MF Ortopedijos traumatologijos klinika (04.31)

Plaučių vėžys vis dar tebėra didžiulė grėsmė ne tik pasaulio, Europos Sąjungos, bet ir Lietuvos gyventojams. Siekiant pagerinti pagalbą plaučių vėžiu sergantiems ligoniams, suvienodinti specialistų požiūrį į šios ligos diagnostikos ir gydymo standartus, Lietuvos sveikatos mokslų universiteto ir Lietuvos sveikatos priežiūros specialistų draugijų iniciatyva bei bendru darbu nuo 2007-ųjų kas kelerius metus išleidžiamos „Plaučių vėžio diagnostikos ir gydymo rekomendacijos“. Išlaikydami tradicijas ir tęstinumą pristatome aštuntąsias atnaujintas ir papildytas „Plaučių vėžio diagnostikos ir gydymo rekomendacijas“, kurios yra gausaus autorių, savo srities ekspertų ir pagrindinių Lietuvos sveikatos priežiūros specialistų draugijų atstovų, kolektyvo ilgametės patirties, bendro nuolatinio darbo rezultatas. Plaučių vėžio gydymas išlieka viena dinamiškiausių onkologijos sričių, todėl ankstesnes rekomendacijas buvo būtina atnaujinti apžvelgiant svarbiausias prigijusias naujoves. Plaučių vėžio profilaktika, ankstyva diagnostika ir atrankinė patikra yra viena iš prioritetinių sričių naujame Europos Sąjungos kovos su vėžiu plane. Kai kuriose Europos Sąjungos šalyse jau yra įdiegtos nacionalinės plaučių vėžio patikros programos, kitose, taip pat ir Lietuvoje, vykdomos ar jau atliktos bandomosios programos. Tačiau, kol nėra patvirtinta nacionalinė plaučių vėžio patikros programa Lietuvoje, šiose rekomendacijose paliekame tikslinės plaučių vėžio atrankinės patikros gaires, kurios sėkmingai pritaikytos daugelyje Europos Sąjungos šalių ir yra patvirtintos Lietuvoje Plaučių vėžio metodiniame dokumente. Tikimės, kad netolimoje ateityje galėsime pristatyti ir nacionalinę plaučių vėžio atrankinės patikros programą. [...].

Background: Management of prosthetic joint infections (PJIs) due to Candida spp. remains challenging and poorly standardized. Epidemiological patterns and therapeutic strategies may vary between centers and countries, potentially reflecting differences in access to antifungal agents. Methods: We performed a secondary analysis of an international, multicenter, retrospective study supported by the European Society of Clinical Microbiology and Infectious Diseases, including Candida PJI diagnosed between 2010 and 2020. Cases met European Bone and Joint Infection Society criteria, combining clinical signs of infection with at least 2 intraoperative samples positive for Candida spp. Follow-up was 2 years. Epidemiology, management, and outcomes were compared across 5 groups: France, Spain, England, Austria, and other countries. Results Overall, 268 cases were included: France (n = 142), Spain (n = 42), England (n = 38), Austria (n = 36), and others (Brazil, Lithuania, Italy; n = 9). Distribution of infected sites was similar across countries (hip 53.4%, knee 43.3%, and other 3.3%), as was species epidemiology (Candida albicans 55.6%, Candida parapsilosis 29.5%, Candida glabrata 7.8%, and Candida tropicalis 5.6%). Surgical strategies differed: 1-stage exchange was more frequent in France (36.0%) and Austria (34.3%), whereas 2-stage exchange predominated in England (42.1%) and Spain (37.2%). Echinocandins were prescribed significantly more often in France (41.8%) than elsewhere. Overall outcomes were poor, with a global failure rate of 43%, without significant differences between countries. Conclusions International differences in epidemiology and management of Candida PJI appear limited. Variations in surgical and antifungal strategies did not translate into improved outcomes, highlighting the need for optimized and standardized management approaches in future collaborative prospective studies worldwide and clinical.

Persistent talar malalignment despite appropriate closed reduction in a trimalleolar ankle fracture-dislocation, later found to be caused by posterior tibial tendon interposition and complicated by acute alcohol withdrawal delirium that significantly influenced treatment strategy. A 54-year-old woman was admitted after domestic trauma with pain and deformity of the right ankle. On arrival, she was in acute alcohol withdrawal delirium with tremor, agitation, tachycardia, and hypertension. CT confirmed a comminuted trimalleolar fracture with syndesmotic disruption and talar subluxation. A 3–4 cm area of medial skin necrosis was present. Closed reduction under procedural sedation and plaster immobilization were performed; however, anatomical alignment could not be achieved and talar subluxation persisted. Due to ongoing instability and soft tissue compromise, calcaneal skeletal traction was applied for temporary stabilization. Because of severe delirium, the patient required intensive care management including sedation, benzodiazepines, antipsychotics, anticoagulation, antibiotics, and fluid therapy. After stabilization of her general condition, definitive open reduction was performed due to persistent malalignment. Intraoperatively, posterior tibial tendon interposition between fracture fragments was identified and released, allowing anatomical reduction. The fracture was stabilized with three 2.0 mm Kirschner wires under fluoroscopic control. Postoperatively, the patient remained in intensive care until delirium resolved and was subsequently transferred to the orthopedic department in stable condition. Failure to achieve anatomical alignment after closed reduction should raise suspicion of mechanical obstruction. In this patient, persistent talar subluxation and medial skin necrosis limited immediate fixation and required temporary skeletal traction to protect soft tissues. During open reduction, posterior tibial tendon interposition was identified and released before stabilization with Kirschner wires. Acute delirium complicated perioperative management and required monitoring and sedation to protect fixation. Persistent malalignment after closed reduction in ankle fractures requires reassessment of causes and appropriate surgical timing. Early recognition of mechanical obstruction may prevent repeated manipulation and soft tissue injury. Successful management depends not only on fracture fixation but also on coordinated multidisciplinary care.

This case demonstrates the development of acute compartment syndrome (ACS) during in-hospital observation in an elderly polytrauma patient who initially presented hemodynamically stable and without neurovascular deficit. The delayed progression of a limb-threatening condition in the absence of prior surgical intervention required urgent reassessment and emphasizes the evolving nature of post-traumatic compartment pathology. A 74-year-old woman was admitted after being struck by a vehicle. On arrival, she was conscious, oriented, and hemodynamically stable. CT revealed a displaced right tibial shaft fracture, left pubic ramus fracture, sacral lateral mass fracture, L5 transverse process fracture, and a small retroperitoneal hematoma without active extravasation. The right lower leg was markedly swollen with a tense hematoma but preserved distal pulses and intact neurological function. The limb was immobilized in a splint. Conservative treatment was initiated for pelvic and spinal injuries. No surgical procedures had been performed prior to the onset of compartment syndrome. Approximately 8 hours after admission, the patient developed progressively worsening pain in the affected leg, disproportionate to the apparent injury severity and poorly responsive to opioid analgesia. Pain on passive stretch and increasing compartment tension were observed. Based on clinical findings, acute compartment syndrome was diagnosed. Emergency four-compartment fasciotomy was performed, revealing viable musculature without signs of necrosis. Postoperatively, distal perfusion remained intact and no neurological deficits developed. At 3 months, limb function was preserved without residual deficit. Tibial fractures are a common cause of ACS after high-energy trauma. Diagnosis remains primarily clinical, as delayed decompression significantly increases the risk of permanent neuromuscular damage. In polytrauma patients, attention to associated injuries may delay recognition of evolving compartment syndrome. This case illustrates that ACS may develop despite initial clinical stability, even in elderly patients. Early post-traumatic assessment represents only a single time point in a potentially evolving pathological process. Acute compartment syndrome may develop during observation even without preceding surgical intervention. Continuous reassessment and timely surgical decompression are critical to preserving limb viability and preventing permanent functional impairment.

Introduction Dislocation of the meniscal bearing is a well-recognized complication of medial Oxford unicompartmental knee arthroplasty (UKA) with a mobile design [1]. In Oxford UKA, the polyethylene meniscal bearing mimics the native meniscus; however, this design carries a risk of bearing dislocation [2]. Bearing dislocation occurs in approximately 0.6–4.0% of Oxford UKAs, but recurrent cases requiring multiple revisions remain uncommon [3,4]. Case Presentation A 52-year-old woman underwent right medial Oxford UKA for isolated medial compartment osteoarthritis with a 4-mm polyethylene meniscal bearing. Intraoperative soft-tissue balance was satisfactory in flexion and extension, with flexion to 110°. Three months postoperatively, after squatting, she developed acute knee pain and loss of extension. Radiographs showed medial bearing dislocation, and a bearing exchange to a 5-mm bearing was performed. The ACL was clinically intact with no definite ligament injury on clinical assessment. Five months after the first bearing exchange, she presented again with recurrent severe knee pain and functional impairment. Repeat radiographs confirmed recurrent medial dislocation, and a second bearing exchange was undertaken, upsizing to a 7-mm bearing after reassessment of valgus laxity and flexion–extension balance. Serial radiographs showed well-fixed femoral and tibial components with appropriate alignment. Postoperatively, stability and function were restored. Discussion Medial meniscal bearing dislocation after Oxford UKA is multifactorial and associated with ligament attenuation and flexion instability [3]. In our case, dislocation occurred during deep flexion; both episodes were medial despite a clinically intact ACL and no clear ligament injury on clinical assessment, making an anteroposterior instability mechanism less likely and supporting a soft-tissue laxity or flexion-gap mechanism [3,5]. This highlights the importance of reassessing valgus laxity and bearing tracking at the first bearing exchange to guide appropriate bearing selection and reduce the risk of recurrent dislocation [3,6]. Conclusions Isolated bearing exchange is reasonable when femoral and tibial components are well fixed and appropriately aligned. Recurrent medial dislocation should prompt reassessment for instability, including possible ligamentous laxity.

Introduction Total knee arthroplasty (TKA) effectively reduce pain in advanced osteoarthritis cases, however, mechanical failure, especialy in early stages, remains a serious complication requiring revision surgery [1]. Component loosening shortly after implantation is uncommon and challenging to manage [2]. We present a case of early mechanical femoral component failure following primary TKA. Case Presentation A 77-year-old woman developed progressive pain, instability, and reduced function in the left knee two months following primary TKA for osteoarthritis. Conservative treatment was unsuccessful. Examination showed painful, limited motion, medial laxity, difficult weightbearing without infection signs. Radiographs confirmed femoral component loosening. Patient underwent revision TKA. Intraoperatively, loosening of the femoral component with a medial femoral condyle fracture was noted. Revision was performed using a constrained condylar knee implant with stem extensions and augments to restore alignment, manage bone loss, and improve stability. There were no intraoperative complications. During postoperative period, the patient received antibiotic treatment, thromboembolism prophylaxis, early mobilization and physiotherapy. Recovery was satisfactory with improved mobility and reduced pain. Control radiographs showed proper implant position without loosening or fractures. Discussion Early failure after TKA may result from insufficient fixation, ligament imbalance or osteoporotic bone. Correct diagnosis and further treatment are crucial to avoid further morbidity. Constrained revision systems provide adequate stability in cases with ligament insufficiency and bone defects[3]. Conclusions This case emphasizes the necessity for early diagnosis of mechanical TKA complications. Prompt revision arthroplasty can result in favourable outcomes even when early loosening and bone compromise are present.

Introduction Recurrent lateral patellar dislocations are a persistent concern after the first episode, with approximately 60% of patients experiencing the same injury after initial healing or instability issues in the future[1]. Critical anatomical factors, such as trochlear dysplasia, the Insall-Salvati index, tibial tuberosity-trochlear groove distance, and younger age, affect the decision-making process regarding surgical management[1,2] Case Presentation A 26-year-old female patient presented with a history of recurrent left knee patellar dislocations, pain, and functional impairment. The patient had previously undergone a tibial tuberosity osteotomy (TTO) with medialization and medial patellofemoral ligament (MPFL) reconstruction of the contralateral knee, one year prior with no recurrent dislocations recorded postoperatively. Physical examination revealed increased patellar mobility, lateralization, tenderness, and a positive J-sign. The surgical management chosen was an Elmslie-Trillat procedure, combined with knee arthroscopy, which comprised tibial tuberosity osteotomy with medialization, lateral patellar release, and medial patellar plication The postoperative course was uncomplicated; the patient underwent continuous passive motion (CPM) therapy and was discharged for outpatient rehabilitation. Discussion The Elmslie-Trillat procedure is a well-established, biomechanically precise technique with low recurrent dislocation rates and adequate preservation of physiological joint movements; thus, it was favored for this case[2]. This technique preserves the hamstring tendons, maintaining knee flexion strength and dynamic knee stability while avoiding donor-site morbidity and complications associated with tendon grafts, unlike medial patellofemoral ligament reconstruction[3,4]. Identifying the underlying mechanism of patellar pathology remains crucial when selecting a surgical approach[5]. For patients with soft-tissue deficiencies or excessive patellofemoral joint pressure, MPFL reconstruction or Fulkerson’s anteromedialization may be more appropriate[6,7]. Conclusions Individualized surgical planning is key in recurrent patellar instability, with the Elmslie-Trillat procedure representing a viable option for restoring stability when alignment abnormalities are present.

Introduction Prosthetic joint infection (PJI) is a severe complication of joint arthroplasty associated with high mortality rates and economic burden [1]. While two-stage revision is widely accepted as the standard treatment for hip PJI, polymicrobial infections further compromise treatment success [2,3]. This case highlights the complexity of managing such infections. Case Presentation A 56-year-old male underwent right total hip arthroplasty in 2006 and later developed PJI requiring implant removal and multiple revision procedures abroad. In 2022, the patient presented to LSMU KK with PJI of the right hip caused by Pseudomonas aeruginosa, Staphylococcus epidermidis, Staphylococcus aureus, necessitating a two-stage surgical approach. Subsequently, first-stage revision surgery was performed using cement spacers and targeted antimicrobial therapy with amikacin. Treatment was complicated by acute kidney injury, prompting modification of antimicrobial therapy to meropenem and colistin following multidisciplinary consultation. Despite initial management, persistent infection required additional surgical management. Recurrent isolation of Pseudomonas aeruginosa from intraoperative cultures was treated with repeated antimicrobial therapy using colistin and ceftazidime. Dosing was adjusted according to renal function under the guidance of a clinical pharmacologist. During follow-up, joint aspiration performed in 2023 revealed infection with Enterococcus faecalis, for which intravenous antimicrobial therapy with linezolid was initiated. After clinical evaluation and serum inflammatory markers suggested that the infection was resolved, the second-stage revision was completed in 2024. At 17 months postoperatively, the patient remains well with no clinical or laboratory evidence of infection. Discussion Infections caused by Pseudomonas aeruginosa and Enterococcus faecalis, each account for around 3% of PJI cases and pose significant therapeutic challenges [4,5]. This case was further complicated by renal dysfunction, which limited effective antibiotic options and required individualized dosing and close monitoring. Conclusions Management of persistent polymicrobial PJI often requires a multistage surgical intervention, multidisciplinary approach and prolonged antimicrobial therapy to achieve successful outcomes.

Synthetic biomaterials used as bone graft extenders (BGE) in spinal fusion surgery can supplement but do not replace autologous bone. This pilot study evaluated a calcium sulfate/hydroxyapatite (CaS/HA) material as an antibiotic-eluting BGE and a carrier for bone morphogenetic protein-2 (BMP-2) in a rabbit posterolateral lumbar (L4–L5) spinal fusion model (PLF). Pre-set CaS/HA beads were loaded with tobramycin (TOB) and tested for in vitro antibiotic release and antibacterial activity against Staphylococcus aureus. For the in vivo PLF study, CaS/HA beads were used in two treatment strategies: (1) CaS/HA + TOB + autograft (left side) and (2) CaS/HA + BMP-2 (right side). Serum levels of TOB were quantified and spinal fusion was evaluated after 12 weeks. TOB exhibited a rapid initial release, followed by a decline below detectable levels after 6 h in vitro and 48 h in vivo. TOB-loaded CaS/HA beads demonstrated in vitro antibacterial activity for 19 days. In the PLF study, 5/6 and 6/6 specimens were fused radiologically in the TOB and BMP groups, respectively, and 100% using mechanical testing. Micro-CT analysis showed no significant difference in bone volume between the TOB and BMP-2 groups (364 ± 84 vs. 479 ± 95 mm3). Histology verified continuous bone bridging in both groups. Our in vitro findings indicate that locally added TOB could protect the CaS/HA material from bacterial colonization and did not adversely impact the CaS/HA material negatively to act as BGE. The addition of low-dose BMP-2 to the CaS/HA material proved effective in building bone without the need to harvest autologous bone. In summary, this pilot PLF study demonstrates that the tested CaS/HA material combined with BMP-2 could replace autologous bone harvesting in spinal fusion surgery. Addition of TOB could potentially protect the material from bacterial colonization during the early post-operative period but further studies in infection models are warranted.

Background: Mycetoma is a chronic infectious disease caused by bacteria or fungi which typically affects the skin, deep tissues, and bones. This case involves bone mycetoma in an immunocompetent patient, marking the first known instance of actinomycetoma caused by Gordonia rubripertincta. Case Report: A 25-year-old male presented with severe pain and deformity in his left foot, symptoms that began five years prior after stepping on a wire. Initial surgery provided temporary relief, but symptoms worsened over time. Doxycycline treatment was ineffective. Skin biopsies were performed. The patient was diagnosed with actinomycetoma, with Gordonia rubripertincta identified in culture. Although initial improvement was observed with amoxicillin–clavulanate treatment, the condition later worsened, requiring long-term penicillin therapy and eventual surgical excision. Despite treatment, symptoms persisted, leading to a bone biopsy that showed no microorganism growth. A six-week course of ampicillin–sulbactam and ciprofloxacin, along with offloading, decreased pain and stabilized radiological findings. Conclusion: Gordonia infections mean there is no universally established treatment protocol. This case underscores the diagnostic and therapeutic challenges associated with mycetoma, particularly in non-tropical regions.