBD cannulation, LERV reduces the risk of pancreatitis and failed CBD cannulation. Additionally, LERV is performed exclusively in patients presenting CBD stones at intraoperative cholangiography, avoiding unnecessary ERCPs. Despite its advantages, considering the logistical burden of coordinating different specialties, LERV is performed in few centers. Here, we present the largest retrospective series of LERVs performed at our department, analyzing elective and emergency procedures. All consecutive patients undergoing LERV for CCL between January2014 and December2021 were included. LERV success rate, operative time, biliary outflow restoration rate, postoperative complications (POC), length of hospital stay (LOS), and recurrences were analyzed. 181patients were included (61elective LERVs, 120emergency LERVs). We reported a 100% LERV success rate, a 97.79% biliary outflow restoration rate, a 0% conversion rate, a mean intraoperative time of 120.17 ± 31.35min, and LOS of 4.00 ± 2.82days. POC included 7Clavien-Dindo type 1, 11type2, and 3type3 cases. Seven patients presented with CBD stone recurrence: 2 within 30days after discharge, 3 within 6 months after discharge, and 2patients at 1year. No statistically significant difference was found between elective and emergency patients. LERV is safe, representing a valid option even in emergency settings, thus enabling the management of CCL within a single procedure, consequently sparing additional anesthesia and decreasing post-ERCP complications.

Effect of a High-Temperature Treatment on Structural-Phase State and Mechanical Properties of IMC of the Ti-25Al-25Nb at.% System.

In this research, samples of an alloy with a bimodal structure were studied on the basis of a previously developed technology for obtaining hydrogen storage materials based on the Ti-Al-Nb system. The results of SPS of mechanically activated powder mixtures of the Ti-Al-Nb system at a temperature of 1300 °C make it possible to obtain an alloy with a predominantly bimodal structure. However, an insignificant presence of TiAl3, AlNb2 phases, and unreacted niobium is still observed in the structure. The mechanical properties of alloys of the Ti-Al-Nb system after sintering show abnormally low values of strength and ductility (less than 150 MPa). Two-stage heat treatment of alloys of the Ti-Al-Nb system leads to the decomposition of large precipitates of TiAl3 with the formation of O-phase nuclei, as well as to the complete dissolution of unreacted niobium and AlNb2 phases. Heat treatment of alloys of the Ti-Al-Nb system contributes to an increase in its strength by approximately 10 times (1310 MPa, MA-180), and ductility by 2 times (1322 MPa, MA-20). The surface fracture of samples obtained after testing is characterized by intergranular (intercrystalline) brittle fracture with “river” or “step” features.

Метод двухэтапного лечения пациентов с тотальными и субтотальными дефектами стопы при нейроостеоартропатии Шарко

Introduction One of the complications of diabetes mellitus is Charcot's osteoarthropathy, associated with the development of angio-neuropathic and metabolic disorders in the foot and loss of limb weight-bearing. Its association with purulent infection not only worsens the quality of life of patients, but also poses a threat to life. The literature reports very conflicting information about the choice of reconstruction technologies and methods of foot fixation. The lack of unified approaches and generally recognized protocols indicates the dissatisfaction of orthopedists with the results achieved and the imperfection of the technologies used. The aim of the work is to evaluate the effectiveness of the combined use of the Masquelet technology and Ilizarov transosseous osteosynthesis in Charcot osteoarthropathy in conditions of purulent infection. Material and methods The authors present an original approach to foot reconstruction in 8 patients, based on the combined use of the Masquelet technology and Ilizarov transosseous osteosynthesis. The follow-up period ranged from 1 to 11 months from the date of the primary operation. Results In all patients treated by this technique, the limb support was restored. Nonunion, loss of correction, and late infection complications were not detected. Discussion The combined use of transosseous osteosynthesis allows discrete correction of multicomponent foot deformities without creating additional angiotrophic disorders, and the use of Masquelet bone grafting to sanitize pathologically altered tissues with the formation of an induced membrane that produces growth factors and has antimicrobial activity. Choosing the tactics of treatment for preservation of the foot as an organ in patients with severe condition of the feet with Charcot osteoarthropathy, the method of two-stage surgical treatment is justified and provides length compensation of the segments, limb support even in cases where, at first glance, amputation has relative indications. Conclusion Differentiated application of the Ilizarov and Masquelet technologies is effective and justified in conditions of Charcot's arthropathy.

Periprosthetic Joint Infections Caused by Candida Species-A Single-Center Experience and Systematic Review of the Literature.

Background: The aim of this study was to analyze the treatment results of fungal periprosthetic joint infections (PJI) caused by Candida species from a single orthopedic center and to compare them with reports from other institutions. Methods: Eight patients operated on from January 2014 to December 2021 met the inclusion criteria and were analyzed in terms of clinical outcomes. A systematic review of the literature identified 153 patients with Candida PJIs extracted from 12 studies according to the PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. Results: The success rate of the treatment in the case series was 50%. The most frequent pathogens were Candida albicans (three cases; 37.5%) and Candida parapsilosis (three cases; 37.5%). In one patient (12.5%), bacterial co-infection was noted, and in five patients (62.5%) significant risk factors of PJI were confirmed. The overall success rate on the basis of data collected for systematic review was 65.5%. A sub-analysis of 127 patients revealed statistically significant differences (p = 0.02) with a higher success rate for the knees (77.6%) than for the hips (58%). In 10 studies the analysis of risk factors was performed and among 106 patients in 77 (72.6%) comorbidities predispose to fungal PJI were confirmed. Bacterial co-infection was noted in 84 patients (54.9%). In 93 patients (60.7%) Candida albicans was the culprit pathogen, and in 39 patients (25.5%) Candida parapsilosis was the culprit pathogen. Based on these two most frequent Candida species causing PJI, the success rate of the treatment was statistically different (p = 0.03), and was 60.3% and 83.3%, respectively. The two-stage strategy was more favorable for patients with Candida parapsilosis infections (94.4% success rate) than the one-stage protocol (50% success rate; p = 0.02); as well as in comparison to the two-stage treatment of Candida albicans (65% success rate; p = 0.04). Conclusions: The analysis of the literature showed no differences in the overall success rate between one- and two-stage surgical strategies for all Candida species, but differed significantly comparing the two most frequent strains and concerning PJI localization. The frequent presence of bacterial co-infections makes it necessary to consider the additional administration of antibiotics in the case of fungal PJI.

Effect of Cd on Mechanical Properties of Al-Si-Cu-Mg Alloys under Different Multi-Stage Solution Heat Treatment

Multi-stage heat treatment is an important method to improve the mechanical properties of Al-Si-Cu-Mg aluminum alloys. In this paper, the multi-stage heat treatment was carried out for the Cd-free and Cd-containing alloys. The experimental results show that the addition of Cd promoted the precipitation of Q″ and θ″, which led to the formation of a large number of fine, dispersed precipitates and a higher yield strength (YS) and ultimate tensile strength (UTS) for the Cd-containing alloys. The addition of Cd also altered the optimal heat treatment parameters. For the Cd-free alloys, the Cu-rich phase fully dissolved after three-stage heat treatment, and the YS and UTS of the three-stage heat-treated alloys were higher than their two-stage heat-treated counterparts. For the Cd-containing alloys, the three-stage heat treatment led to the precipitation of Cd-rich low melting point phases, caused defects, and reduced the mechanical properties of the alloy. The size and volume fractions of the precipitates were significantly less than those of the alloys after two-stage heat treatment and the strength of the alloys decreased. Therefore, the solution time should be strictly controlled for Cd-containing Al-Si-Cu-Mg alloys.

Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer

BackgroundThe current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. MethodsAn institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. ResultsA comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. ConclusionAge, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.

Two-stage tendoplasty of the flexor digitorum profundus in a small child

BACKGROUND: Injuries to the flexor tendons of the fingers are uncommon in young children, and chronic injury is an extremely rare injury. Many issues of damage diagnosis, surgical intervention and rehabilitation techniques remain unresolved. In this regard, the treatment of chronic damage to the flexor tendons of the fingers in young children has practical and theoretical significances.&#x0D; CLINICAL CASE: A 16-month old underwent a two-stage treatment of chronic damage to the flexor tendons of the small finger. At the first stage, scars were removed from the fibro-synovial canal, and a silicone rod was inserted into the canal. At the second stage, the silicone spacer was replaced by a tendon autograft. The surgical treatment and postoperative management of the patient was described in detail. The full range (270 degrees) of active and passive motion was restored five months after the second stage of tendoplasty. Two years after the operation, good hand function.&#x0D; DISCUSSION: The analyzed publications mainly present the results of treatment of patients older than 1 year and 4 months. Only in the study by S.L. Piper et al. (2019) the youngest patient at the time of injury was 7 months old, at the time of first stage of tendoplasty 1 year and 3 months. The final volume of active motion was 160 degrees. In our case, the functional result was higher. Considering the undoubted rarity of damage uncharacteristic for this age, we intend to continue monitoring the patient.&#x0D; CONCLUSIONS: Comprehensive long-term treatment of a serious injury to the hand, considering the anatomical and physiological characteristics of a small child, made it possible to obtain a good functional result.

Bone regeneration after marginal bone resection in two-stage treatment of chronic long bone infection - a combined histopathological and clinical pilot study

IntroductionIn chronic bone infection, marginal bone resection avoids large and difficult to reconstruct bone defects. However, there is still a lack of knowledge on bone regeneration during chronic bone infection and bone healing capability after marginal bone resection. Therefore, the purpose of this study was to investigate the clinical and histopathological outcomes after marginal bone resection in chronic long bone infection. We hypothesized that there is a regenerative bone healing potential after marginal bone resection that results in an acceptable clinical outcome and improved pathohistological bone healing parameters during treatment. Materials and methodsNine patients were treated for chronic bone infections in a two-stage manner with marginal bone resection of the infected area and the placement of an antibiotic-loaded polymethyl methacrylate (PMMA) spacer at stage one followed by bone reconstruction at stage two combined with systemic antibiotic therapy. Comparable bone samples were harvested at the border region between vital and necrotic bone area during stage one and the identical location during stage two. Control bone samples were harvested from five healthy patients without bone infection. Clinical outcome in terms of infection eradication and bone consolidation were assessed. The phenotypic changes of osteocyte and morphological changes of lacunar-canalicular network were investigated by histological and immunohistochemical staining between the two observation periods. Furthermore, expression levels of major bone formation and resorption markers were investigated by immunohistochemical and tartrate-resistant acid phosphatase (TRAP) staining. ResultsThe clinical results with a follow-up of 12.9 months showed that eight of nine patients (88.9%) achieved bone consolidation after a planned two-stage procedure of marginal resection of necrotic bone and consecutive reconstruction. In four of the nine patients (44.4%), additional marginal debridements after stage two had to be performed. After marginal resection at stage one, the improved bone formation ability at stage two was demonstrated by significantly lower percentage of empty lacunae, significantly more mature osteocytes and higher BMP-2 positive cell density, whereas decreased resorption was indicated by significantly lower osteoclast density and RANKL/OPG ratio. In patients requiring additional debridement compared to patients without additional debridements, a significantly higher percentage of empty lacunae was found at stage one. ConclusionMarginal bone resection combined with local and systemic antibiotic therapy is a feasible treatment option to avoid large bone defects as bone from the marginal resection area seems to have good regenerative potential. Despite a high revision rate of 44.4%, this technique avoids large bone resection and revisions can be done by further marginal debridements.

The influence of anaerobic dechlorination on the aerobic degradation of PCBs in e-waste-contaminated soils in an anaerobic-aerobic two-stage treatment

The combination of microbial reductive dechlorination and aerobic oxidation (RD-AO) process was proposed to be a promising strategy for extensive bioremediation of highly chlorinated polychlorinated biphenyls (PCBs). Nonetheless, experimental evidence on the impact of the RD on subsequent AO in anaerobic-aerobic two-stage treatment remains scarce. The present study applied stable-isotope probing (SIP) to explore the RD-AO mediated degradation of PCBs in an e-waste-contaminated soil. The RD-AO treatment resulted in 37.1 % and 48.2 % degradation of PCB180 and PCB9, respectively, while the PCB9 degradation efficiency decreased compared to the sole AO (81.2 %). The inhibition of PCB aerobic degradation might be caused by the alteration of aerobic bacterial community, which was proved by a higher abundance of anaerobic bacteria and a lower abundance of aerobic bacteria being observed in the aerobic stage of RD-AO. Further evidence was obtained using DNA-SIP that the anaerobic stage altered the PCB degraders' community structures and changed three of the five degraders. There were four lineages (Arenimonas, Steroidobacter, Sulfurifustis, and Thermoanaerobacterales) identified as PCB degraders for the first time. Interestingly, three of them were found in RD-AO microcosm, suggesting that anaerobic-aerobic two-stage treatment can recruit novel bacteria involved in PCBs aerobic degradation. The present study provided novel insight into the synergistic integration of anaerobic and aerobic processes for extensive degradation of highly chlorinated PCBs.

Cellular Mechanisms in Acute and Chronic Wounds after PDT Therapy: An Update.

PDT is a two-stage treatment that combines light energy with a photosensitizer designed to destroy cancerous and precancerous cells after light activation. Photosensitizers are activated by a specific wavelength of light energy, usually from a laser. The photosensitizer is nontoxic until it is activated by light. However, after light activation, the photosensitizer becomes toxic to the targeted tissue. Among sensitizers, the topical use of ALA, a natural precursor of protoporphyrin IX, a precursor of the heme group, and a powerful photosensitizing agent, represents a turning point for PDT in the dermatological field, as it easily absorbable by the skin. Wound healing requires a complex interaction and coordination of different cells and molecules. Any alteration in these highly coordinated events can lead to either delayed or excessive healing. The goal of this review is to elucidate the cellular mechanisms involved, upon treatment with ALA-PDT, in chronic wounds, which are often associated with social isolation and high costs in terms of care.