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The aim of the study – Is to evaluate the effectiveness and safety of the use of a functional unloading orthosis with the possibility of varus–valgus correction (FUOVVC) in patients with stage III osteoarthritis of the knee joint.Materials and methods. The study involved 10 patients with stage III osteoarthritis of the knee joint who underwent outpatient treatment at the V.A. Nasonova Federal State Medical University of the Russian Academy of Medical Sciences. All patients used the FUOVVC for 3 months. To evaluate the results, pain intensity was determined using a visual analog scale (VAS) and knee joint function according to the knee injury and osteoarthritis KOOS (Knee injury and Osteoarthritis Outcome Score) questionnaire before using the orthosis, after 1 and 3 months. Additionally, the assessment of VAS was carried out immediately after fixation of the orthosis on the knee joint.Results. The median age of the patients was 63.5 [55.0; 74.0] years, body mass index – 29.9 [27.9; 34.0] kg/m2, pain according to VAS baseline – 40.0 [40.0; 60.0] mm, pain according to VAS 1 hour after the start of the use of The median age of the patients was 63.5 [55.0; 74.0] years, body mass index – 29.9 [27.9; 34.0] kg/m2, pain according to VAS baseline – 40.0 [40.0; 60.0] mm, pain according to VAS 1 hour after the start of the use of FUOVVC – 25.0 [10.0; 30.0] mm, pain according to VAS after 1 month – 10.0 [0.0; 20.0] mm, VAS after 3 months – 10.0 [0.0; 20.0] mm. The median score according to the KOOS questionnaire was initially 41.5 [38.0; 50.0], after 1 month – 61.0 [53.0; 63.0], after 3 months – 63.5 [58.0; 64.0]. None of the patients had any adverse events when wearing the FUOVVC. – 25.0 [10.0; 30.0] mm, pain according to VAS after 1 month – 10.0 [0.0; 20.0] mm, VAS after 3 months – 10.0 [0.0; 20.0] mm. The median score according to the KOOS questionnaire was initially 41.5 [38.0; 50.0], after 1 month – 61.0 [53.0; 63.0], after 3 months – 63.5 [58.0; 64.0]. None of the patients had any adverse events when wearing the FUOVVC.

Introduction. Hip-spine syndrome (HSS) is a combination of coexisting hip osteoarthritis (OA) and degenerative lumbar spine stenosis (LSS). Main difficulties in treating patients with HSS are in early diagnostics and in choosing right surgery, because mistakes lead to pain maintenance. Existing diagnostic algorithms show right surgery choosing failure in 15–20%. We present results of examination patients with HSS in our survey.The aim – to present clinical and instrumental results of examination of patients with hip-spine syndrome.Materials and methods. We have examined 378 patients with typical pain pattern (buttocks, low back spine, groin and lateral hip) and difficulties in pain source definition. We performed hip X-rays and low back spine MRI.Due to results we divided patients into three groups – patients with HSS (n=100), with hip OA (n=172) and patients with LSS (n=106). We used Harris Hip Score, Oswestry Disability Index and Visual Analogue Score to determine hip and lumbar spine functional status and pain level.Results. Patients with HSS had higher (p

Injuries cause a systemic neurohumoral and behavioral response of the body, aimed at restoring damaged tissues and correcting biomechanical disorders. However, in many cases, full-fledged repair is impossible – traumatic injury, inflammation that occurs against its background, and degenerative processes (fibrosis, neoangiogenesis, heterotopic ossification) lead to severe structural changes and a progressive decrease in functional ability. The most common complications of trauma include chronic post-traumatic pain and post-traumatic osteoarthritis (PTOA). These complications are interrelated – pain (accompanied by stiffness and dysfunction) that occurs in 10–50% of people who have suffered a joint injury may indicate the formation of early (pre-radiological) stages of PTOA. The development of typical structural changes in PTOA is observed 10–15 years after a knee injury (in >30% of patients). PTOA of large joints is more aggressive, often accompanied by synovitis, and requires arthroplasty on average 10–15 years earlier than primary osteoarthritis. Early diagnosis of PTOA is based on the analysis of the dynamics of clinical manifestations (primarily post-traumatic pain), visualization of early changes in the structure of the joint (magnetic resonance imaging), as well as the study of the level of biomarkers of inflammation and osteochondral destruction. As additional risk factors for PTOA, genetic features are considered that determine the chronicity of inflammation, pain, and impaired repair of cartilage and bone tissue.

Avascular necrosis (AN) of bone tissue is a common pathology that affects people of any age, more often young and able-bodied. The disease leads to rapid destruction of the subchondral bone and collapse, followed by the development of secondary osteoarthritis (OA) of the affected joint.The purpose of this review article is to present the accumulated knowledge about the prevalence of AN, the most commonly affected joints, risk factors and pathogenesis of the disease. Since most of the world’s literature sources present knowledge about the individual parts and facts that make up the pathogenesis of AN, this article analyzes all known paths of the development of the disease from the onset of ischemia to collapse and the development of secondary OA and the pathogenesis is presented in chronological order. Based on the results of the article, a definition of the term AN was proposed, and the stages of the disease within the pathogenesis, the most promising for conservative methods of treatment, were identified.

Pain in the shoulder joint is one of the most common reasons for seeking medical help associated with the pathology of the musculoskeletal system. The most common disease in this area that causes chronic pain is impeachment syndrome (IS) of the rotator muscles of the shoulder. The domestic literature describes in sufficient detail surgical and conservative approaches for lesions of the shoulder joint, but there are only a few publications on the types of IS. This review is devoted to the description of all occurring types of compression of the tendons of the muscles of the rotator cuff of the shoulder joint within the framework of IS.

Objective – to assess the effect of patient-specific parameters (age, body mass index (BMI), stage of the knee osteoarthritis (KOA), the osteotomy gap size, concomitant medial opening angle high tibial osteotomy (MOWHTO) arthroscopic plastic (AP) and open chondroplasty (OCHP) on the development of complications and the outcome of the operation.Materials and methods. The study included 76 patients who underwent MOWHTO. To study the influence of each of the parameters, comparison groups were created: 1) by age: patients younger and older than 60 years (45 versus 31); 2) by BMI: patients with BMI10 mm (29 versus 47); 4) by stages of KOA: patients with stage I and II versus patients with stage III (43 versus 33); 5) patients with MOWHTO + AP of the knee or OCHP versus patients who underwent only MOWHTO (34 versus 42). To assess the result, we studied the change in pain intensity according to the visual analogue scale (VAS), as well as the state of the knee joint according to the Knee Society Score (KSS) scale before surgery and 1 year after MOWHTO.Results. The development of complications had a weak direct relationship with stage III of the KOA (r=–0.24) and moderate strength a direct relationship with the osteotomy gap size >10 mm (r=–0.42). Age, BMI, the presence of concomitant AP of the knee or OCHP did not affect the development of complications. However, the number of complications was statistically significantly higher among patients with stage III and osteotomy gap size >10 mm relative to patients with stage II of the KOA (p=0.03) and patients with deformity correction ≤10 mm (p=0.0002). Age over 60 years and BMI30 kg/m2 (p=0.08 and p=0.04). At stage III, an excellent result was obtained 3 times less frequently than in patients with stages I and II of the KOA (p=0.004). In patients with gap size ≤10 mm, excellent results were 1.5 times greater than in patients with a gap size >10 mm (p=0.00006). There were no differences in the results in patients who underwent MOWHTO in isolation and in patients in whom MOWHTO was supplemented with AP of the knee or OCHP.Conclusions. The development of complications is associated with stage III of the KOA and the need for correction (the osteotomy gap size) >10 mm. The best result of MOWHTO can be obtained in patients under the age of 60 years, with a BMI

The SARS-CoV-2 coronavirus pandemic is a leading medical problem that is in the focus of attention of representatives of all medical specialties. In addition to fighting the COVID-19 infection itself, the task of preventing and treating a wide range of complications arising after the disease is becoming increasingly urgent. One of these complications is avascular necrosis (AN) of bone tissue – a severe pathology that leads to serious suffering, a decrease in the quality of life and disability of patients. For the period from 2020 to 2022 there are 9 reviews in the world literature devoted to the pathogenesis, clinical features and treatment possibilities of this complication. During the same period, 5 articles were published describing clinical observations of AN after suffering COVID-19.The purpose of this work is to demonstrate our own clinical observations, as well as to review the available literature data on the problem of AN after COVID-19 infection. Based on the analysis, it can be concluded that AN after SARS-CoV-2 infection most often develops in the femoral head (>50% of cases), occurs regardless of the severity of the disease and the cumulative dose of glucocorticoids used in the acute period of the disease. It seems advisable to perform an MRI of the hip joints at least once every 3 months for all patients who have had COVID-19 in severe and moderate form during the first year after convalescence.

Objective – to compare the results and complications of open wedge high tibial osteotomy (OWHTO) in patients operated on according to the standard technique and using the developed method of performing the operation using the original fixator.Materials and methods. 73 patients with primary and secondary OA of the knee I–III stages were recruited into the study, which were divided into 2 groups. Group 1 consisted of 43 patients, who underwent 46 OWHTO from 2005 to 2019 using the standard technique using short plates with a fixed spacer (Puddu I (5 times) and II generation (24 times), Osteomed (17 times)) and bone grafting. Group 2 consisted of 30 patients who were operated on in 2018– 2020 using the developed surgical technique and the original fixator. To assess the result, we studied the change in pain according to the Visual Analog Scale (VAS), as well as the functional (FS) and objective scores (OS) of the knee according to the Knee Society Score (KSS) before surgery, after 3 months and 1 year after OWHTO.Results. In group 1, one year after OWHTO, the results were obtained: excellent in 43.5% of cases, good – in 41.0% and satisfactory – in 15.2% of patients. In group 2, an excellent result was obtained in 59.3% of patients, good – in 33.4% and satisfactory – in 7.3% of cases. In group 1, 15 (32.7%) patients were diagnosed with 26 complications, and in group 2 – 5 (16.6%) patients with 5 complications.Conclusions. The use of the developed surgical technique and the original fixator made it possible to increase the percentage of excellent and good treatment results from 84.5% to 92.7% and to reduce the number of complications associated with OWHTO from 32.7% to 16.6%.

Aim of the study – to determine the risk factors for the early development of osteonecrosis and to analyze the results of surgical treatment of patients with systemic lupus erythematosus in the long term after total hip arthroplasty.Materials and methods. The study group included 42 patients with systemic lupus erythematosus (SLE) complicated by osteonecrosis (ON) of the femoral head, who underwent 59 total hip arthroplasty (THA) operations. Before surgery and 6–21 years after THA, in order to assess the long-term results of surgical treatment of patients, the following was assessed: activity of the underlying disease – according to the SLEDAI-2K (Systemic Lupus Erythematosus Disease Activity Index 2000); the severity of irreversible changes in internal organs – according to the SLICC/ACR index of damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology); the clinical and functional state of the hip joint – according to the HHS (Harris Hip Score); the intensity of pain syndrome – according to the visual analogue scale (VAS); quality of life (QOL) – using the SF-36 questionnaire. The concentration of antibodies to cardiolipin (aCL) of IgM and IgG isotypes was determined by enzyme-linked immunosorbent assay (normal range – 0.0–10.0 GPL for IgM, 0–7 MPL for IgG).Results. After 6–21 years of follow-up after THA, there was a statistically significant decrease in pain intensity according to VAS, improvement according to the HHS from 40.0±14.9 to 83.3±17.4 points, SLE activity according to the SLEDAI-2K from 0 to 20 points (median – 4 [4; 8] points) before surgery and from 0 to 41 points (median – 0 [0; 4] points) after a long period of observation. There was a pronounced statistically significant positive dynamics for all QOL indicators studied (p≤0.005 in all cases). The most significant changes were found on the scales RE (Role-Emotional), RP (Role-Physical Functioning) and BP (Bodily Pain). The early development of ON was associated with the degree of activity of the underlying disease, the cumulative dose of glucocorticoids, kidney damage and arthritis in the first year from the onset of SLE, as well as hematological disorders and the presence of aCL in the blood serum 3 years before the onset of ON. The total number of complications was 10.2%.Conclusion. Total hip arthroplasty in patients with systemic lupus erythematosus can achieve a statistically significant reduction in pain intensity, increase functional activity and improve their quality of life.

Objective – to study the complications of open wedge high tibial osteotomy (OWHTO) in patients who underwent this surgery in the V.A. Nasonova Research Institute of Rheumatology.Materials and methods. The study included 43 patients (46 knee joints) with primary and secondary OA of the knee of I–III stages, who underwent OWHTO in the period from 2005 to 2019. The operation was performed according to the standard technique using short spacer plates (Puddu I (5 times) and II generation (24 times), Osteomed (17 times)) and bone grafting. The identified OWHTO specific complications were divided into those related to the osteotomy, fixation, and bone grafting. To assess the result, we studied the change in pain according to the Visual Analog Scale (VAS), as well as the functional and objective state of the knee according to the Knee Society Score (KSS) before surgery, after 3 months and 1 year after surgery.Results. In 15 (32.7%) cases have been diagnosed 26 complications. Of these, 21 (81.0%) were associated with fixation, 2 (7.7%) with the osteotomy 2 (7.7%) with bone grafting of the osteotomy gap, and 1 (3.6%) a local complication. Patients without complications had a statistically significantly better decrease in pain intensity according to VAS (p=0.0005), and an improvement in the total score of KSS (p=0.0023) one year after surgery. Outcomes were also better in patients without complications: 96.7% excellent and good results versus 60.0% in patients with complications one year after OWHTO. In total, we had 43.5% excellent, 41.3% good and 15.2% satisfactory results one year after surgery.Conclusions. OWHTO is a highly effective method of surgical treatment of the osteoarthritis of the knee, which allows to obtain an excellent and good treatment result in 84.8% of cases one year after surgery. Performing OWHTO with fixing the height of the osteotomy gap using short spacer plates and bone grafting in 32.7% of cases is associated with the development of complications. To improve the results of OWHTO, it is necessary to improve the surgical technique and fixator.

Aim: to evaluate the effectiveness of hyaluronic acid (HA) preparations with different molecular weights and in combination with chondroitin sulfate (HS) for intra-articular (IA) injections in the treatment of patients with stage I–III knee OA.Subjects and methods. IA HA injections were performed 160 patients with primary and post-traumatic knee OA of the I–III stages at the department of traumatology-orthopedics, V.A. Nasonova Research Institute of Rheumatology for the period from September 2017 to June 2019. Patients were divided into 4 groups. Group 1 consisted of 80 patients treated with low molecular weight (LMW) HA, group 2–20 patients treated with medium molecular weight (MMW) HA, group 3–30 patients treated with high molecular weight (HMW) HA, and group 4–30 patients who were intraarticular introduced HA with HS. The course of IA injections was 2 for LMW, HMW, and HA with HS, and 3 for MMW HA. Injections were performed with an interval of 1 week. To evaluate the results of treatment, we studied the intensity of pain according to VAS and the total score of KOOS before treatment and on follow-up examinations 1, 3 and 6 months after the course of IA HA injections.Results. The maximum reduction in pain with IA HA injections at stage I of knee OA occurred by 3 months after the course of treatment. Moreover, improvement was detected by 1 month in 84.3% of cases, and remained until the end of the study in 71.1% of patients. All HA preparations used in stage I of knee OA were effective. At stage II of the knee OA after 3 months after the course of IA HA, different efficiencies of HA preparations were revealed. So, in the groups of LMW, MMW and HA with HS, the improvement persisted up to 3 months, and in the group of HMW HA – up to 1 month. After 3 months, the best results were shown by HA with HS, by 6 months the results were comparable. IA HA injections at the II stage of knee OA led to good and excellent results 1 month after the course of treatment in 53.9% of cases, but by the end of the study, improvement remained in only 30.8% of patients. In the case of the use of HA in stage III of the knee OA, the effectiveness of the studied drugs was comparable, and the maximum improvement was achieved by 1 month. The positive effect of IA HA injections in patients with stage III of the knee OA one month after the course of treatment was obtained in 40.6% of cases, by 3 months it decreased to 18.8%, and by 6 months – to 15.7% of patients.Conclusions. IA injections of HA at stage I of the knee OA is a highly effective method of conservative treatment, which allows to relieve pain and improve the condition of the knee joint for a period of 6 months or more. The use of HA preparations at stage II of the knee OA allows reducing pain up to 3 months with IA injections of LMW and MMW HA, as well as HA with HS. HMW HA helps reduce pain intensity for a period of 1 month. The use of HA preparations in stage III of the knee OA leads to a short-term relief of symptoms of OA.

Local injections of platelet-rich plasma (PRP) and hyaluronic acid (HLA) are considered an effective method for treating chronic shoulder pain (CSP) associated with damage to the tendons of the rotator cuff muscles (RCM).The aim of the study is to compare the effectiveness and safety of local therapy of PRP and HLA in patients with CSP caused by damage to the tendons of the RCM muscles.Materials and methods. The study included 100 patients (54% women and 46% men, average age 51.5±15.1 years) with CSP (persisting for ≥3 months) associated with damage and tendinitis of the supraspinatus, subacute, scapular or small round muscle, confirmed by magnetic resonance imaging or ultrasound (ultrasound). The patients were randomized into two groups of 50 people who were treated with PRP (three injections at 7-day intervals) or HLA (two injections at 7-day intervals). The injections were performed under ultrasound control in the subacromial SAC. The results of the study were evaluated by the dynamics of pain intensity (on a visual analog scale, up to 100 mm) and functional disorders (ASES and CSS indices) after 1, 3 and 6 months.Results. Against the background of the use of PRP and HLA, there was a significant improvement in the condition of patients, while both drugs showed approximately the same effectiveness. The severity of VAS pain decreased from 56.8±15, respectively, after 6 months.5 and 57.6±17.8 mm to 31.8±27.8 and 30.2±26.3 mm, ASES-c 55.8±15.9 and 53.6±14.7 to 74.6±22.4 and 77.3± 22.4, CSS-c 59.2±14.4 and 47.8±16.9 to 69.9±17.3 and 65.6±19.2. the Dynamics of all these indicators in comparison with the baseline level was statistically significant (p0.05). The effectiveness of PRP and HLA (in terms of pain dynamics, ASES, and CSS) was significantly higher in individuals younger than 45 years, compared to older patients. The tolerability of therapy was good – after the introduction of PRP, 40% of patients had a short-term (3–4 days) increase in pain, which did not require the use of additional analgesics or interruption of treatment. No serious adverse reactions were observed when using PRP and HLA.Conclusion. OTP and GLA are effective and safe in the treatment of CSP associated with damage to the tendons of the RCM muscles. The dynamics of pain intensity and functional status after the use of these drugs did not differ. Treatment of PRP and HLA is more effective in people younger than 45 years.

Objective. To analyze early surgical outcomes after total hip replacement in systemic lupus erythematosus (SLE) patients.Subjects and Methods. The study included 42 SLE patients with femoral head osteonecrosis (ON) undergoing 59 total hip replacement (THR) surgeries at the traumatology and orthopedics department of VA Nasonova Research Institute of Rheumatology during 1998-2013 yy. All patients were thoroughly evaluated at baseline and one year after surgery using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K), damage index (DI) of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) to assess the degree of irreversible organ damage, Harris hip function scale, and VAS for pain intensity to assess early results of THR procedure.Results. Significant improvement of pain intensity was documented based on VAS assessments, as well as hip function improvement from 40,0±14,9 (13,8 – 82,7) to 80,8±12 (46,7-96,0) scores based on Harris scale, improvement of SLE activity based on SLEDAI-2K assessment: from 0 -20 scores (median 4[4;8]) at baseline to 0 – 43 scores (median 0[0;4]) at one year, and DI – from 0-12 (median 3[2;5]) to 0 -15 scores one year after THR procedure. Complications including dislocation of femoral component, peroneal nerve paralysis, periprosthetic fracture, venous thrombosis, and delayed wound healing were documented totally in 10,2% of patients. No post-surgery deaths occurred.Conclusion. The results obtained are indicative of better pain control and improved hip function following THR in SLE patients.

Chronic shoulder pain (CSP) is one of the most common reasons for seeking medical care. Identifying the specific cause of CSP is necessary to determine the treatment strategy.Objective: to determine which pathology of the musculoskeletal system is the main cause of CSP.Subjects and methods. A study group consisted of 151 patients (49.7% females; mean age, 49.8±18.8 years), who experienced shoulder joint pain that persisted when taking nonsteroidal anti-inflammatory drugs (NSAIDs) and after local administration of glucocorticoids. They underwent clinical and instrumental studies (radiography, magnetic resonance imaging, and ultrasound). The investigators assessed pain intensity using a visual analogue scale (VAS), and functional impairment with the American Shoulder and Elbow Surgeons (ASES) Assessment Scores and the Constant Score (CS).Results and discussion. The mean CSP intensity at rest and during movement was 56.1±21.7 and 67.3±19.1 mm VAS. The degree of functional disorders was 55.5±17.6 ASES scores and 54.1±14.5 CS scores. Tendonitis that is an injury to the tendon of the supraspinatus muscle (74.8%) was most common. There was shoulder osteoarthritis (OA) in 31.7%, acromioclavicular (AC) OA in 19.2%, rotator cuff tendon injury concurrent with shoulder OA in 25.2%, that with AC OA in 16.6%, and that with shoulder OA and AC OA in 9.2%. The intensity of pain with only rotator cuff tendon injury and that concurrent with shoulder OA and/or AC OA did not differ and that averaged 57.2±20.2 and 54.6±18.6 mm at rest, respectively, and 68.3±22.4 and 65.4±19.2 mm during movement (p>0.05 in both cases).Conclusion. The main cause of CSP is tendonitis of the rotator cuff, primarily of the supraspinatus muscle. Moreover, more than half of patients have rotator cuff tendon injury concurrent with biceps tendon injury, shoulder OA and/or AC OA.

Chronic shoulder pain associated with subacromial impingement syndrome (SIS) is a common pathology that causes suffering and disability. One of the treatments for SIS is the local injection of hyaluronic acid (HA) preparations.Objective: to evaluate the efficiency of subacromial injection of HA in chronic shoulder pain associated with SIS.Subjects and methods. A study group consisted of 31 patients (48.4% of women and 51.6% of men; mean age 53.8±15.2 years) with chronic shoulder pain (>3 months) that had occurred after rotator tendon injury confirmed by ultrasound and/or magnetic resonance imaging. All the patients received two subacromial injections of 40 mg HA in 2 ml at a 7-day interval. The efficacy criteria were the changes of pain during movement (100-mm visual analogue scale (VAS)) and functional ability according to the ASES and CSC questionnaires at 1, 3 and 6 months.Results and discussion. During the treatment, there was a considerable improvement in all measures. At baseline and 1, 3, and 6 months, the mean pain severity measured on VAS was 60.0±20.0, 40.0±25.4, 31.6±26.0, and 32.2±26.5 mm (p

Intra-articular administration of hyaluronic acid (HA) is one of the methods of conservative treatment of knee osteoarthritis (OA). However, the data of its efficacy in the modern literature are contradictory.Objective: to assess the efficacy of intra-articular administration of HA preparations with different molecular weight in the treatment of patients with knee OA and to study the factors that can influence the effectiveness of such therapy.Subjects and methods. HA preparations were administered to 60 patients with idiopathic and posttraumatic knee OA. The ratio of women to men was 3:1. The average age was 59.5±13.7 years and body mass index – 30.3±5.8 kg/m2. The presence of enthesitis was evaluated prior to treatment by the characteristic clinical picture. The x-ray stage of OA was determined in accordance with the classification of Kellgren–Lawrence. Distribution of of knee joint lesions, relationship of femur and tibia anatomical axes, presence of varus and valgus deformities were also evaluated. The patients were divided into three groups: 18 patients received low-molecular (LM), 19 – medium-molecular (MM) and 23 – high-molecular (HM) HA. To assess the efficacy of the treatment the severity of pain on a visual analog scale (VAS) and the total score of the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire before, 1, 3 and 6 months after treatment were evaluated.Results and discussion. Enthesitis was detected in 17 (28,3%) patients. Stage I of knee OA was diagnosed in 10 (16.6%), II – in 36 (60%) and III – in 14 (23.3%) patients. Varus deformity was detected in 43 (71.7%) patients, neutral axis of the lower limb - in 14 (23.3%), valgus deformity – in 3 (5%). The most significant decrease in the severity of pain was noted in patients with stage I of knee OA: from 54±17.1 to 10.0±10.0 mm. At stage II, the pain decreased from 59.4±12.6 to 45.5±20.3 mm, and at stage III – from 66.4±13.5 to 60.7±23.3 mm. By the 6th month, the severity of pain in patients with enthesitis was higher, and the values of KOOS total score were worse than in patients without it. At stages II and III of knee OA, the ratio of positive to unsatisfactory results for MM, LM and HM HA was as follows: 2:1, 3:1 and 3.6:1. In the group of patients with excellent results, the value of varus deformation averaged 8.5±1.5°, in patients with a good result – 9.8±2.8°, with a satisfactory result – 11.3±4.5°, and with an unsatisfactory – 11.5±3.2°.Conclusion. Intra-articular injection of HA is very effective at stage I of knee OA. The expression and duration of this effect are reducedwith decrease of cartilage thickness and increase of knee joint varus deformation (i.e., at the II and III stages of knee OA). The presence of varus deformation does not affect HA efficacy. Three factors are important: the appearance of varus deformation of the lower limb with initially neutral axis; the increase of varus deformation; the value of varus deformation >10°.

Surgical treatment in patients with rheumatic diseases (RDs) is associated with the higher risk of complications due to the presence of the inflammatory process, to long-term therapy with glucocorticoids, disease-modifying antirheumatic drugs, and biologic agents (BA), to decreased physical activity, and the severity of functional disorders, and to obvious osteoporosis. All this increases the risk of intraoperative complications, including periprosthetic fractures.Objective: to comparatively analyze intraoperative periprosthetic fractures of the greater trochanter, acetabulum, and proximal femur during total hip arthroplasty (THA) in patients with RDs.Subjects and methods. From 1998 till 2017, a total of 1569 THA were performed in patients with RA, including 464 patients with rheumatoid arthritis (RA), 396 with juvenile rheumatoid arthritis (JRA) and systemic lupus erythematosus (SLE), and 709 with osteoarthritis (OA).Results and discussion. Periprosthetic fractures after THA were diagnosed in a total of 68 (4.33%) patients, including 23 (4.96%) patients with RA, 27 (6.82%) with JRA and SLE, and 18 (2.54%) with OA; 42 (61.8%) patients with periprosthetic fractures underwent osteosynthesis. Statistical analysis of the findings revealed significantly higher rates of complications in patients with RA and JRA with SLE (p < 0.005).Conclusion. The findings confirm that the risk of periprosthetic fractures is higher in patients with inflammatory diseases, including RA, JRA, and SLE. These patients require a special approach that involves medical correction of impaired bone metabolism and proper individual selection of endoprosthetic components, by taking into account the anatomical features of female patients and delicate bone handling during surgery.

Patients who have undergone large (hip, knee) joint replacement constitute a group at high risk for developing venous thromboembolic events (VTEs). According to different authors, the risk of nonpreventable VTEs in these patients varies from 40 to 80%.Objective: to analyze the incidence of VTE and the risk of postoperative wound-related bleeding and complications in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) after total hip arthroplasty. Subjects and methods. The investigation enrolled 486 patients with RA (n=212) and OA (n=274) who underwent primary hip arthroplasty. Each patient group was divided into three subgroups according to prevention with the following drugs: 1) nadroparin calcium; 2) dabigatran etexilate; 3) nadroparin calcium switched to dabigatran etexilate. According to the International Society on Thrombosis and Haemostasis criteria, intra- and postoperative blood loss was assessed during the first 7 days after surgery; the wound healing process was also evaluated.Results and discussion. VTE was prevented with the drugs in 239 (49.2%) patients, 130 (26.8%) of them received nadroparin calcium, the remaining 117 (24.0%) patients had dabigatran etexilate or both drugs. Postoperative VTEs were recorded in 36 (7.4%) out of the 486 patients. VTEs were detected significantly less frequently In RA than in OA (1.2 and 6.1%, respectively; p=0.0013). VTEs were more commonly asymptomatic in both groups. No fatal bleeding was seen in any patient, which confirms the safety of anticoagulant therapy. Blood transfusions were more frequently given to bleeding patients with RA than to those with OA (14.4 and 5.7% of cases, respectively; p

Opening wedge high tibial osteotomy (OWHTO) is a surgical treatment option for osteoarthritis (OA) of the knee with a predominant lesion of its medial segment, which can restore the mechanical axis of the lower limb, transfer load from affected medial to intact lateral part of knee joint, and thus slow OA progression, reduce or even abolish pain, prolong the function of the patient’s own knee joint, and delay total knee arthroplasty. Like any surgical intervention, OWHTO can be responsible for common, local, and specific surgical complicationsObjective: to investigate complications from OWHTO and to determine the impact of the design of short spacer plates, bone graft materials and/or bone substitutes, as well as age, body weight and wedge angle correction on the development of complications in patients undergoing this surgery.Subjects and methods. Twenty-eight OWHTOs were performed in 26 patients in 2003 to 2016. The male and female ratio was approximately 2:1. The patients’ mean age was 58.1±11.24 years; body mass index, 28.56±3.61 kg/m2; correction angle, 11.8±2.4°. Fixation was carried out using short spacer plates of three different designs: Puddu plate I, II, and Osteomed. Bone grafting was performed applying an iliac wing autograft or a biodegradable bone substitute (β-tricalcium phosphate) as rectangular blocks, or Inject. Bone grafting was not done when the wedge size was

Glycosaminoglycan-peptide complex (GPC) (Rumalon®) is an injectable slow-release anti-inflammatory agent (SRIA) that has complex anti-inflammatory and metabolic effects. GPC has been successfully used in the treatment of osteoarthritis (OA) for several decades. The agent now returns again to Russian clinical practice. Objective: to evaluate the efficacy and tolerability of GPC in patients with knee OA, in whom other SRIAs have been previously ineffective.Subjects and methods. A study group consisted of 104 patients (92.3% women) (mean age, 63.2±8.5 years; body mass index (BMI), 28.5±5.4 kg/m2) with severe joint pain (≥40 mm on a 100-mm visual analogue scale (VAS)) and/or the need to regularly use nonsteroidal anti-inflammatory drugs (NSAIDs). All the patients received oral SRIAs in the last 6 months and had no improvement. At baseline, VAS pain intensity was 59.4±13.1 mm; the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain was 227.3±90.8; WOMAC stiffness, 97.9±42.1; WOMAC function, 769.2±326.1; total WOMAC scores, 1095.1±426.6. GPC was used by the standard scheme: 25 intramuscular injections every other day per treatment cycle; the results of treatment were assessed at 8 and 12 weeks by VAS and WOMAC pain scores, needs for NSAIDs, satisfaction with treatment (measured on a 1- to 5-pont scale where 1 = no improvement or deterioration and 5 = the best result).Results and discussion. At 8 and 12 weeks, VAS pain scores decreased by 30.1±18.3% and 36.9±16.9%, respectively; the reductions in WOMAC pain scores were 29.8±16.3 and 38.2±23.4%; WOMAC stiffness scores, 29.2±15.4 and 31.6±17.4%; WOMAC function scores, 27.7±14.7 and 30.6±18.4%; and total WOMAC scores, 27.2±13.5 and 33.6±18.0%. The changes in pain intensity and WOMAC scores were statistically significant in both followup periods (p

Knee osteoarthritis (OA) is the most common form of OA. Medical treatment for OA does not provide the desired effect in a significant proportion of patients. With greater rates of knee OA and its rejuvenation, high tibial osteotomy (HTO) that can prolong the period of the patient’s own knee joint (KJ) function and postpone or completely avoid total knee arthroplasty is becoming increasingly relevant. Objective: to investigate the efficiency of HTO for stage II–III knee OA and the impact of age, body mass index (BMI), and correction angle on the immediate result of surgery. Subjects and methods. Thirty-five HTOs were carried out in 32 patients in 2003 to 2016. The male and female ratio was approximately 2:1. The patients’ mean age was 59.0±13.1 years; BMI, 29.04±3.57 kg/m2 , correction angle, 12.5±2.78°. A visual analog scale (VAS) was used to assess pain; and the Knee Society Score (KSS) was employed to rate the functional and objective status of the KJ. The degenerative process was graded using the Kellgren–Lawrence radiographic classification. Results and discussion. HTO proved to be effective in patients with both Stage II and III knee OA. A year after surgery, there was a substantial reduction in VAS pain (from 72.27±11.79 to 7.72±6.62 mm) and an improvement in functional and objective KSS scores (from 43.66±11.5 and 54.39±11.77 to 86.51±10.86 and 81.93±6.65 mm, respectively). The results were excellent (36.4%), good (57.6%), and satisfactory (6%). No X-ray signs of progressive OA were revealed one year after surgery. BMI affected immediate results (Spearman correlation coefficient = -0.34; p < 0.05). Thus, HTO has been established to be more effective in Stage II knee OA than in its Stage III. Age and correction angle do not affect immediate results while higher BMI is associated with worse outcomes and complications.

Total joint replacement (TJR) in the presence of severe joint degradation and arthralgias in patients with rheumatic diseases (RDs) is one of the effective ways to improve the functional status of patients and their quality of life. In recent years, there has been an increase in the number of such knee and hip replacements worldwide. Despite advances in medicine in the 21st century, up to 5% of TJRs culminate in early complications, in which there are irreversible joint changes that cause joint functional loss and persistent pain and, in 2–3% of cases, require early re-revision surgery.Subjects and methods. The investigation included 2142 patients with rheumatoid arthritis (RA) and osteoarthritis (OA) who underwent knee or hip joint replacement (KJR or HJR) at the V.A. Nasonova Research Institute of Rheumatology during the period 1998 to 2016: HJR in 1177 patients and KJR in 965. The patients with RA had 467 HJRs and 651 KJRs (a total of 1118 operations). A comparison group consisted of patients with OA who underwent710 HJRs and 314 KJRs (a total of 1024 operations). Postoperative surgical complications, such as superficial or deep suppuration, joint dislocation, periprosthetic fractures, sciatic and/or peroneal neuropathies, aseptic instability of endoprosthesis components, and complications of wound and ligamentous apparatus, were considered within 2 years after surgeryResults and discussion. Overall, the frequency of local complications after HJR and KJR was comparable and amounted to 7.22 and 7.25%, respectively (p=0.83), but their pattern greatly differed: there were a larger number of periprosthetic fractures after HJR than after KJR (3.48% and 0.93%; p

Bacterial arthritis (BA) and prosthetic joint infection (PJI) are very relevant problems under current conditions. BA and PJI are responsible for 0.2–0.7% of all hospital admissions per year. The increase in the number of endoprosthesis replacements is accompanied by the rising number of patients with periprosthetic infection. The frequency of fatal outcomes in patients with BA and PJI has not changed significantly over the past 25 years and amounts to 5–15%. The lecture gives an update on the etiology, pathogenesis, clinical presentations, diagnosis, and treatment of the above nosological entities. Emphasis is placed on the importance of a comprehensive approach to treating PJI, which involves a combination of surgery and etiotropic antibacterial therapy.

Objective: to study the molecular mechanisms underlying the suppression of collagenase activity in the presence of deferoxamine (DFO) in articular cartilage explants from patients with osteoarthritis (OA).Subjects and methods. The knee joint cartilage obtained during arthroplasty from 33 patients (mean age, 61.8±10.3 years) with OA, and that derived at autopsy from 25 people (mean age 40±6.1 years) without this disease were investigated. The cartilage was cultured in the presence of 10 μm DFO. The gene expression in the cartilage explants was determined by real-time reverse transcriptase and polymerase chain reaction.Results and discussion. The reduced collagenase activity in the presence of DFO in the articular cartilage explants from patients with OA, which had been shown earlier, was accompanied by the significantly inhibited expression of matrix metalloproteinases 1 and 13 and cathepsin K, which had collagenase activity, as well as the marker of hypertrophic chondrocytes, such as X type collagen, and the proinflammatory cytokines interleukin-1β and tumor necrosis factor-α. DFO did not change the expression levels of the phosphoglucomutase and pyruvate kinase genes responsible for the production of adenosine triphosphate (ATP) during glycolysis and the glucose transporter Glut 1. On the contrary, the expression of the genes associated with ATP generation in the tricarboxylic acid cycle: isocitrate dehydrogenase, succinate dehydrogenase, α-ketoglutarate dehydrogenase, malate dehydrogenase, and adenosine monophosphate- activated protein kinase (AMPK) significantly increased. The expression of AMPK in the articular cartilage of patients with OA was significantly lower than that in healthy individuals.Conclusion. Inhibition of collagen cleavage in the presence of DFO in the articular cartilage explants from OA patients, which was accompanied by a considerable decrease in the expression of the proteases responsible for degradation of the extracellular matrix, proinflammatory cytokines and chondrocytes hypertrophy, was due to the enhanced activity of mitochondrial oxidative phosphorylation in the chondrocytes.

Objective: to study the mechanisms determining the level of pain on the basis of an analysis of the expression profiles of the genes involved in joint destruction, inflammation, and metabolic regulation in the blood of patients with osteoarthritis (OA) with different expression levels of the Mammalian Target Of Rapamycin (mTOR) gene and at different disease stages.Material and methods. Peripheral blood samples from 47 outpatients with OA, from 21 late-stage OA patients admitted to hospital for endoprosthetic knee joint replacement, and from 27 healthy individuals who formed a control group (mean age, 60.0±7.1, 56.6±8.9, and 58.6±8.3 years, respectively), as well as articular cartilage samples obtained intraoperatively from 21 patients with OA and at autopsy from previously healthy people (mean age, 38.2±4.3 years) who had died from trauma, were examined. Clinical, radiographic, ultrasound, and densitometric examination was performed. Total RNA was isolated from blood and after reverse transcription it was used to estimate gene expression levels in real-time polymerase chain reaction.Results and discussion. In the low mTOR gene expression subgroup, the expression of all the study genes proved to be at the control level, except the matrix metalloproteinase 9 (MMP9) gene, the expression of which was significantly higher. In the patients with a high expression of the mTOR gene and in those with late-stage OA, the expression of all the study genes was much higher than in the control group. There was a positive correlation of the gene expression of the transforming growth factor β1 (TGF-β1) (r = 0.594; p = 0.005) and cathepsin K (r = 0.595; p = 0.003) in the blood and articular cartilage of patients with late-stage OA.Conclusion. The different levels of pain in OA patients with different expression levels of the mTOR gene may be associated with the expression ratio of the genes MMP9 and tissue inhibitor of metalloproteinases 1 (TIMP1), the excessive or insufficient activity of the mTOR gene, and the expression of the growth factors TGF-І1 and vascular endothelial growth factor, which are involved in the processes of tissue regeneration.

The genes, the high basic expression of which indicates the efficiency of methotrexate (MTX) therapy in relieving joint inflammation and destruction in patients with rheumatoid arthritis (RA), have been defined.Objective: to find an association between the initial expression of the genes: mTOR (mammalian target of rapamycin), a major regulator of cell growth and proliferation; ULK1 (an autophagy marker 1); p21 (a cyclin-dependent kinase inhibitor); kaspase-3 (an apoptosis activity indicator); MMP-9 (matrix metalloproteinase 9), and cathepsin K, which are involved in joint destruction, and the cytokines: TNF-α (tumor necrosis factor-α), TGFβ1 (transforming growth factor β1) and Runx2 (Runt-related transcription factor 2) in the blood of RA patients with disease activity and joint destruction before and after MTX therapy during 24 months.Subjects and methods. Forty patients (mean age, 47.5 years) with RA lasting < 2 years) and 26 healthy donors (mean age, 45.1 years) were examined. All the patients took MTX for 2 years. A clinical response was assessed with disease activity score (DAS28); erythrocyte sedimentation rate and the serum levels of anti-cyclic citrullinated peptide antibodies (ACCPA), C-reactive protein (CRP), and rheumatoid factor (RF) were also estimated. Joint destructive changes were assessed by radiography. Furthermore, blood and knee articular cartilage samples from 21 patients (mean age, 50.4 years) with late-stage RA and cartilage samples from 25 healthy individuals were investigated. Gene expression in the cells of peripheral blood and cartilage was determined by real-time reverse transcriptase polymerase chain reaction.Results and discussion. MTX therapy considerably reduced disease activity assessed by DAS28, CRP levels, stiffness, tender and swollen joint counts (TJC and SJC); however, joint space (JS) narrowing (JSN) substantially increased compared with the baseline values. The expression of the ULK1, p21, MMP-9, cathepsin K genes, and TGFβ1 was increased both at the beginning of the investigation and 24 months later whereas the initially higher expression of mTOR, TNF-α, caspase 3, and Runx2 was decreased by the end of therapy to the level of the healthy individuals. The initial expression of the TGFβ1, Runx2, caspase 3, and р21 genes correlated negatively with the RF level measured both at the beginning of the investigation and 24 months later. There was a positive correlation of the initial expression of ULK1 and MMP-9 with CRP levels prior to therapy and that of the initial expression of MMP-9 with baseline DAS28 scores and NSJ. Moreover, the initial expression of the TNF-α gene positively correlated with JSN at the end of therapy and that of the p21, caspase 3, and Runx2 genes with a change in DAS28. There was also a negative correlation of the initial expression of the mTOR gene with the SJC and the number of erosions; the p21 and TNF-α genes correlated negatively with SJC and TJC; and the TNF-α, TGFβ1, Runx2, and cathepsin K genes also negatively correlated to the duration of stiffness at the end of therapy. A positive correlation was found between the expression of the cathepsin K and TGFβ1 genes in the blood and articular cartilage of patients with late-stage RA.Conclusion. The expression of the MMP-9 and ULK1 genes is associated with disease activity. The high initial blood expression of the other examined genes is associated with the more effective action of MTX on stiffness (TNF-α, Runx2, cathepsin K, and TGFβ1), TJC and SJC (mTOR, p21, and TNF-α), and the progression of joint destruction (mTOR) and may play a protective role. The positive correlation of the blood and articular cartilage expression of the TGFβ1 and cathepsin K genes may point to their co-regulation in these tissues in RA.

One of the most menacing complications of large joint total endoprosthesis (TE) in patients with rheumatic diseases (RD) is the development of periprosthetic infection (PI), progression of which may give rise not only to limb loss, but also death. At the same time, early diagnosis and adequate surgical care make it possible not only to arrest the infectious process, but also to preserve an implanted joint.Objective: to define criteria for the diagnosis, prevention, and treatment of PI after hip and knee joint (HJ and KJ) TE in patients with RD.Subjects and methods. In 2009 to 2013, 654 KJ and 549 HJ TE was performed in the V.A. Nasonova Research Instituteof Rheumatology performed KJ (n = 654) and HJ (n = 549) joint ERs.Results and discussion. PI developed in 12 (3.63%) and 8 (2.95%) patients after KJ and HJ ER, respectively. Early, delayed, and late PI was seen in 11, 6, and 3 patients, respectively. Eleven patients with early PI underwent joint revision/ debridement with preservation of an endoprosthesis and replacement of HJ endoprosthetic inserts and heads. The operations were completed with the collagen hemobiotics being left in the wound and its drainage. Systemic antibiotic therapy was used for 4–6 weeks. No recurrent infection was observed in 9 cases. Two patients underwentresurgery, by setting suction-irrigation systems. Nine patients with delayed or late PI had the following operations: A single-stage revision operation (the endoprosthesis was removed and a new one was implanted) was performed in two cases of stable endoprosthetic components and accurately verified low-virulent microorganisms susceptible to certain antibiotics. It was imperative to use cement with an antibiotic, collagen hemobiotics, and systemic antibiotic therapy for 6 weeks. The other 7 patients with unstable endoprosthetic components underwent two-stage revision: Stage 1, endoprosthetic removal and antibiotic-loaded spacer implantation; 6-12 weeks after postoperative wound healing, 6 patients underwent Stage 2, removal of the spacer and implantation of a new endoprosthesis. Following Stage 1, one female patient developed generalized infection and, because of her advanced age and comorbidities, underwent amputation followed by exoprosthetic replacement.Conclusion. The practical application of the current diagnostic criteria allowed to reveal early slowly progressive PI, perform early surgical treatment without endoprosthetic removal in 11 patients, and prevent recurrent infection in 81.8% of the patients. The described treatment policy for PI turned out to be effective and prevented recurrent infection in 70% of the patients during 1 to 5 years.

Prolonged hip arthritis in juvenile arthritis (JA) is a cause of serious joint destruction, leading to severe pain and functional disorders.Objective: to assess the results of total hip arthroplasty (THA) in patients with JA. Subjects and methods. The investigation enrolled 20 women and 2 men. Their mean age at the time of surgery was 27.9 (18–49) years, mean weight – 47.7±2 kg. Mean height was 155.1 cm, which confirms growth retardation in these patients. The disease duration averaged 7.1 years. Mild protrusion of the acetabulum was stated in 9 (41%) and 13 (59%) patients, respectively.Results and discussion. Functional status was assessed with Harris hip score (HHS), and Health Assessment Questionnaire (HAQ), pain – with visual analogue scale (VAS) quality of life (QL) – with EQ-5D before and 6–12 months after surgery. Six months after surgery, the mean EQ-5D score increased from 0.13 to 0.47 (ΔEQ-5D = 0.34;р< 0.05), which corresponded to a moderate clinical response in QL. Only after 12 months of follow-up, there was a pronounced effect of surgical treatment: the EQ-5D index increased up to 0.64 (ΔEQ-5D = 0.51; p< 0.05). On the average, HAQ decreased from 2.016 to 1.429 after 6 months and to 1.159 after 12 months, which was suggestive of a significant clinical improvement. Functional status also improved according to HHS: at 6 months, it was assessed as good (HHS, 80-89) in 3 (13.6%) patients; satisfactory – in 9 (40.9%), and 10 (45.5%) patients had HHS below 70; at 12 months, it was excellent (HHS, 90–100) in 4 (18.2%), good (80–89) – in 4 (18.2%), satisfactory – in 8 (36.4%) and 6 (27.2%) patients had HHS lower than 70. Preoperatively, pain on VAS averaged 65.4 mm; 6 and 12 months following surgery, it reduced to 41.6 and 36.3 mm, respectively. Conclusion. THA in patients with JA significantly improves the function of the affected hip joint and QL. It is also important to note that THA promotes social adaptation – three patients have entered higher educational establishments and two more patients have got married and given birth to healthy babies.

The paper considers the joint management of rheumatoid arthritis patients needing endoprosthetic replacement of the large joints of the lower extremities by rheumatologists and orthopedic traumatologists.Due to the fact that there are no conventional standards or guidelines for the perioperative management of patients with rheumatic diseases, adopted by international rheumatology associations, the authors generalize their experience in managing the patients in terms of international approaches and guidelines from different countries. The medical assessment and reduction of cardiovascular risks, the prevention of infectious complications, hemorrhages, and lower extremity deep vein thrombosis, and the specific features of management of patients with osteoporosis are under consideration. The authors' experience in managing the patients receiving antirheumatic therapy with nonsteroidal antiinflammatory and disease-modifying antirheumatic drugs, such as methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine, is detailed. Recommendations for managing patients taking glucocorticoids and biologic agents (tumor necrosis factor-α inhibitors, anti-B-cell therapy, and interleukin-6 receptor inhibitors) in the preoperative andpostoperative periods are given.

Objective: to study the pattern of impaired regulatory mechanisms of the mammalian target of rapamycin (TOR) signaling pathway, by monitoring gene expression in the blood of patients with osteoarthrosis (OA) at different stages of the disease. Subjects and methods. The study covered 33 outpatients with OA, 14 patients with this condition prior to knee joint endoprosthesis, and 27 healthy individuals (controls) (mean age 58.0+7.4, 56.5+8.9, and 55.0+8.3 years, respectively). Total RNA was isolated from their blood and used to determine the level of gene expression by a real-time polymerase chain reaction for AMP-activated protein kinase (AMPK), hypoxia-inducible factor-1α (HIF1α), the rate-limiting proteins of the hexosamine signaling pathway — glutamine-fructose-6-phosphate amidotransferase and acetylglucosaminyltransferase, as well as the glucose transporter GLUT1 and steps 6 and 7 glycolytic pathway components — glucose-6-phosphate dehydrogenase and phosphoglycerate kinase-1, respectively; the lipogenesis-related genes — fatty acid synthase (FAS) and the activity of the pentose phosphate pathway — glucose-6-phosphate dehydrogenase in the blood of patients with OA at different stages of the disease. Results. Analysis of gene expressions showed that in the OA patients with a low expression of the mTOR gene (a LOW subgroup), the expression of AGT and GLUT1 genes proved to be significantly lower and that of the AMPK gene was higher than in the healthy individuals. In the OA patients with a high expression of the mTOR gene (a HIGH subgroup), the expression of all the genes under study was much higher, except for the FAS gene; moreover, the greatest expression excess as compared to the controls was observed for the AMPK and HIFlα genes. In the patients with endstage disease (an ES subgroup), the expression of all the study genes, including the FAS gene, turned out to be higher than in the healthy individuals. Conclusion. The development of OA is accompanied by a considerable decrease in the efficiency of energy metabolism. At the same time, in the patients with a low mTOR gene expression, energy deficiency may be due to decreased cellular metabolite transport. It may be caused by the deficiency of the end electron acceptor oxygen in the patients with a high mTOR gene expression and the pathological redistribution of energy substrate in favor of lipogenesis cannot be ruled out in those with end-stage disease.

Objective: to study the expression ratio of the non-tissue specific regulatory genes mTOR, р21, ATG1, caspase 3, tumor necrosis factor-а (TNF-а), and interleukin-6 (IL-6), as well as matrix metalloproteinase 13 (MMP-13) and X type collagen (COL10A1), cartilage resorption-associated MMP13 and COL10A1 in the blood and knee articular cartilage in patients with rheumatoid arthritis (RA). Subjects and methods. Twenty-five specimens of the distal femoral articular cartilage condyles were studied in 15 RA patients (mean age 52.4+9.1 years) after endoprosthetic knee joint replacement and in 10 healthy individuals (mean age 36.0+9.1 years) included into the control group. Twenty-eight blood samples taken from 28 RA patients (aged 52+7.6 years) prior to endoprosthetic knee joint replacement and 27 blood samples from healthy individuals (mean age 53.6+8.3 years; a control group) were also analyzed. Real-time quantitative polymerase chain reaction was applied to estimate the expression of the mTOR, p21, ATG1, caspase 3, TNF-а, IL- 6, COL0A1, and MMP-13 genes. The levels of a protein equivalent in the p70-S6K(activated by mTOR), p21, and caspase 3 genes concerned was measured in the isolated lymphocyte lysates, by applying the commercially available ELISA kits. Total protein in the cell extracts was determined using the Bradford assay procedure. Results. The cartilage samples from patients with end-stage RA exhibited a significantly higher mTOR, ATG1, p21, TNFа, MMP-13, and COL10A1 gene expressions than did those from the healthy individuals. At the same time, IL6 gene expression was much lower than that in the control group. The expressions of the mTOR, ATG1, p21, TNFа, and IL 6 genes in the blood of RA patients were much greater than those in the donors. Caspase 3 expression did not differ essentially in the bloods of the patients with RA and healthy individuals. The bloods failed to show MMP-13 and COL10A1 expressions. High mTOR and p21 gene expressions were accompanied by the elevated concentrations of the corresponding proteins in the cell lysates of the patients with RA compared to the controls. Conclusion. The findings suggest for the first time that regulatory mTOR, ATG1, p21, and TNFа gene expressions are enhanced in the blood and articular cartilage of RA patients. These changes are accompanied by the increased expression of MMP 13 gene that is responsible for articular cartilage resorption. Therefore, the higher expression of the examined regulatory genes in the blood of RA patients may be indicative of articular cartilage degradation.

Objective: to study the clinical features and to define the frequency of postoperative complications in patients with rheumatic diseases (RD) who had undergone endoprosthetic knee and hip joint replacement (EKJR and EHJR) during therapy with genetically engineered biological agents (GEBAs). Subjects and methods. The study included 37 patients with RD: 30 with rheumatoid arthritis (RA), 6 with ankylosing spondylitis (AS), and 1 with psoriatic arthritis (PsA). All the patients had indications for endoprosthetic joint replacement (EJR): evident deformity and dysfunction of the joint; pain unrelieved by analgesics and nonsteroidal antiinflammatory drugs; and low quality of life (QL). EHJR and EKJR were performed in 21 and 16 patients, respectively. Their mean age was 40.6+15.8 years (range 18 to 64 years); 78.4% were women; the mean duration of disease was 15 years. 73% patients received synthetic disease-modifying antirheumatic drugs (DMARDs); 68% took small-dose glucocorticosteroids (GCs). All the patients were on GEBA therapy: 16 patients on rituximab, 15 on infliximab, 1 on adalimumab, 3 on abatacept, and 2 on tocilizumab. The activity of RA was determined using DAS 28 scores, that of AS and PsA was estimated using BASDAI and DAS 4 scores, respectively; functional activity was calculated from HAQ scores; QL was defined using the EQ-5D questionnaire. Results. The diagnosis was established in 73% of the patients within the first 2 years after disease onset; at that time, half of them started receiving DMARD therapy. GEBAs were given to patients with high disease activity, inefficacy or intolerance of synthetic DMARDs at an average of 13 years of disease. Addition of GEBAs could lessen preoperative disease activity in the majority of patients (to moderate and low activities in 60 and 27% of the patients, respectively) and the activity remained high only in 13%. During their disease, 84% of the patients took small-dose GCs long (for 1 to 19 years); however, only 68% continued to receive this therapy within 6 months before surgery. In the period of 1 to 12 months following surgery, there was venous thrombosis in 1 (2.7%) patients and instability of the ligamentous apparatus in the replaced joint in 2 patients. No cases of replaced joint infection were found throughout the follow-up. Conclusion. The use of GEBAs made it possible to diminish disease activity in most patients, to reduce needs for GCs, and to perform EJR with a more favorable background. This therapy was not accompanied by the development of infectious complications at the site of prosthetic replacement.

Objective: To study whether the course of the disease can be predicted in patients with osteoarthrosis (OA), by monitoring mTOR (Mammalian Target Of Rapamycin) gene expression in their blood. Material and methods. The investigation was conducted on the peripheral blood samples from 33 outpatients (58.4±7.4 years) with OA; 10 patients (56.5±8.9 years) before endoprosthetic knee joint replacement, и 27 healthy individuals (55.6+8.3 years) who formed a control group. Total RNA was isolated from the blood and used to estimate the gene expression of mTOR, autophagy-related protein 1 (ATG1), the cyclin-dependent kinase inhibitor p21, caspase 3, and tumor necrosis factor-а (TNF-а) by real-time polymerase chain reaction. Results. Analysis of gene expression in the outpatients with OA identified two subgroups: in one subgroup (n = 13) mTOR expression was considerably much less than that in the control group; the expression of ATG1 and p21 did not differ greatly from the control and that of caspase 3 and TNF-α was significantly higher. The other outpatients (n = 20) and all the examined patients needing endoprosthetic replacement were ascertained to have a higher gene expression of mTOR, ATG1, p21, caspase 3, and TNF-α than in the control group. Before endoprosthetic replacement, severe joint destruction in patients with OA was associated with enhanced gene expression of mTOR, ATG1, p21, and caspase 3. Conclusion. In early-stage disease, increased mTOR gene expression may serve as a prognostic marker of the severity of the disease and articular cartilage destruction.

Objective: to evaluate the efficiency of surgical treatment and the quality of life (QL) in patients with rheumatoid arthritis (RA) and elbow damage. Subjects and methods. Fifty-three patients who had undergone elbow synovectomy and debridement were examined 11±5.2 years postoper atively. Clinical and X-ray studies of the operated joint were conducted and its function and QL were assessed using the Mayo Elbow Score, Oxford Elbow Score, HAQ, and EQ-5D. Results. A control examination revealed the larger volume of elbow movements than that preoperatively. The preoperative and postoperative flexion of the elbow was 96.3±21.6 and 127.5±11.7° , respectively (p ≤ 0.05) and its extension was 37.1±8.7 and 17.3±6.9° , (p ≤ 0.05). According to the Mayo Elbow Score and Oxford Elbow Score, there was joint function improvement in the late periods. The mean Mayo index score preoperatively was 25.0±14.5 and the mean score postoperatively was 79.4±6.4. The mean preoperative and postoperative Oxford index scores were 13.8±4.8 and 32.2±8.6, respectively (p ≤ 0.05). The mean HAQ index score preoperatively was high (2.36±0.56). Postoperatively, there was substantial functional improvement in patients with a reduction in HAQ score to 1.67±0.22; the difference in the scores being 0.69 before and after treatment, which corresponded to the significant positive effect of therapy (at least 50% clinical improvement according to the American College of Rheumatology (ACR) criteria). The preoperative and postoperative EQ-5D scores were 019±0.028 and 0.53±0.07, respectively; the Δ EQ-5D score being equal to 0.34, which was indicative of a marked QL improvement in patients after surgical treatment (70% clinical improvement according to the ACR criteria). In the late postoperative period, pain in the affected elbow was reduced by almost twice: according to the visual analogue scale it was 73.8 and 40.6 mm preoperatively and postoperatively, respectively (p≤0.01). Analysis of some EQ-5D scales revealed that there was postoperative psychoemotional improvement; the patients had virtually no difficulty with self-care and day-to-day activity. Conclusion. Synovectomy with debridement and resection of the radial head causes pain relief, a larger volume of movements, improved function and QL in patients with RA in the late postoperative period.

Objective: to analyze disease activity, functional state, quality of life (QL), and the frequency of infectious complications in methotrexate (MT) – or leflunomide (LF)-treated patients with rheumatoid arthritis (RA) who had undergone endoprosthetic replacement of the large joints of the lower limbs. Subjects and methods. One hundred and fourteen patients with RA who had undergone endoprosthetic replacement of the knee and hip joints were divided into 3 groups: 1) 36 patients who continuously received MT or LF in the perioperative period; 2) 42 patients who dis- continued MT or LF 2 and 4 weeks, respectively, prior to surgery; 3) 36 patients who took no disease-modifying anti-rheumatic drugs (DMARDs) within 12 months before surgery. Disease activity was estimated by the DAS28 index. QL was determined using the EQ-5D questionnaire and functional capacity was estimated by the HAQ index. Results and discussion. In all the groups, there was a preponderance of patients with moderate RA activity (more than 60%). In Groups 1 and 2, the mean dose of MT was about 10 mg weekly and that of LF was 20 mg daily. The use duration of glucocorticoids (GC) and their doses were comparable in all the groups. Twelve months after surgery, DAS28 significantly reduced from 4.22±1.08 to 3.58±1.07 months in Group 1 (p = 0.01); in Group 2, the decrease was insignificant: from 4.17±1.17 to 3.80±1.15 (p > 005); in Group 3, RA activity remained as before. All the groups achieved 50% functional improvement; better results were obtained in the group of patients who continued to use DMARDs in the perioperative period (∆HAQ=-0.67). The difference in the Eq-5D index corresponded to a moderate QL improvement: ∆EQ-5D = 0.28, 0.29, and 0.31 in Groups 1, 2, and 3, respectively (p < 0.05). There were no significant group differences. Deep infection in the endoprosthetic replacement area was detected in 2.8, 2.4, and 8.3% of cases, respectively (p > 005). Conclusion. Continuous use of MT and LF leads to a reduction in total disease activity and to functional improvement in patients with RA after endoprosthetic joint replacement, without increasing the frequency of infectious complications.

Objective: to analyze the course of rheumatoid arthritis (RA), to assess its previous therapy, and to evaluate the efficiency of endoprosthetic replacement of knee or hip joints (EKJ or EHJ). Subjects and methods. The study enrolled 50 patients with RA who had undergone EKJ (Group 1; n = 32) or EKJ (Group 2; n = 18); their mean age was 51.8±11.6 and 48.7±8.5 years and the disease duration was 16.5±7.8 and 15.5±7.5 years, respectively. Their quality of life (QL) was estimated by the EQ-5D and SF-36 questionnaires; joint functional capacity was assessed by the HAQ index and the Harris and Insall scales. Results and discussion. Before surgical treatment, the majority of patients took methotrexate (MT) in a weekly dose of 7.5-10 mg, which was prescribed 7-10 years after the disease onset. Oral glucocorticoids (GC) were given to 65.4 and 84.6% of the patients of Groups 1 and 2, respectively. Six months after endoprosthetic replacement, there was functional improvement: the HAQ index decreased from 1.64±0.7 to 1.40±0.6 after EKJ (p = 0.003) and from 2.07±0.6 to 1.72-0.7 after EHJ (p = 0.04). The EQ-5D QL index increased from 0.52 [0.0- 0.61] to 0.59 [0.52-0.69] scores after EKJ (p = 004) and from -0.02 [-0.02-0.52] to 0.52 [-0.02-0.62] scores after EHJ (p = 0.096). There was a significant improvement in the SF-36 physical component summary (PCS): APCS = 4.3 (p = 0.04) after EKJ and APCS = 5.7 (p = 0.02) after EHJ and a trend towards stabilization of the patients' mental status. Conclusion. The majority of patients had not initially received adequate disease-modifying anti-inflammatory therapy for many years. Endoprosthetic replacement of the lower limb joints in the first 6 months after surgery improved the functional capacity of the operated joint, by increasing QL in the patients as a whole. There was no substantial decrease in global disease activity 6 months following surgery.

Periprosthetic infection (PI) in patients with rheumatoid diseases (RD) after total hip joint endoprosthesis (THJE) is a relevant problem of rheumoorphopedics that has not been solved yet. The relative assessment of PI incidence rate after THJE and treatment outcomes in patients with this complication is expected to be carried out. A total of 1201 THJE performed in 1069 patients with RD are considered. The female : male ratio was 3.6 : 1; the mean age was 49.6 years (range: 16 to 83 years). 323 patients had rheumatoid arthritis (RA); 124 patients had juvenile rheumatoid arthritis (JRA); 80 patients had ankylosing spondylitis (AS); 79 patients had systemic lupus erythematosus (SLE); 11 patients had systemic sclerodermatitis (SSD); 18 patients had psoriatic arthropathy (PsA); and 353 patients had osteoarthritis (OA). Other RD were revealed in 81 patients. PI were detected in 9 (0.84%) of 1069 patients with RD, including 7 (2.17%) of 323 patients with RA; 1 (0.8%) of 124 patients with JRA; and 1 (0.28%) of 353 patients with OA. No PI were detected in 81 patients who had other RD. An eightfold (in patients with RA) and a threefold (in patients with JRA) increase in PI compared to that in patients with OA attests to the high risk of this complication in patients with inflammatory as compared to the patients with degenerative RD. After integrated treatment (revision surgery, sanation, continuous irrigation with antibiotics/lavasept), the graft was preserved in OA patients; the complication was prevented in RA patients. Six patients will be subjected to repeated revision surgery; one patient died of diabetes complications after the graft had been removed. A significant increase in PI incidence rate after THJE in patients with RA and JRA as compared to that in OA patients allows one to regard inflammatory RD as risk factors of this complication. The low effectiveness of the procedure for integrated therapy for PI in RD patients indicates that it needs to be modernized.

Лечение дефектов гиалинового хряща у больных с гонартрозом является сложной ортопедической проблемой. Использование мезенхимальных стволовых клеток (МСК), обладающих способностью дифференцироваться в клетки с хондрогенной направленностью, и генно-инженерных технологий перспективно для восстановления суставного хряща. МСК могут быть выделены из различных тканей и размножены без потери способности к хондрогенной дифференцировке [8,17,27]. В данной статье рассматриваются новейшие технологии лечения дефектов суставного хряща коленного сустава при гонартрозе, основанные на применении МСК и прицельной генной терапии.

There are the common principals of the rehabilitation after knee and hip replacements in accordance with particularities of the corse and medical treatment for concrete forms of the rheumatic diseases. Such factors of the surgical risk as osteoporosis, haemorrhage, decrease resistance to infection, accompanying heart diseases, cndo- crin system insufficiency were took into consideration for elaboration of the rehabilitation program. It has been emphasized the accuracy observance for the technology of the operation as the basis of the successful rehabilitation

Summary Analysis of 100 patients with rheumatic diseases after surgery of knee and hip joints carried out at the clinical department of the Institute of Rheumatology was done. Some details of surgical technique of endoprosthetics, short and long term results of the treatment are described.