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Infective complications in orthopaedic and tumoral surgery

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Dr. Oleg Vyrva, MD, PhD
Sytenko Institute of Spine and Joint Pathology Kharkiv, Ukraine

Infective complications  in orthopaedic and tumoral surgery

Dr Vyrva can you introduce your Hospital?

Sytenko Institute of Spine and Joint Pathology is in Kharkiv and is the oldest orthopaedic hospital in the former Soviet Union, and now Ukraine as well, having almost 110 years of history.
There are 5 different departments (TJR, Paediatric, Spine, Trauma and Emergency for difficult cases) with 240 orthopaedic beds. I'm the chief of the Medical Office (Deputy director on scientific and curative work), which is mainly an administrative bureau, but I'm a surgeon as well.

I do a lot of TJR, complicated trauma surgery and tumoral surgery, which is my main scientific interest. There are only two departments and two surgeons in Ukraine for tumoral surgery, one in Kharkiv and one in Kiev, performing this kind of surgery.

Currently in Kharkiv, we we have a nice and young team of about 10 persons, and we perform tumoral surgeries and revision surgeries almost every day. Our team is also involved in research: as a matter of fact our hospital is not only a place for patient's healthcare, but also a place for research thanks to the presence of many different labs, each one dedicated to the specific work that has to be done for the specific departments.

Your main interest is tumoral surgery. Which are the most common complications encountered when dealing with bone tumors?

We started to perform tumoral surgery 12 years ago. My teachers in the past decades performed some thousands of tumoral surgeries, tipically some kind of bone grafting performed with completely open bone. But now the tumoral therapy and the new generation of modular prosthesis system has changed this this situation. Nowadays, 85-90% of the patients undergoing tumoral surgery can have a chance to have their limb saved.
The biggest problem when you remove a bone tumors is the huge bone or joint defect you leave. The same situation is patient's care when we have revision surgeries after the onset of an infection.

Sytenko Institute is one of the biggest centers which collects such difficult cases from all over Ukraine. It' is a really difficult and complex work because it involves a lot of surgery planning for an adequate management of the problem.

You mentioned infection. Is it an important complication?

Yes, it is a big problem. The number of TJR is increasing in Ukraine as well as the number of surgeons performing them, however TJR surgery requires adequate education and training. IT is necessary to be able to perform a good surgery, but you also need to be able to face the complications and to follow-up the patients even for long time after surgery. I usually know everything about my patients and I follow them up for 7-8 years after surgery, especially when dealing with tumors or revision cases.

Three years ago we also started to create a national recruitment register, and we are trying to have more and more surgeons filling the register with data.

Which is the infection rate in orthopaedic surgery in Ukraine?

I think that after primary TJA it's about 2.5-3%. It's a little bit higher than in the rest of Europe, but it depends from a lot of factors. My personal infection rate is lower (about 0.5%) and this is thanks to my American colleagues. I usually spend at least 3-4 weeks every years in US clinics, trying always to keep a very high level of surgery.

Speaking about muscoloskeletal tumors, which is the incidence of infection? Does it depend upon the type of surgery?

There are two different data to report, because the incidence of infection as a complication after primary arthroplasty or after tumoral surgery is very different. My data regarding infection rate after tumoral surgery is about 20%. This is mainly because patients have usually undergone previous surgery in their original hospitals. As they generally come after 4-5 previous surgery, the level of complications increases immediately.

Is there a difference in treating “simple” orthopaedic infections or an orthopaedic infection which is related to a tumour? Is there a different approach?

Generally the approach is the same, but in revision cases related to infected tumors usually you deal with difficult soft tissue conditions and sometimes you have to work with a plastic surgeon. That's the main difference.

What is your suggestion to a surgeon who is dealing with a tumour? Do you think it's better to send patients to your Institute as it is one of the two reference centers in Ukraine?

My recommendation for all Ukrainian surgeons who deal with tumours is that they have to correctly manage primary bone tumours. In my experience I have been sent patients after terrible, incredible surgeries and sometimes it is too late to solve the problem.

Which are the solutions offered to the surgeons by medical devices' manufacturer in Ukraine, when dealing with orthopaedic bone tumours?

For primary TJR there are a lot of companies helping us, however for revision cases, and hence for revision systems, there are few companies which provide some useful solutions. In some cases there is a need for custom made devices, especially for customized revision prosthesis.

In this field Tecres may play an important role in our country

You recently treated a case with a Tecres custom made device. Can you describe the patient clinical history and the case till the latest follow-up?

This man is 34 years old. 8 years ago he got a car accident with many different types of fracture the biggest problem was the femoral neck fracture and the distal femur fracture on the same site.

He had 5-6 different types of prosthetic syntheses, with infective complication after bone plating of the distal femur. He moved then to Austria and Germany where he had some additional surgeries. He had a primary hip replacement, but 3-5 weeks later he had an infective complication involving the distal femur and during the last 3 years the infection went deep to the bone and down to the knee.
At this point, many of the surgeons he consulted thought about amputation. When he arrived at my clinic, I thought that he had good enough muscles conditions and I explained him all the difficulties he had to expect from that kind of surgery. He eventually said “Ok, but give me a chance to save my leg” and I said “Ok, so I'll try to arrange it, but I will need a customized implant”.
I therefore started to contact Tecres. I was really surprised when I've started this collaboration because I had previous experiences with this type of custom implants for tumoral surgeries and revision cases from another company, but usually I sent the information required and I didn't get an answer, then I send it again and again continuously for 2 months before receiving an answer. I work with patients and I have urgent cases to treat, so I need to schedule my surgery right now and not 2-3 weeks later, because we're dealing with lives. Conversely there was a great and fast communication with Tecres and when I was in the OR for the surgery I was very happy to see that your custom made cement spacer fitted very well into patient's bone.

Now the patient is in his 2 month after surgery, he has many scars and very stiff soft tissues around the knee, but he has told me that he walks without support in full weight-bearing and drives a car even if I have told him not to do this and to be much more careful.

Anyway, I got some news from my assistant because this patient came for a regular examination and he told me that everything is going well.

 

Figures

1a) pre-op X-ray (full view)

1b) upper femur (detail)

1c) lower femur (detail)

1d) tibia (detail)

2) pre-op X-ray with superimposed device

3) technical drawing

4a) post-op X-ray (frontal view)

4b) post-op X-ray (lateral view)