Chirurgia Narządów Ruchu

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) www.polishorthopaedics.pl Oficjalny Organ Polskiego Towarzystwa Ortopedycznego i Traumatologicznego The Official Journal of the Polish Society of Orthopaedics and Traumatology ISSN 0009-479X DWUMIESIĘCZNIK 5/2017 Chirurgia Narządów Ruchu I Ortopedia Polska Polish Orthopaedics and Traumatology Chirurgia Organorum Motus et Orthopaedia Polonica Acta Societatis Orthopaedicae Polonicae

POLSKIE TOWARZYSTWO ORTOPEDYCZNE I TRAUMATOLOGICZNE POLISH SOCIETY OF ORTHOPAEDICS AND TRAUMATOLOGY Zarząd Główny / Head Council Prezes / President: prof. dr hab. med. MAREK SYNDER I Wiceprezes / 1st Vice-president: prof. dr hab. med. ANDRZEJ BOHATYREWICZ II Wiceprezes / 2nd Vice-president: prof. dr hab. med. LESZEK ROMANOWSKI Redaktor Naczelny / Editor-in-Chief: dr hab. med. ANDRZEJ NOWAKOWSKI Członek Zarządu / Member of Council: prof. dr hab. med. JAROSŁAW CZUBAK Członek Zarządu / Member of Council: dr hab. med. BOGDAN KOCZY CHIRURGIA NARZĄDÓW RUCHU I ORTOPEDIA POLSKA POLISH ORTHOPAEDICS AND TRAUMATOLOGY Chirurgia Narządów Ruchu i Ortopedia Polska jest organem Polskiego Towarzystwa Ortopedycznego i Traumatologicznego publikującym oryginalne prace kliniczne i doświadczalne z zakresu ortopedii, traumatologii i rehabilitacji narządu ruchu. Czasopismo publikuje także opisy przypadków kazuistycznych, technik leczenia operacyjnego, postępowania nieoperacyjnego oraz prace dotyczące zaopatrzenia ortopedycznego i działalności Towarzystwa. W czasopiśmie zamieszczane są również recenzje książek, sprawozdania z międzynarodowych zjazdów, kongresów i szkoleń. Surgery of the Motor Systems and Polish Orthopaedics is the official journal of the Polish Society of Orthopaedics and Traumatology. It publishes original research articles, clinical reviews, research reports and state-of-the-art reviews related to the area of orthopedics, rehabilitation and advances in patient care. It promotes information exchange among specialists in orthopedics, neurosurgery, and rehabilitation. The journal includes book reviews and announcements of international congresses, meetings and workshops relevant to orthopedic conditions and their treatment, operative techniques and methods, non-operative approach to patients with motor impairment. It promotes a multidisciplinary approach to the pathologic conditions of the motor system, in order to optimize quality of treatment and patient s life standards. Redaktor naczelny / Editor-in-Chief and Chairman Board of Editors: ANDRZEJ NOWAKOWSKI Zastępcy redaktora naczelnego / Vice Editor-in-Chief: JAROSŁAW CZUBAK, TOMASZ MAZUREK Sekretarze redakcji / Secretaries: ŁUKASZ KUBASZEWSKI, MARCIN CEYNOWA, MIKOŁAJ DĄBROWSKI, MAREK ROCŁAWSKI Redaktor Honorowy / Honorary Editor: LESŁAW ŁABAZIEWICZ Redaktor techniczny / Technical Editor: TOMASZ ADAMSKI KOMITET REDAKCYJNY / EDITORIAL BOARD AEBI M. Bern BENDEK A. Warszawa BIAŁECKI J. Warszawa BIELAWSKI J. Lubin BIELECKI A. Rzeszów BOHATYREWICZ A. Szczecin CABAN A. Warszawa CEYNOWA M. Gdańsk CHOPIN D. Berck-sur-Mer CHROBOK J. Praga CZERNER M. Opole CZERWIŃSKI E. Kraków DESZCZYŃSKI J. Warszawa DRAGAN Sz. Wrocław DUTKA J. Kraków DUTKIEWICZ Z. Warszawa DWORAK L. Poznań FABIŚ J. Łódź FABRIS D. Padova GAWLIKOWSKI J. Gdańsk GAŹDŹIK T. Sz. Sosnowiec GĄGAŁA J. Lublin GEORGE J. Johannesburg GRABOWSKI M. Bad Bergzabern GUSTA A. Szczecin HARAMATI N. Nowy Jork HAWRANEK M. Zabrze HIRAJZUMI Y. Tokyo HVID I. Arhus JACKOWIAK M. Toruń JANKOWSKI R. Poznań JÓŹWIAK A. Warszawa JÓŹWIAK M. Poznań KACZMARCZYK J. Poznań KANDZIERSKI G. Lublin KARPIŃSKI M. Hull KIWERSKI J. Konstancin KŁOSIŃSKI P. Kraków KOCZY B. Piekary Śląskie KOŁBAN M. Szczecin KOWALCZEWSKI J. Warszawa KOTELA I. Warszawa KOTRYCH D. Szczecin KOTWICKI T. Poznań KRBEC M. Praga KRÖDEL A. Essen KRUCZYŃSKI J. Poznań KRZEMIŃSKI M. Kościerzyna KUSZ D. J. Katowice KWIATKOWSKI K. Warszawa ŁOKIETEK W. Brussels ŁUKAWSKI S. Otwock MAŁDYK P. Warszawa MANIKOWSKI W. Poznań MARCZYŃSKI W. Warszawa MARGULIES Y. New York MATUSZEWSKI Ł. Lublin MAZUREK T. Gdańsk MAZURKIEWICZ S. Gdańsk MAZURKIEWICZ T. Lublin MICHALSKI P. Warszawa MILECKI M. - Otwock MODRZEWSKI K. Lublin MOLSKI M. Warszawa MROWIEC A. Polanica Zdrój NAWROT P. Poznań NAZAR J. Poznań NIEDŹWIECKI T. Olsztyn NIEDŹWIEDZKI T. Kraków NOWAK R. Katowice PANKOWSKI R. Gdańsk POMIANOWSKI S. Otwock POPKO J. Białystok RADEK A. Łódź RAMOTOWSKI W. Warszawa RĄPAŁA K. Otwock ROCŁAWSKI M. Gdańsk ROGALA P. Poznań ROMANOWSKI L. Poznań RUSZKOWSKI K. Poznań SAMBORSKI W. Poznań SCHLENZKA D. Helsinki SERAFIN J. Warszawa SKOWROŃSKI J. Białystok SŁOWIŃSKI K. Poznań SMOCZYŃSKI A. Gdańsk SNELA S. Rzeszów STRZYŻEWSKI W. Poznań SYNDER M. Łódź SZCZĘSNY G. Warszawa SZOSTEK A. Giżycko ŚWIĄTKOWSKI J. Warszawa TROJANOWSKI T. Lublin TRZASKA T. Poznań URBANIAK I. Kalisz WALL A. Wrocław WASILEWSKI A. Puszczykowo WIDUCHOWSKI J. Piekary Śląskie WIERUSZ-KOZŁOWSKA M. Poznań WINGSTRAND H. Lund WÓJCIK A. Cambridge ZARZYCKI D. Zakopane ZWIERZCHOWSKI H. Łódź ŻOŁYŃSKI K. Łódź ŻYLUK A. Szczecin Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) DWUMIESIĘCZNIK, 5/2017 ISSN0009-479X Adres: Redakcja Chirurgii Narządów Ruchu i Ortopedii Polskiej ul. 28 Czerwca 1956 nr 135, 61-545 Poznań e-mail: office@polishorthopaedics.pl www.polishorthopaedics.pl Copyright Poznań 2017 All rights reserved Wydawca: Exemplum

ISSN 0009-479X Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) Contents / Spis treści PRACE ORYGINALNE 151 Kończyna dolna i obręcz biodrowa Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Wyniki zastosowania preparatu kwas hialuronowy z autologicznym osoczem bogatopłytkowym w chorobie zwyrodnieniowej stawu kolanowego w krótkim okresie obserwacji Paweł Łęgosz, Sylwia Sarzyńska, Piotr Stępiński, Łukasz Pulik, Paweł Niewczas, Andrzej Kotela, Marek Gołębiewski, Paweł Małdyk 160 Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years Wyniki endoprotezoplastyki stawu biodrowego z użyciem trzpienia Fitmore w 4-letnim okresie obserwacji Piotr Łuczkiewicz, Dawid Jaskólski, Mariusz Stasiak, Katarzyna Gołąbek-Dropiewska, Adam Buciński, Bogusław Baczkowski 165 Patient with a fracture of the proximal end of the femur in an urban hospital Pacjent ze złamaniem bliższego końca kości udowej w szpitalu miejskim Adam Konik, Bartłomiej Osadnik, Łukasz Wiktor PRACE ORYGINALNE 170 Kręgosłup i klatka piersiowa Survival analysis amongst patients with metastatic spine tumor treated with corpectomy Analiza przeżyć pacjentów po korpektomiach wykonanych z powodu guzów przerzutowych kręgosłupa Piotr Biega, Grzegorz Guzik, Tomasz Pitera OPIS PRZYPADKU 175 Kończyna górna i dolna Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Wspomaganie zrostu tkanki kostnej za pomocą ultradźwięków studium 4 przypadków Mateusz Stolarz, Robert Hawranek, Grzegorz Wrzask, Marek Hawranek, Jakub Hawranek, Zygmunt Wróbel PRACE ORYGINALNE 183 Choroby narządu ruchu na tle zapalnym Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications Zespoły hiperandrogenne oraz trądzik jako potencjalne przyczyny powikłań operacji ortopedycznych Szymon Czech, Grzegorz Franik, Jacek Hermanson, Robert Kokot, Bogdan Koczy, Paweł Madej, Michał Mielnik PRACE ORYGINALNE 188 Prace historyczne Professor Józef Szczekot (1932-1997) In Memoriam Profesor Józef Szczekot (1932-1997) Wspomnienie Tomasz Mazurek, Michał T.W. von Grabowski

90 rocznica urodzin profesora Heinza Mittelmeiera Dziewiątego października 2017 r. dziewięćdziesiąte urodziny obchodził prof. dr hab. med. dr h.c. Heinz Mittelmeier, światowej sławy niemiecki chirurg-ortopeda, w latach 1964-1996 kierownik Katedry, Kliniki i Polikliniki Ortopedii Wydziału Medycznego Uniwersytetu Saary w Homburgu. Od czasu zaprzyjaźnienia się z profesorem Wiktorem Degą (1959) był częstym uczestnikiem polskich kongresów naukowych i polskich klinik ortopedycznych, dzieląc się swoim doświadczeniem i wiedzą. Z profesorem Mittelmeierem przez wiele lat blisko współpracował dr Michał von Grabowski, naukowy asystent jego Kliniki, przybyły w 1980 r. z Kliniki Ortopedii Akademii Medycznej w Gdańsku. Szczególnie bliskie kontakty łączyły profesora Mittelmeiera z Kliniką Ortopedii profesora Andrzeja Walla we Wrocławiu, a także z profesorem Józefem Szczekotem, kierownikiem Katedry i Kliniki Ortopedii w Gdańsku. Skonstruowana przez prof. H. Mittelmeiera oryginalna bezcementowa, ceramiczna endoproteza stawu biodrowego znalazła praktyczne zastosowanie w wielu polskich klinikach. Profesor Heinz Mittelmeier był jednym ze współorganizatorów Niemiecko-Polskiego Koła Przyjaciół Ortopedii i Traumatologii (1995), nadal aktywnie działającego. W uznaniu szczególnych zasług dla polskiej ortopedii przyznano Profesorowi między innymi honorowe członkostwo Polskiego Towarzystwa Ortopedycznego i Traumatologicznego (1984) oraz tytuł doktora honoris causa Akademii Medycznej w Gdańsku (1993). Z okazji urodzin Redaktor Naczelny i Redakcja Chirurgii Narządów Ruchu i Ortopedii Polskiej, a także zaprzyjaźnieni polscy ortopedzi życzą serdecznie naszemu Przyjacielowi, profesorowi Heinzowi Mittelmeierowi, dobrego zdrowia, pogody ducha i długich jeszcze lat życia. Prof. dr hab. n. med. Andrzej Nowakowski Redaktor Naczelny Chirurgii Narządów Ruchu i Ortopedii Polskiej Dr med. Michał T. W. von Grabowski Członek Komitetu Redakcyjnego

Zum 90. Geburtstag von Professor Heinz Mittelmeier Am 9. Oktober 2017 vollendete Professor Dr. hab. med. Dr. h.c. Heinz Mittelmeier, weltberühmter deutscher Chirurg-Orthopäde, sein 90. Lebensjahr. In den Jahren 1964-1996 war er Leiter des Lehrstuhles, der Klinik und der Poliklinik für Orthopädie der Medizinischen Fakultät der Universität des Saarlandes in Homburg gewesen. Nachdem er sich mit Professor Wiktor Dega befreundet hatte (1959), war Prof. Mittelmeier häufiger Besucher polnischer wissenschaftlicher Kongresse und visitierte polnische orthopädische Kliniken, um seine Erfahrung und sein Wissen weiterzugeben. Mit ihm arbeitete viele Jahre Dr. Michał von Grabowski, wissenschaftlicher Assistent seiner Klinik, der im Jahre 1980 aus der Orthopädischen Klinik der Medizinischen Akademie in Gdańsk gekommen war. Besonders enge Kontakte unterhielt Prof. Mittelmeier zu der Orthopädischen Klinik von Prof. Andrzej Wall in Wrocław und zu Prof. Józef Szczekot, Leiter des Lehrstuhles und der Klinik für Orthopädie der Medizinischen Akademie in Gdańsk. Die von Prof. Heinz Mittelmeier entwickelte, zementfreie, keramische Endoprothese des Hüftgelenkes wurde in vielen polnischen Kliniken implantiert. Prof. Mittelmeier war Mitbegründer des Deutsch-Polnischen Freundeskreises für Orthopädie und Traumatologie (1995), der erfolgreich weiterbesteht. Für die besonderen Verdienste für die polnische Orthopädie wurde Professor Heinz Mittelmeier u.a. zum Ehrenmitglied der Polnischen Gesellschaft für Orthopädie und Traumatologie (1984) und zum Ehrendoktor der Medizinischen Akademie in Gdansk (1993) ernannt. Zum Geburtstag wünschen herzlichst der Chefredakteur und die Redaktion der Chirurgia Narządów Ruchu i Ortopedia Polska (Chirurgie des Bewegungsapparates und Polnische Orthopädie) sowie die befreundeten polnischen Orthopäden unserem Freund, Professor Heinz Mittelmeier, gute Gesundheit, Zufriedenheit und noch viele Lebensjahre. Prof. dr hab. n. med. Andrzej Nowakowski Chefredakteur Chirurgie des Bewegungsapparates und Polnische Orthopädie Dr med. Michał T. W. von Grabowski Mitglied des Redaktionskomitee

Prace zamieszczane w Chirurgii Narządów Ruchu i Ortopedii Polskiej / Polish Orthopaedics and Traumatology obejmują wiedzę z zakresu ortopedii i traumatologii narządu ruchu ujęte tematycznie w XVII działach: I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII Kończyna górna i obręcz barkowa Kręgosłup i klatka piersiowa Kończyna dolna i obręcz biodrowa Onkologia ortopedyczna Choroby układowe i metaboliczne narządu ruchu Choroby narządu ruchu na tle zapalnym Traumatologia narządu ruchu Obrażenia narządu ruchu w sporcie Zaopatrzenie ortopedyczne i protezowanie Ortopedia dziecięca Choroby narządu ruchu w praktyce lekarza rodzinnego Prace historyczne (dzieje ortopedii, traumatologii i rehabilitacji) Diagnostyka obrazowa, statystyka Farmakologia Instrumentarium, materiały biochirurgiczne, iniekcje Rehabilitacja przed- i pooperacyjna Dysertacje naukowe

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 ISSN 0009-479X PRACA ORYGINALNA Kończyna dolna i obręcz biodrowa Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Wyniki zastosowania preparatu kwas hialuronowy z autologicznym osoczem bogatopłytkowym w chorobie zwyrodnieniowej stawu kolanowego w krótkim okresie obserwacji Paweł Łęgosz, Sylwia Sarzyńska, Piotr Stępiński, Łukasz Pulik, Paweł Niewczas, Andrzej Kotela, Marek Gołębiewski, Paweł Małdyk Department of Orthopaedics and Traumatology, 1st Faculty of Medicine, Medical University of Warsaw, Poland Abstract Introduction: Knee is one of the most common locations of degenerative changes. Various attempts of conservative therapy are undertaken to inhibit progression of the disease and delay the requirement for surgical treatment. One such attempt involves simultaneous injections of hyaluronic acid in combination with platelet rich plasma. Combination of these therapies may have an additive effect and lead to an improvement in the patient s condition. Aim: Assessment of early term results of treatment of the knee osteoarthritis using combined hyaluronic acid and platelet rich plasma formulation. Comparison of obtained results with that in available literature related to injections of hyaluronic acid alone. Materials and methods: The study enrolled 53 patients with knee osteoarthritis who were given a combination of hyaluronic acid and autologous platelet rich plasma. The following clinical scales were completed before the procedure for each patient: Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Scale (VAS) and Knee Society Score (KSS) as well as based on previous X-ray images, degree of arthritis seen on X-ray images was assessed using Kellgren-Lawrence scale. After 6 weeks, the outcome of the procedure was assessed using the same clinical scales. Results: 52 patients attended a follow-up visit. Statistically significant improvement 6 weeks after injection of a combination of hyaluronic acid and autologous platelet rich plasma was found on each subscale of KOOS and WOMAC questionnaires for the knee. A significant improvement was also found on KSS subscale assessing the joint function and improvement on VAS scale after 6 weeks was 37.4%. Conclusions: 1. A combination therapy of hyaluronic acid and platelet rich plasma is an effective method of treatment of knee osteoarthritis in short follow- -up. 2. Based on our study and comparison of our results and results obtained for hyaluronic acid alone available in the literature, we cannot clearly confirm superiority of combination therapy over hyaluronic acid alone. Key words: knee osteoarthritis, hyaluronic acid, platelet rich plasma, WOMAC, VAS Streszczenie Wstęp: Staw kolanowy jest jedną z najczęstszych lokalizacji zmian zwyrodnieniowych. Celem zahamowania progresji choroby i przesunięcia w czasie momentu, kiedy operacja jest wskazana, podejmuje się różne próby terapii zachowawczych. Jedną z nich jest stosowanie jednoczasowych iniekcji kwasu hialuronowego w połączeniu z osoczem bogatopłytkowym. Łączenie tych terapii może wywierać efekt addycyjny i prowadzić do poprawy stawu chorego stawu. Cel: Ocena wyników leczenia choroby zwyrodnieniowej stawu kolanowego z wykorzystaniem preparatu łączonego kwasu hialuronowego oraz osocza bogatopłytkowego w krótkim okresie obserwacji. Porównanie uzyskanych wyników w odniesieniu do dostępnej literatury dotyczącej iniekcji samego kwasu hialuronowego. Metody i materiał: Do badania włączono 53 chorych z choroba zwyrodnieniową stawu kolanowego, którym podano preparat łączący kwas hialuronowy z autologicznym osoczem bogatopłytkowym. Przed zabiegiem u każdego pacjenta wykonane zostały skale kliniczne: Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Scale (VAS) oraz Knee Society Score (KSS) oraz na podstawie wcześniej wykonanych zdjęć rentgenowskich, dokonano oceny zaawansowania zmian zwyrodnieniowych widocznych w obrazie radiologicznym przy pomocy skali Kellgrena-Lawrence a. Po 6 tygodniach oceniono wyniki zabiegu na podstawie tych samych skal klinicznych. Wyniki: Na wizytę kontrolną zgłosiło się 52 chorych. W każdej podskali kwestionariuszy KOOS i WOMAC obserwowano istotną statystycznie poprawę po 6 tygodniach od iniekcji preparatu kwasu hialuronowego oraz autologicznego osocza bogatopłytkowego w zakresie stanu stawu kolanowego. W części skali KSS oceniającej funkcję stawu także obserwowano istotną poprawę. W skali VAS poprawa po 6 tygodniach wynosiła 37,4%. Wnioski: 1. Stosowanie terapii łączącej kwas hialuronowy z osoczem bogatopłytkowym jest skuteczną metodą leczenia zmian zwyrodnieniowych stawu kolanowego w krótkim okresie obserwacji. 2. Na podstawie naszej pracy i porównania wyników do wyników samego kwasu dostępnych w literaturze nie można jednoznacznie stwierdzić wyższości stosowania terapii łączonej nad stosowaniem samego kwasu hialuronowego. Słowa kluczowe: choroba zwyrodnieniowa stawu kolanowego, kwas hialuronowy, osocze bogatopłytkowe, WOMAC, VAS Author s address: Paweł Łęgosz, Department of Orthopaedics and Traumatology, 1st Faculty of Medicine, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland, tel.: +48 501 230 328, e-mail: p.legosz@gmail.com Received: 26.07.2017 Accepted: 29.09.2017 Published: 03.11.2017 151

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Introduction Osteoarthritis (OA) is a common disease of the articular cartilage and adjacent soft tissues and subchondral bone [1]. The knee is one of the most common locations of osteoarthritic changes[2]. It is estimated that approximately 13.3 million people suffer from knee OA in the United States alone [3]. OA in elderly persons is in certain aspect a physiological process related to degeneration and injury of multiple structures in the joint that proceeds with age. However, osteoarthritis changes are more and more commonly found in relatively young persons, negatively affecting satisfaction with life and ability to work. Current lifestyle predisposes to this phenomenon on one hand it is the epidemics of obesity, on the other physical activity and related injuries [4]. Multiple methods of therapy of knee OA are available. Initially conservative therapies are used: body weight reduction, rehabilitation and local and/or systemic pharmacotherapy. In more severe osteoarthritic changes surgical treatment may be indicated, including total knee replacement in massive osteoarthritis. Intraarticular injections of various formulations are one of the methods of local therapy: hyaluronic acid (HA), autologous platelet rich plasma (PRP), mesenchymal Adipose Derived Stem Cells (ADSCs) [5], chondroitin and glucosamine formulations or glycocorticosteroids. Many studies proved the efficacy of HA injections into the knee in mild and moderate changes [6]. A paper presenting position of a group of 8 experts in the field of osteoarthritis postulates that viscosupplementation is a well-tolerated method in osteoarthritis of various joints and that it should not be recommended for use only as an alternative after failure of other methods of treatment [6]. Due to good safety profile and ease of application, it is increasingly commonly used as an alternative or supplementation of conventional conservative therapies. Through reduction of pain it is suggested to allow for reduction of analgesic doses, both nonsteroidal and opioid ones and for delay of requirement for total joint replacement or initiation of other surgical methods [7, 8]. Platelet Rich Plasma (PRP) is another method that is used increasingly commonly. PRP is a concentrate of blood platelets suspended in a small volume of plasma, obtained from the whole blood of a patient through its centrifugation [9]. Apart from platelets, the formulation includes numerous proinflammatory, anti-inflammatory, catabolic, anabolic mediators. Such concentration of undifferentiated factors is suggested to stimulate physiological processes and increase the tissue healing potential [10]. Clinical trials revealed efficacy of PRP in osteoarthritis [11]; some of them suggest higher efficacy of plasma versus hyaluronic acid [11, 12]. Due to encouraging results of treatment using hyaluronic acid or platelet rich plasma in mild and moderate osteoarthritis, combined use of these products seems to possibly provide additive effects and improve the condition of the affected joint even better [10]. The benefit of combined hyaluronic acid and PRP therapy may be related to their properties increasing migrating ability of fibroblasts and synoviocytes even by 335% versus injection of HA alone [14]. The regenerative potential of platelet rich plasma has been proven to be markedly improved by using a mixture of PRP and collagen matrix including hyaluronic acid, increasing enhancement of chondrogenesis in the articular cartilage [15]. Currently, few data is available to assess efficacy of combined hyaluronic acid and platelet rich plasma therapy in knee OA. Assumptions and aim of the study Assessment of early term results of treatment of the knee osteoarthritis using combined hyaluronic acid and platelet rich plasma formulation. Comparison of obtained results with that in available literature related to injections of hyaluronic acid alone. Material and methods The study group The surgical procedure was performed in 53 patients. 58.49% (N = 31) were women, 41.51% (N = 22) men. The oldest study subject was 71 years old, the youngest was 21 years old. An average age was 52.02±12.72 years. The highest BMI was 38.09, while the lowest recorded index was 19.03. An average BMI was 28.20±4.95. The severity of radiographic changes in osteoarthritis was scored on a five-point Kellgren Lawrence scale. The study subjects most commonly had stage II disease (N = 25, 47.17%), stage I was less common (N = 13, 24.53%), while prevalence of stage III disease was similar (N = 12, 3.92%). Stage IV, indicating most severe changes, was the least common (N = 3, 5.56%). No cases of stage 0 disease, indicating lack of osteoarthritic changes, were found. An average duration of knee pain before the procedure was 38.31+/-39.69 months. The longest duration of pain before the procedure was 20 years, the shortest 2 months. Among subjects qualified for the procedure, majority of patients denied previous knee injury (N = 46, 86.79%); one subject did not specify this information. In 6 subjects (11.32%), knee injury preceded the procedure. Study method / procedures All patients underwent administration of combined formulation of hyaluronic acid and autologous platelet rich plasma due to knee osteoarthritis at the Department of Orthopaedics and Traumatology, Medical University of Warsaw (MUW) 152

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 PRACA ORYGINALNA Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis from 2016 to 2017. The procedure was preceded by complete physical orthopedic examination supplemented by history concerning complaints related to the knee undergoing surgical treatment. The following clinical scales were completed before the procedure for each patient: Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Scale (VAS) and Knee Society Score (KSS). Before the procedure, based on previous X-ray images, degree of arthritis seen on X-ray images was assessed using Kellgren-Lawrence scale. After 6 weeks, the outcome of the procedure was assessed using the same clinical scales. The assessment was performed in 52 of 53 previously questioned patients (one patient did not attend the follow-up visit). Statistical methods Continuous variables were characterized using range, mean and standard deviation and medians with minimum and maximum values for the distribution, while categorical variables were presented using frequency tables. Wilcoxon signed rank test was used to compare dependent variables. Changes in mean values of compared dependent variables were presented using percentages. Chi-square test was used to analyze relations between the categorical variables. 0.05 was considered as a significance level. All calculations were made using the statistical package STATISTICA, version 13.1. Results KOOS scale Knee injury and Osteoarthritis Outcome Score (KOOS) is composed of five subscales concerning various complaints or limitations of knee function. Normalized index is calculated for each of the subscales (100 corresponds to lack of symptoms, while 0 indicates most severe symptoms). With regard to perceived pain, patients who underwent surgical treatment achieved a significant, 29.09% improvement of average score versus pain reported before the procedure (median 75.00 vs 56.00 before the procedure; p < 0.05). On the subscale of other symptoms such as edema, limited range of movements and feeling of joint blockade, patients also achieved a significant 24.38% improvement after the procedure (median 75.00 vs 57.14 before the procedure; p < 0.05). With regard to part of KOOS scale concerning degree of disability during daily activities, after the procedure the patients achieved significantly better results than before the procedure (improvement by 23.62%, median 79.41 vs 58.82 before the procedure; p < 0.05). Also on parts of the scale concerning sports and recreation (improvement by 71.49%, median 50.00 vs 25.00 before the procedure; p < 0.05) and impairment of quality of life related to knee complaints (improvement by 28.95%, median 46.88 vs 37.50 before the procedure; p < 0.05) patients achieved significantly better clinical results. Table 1 and Figure 1 present scores on KOOS scale. Table 1. Knee Injury and Osteoarthritis Outcome Score. N Mean Median Minimum Maximum Lower Q Upper Q SD Pain BEFORE 53 53,35 56,00 3,00 92,00 42,00 67,00 19,50 AFTER 52 68,87 75,00 3,00 100,00 55,56 84,72 22,21 p<0,05 Other symptoms BEFORE 53 56,32 57,14 0,00 89,29 50,00 71,43 21,92 AFTER 52 70,05 75,00 0,00 100,00 55,36 85,71 22,84 P<0,05 Function in daily living BEFORE 53 57,79 58,82 5,88 92,65 47,06 75,00 21,37 AFTER 52 71,44 79,41 5,88 100,00 51,47 91,91 24,82 p<0,05 Function in sport and recreation BEFORE 53 25,85 25,00 0,00 80,00 5,00 40,00 21,50 AFTER 52 44,33 50,00 0,00 100,00 15,00 65,00 31,11 p <0,5 Knee related quality of life BEFORE 53 37,75 37,50 0,00 81,25 18,75 50,00 20,84 AFTER 52 48,68 46,88 0,00 100,00 31,25 68,75 24,80 p<0,05 153

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Fig. 1. Knee Injury and Osteoarthritis Outcome Score. 154

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 PRACA ORYGINALNA Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis WOMAC scale Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) scale includes questions concerning three different categories: pain, rigidity and physical functioning of the patient. Higher scores in this scale correspond to more severe complaints. On the scale concerning the degree of perceived pain, patients achieved 33.25% improvement after the procedure of administration of combined hyaluronic acid and autologous platelet rich plasma due to knee osteoarthritis (median 4.00 vs 8.00 before the procedure; p < 0.05). There was also 34.06% improvement in the perceived articular rigidity (median 2.00 vs 4.00 before the procedure; p < 0.05). Furthermore, physical functioning of the patient significantly improved over 6 weeks after the procedure by 32.32% (median 14.00 vs 28.00 before the procedure; p < 0.05). Table 2 and Figure 2 present scores on WOMAC scale. KSS scale Knee Society Score (KSS) scale, contrary to the other scale, assesses mainly objective clinical parameters concerning range of motion for the knee. The questionnaire based scales are completed by a physician based on orthopedic physical examination of the knee. The second, subjective part of the scale, includes questions related to pain and function of the knee and is completed by the patient. Since KSS scale includes two different types of questions, two separate subscales were created: clinical scale and functional scale. Normalized index is calculated for each of the subscales (100 - corresponds to lack of symptoms or the best score in physical examination, while 0 indicates most severe symptoms). In objective orthopedic physical examination of the knee, performed by a physician, 6 weeks after the procedure the study subjects achieved statistically significant improvement of average score (13.90%) versus baseline score before the procedure (median 68.00 vs 55.00 before the procedure; p < 0.05). With regard to the part of the scale concerning subjective patient impression related to function of the knee, difference in the score after the procedure vs before the procedure was not statistically significant. Table 3 and Figure 3 present scores on KSS scale. VAS scale Visual Analogue Scale (VAS) is a psychomotor response scale that can be used in questionnaires. It is a tool to measure subjective features or attitudes that cannot be directly measured. In this case VAS scale was used to measure pain. The patient s task was to mark a point on a 100-mm line, where 0 mm denotes complete lack of pain and 100 mm the most severe pain one can imagine. VAS scale, assessed 6 weeks after the procedure, revealed a statistically significant, 37.40% improvement versus the baseline score before the procedure (median 25.00 vs 48.00 before the procedure; p < 0.05). To evaluate parameters that could potentially additionally affect improvement of pain (average achieved improvement 17.41+/-15.18), improvement on VAS scale was categorized as: mild (0-10), moderate (10-20), large (20-40) and very large (>40). Then Yates-modified chi-square test was used to evaluate effect of score on Kellgren-Lawrence scale, age category (<45, 45-60, >60) and BMI category (18.5-24.99, 24.99-29.99, >29.99) on this parameter. No statistically significant relation between categorized score of improvement on VAS scale and score on Kellgren Lawrence scale (χ2 = 4.86, k = 9, α = 0.05, p > 0.05), age category (χ2 = 2.54, k = 6, α = 0.05 p > 0.05) and BMI category (χ2 = 0.52, k = 6, α = 0.05 p > 0.05) was found. Table 4 and Figure 4 present scores on KSS scale. Discussion There are always questions related to efficacy of newly adopted treatment methods, in particular versus commonly used methods. Combined therapy of hyaluronic acid and platelet rich plasma seems to be a good alternative therapy of mild and moderate OA. Further part of the discussion presents papers assessing results of such treatment and therapy with hyaluronic acid alone. Studies with short follow-up were selected to compare them to our own results. A study of 2016 demonstrates significant differences in the outcomes of the treatment of patients with grade III and IV knee osteoarthritis [16]. One group of patients received a combined formulation of hyaluronic acid and platelet rich plasma, while the other received HA alone. The assessment was based on the following questionnaires: International Knee Documentation Committee (IKDC) and Visual Analog Score (VAS). The outcomes were compared after 2 and 6 months of follow-up. Better results were achieved in the group of combined therapy. After 2 months, improvement on VAS scale was 10 in PRP + HA group vs 4 in the HA alone group. In our study, we assessed treatment outcomes 6 weeks after the injection of the combined formulation. Improvement on VAS scale was 23. Our study supports results of the above-mentioned authors, indicating feasibility and efficacy of combined HA and PRP therapy in knee OA with regard to pain reduction. In a randomized study by Lana et al. [10] better treatment outcomes were achieved in patients who were given a combination therapy of HA and PRP versus patients in whom each of these products was given alone. Outcomes were assessed on VAS and WOMAC scales. When treatment outcomes were assessed between PRP + HA group and HA alone, better results on VAS and WOMAC scales that assessed activity were achieved 1, 2, 3, 6 and 12 months after the treatment, while when PRP + HA was compared to PRP alone, the out- 155

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Table 2. The Western Ontario and McMaster Universities Osteoarthritis Index. N Mean Median Minimum Maximum Lower Q Upper Q SD Pain BEFORE 53 8,36 8,00 2,00 19,00 6,00 11,00 4,25 AFTER 52 5,58 4,00 0,00 19,00 2,50 8,00 4,75 p<0,05 Stiffness BEFORE 53 3,64 4,00 0,00 8,00 2,00 5,00 2,07 AFTER 52 2,40 2,00 0,00 8,00 1,00 4,00 2,05 p<0,05 Physical function BEFORE 53 28,70 28,00 5,00 64,00 17,00 36,00 14,53 AFTER 52 19,42 14,00 0,00 64,00 5,50 33,00 16,88 p<0,05 Fig. 2. The Western Ontario and McMaster Universities Osteoarthritis Index. 156

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 PRACA ORYGINALNA Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis Table 3. Knee Society Score Outcomes. N Mean Median Minimum Maximum Lower Q Upper Q SD Clinic BEFORE 53 56,92 55,00 29,00 85,00 45,00 70,00 15,98 AFTER 52 64,83 68,00 29,00 90,00 54,00 77,00 14,97 p<0,05 Function BEFORE 53 76,98 80,00 40,00 100,00 60,00 90,00 18,77 AFTER 52 80,00 90,00 40,00 100,00 60,00 100,00 20,00 p=0,08 Table 4. Visual Analogue Scale Outcomes. N Mean Median Minimum Maximum Lower Q Upper Q SD BEFORE 53 45,13 48,00 0,00 100,00 26,00 72,00 25,98 AFTER 52 28,25 25,00 0,00 100,00 10,00 42,00 24,06 p<0.05 Fig. 3. Knee Society Score Outcomes. Fig. 4. Visual Analogue Scale Outcomes. comes were better 1 and 3 months after the treatment. After one month, median improvement on VAS scale in the PRP + HA group was 40 points, while on WOMAC scale 7 points for the pain subscale, 3 points for the rigidity subscale and 26 points for the physical functioning subscale. Different factors were used in WOMAC scales so the above-mentioned results were corrected accordingly. We observed satisfactory results in our study, both on VAS and WOMAC scales 6 weeks after the injection. Median for the VAS scale was 23, while for the WOMAC pain subscale 4, rigidity 2 and physical functioning 14. Results in our population of patients were slightly worse than those achieved in Lana et al. study; however, both studies demonstrated improvement for the combined HA + PRP therapy. On the other hand, Abate et al. [17] in a study comparing PRP + HA (2 ml + 2 ml) and PRP alone (4-5 ml) based on 157

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis VAS and KOOS scales obtained 1, 3 and 6 months after the injection demonstrated that patients in both groups achieved comparable results. This study demonstrated that a combination of PRP and HA is effective and safe in the treatment of mild to moderate knee osteoarthritis. The authors emphasized that lack of significant differences between both groups may be the result of different volumes of platelet rich plasma that were administered. Also according to our study, PRP + HA is an effective and safe therapy. We did not observe complications after administration of the formulation. We found a marked improvement with regard to the knee on VAS and KOOS scales assessed after 6 weeks. Most studies emphasize feasibility and efficacy of HA, PRP or their combination in mild or moderate OA. Chen et al. [9] based on 3 case reports demonstrated that it can be an effective method of treatment in some cases of severe OA. Marked improvement upon PRP + HA administration was found in each of the reported patients at the last follow-up visits assessed based on VAS and WOMAC scales. Such attempts should be particularly indicated in patients with contraindications to surgical treatment. Unfortunately, there are no studies to assess efficacy of combined PRP + HA therapy in larger patient groups and with longer follow-up. Currently HA alone remains the most common injectable therapy of the knee OA. Thomas et al. in their study [18] demonstrated that injections of 2% hyaluronic acid in patients with grade II and III OA result in improvement of the condition of the knee assessed based on WOMAC scale. Three months after the injection, pain score decreased by 3,28, rigidity score by 1,11, while knee function by 6,5. We must emphasize that these are recalculated values since Thomas et al. expressed all scales in the range of values from 0 to 100, while we assessed pain on 0-20 scale, rigidity on 0-8 scale, and function of 0-68 scale. We assessed efficacy of treatment 6 weeks after the injection. We obtained the following results on WOMAC subscales: the difference was 2,78 for the pain, 1,24 for the rigidity, and 9.28 for the function. Only for pain, HA alone therapy proved to be slightly more effective. Knee function and rigidity (to a small degree) were better with combined therapy. Lamo-Espinosa et al. [19] investigated the outcomes of HA alone treatment in knee OA with a maximum one year follow-up. According to the presented data, the therapy had positive effect on knee complaints assessed based on WOM- AC and VAS scales 3, 6 and 12 months after the injection. There was a reduction of median for pain by 2.5 and for the joint function by 12 on WOMAC scale after 3 months. No changes for the rigidity subscale were found. However, median reduction on VAS scale was 2 points. We obtained the following results in our study: for the WOMAC pain subscale, the median decreased by 4 points, rigidity by 2, and knee function by 14 points. For the VAS scale, median difference was: 23 (2.3). Better results assessed in the above-mentioned clinical scales were achieved for PRP + HA than for HA alone. However we must emphasize that the authors assessing HA conducted their investigation after 3 months (12 weeks), while we conducted our investigations after 6 weeks. Possibly timing of the follow-up investigation could have affected the results. Duymus et al. [20] assessed outcomes of hyaluronic acid therapy 1, 3, 6 and 12 months after the injection. They found marked improvement of the knee condition, assessed on VAS and WOMAC scales, at the first follow-up visit after one month. It was by 5.7 for the first questionnaire. It was by 10.5 for pain, 3.3 for rigidity and 30 for function subscales of WOMAC scale. The outcomes became gradually worse at subsequent follow-up visits; however, after one year were markedly lower than at baseline. After 6 weeks, we obtained the following results in the same questionnaires: 2.78 for the pain, 1.24 for rigidity and 9.28 for function subscales of WOMAC scale. The authors achieved markedly better results for HA alone as compared to our results. Zhang et al. [21] also assessed outcomes of hyaluronic acid therapy in patients with knee osteoarthritis based on WOMAC scale 18 and 26 weeks after the injection. After 18 weeks, they found reduction by 5.97 on the pain subscale, by 1.87 on the rigidity subscale and by 12.75 on the joint function. In our study, the difference for pain was 2.78, for rigidity - 1.24 and for function - 9.28. We obtained better results only on the rigidity subscale, while on the other subscales positive result favored the hyaluronic acid alone group. Based on the above-mentioned data it is difficult to unequivocally state which of these therapies is a better treatment of knee OA. Each of these reduces complaints assessed based on commonly used clinical scales. Further studies involving larger groups of patients are recommended to determined superiority of one of these methods. Conclusions 1. A combination therapy of hyaluronic acid and platelet rich plasma is an effective method of treatment of knee osteoarthritis in short follow-up. 2. Further studies enrolling larger groups of patients and involving longer follow-up are warranted to confirm effectiveness of therapy. 3. Based on our study and comparison of our results and results obtained for hyaluronic acid alone available in the literature, we cannot clearly confirm superiority of combination therapy over hyaluronic acid alone. Acknowledgements The authors are grateful to all the patients whose cooperation made this study possible. 158

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 151-159 PRACA ORYGINALNA Paweł Łęgosz et al., Early term results of usage combined hyaluronic acid and platelet rich plasma in knee osteoarthritis References [1] Jin X, Wang BH, Wang X, et al. Associations between endogenous sex hormones and MRI structural changes in patients with symptomatic knee osteoarthritis. Osteoarthritis Cartilage. 2017. [2] Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59(9):1207-13. [3] Dillon CF, Rasch EK, Gu Q, et al. Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey 1991-94. J Rheumatol. 2006;33(11):2271-9. [4] Ackerman IN, Kemp JL, Crossley KM, et al. Hip and Knee Osteoarthritis Affects Younger People, Too. J Orthop Sports Phys Ther. 2017;47(2):67-79. [5] Pak J, Lee JH, Park KS, et al. Regeneration of Cartilage in Human Knee Osteoarthritis with Autologous Adipose Tissue-Derived Stem Cells and Autologous Extracellular Matrix. Biores Open Access. 2016;5(1):192-200. [6] Henrotin Y, Raman R, Richette P, et al. Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis. Semin Arthritis Rheum. 2015;45(2):140-9. [7] Chojnacki M, Kwapisz A, Synder M, et al. [Osteoarthritis: etiology, risk factors, molecular mechanisms]. Postepy Hig Med Dosw (Online). 2014;68:640-52. [8] Legre-Boyer V. Viscosupplementation: techniques, indications, results. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S101-8. [9] Chen SH, Kuan TS, Kao MJ, et al. Clinical effectiveness in severe knee osteoarthritis after intra-articular platelet-rich plasma therapy in association with hyaluronic acid injection: three case reports. Clin Interv Aging. 2016;11:1213-9. [10] Lana JF, Weglein A, Sampson SE, et al. Randomized controlled trial comparing hyaluronic acid, platelet-rich plasma and the combination of both in the treatment of mild and moderate osteoarthritis of the knee. J Stem Cells Regen Med. 2016;12(2):69-78. [11] Patel S, Dhillon MS, Aggarwal S, et al. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013;41(2):356-64. [12] Kon E, Mandelbaum B, Buda R, et al. Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis. Arthroscopy. 2011;27(11):1490-501. [13] Spakova T, Rosocha J, Lacko M, et al. Treatment of knee joint osteoarthritis with autologous platelet-rich plasma in comparison with hyaluronic acid. Am J Phys Med Rehabil. 2012;91(5):411-7. [14] Anitua E, Sanchez M, De la Fuente M, et al. Plasma rich in growth factors (PRGF-Endoret) stimulates tendon and synovial fibroblasts migration and improves the biological properties of hyaluronic acid. Knee Surg Sports Traumatol Arthrosc. 2012;20(9):1657-65. [15] Wu CC, Chen WH, Zao B, et al. Regenerative potentials of platelet-rich plasma enhanced by collagen in retrieving pro-inflammatory cytokineinhibited chondrogenesis. Biomaterials. 2011;32(25):5847-54. [16] Saturveithan C, Premganesh G, Fakhrizzaki S, et al. Intra-articular Hyaluronic Acid (HA) and Platelet Rich Plasma (PRP) injection versus Hyaluronic acid (HA) injection alone in Patients with Grade III and IV Knee Osteoarthritis (OA): A Retrospective Study on Functional Outcome. Malays Orthop J. 2016;10(2):35-40. [17] Abate M, Verna S, Schiavone C, et al. Efficacy and safety profile of a compound composed of platelet-rich plasma and hyaluronic acid in the treatment for knee osteoarthritis (preliminary results). Eur J Orthop Surg Traumatol. 2015;25(8):1321-6. [18] Thomas T, Amouroux F, Vincent P. Intra articular hyaluronic acid in the management of knee osteoarthritis: Pharmaco-economic study from the perspective of the national health insurance system. PLoS One. 2017;12(3):e0173683. [19] Lamo-Espinosa JM, Mora G, Blanco JF, et al. Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: multicenter randomized controlled clinical trial (phase I/II). J Transl Med. 2016;14(1):246. [20] Duymus TM, Mutlu S, Dernek B, et al. Choice of intra-articular injection in treatment of knee osteoarthritis: platelet-rich plasma, hyaluronic acid or ozone options. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):485-92. [21] Zhang H, Zhang K, Zhang X, et al. Comparison of two hyaluronic acid formulations for safety and efficacy (CHASE) study in knee osteoarthritis: a multicenter, randomized, double-blind, 26-week non-inferiority trial comparing Durolane to Artz. Arthritis Res Ther. 2015;17:51. 159

ISSN 0009-479X Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 160-164 PRACA ORYGINALNA Kończyna dolna i obręcz biodrowa Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years Wyniki endoprotezoplastyki stawu biodrowego z użyciem trzpienia Fitmore w 4-letnim okresie obserwacji Piotr Łuczkiewicz 1, Dawid Jaskólski 1, Mariusz Stasiak 1, Katarzyna Gołąbek-Dropiewska 1, Adam Buciński 2, Bogusław Baczkowski 1 1 2-nd Clinic of Orthopaedics and Kinetic Organ Traumatology, Medical University of Gdansk, Poland 2 Department of Biopharmacy, Faculty of Pharmacy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland Abstract Introduction: The use of short stem implants is associated with higher incidence of complications such as stem malpositioning and early implant migration. So far a few studies have addressed the question of the effects of varus short stem alignment. The objective of this study was to evaluate the migration pattern of short stem implant and the influence of stem malpositioning on implant migration Materials and methods: The group of 21 patients operated between 2012 and 2013 has been analysed. All patients received a cementless femoral stem (Fitmore Zimmer Inc. Warsaw, IN) and a cementless acetabular cup. Hip function and radiographs were evaluated in the immediate postoperative period and at the most recent follow-up, with at least 4 years of data for all patients. Results: In four years observation period neither prosthesis dislocations nor wound complications were reported. Harris hip score averaged 88,81. Acetabular cup abduction angle averaged 49.7 ± 7.57. Among all, 7 of the femoral components were in neutral position, 16 prostheses were in varus (mean 4.43 ± 2.8 ) and 4 stems in valgus ( mean 2.25 ± 1.89 ). Migration according to Sutherland et al. method averaged 1.77 mm ±1.29. Neither radiolucence line nor osteolysis lines over 2 mm were not observed. No relationship between varus stem position and stem migration was revealed. Conclusions: Radiographic and clinical outcome confirm that Fitmore Hip Stem achieves good clinical mid-term results in most cases. Neither aseptic loosening nor other signs of implant failure were seen after four years. Implantation of the stem in varus position did not affect clinical outcome and did not cause implant migration. Migration pattern similar to standard straight stem implant, lack of long-term results and randomised clinical trials in comparison with the traditional stems suggest that wide use of short stem is not justified enough. Key words: Fitmore, THA, stem migration Streszczenie Wstęp: Zastosowanie implantów z krótkim trzpieniem wiąże się z większą częstością występowania powikłań, takich jak nieprawidłowe ustawienie trzpienia i wczesna jego migracja. Jak dotąd jedynie kilka badań dotyczyło oceny wpływu ustawienia szpotawego trzpienia na efekt długoterminowy zabiegu alloplastyki. Celem pracy było zbadanie przebiegu migracji implantu z krótkim trzpieniem (Fitmore Zimmer Inc. Warszawa, IN) i wpływu ustawienia implantu na jego migrację. Materiał i metody: Analizie podano grupę 21 pacjentów, u których wykonano, w latach 2012-2013, pierwotną bezcementową endoprotezoplastykę stawu biodrowego z użyciem krótkiego trzpienia (Fitmore Zimmer Inc. Warszawa, IN). Bezpośrednio po operacji i po 4 latach oceniono u wszystkich pacjentów wyniki kliniczne i radiologiczne (kąt ustawienia panewki, trzpienia, migracja trzpienia, przerost warstwy korowej) Wyniki: W ciągu czterech lat obserwacji nie stwierdzono obluzowania protezy ani powikłań gojenia rany. Wynik w skali Harrisa wynosił średnio 88,81 pkt. Kąt nachylenia panewki wynosił średnio 49,7 ± 7,57. W 7 przypadkach trzpień znajdował się w pozycji neutralnej, w 16 ustawienie trzpienia było szpotawe (4,43 ± 2,8 ), w 4 koślawe (średnio 2,25 ± 1,89 ). Migracja mierzona według Sutherlanda wynosiła średnio 1,77 mm ± 1,29. Nie obserwowano linii radiolucencji lub osteolizy o wymiarze powyżej 2 mm. Nie stwierdzono związku pomiędzy szpotawym ustawieniem trzpienia, a jego migracją. Wnioski: Wyniki radiograficzne i kliniczne potwierdzają, że zastosowanie trzpienia Fitmore Hip Stem pozwala osiągnąć w większości przypadków dobre wyniki kliniczne, w średnim okresie obserwacji. Po czterech latach nie zaobserwowano aseptycznego obluzowania protezy ani innych objawów niewydolności implantu. Implantacja trzpienia w pozycji szpotawej nie wpływała na wyniki kliniczne i migrację implantów. Wielkość migracji podobna do migracji standardowego prostego implantu, brak długoterminowych wyników i randomizowanych badań klinicznych, w porównaniu z tradycyjnymi trzpieniami powoduje, że stosowanie krótkiego trzpienia na dużą skalę budzi nadal wiele kontrowersji. Słowa kluczowe: Fitmore, endoprotezoplastyka stawu biodrowego, migracja trzpienia Author s address: Piotr Łuczkiewicz, ul. Smoluchowskiego 17, 80-214 Gdańsk, Poland, tel.: +48 58 349 36 21, e-mail: plucz@gumed.edu.pl Received: 24.08.2017 Accepted: 29.09.2017 Published: 03.11.2017 160

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 160-164 PRACA ORYGINALNA Piotr Łuczkiewicz et al., Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years Introduction Total hip arthroplasty (THA) is one of the most effective operations in orthopaedic surgery [1]. Excellent results obtained with THA led to the extension of this procedure to younger patients with higher comfort of life expectations [2]. Therefore, the concept of short-stem hip implants have been rediscovered, especially in middle Europe, as a bone and soft tissue preserving option for THA in the younger and more active population [3]. Short stem implants preserves more bone stock, facilitate insertion in minimal invasive surgery and ensure a more physiologic load transfer [4]. However their use is controversial because of challenging surgical technique and higher incidence of complication such as periprosthetic fractures and malpositioning of the stem [5]. In our previous study the clinical effects of minimally invasive THA performed through the posterolateral approach using Fitmore Short Stem has been evaluated. In most cases, stems deviation in varus position greater than 2 has been observed [6]. Traditionally such position of the femoral prosthethic component has been reported as associated with poor result [7]. On the other hand it has been reported that varus position of a short-stemmed implant has unsignificant influence on internal loads of the proximal femur in comparison to the changes from the intact femur [8]. Thus we decided to examine long term clinical and radiographic results of cementless THA performed through the minimally invasive posterolateral approach using Fitmore Short Stem. appropriate stem type pre-operative radiological templating was used. All procedures were made by the same surgeon performing minimally invasive total hip arthroplasty (MIS- THA). All bearing surfaces used were metal-on-polyethylene. There was no need to use screws for acetabular fixation. In 6 patients MIS THA with Fitmore stem was performed bilaterally. In 2 patients MIS THA followed previous unilateral hip arthroplasty using different type of prosthesis. In follow-up examinations performed with clinical and radiographic data analysis no complications such as infection, deep venous thrombosis, and signs of aseptic prosthesis loosening were observed. Postoperative hip function was assessed with the Harris Hip Score (patients quality of life assessment after the hip replacement). Anteroposterior hip radiographs were used to determine cup abduction angle (Fig. 1), stem alignment (Fig. 2), implant migration using Sutherland et. al. method [9] (Fig. 3), cortical hypertrophy and radiolucent lines measurement in each Gruen zones (Fig. 4). According to Sutherland and al. [9] implant migration was assessed on the basis of distance differences measured on postoperative and current hip radiographs while femoral head center and greater trochanter where used as reference points. In every Gruen zone bone cortical overgrowth was assessed. The presence of radiolucence was also evaluated, depending on its size, greater or less than 2 mm. Material i methods Group of 21 patients who underwent total hip replacement in a 2 year time period- from 2012 to 2013- in a single institution has been included in the study. Procedures were approved by the institutional review board. Patients characteristic data are listed in Table 1. All patients received a cementless femoral stem (Fitmore Zimmer Inc, Warsaw, IN) and a cementless acetabular cup (Trilogy Zimmer Inc, Warsaw, IN, USA). To determine the Fig.1. Cup abduction angle measurement technique. Table 1. Characteristics of all patients included in the study. All patients Variable N Average value Median value Minimum value Maximum value Standard deviation Age 21 61.81 62.00 37.00 80.00 9.82 Age when operated 27 59.89 60.00 37.00 80.00 10.13 Height (cm) 27 170.96 170.00 162.00 190.00 7.61 Weight (kg) 27 81.33 83.00 63.00 120.00 13.09 BMI 27 27.79 26.83 22.16 36.25 3.80 Harris Hip Score 27 88.81 94.00 67.00 100.00 11.26 161

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 160-164 Piotr Łuczkiewicz et al., Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years Fig. 2. Stem alignment measurement technique. Fig. 3. Stem migration measurement technique. Fig. 4. Gruen zone cortical hypertrophy and radiolucent lines measurement. Statistical analysis was performed using Dell Statistica (data analysis software system), version 13. (software.dell. com.). For all parameters average value, standard deviation and median value were calculated. Distribution of statistical variables was analysed using the W Shapiro-Wilk test, homogeneity of variance was calculated using the Levene test. If the tested variable was consistent with terms of the standard distribution and homogeneity of variance comparisons across two groups were done using the T Student test. Otherwise the non-parametric Mann- Withney U test was used. Pearson s correlation coefficient (r) was used to determine the level of linear relationship between the variables tested. Differences were considered significant at p < 0.05. Results Secondary complications nor reoperations were not reported. Postoperative Harris Hip Score averaged 88.81 points. The final result was evaluated as poor in 2 patients, moderate in 2 patients, good in 8 patients and very good in 15 patients. Acetabular component position was measured using anteroposterior hip radiographs. Mean value was 49.7º ± 7.57º. In our previous early analysis of 40 cases mean value was 45º ± 7.9º Femoral component position also was measured using anteroposterior hip radiographs. Only in 7 cases femoral components were in neutral position, 16 prostheses were in varus with maximum varus angle 10, minimum 1 ( mean 4.43 ± 2.8 ), and 4 stems in valgus with maximum valgus angle 5, minimum valgus angle 1 (mean 2.25 ± 1.89 ). In primary early analysis of 40 patients 3 of the femoral components were in neutral position, 32 prostheses were in varus with maximum varus angle 9º, and 5 stems in valgus with maximum valgus angle 4º. According to Sunderland et al. implant migration measured on AP hip radiographs was: mean value 1.77 mm ± 1.29 (max 4 mm, min 0.5 mm). In 15 patients implant migration averaged 1.5 mm and in following 3 patients was even 3mm. Maximal implant migration observed only in 1 patient was 4 mm. There were no radiolucence or osteolysis greater than 2mm observed. In 10 cases (37%) radiolucence nor osteolysis lesser than 2 mm was assessed (mainly in Gruen zones 1,5,6). Bone cortical overgrowth was assessed in 16 patients (59%), mainly in Gruen zones 3,5. We could not show any statistically significant difference between the stem position, BMI, clinical outcome, age and stem migration (Table 2). Discussion Long term results and stability of short-stem implants in patients after THA were evaluated only in a few studies so far [10-13]. The aim of this study was therefore to examine clinical and radiographic results of cementless THA, using Fitmore Short Stem. In our previous study clinical effects of THA with Fitmore Short Stem at a minimum 3 month follow-up had been presented. In most cases in our material stems had been deviated in varus position greater than 2 degree [6]. Thus in present study correlations between clinical outcome and potential mechanical failure of prosthesis at a minimum 4-year follow-up was evaluated. 162

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 160-164 PRACA ORYGINALNA Piotr Łuczkiewicz et al., Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years Table 2. The results of the correlation analysis for the whole group and broken down by sex. Pair of variables tested All patients Female Male N r p N r p N r p Implant migration & age 21-0.067 0.774 8-0.231 0.508 13 0.061 0.843 Implant migration & age when operated 27-0.197 0.325 11-0.214 0.527 16-0.170 0.528 Implant migration & Height 27 0.241 0.226 11 0.428 0.189 16 0.066 0.808 Implant migration & weight 27 0.154 0.442 11 0.168 0.622 16 0.059 0.828 Implant migration & BMI 27 0.082 0.683 11-0.057 0.867 16 0.076 0.780 Implant migration & Harris Hip Score 27-0.189 0.493 11 0.309 0.354 16-0.508 0.045 Implant migration & follow- up time 26-0.259 0.201 10-0.176 0.627 16-0.424 0.101 Implant migration & cup abduction angle 27-0.446 0.020 11-0.425 0.192 16-0.436 0.092 Implant migration & stem alignment 27-0.284 0.150 11-0.366 0.268 16-0.220 0.414 In current studies implant migration was specified as the best indicator for mechanical failure of prosthesis [2,11]. The most precise method to detect implant migration is stereophotogrammetry but the need for special instruments and tantalum markers reduce its availability remarkably [14-17]. Thus in this work migration of stem using the methods described by Sutherland et al. was applied since the accuracy of this method to detect implant migration is comparable to Ein-Bild-Roentgen-femoral component analysis (EBRA- FCA) [9]. Krismer et al. report the ten-year results for three designs of stem in 240 THA. In this study stem migration had been measured on plain radiographs. During the first two years they had described a subsidence of more than 1.5 mm in 29% of cases. They had shown strong relationship between stem migration of more than 1.5 mm and revision due to aseptic loosening [18]. In our material a potential critical stem migration of more than 1.5 mm was detected in 15 patients. Gustke had shown Fitmore stem migration of more than 2 mm on radiographs in 34% of cases after mean follow-up of 1.3 years [19]. The author had explained these phenomenon by a tendency toward undersizing the new implant, because of the concern of intraoperative fractures [19]. Freitag et al. showed Fitmore stem migration of more than 1.5 mm after a minimum follow-up of 2 years [14]. They had speculated that the less tapered design of Fitmore stem with less proximal fill and fit in the femoral neck region, could be a reason of this phenomenon. All this patients were painless and none of migrated implant were revised. Similarly in our material none implant were revised and we did not observe any correlations between stem migration and clinical outcome in Harris Hip score. No significant difference concerning cortical hypertrophy and clinical outcome measured by the Harris Hip Score was observed. Similar to other authors cortical hypertrophy mainly located at the distal part of the stem (Gruen zone 3 and 5) was revealed [20]. Pipino et al. in long term followup had reported distal cortical hypertrophy in 48% of patients in Gruen zone 2, 3 and 5. Among patients with thigh pain, five had undersized, varus stems so he interpreted thigh pain to be an expression of transitory instability of the stem [21]. In our present study no relationship between varus stem position and their migration was observed. However cemented femoral stems inserted in varus position have yielded poor clinical results the consequences of varus orientation of cementless stems seem to be less important. Schneider and al. reported on 3732 cementless femoral stems and had not found any significant correlations between varus stem alignment, survival, migration and clinical outcomes measured by the Harris Hip Score [22]. Similarly, in our work no statistically significant differences between varus stem position, stem migration and clinical outcomes has been detected. The presented results have two main limitation. There is a relatively small series of patients and method used to detect implant migrations has relative low sensitivity. Thus our results should be interpreted carefully. Conclusions Radiographic and clinical outcome confirm that Fitmore Hip Stem achieves good clinical mid-term results in most cases. Implantation of the stem in varus position did not affect clinical outcome and implant migration. Migration pattern was similar to standard straight stem implant, lack of longterm results and randomised clinical trials in comparison with the traditional stems caused that their use on a large scale is not justified enough. The reason of relatively high rate of potentially critical stem migration is still unclear. References [1] Earmonth ID, Young C, Rorabeck C: The operation of the century: total hip replacement. Lancet 2007; 370(9597): 1508-19. [2] Kärrholm J, Garellick G, Rogmark C, Rolfson O, Herberts P: Swedish Hip Arthroplasty Register: Annual Report 2011. Sweden: Sahlgrenska University Hospital; 2012. 163

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 160-164 Piotr Łuczkiewicz et al., Results of the Fitmore short-stem total hip arthroplasty at a minimum follow-up of 4 years [3] Institut für angewandte Qualitätsförderung und Forschungim Gesundheitswesen GmbH. Hüftendoprothesenversorgung. Göttingen; 2012. [4] Bieger R, Ignatius A, Reichel H, Dürselen L: Biomechanics of a short stem: in vitro primary stability and stress shielding of a conservative cementless hip stem. J Orthop Res 2013; 31(8):1180-6. [5] Castelli CC, Rizzi L: Short stems in total hip replacement: current status and future. Hip Int 2014; 24(10): 25-28. [6] Jaskólski D, Baczkowski B, Łuczkiewicz P et al.: Use of Fitmore short stem with mini-posterior approach for total hip arthroplasty. Chir Narz Ruchu Ortop Pol 2015;80(5):177-180. [7] Zahiri CA, Schmarlzried TP, Ebramzadeh E et al.: Lesson learned from loosening of the McKee-Farrar metal-on-metal total hip replacement. J. Arthroplasty 1999;14:326. [8] Speirs AD, Heller MO, Taylor WR, Georg N, Duda GN, Perka C: Influence of changes in stem positioning on femoral loading aft er THR using a short-stemmed hip implant. Clin Biomechanics 2007;22:431-9. [9] Sutherland CJ, Wilde AH, Borden LS, Marks KE: A ten-year follow-up of one hundred consecutive Muller curved-stem total hip-replacement arthroplasties. J Bone Jt Surg Am 1982; 64:970. [10] Van Oldenrijk J, Molleman J, Klaver M et al.: Revision rate after shortstem total hip arthroplasty: a systematic review of 49 studies. Acta Orthop 2014, 85:250-258. [11] Acklin YP, Jenni R, Bereiter H, Thalmann C, Stoffel K: Prospective clinical and radiostereometric analysis of the Fitmore short-stem total hip arthroplasty. Arch Orthop Trauma Surg 2016;136(2):277-84. [12] Dutka J, Sosin P, Libura M et al.: Total hip arthroplasty through a minimally invasive lateral approach--our experience and early results. Ortop Traumatol Rehabil 2007,9(1):39-45. [13] Rąpała K, Obrębski M, Rąpała A et al.: Minimally invasive total hip arthroplasty--our clinical experience. Ortop Traumatol Rehabil 2007;9(1):31-8. [14] Freiteg T, Kappe T, Fuchs M, Jung S, Reichel H, Bieger R: Migration pattern of a femoral short-stem prosthesis: a 2-year EBRA-FCA-study. Arch Ort Trauma Surgery 2014;134(7):1003-8. [15] Karrholm J, Herberts P, Hultmark P, Malchau H, Nivbrant B, Thanner J: Radiostereometry of hip prostheses. Review of methodology and clinical results. Clin Orthop Relat Res 1997;344:94-110. [16] Biedermann R, Krismer M, Stockl B, Mayrhofer P, Ornstein E, Franzen H: Accuracy of EBRA-FCA in the measurement of migration of femoral components of total hip replacement. Einzel-Bild-Rontgen-analysefemoral component analysis. J Bone Jt Surg Br 1999; 81(2):266-272. [17] Phillips NJ, Stockley I, Wilkinson JM: Direct Plain Radiographic Methods Versus EBRA-Digital for Measuring Implant Migration After Total Hip Arthroplasty. J Arthroplasty 2002;17 (7):917-25. [18] Krismer M, Biedermann R, Stockl B, Fischer M, Bauer R, Haid C: The prediction of failure of the stem in THR by measurement of early migration using EBRA-FCA. Einzel-Bild-Roentgen-analyse-femoral component analysis. J Bone Jt Surg Br 1999; 81(2):273-80. [19] Gustke K: Short stems for total hip arthroplasty: Initial experience with the Fitmore stem. J Bone Jt Surg Br 2012;94(11 Suppl A):47-51. [20] Maier MW, Streit MR, Innmann MM, Krüger M, Nadorf J, Kretzer J.P., Ewerbeck V, Gotterbarm T: Cortical hypertrophy with a short, curved uncemented hip stem does not have any clinical impact during early follow-up. BMC Musculoskelet Disord 2015;16:371. [21] Pipino F, Molfetta L, Grandizio M: Preservation of the femoral neck in hip arthroplasty: result of a 13 to 17-year follow-up. J Orthop Traumatol 2000;1:31-9. [22] Schneider U, Breusch SJ, Thomsen M, et al.: Influence of implant position of a hipprosthesis on alignment exemplified by the CLS shaft. Unfallchirurg 2002;105:31-5. 164

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 165-169 ISSN 0009-479X PRACA ORYGINALNA Kończyna dolna i obręcz biodrowa Patient with a fracture of the proximal end of the femur in an urban hospital Pacjent ze złamaniem bliższego końca kości udowej w szpitalu miejskim Adam Konik, Bartłomiej Osadnik, Łukasz Wiktor Oddział Chirurgii Urazowo-Ortopedycznej SP ZOZ Zespół Szpitali Miejskich w Chorzowie Abstract Proximal femur fractures present a serious social problem and an immense challenge for doctors, nurses and the entire health care system engaged in the treatment process. Patients suffering from this kind of fracture comprised the greatest group among all trauma patients treated surgically in our ward. Consequently, we not only conducted an epidemiological analysis of the tested group of patients and an analysis of the available treatment methods, but also traced the patients disposition throughout the following year. The group of tested subjects consisted of 1,200 patients who suffered from proximal femur fractures and were treated in our ward over the period 2009-2015. Out study shows that the majority of patients required surgical treatment, 48.7 % were readmitted into hospital within a period of one year and about one fifth of subjects suffering from proximal femur fractures died. Key words: proximal femur fractures, osteoporotic fractures, mortality in patients after a proximal femur fracture. Streszczenie Złamania bliższego końca kości udowej są poważnym problemem społecznym i ogromnym wezwaniem dla leczących lekarzy, pielęgniarek oraz całego systemu opieki zdrowotnej i socjalnej. Pacjenci z tego typu złamaniami stanowili największą grupę wśród pacjentów urazowych operowanych na naszym oddziale. W związku z tym w naszej pracy przeprowadziliśmy analizę epidemiologiczną badanej grupy pacjentów, analizę sposobów leczenia oraz prześledziliśmy dalsze losy chorych w ciągu jednego roku. Grupę badanych stanowiło 1200 pacjentów po złamaniach bliższego końca kości udowej leczonych w naszym oddziale w latach 2009 do 2015. Z naszych badań wynika że większość pacjentów wymagało leczenia operacyjnego, 48,7 % w ciągu roku wymagało ponownej hospitalizacji a ok. 1/5 pacjentów, po złamaniu bliższego końca kości udowej, zmarło. Słowa kluczowe: złamania bliższego końca kości udowej, złamania osteoporotyczne, umieralność pacjentów po złamaniu bliższego końca kości udowej. Author s address: Adam Konik, Odział Chirurgii Urazowo Ortopedycznej SP ZOZ Zespół Szpitali Miejskich w Chorzowie, ul. Strzelców Bytomskich 11, 41-500 Chorzów, te.: 604580531, e-mail: adaskonik@gmail.com Received: 21.02.2017 Accepted: 29.09.2017 Published: 03.11.2017 165

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 165-169 Adam Konik et al., Patient with a fracture of the proximal end of the femur in an urban hospital Introduction The fracture of the proximal end of the femur (PEF) is the most dangerous complication of osteoporosis related to high mortality as well as temporary or permanent loss of patients physical function and independence. The epidemiology data show that after 65 years of age the risk of a fracture of the proximal end of the femur is higher in women than of a heart attack, breast cancer, or diabetes, whereas in men it is higher than the risk of a prostate cancer [1,2,3]. In Poland in 2002 there were c. 6.5 mln people over 60, in 2015 8.7 mln, and according to forecasts in 2030 there will be 10.7 mln [4]. In this group there is the highest rate of motor system injuries and diseases [5]. The most dangerous are PEF fractures. Within the first year after the fracture, according to different sources, from 18% to 43% or 50% patients become disabled. PEF fractures are a serious social problem and a big challenge for hospitals and all healthcare and social care system. Assumptions and aims of the work Surgical operations of PEF fractures are the most common among the patients in our ward. Therefore we have decided to analyze the epidemiology, ways of treatment and further medical history of the operated patients. Material and methods The work presents data concerning all patients treated in our ward from 2009 to 2015 and other wards in our hospital as well as wards in the area covered by our ward. In this analysis we used information from medical documentation: medical history, surgical registry, Infomedica IT system, and data acquired from the Statistical Office. We sorted out the data in tables and we did statistical calculations. Results From 2009 to 2015 we treated 1200 patients with PEF fractures, including 827 women which constitutes 68.9%. The number of patients treated annually in particular years ranged from 156 to 181, 171 on average. Patients between 70 and 89 y/o are the biggest group, namely 76.1%. In the older group of patients the female-tomale ratio increases. In the group below 60 y/o the ratio is 4 to 10, in the group over 90 y/o it is 8.5 to 1. Patients with femoral neck fractures constituted 46.7% of all, whereas patients with subtrochanteric femur fractures constituted only 5.8%. Table 1. Patients treated in the following years according to gender. Women Number 2009 2010 2011 2012 2013 2014 2015 Total 115 119 123 115 123 129 103 827 Women % 64.2 % 69.6 % 71.9 % 70.1 % 69.1 % 71.3 % 66 68.9 % Men Number 57 52 48 49 55 52 53 373 Men % 31.8 % 30.4 % 28.1 % 29.9% 30.9 % 28.7 % 34 31.1 % Total 179 171 171 164 178 181 156 1200 Table 2. Patients treated according to age groups. age d <60 age d 60-69 age d 70-79 age d 80-89 age d >90 2009 2010 2011 2012 2013 2014 2015 Total W M W M W M W M W M W M W M W M 7 35% 13 50% 29 64% 58 86% 8 89% 13 65% 13 50% 16 36% 21 14% 1 11% 9 35% 13 62% 34 64% 52 88% 11 92% 17 65% 8 38% 19 36% 7 12% 1 8% 8 38% 10 63% 27 57% 64 90% 14 88% 13 62% 6 37% 20 53% 7 10% 2 12% 11 32% 17 63% 30 77% 49 89% 8 89% 23 68% 10 37% 9 23% 6 11% 1 11% 7 25% 14 64% 30 64% 53 88% 19 86% 21 75% 8 36% 17 36% 7 12% 2 14% 10 45% 15 56% 38 76% 47 80% 19 83% 12 55% 12 54% 12 24% 12 20% 4 17% 8 36% 10 50% 40 77% 33 70% 12 80% 14 64% 10 50% 12 22% 14 30% 3 20% 60 35% 92 62% 228 68% 356 83% 91 87% 113 65% 57 48% 105 32% 74 17% 14 13% 166

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 165-169 PRACA ORYGINALNA Adam Konik et al., Patient with a fracture of the proximal end of the femur in an urban hospital Table 3. Fractures of the proximal end of the femur according to location. 2009 2010 2011 2012 2013 2014 2015 Total W M W M W M W M W M W M W M W M Femoral neck fractures 54 66% 28 34% 61 76% 19 24% 60 72% 23 28% 47 69% 21 31% 60 68% 28 32% 61 71% 25 29% 44 60% 29 40% 387 69% 173 31% Intertrochanteric fractures 56 66% 29 34% 53 64% 30 36% 53 71% 22 29% 63 70% 27 30% 59 71% 24 29% 60 72% 23 28% 50 70% 21 30% 394 69% 176 31% Subtrochanteric fractures 5 42% 7 58% 5 66% 3 34% 10 77% 3 23% 5 83% 1 17% 4 53% 3 47% 8 67% 4 33% 9 75% 3 25% 46 66% 24 34% Total 115 64% 64 36% 119 70% 52 30% 123 72% 48 28% 115 70% 49 30% 123 69% 55 31% 129 71% 52 29% 103 66% 53 34% 827 69% 373 31% There were few patients not treated surgically, barely 104. 33% of patients received a hip replacement and other patients were treated by fusing the bone fragments by means of a compression plate, gamma nail or cannulated screws. Table 4. Ways of treatment of a fracture of the proximal end of the femur. 2009 2010 2011 2012 2013 2014 2015 Total Preventive 15 12 12 11 20 16 18 104 Fusion 100 98 100 99 101 109 93 700 Hip replacement 64 61 59 54 57 56 45 396 Patients with PEF fractures constituted 15.7% of all patients treated in the ward, whereas annually they constituted 37.4% of man days used by all patients. Patients with PEF fractures often required further hospital stays in the first year after their hospital stay after they had been treated surgically. Generally in this period 48.7% of patients needed to stay in hospital. 8.2% of patients were treated in the trauma and orthopedics ward. Most often the patients who needed treatment in the internal diseases ward constituted over 53.1%. Table 5. Time of stay in hospital for patients with a fracture of the proximal end of the femur. Year All patients man days Average stay of all patients Man days s72.0 Days s72.0 Average stay s72.0 Man days s72.1 Days s72.1 Average stay s72.1 Man days s72.2 2009 10 630 6.94 1 284 1 366 16.59 1 293 1 373 16.12 207 219 18.10 2010 9 167 7.80 1 259 1 339 16.66 1 419 1 502 18.02 89 97 13.02 2011 8 756 6.50 1 295 1 375 17.04 1 062 1 137 15.31 196 13 15.93 2012 8 231 6.60 913 981 14.47 1 281 1 371 15.26 70 76 12.98 2013 7 702 6.38 1 066 1 154 13.16 1 114 83 15.33 107 110 16.19 2014 7 796 5.87 1 106 1 191 14.37 1 022 1 105 13.45 153 155 15.23 2015 7 381 5.40 707 780 10.68 721 792 11.27 111 113 10.19 s72.0 femoral neck fractures s72.1 intertrochanteric fractures s72.2 subtrochanteric fractures Days s72.2 Average stay s72.2 Table 6. Patients requiring another hospital stay post a fracture of the proximal end of the femur. Re-hospitalization up to 12 months after the given orthopedic stay Ward 2009 2010 2011 2012 2013 2014 2015 Total Internal diseases 54 32 41 33 29 42 44 275 Neurology 7 3 4 2 4 6 4 30 Orthopedics 14 15 10 15 17 6 18 95 ICU 5 2 1 2 5 4 1 20 Surgical 7 3 4 9 6 7 5 41 Other 22 18 5 2 3 9 1 60 Total 109 73 65 63 64 74 73 521 167

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 165-169 Adam Konik et al., Patient with a fracture of the proximal end of the femur in an urban hospital During their first hospital stay after the fracture, when the patients were operated on, we recorded 67 deaths which constituted 5.6% of all patients. Generally, within a year after the surgical treatment of the fracture, 230 patients died which constitutes 19.2%. The highest mortality was recorded in the group of patients aged 80-89, because it constituted 27.3%. Table 7. Deaths during the first stay in hospital (1) and within a year after the injury (2). 2009 2010 2011 2012 2013 2014 2015 Total 1 2 1 2 1 2 1 2 1 2 1 2 1 2 1 2 aged <60 0 0 0 0 0 0 1 0 1 0 1 1 0 1 3 2 aged 60-69 1 0 0 0 0 0 0 0 0 1 1 1 0 0 2 2 aged 70-79 3 5 1 4 4 1 4 2 0 3 1 4 4 3 17 22 aged 80-89 9 8 3 3 4 1 4 5 8 3 10 6 1 2 39 28 aged >90 2 0 0 1 2 1 0 0 1 1 1 3 0 5 6 11 Total 15 13 4 8 10 3 9 7 10 8 14 15 5 11 67 65 Table 8. Deaths outside the hospital. Number of patients 2009 2010 2011 2012 2013 2014 2015 Total Review of findings 15 12 13 11 16 17 14 98 Patients with a fracture of the proximal end of the femur constitute the most numerous group of patients treated in the trauma and orthopedic ward. 76.1% were patients aged 70-89. Men under 60 were treated more often because in this group the reason of the fracture was a high energy injury. However, the older the patients get, the bigger the female to male ratio. It is connected with more common osteoporosis in women and a shorter lifespan for men. In the Silesian region the lifespan was the shortest in Poland, namely on average 73.0 years for men and 80.3 for women. Almost all patients were operated on. In 7 years, 280 patients received preservative treatment because they did not qualify for a surgery after tests and examinations due to a general poor condition. A third of patients required a hip replacement for correct treatment of the fracture. Other patients received osteosynthesis using different implants. Remarkably, patients with PEF fractures needed a much longer hospital stay than patients treated due to other injuries. Within a year after the surgery, 8.2% of patients needed re-hospitalization in the trauma and orthopedics ward due to complications after the initial treatment. The reasons for re-hospitalization were wound infections, destabilization of bone fragments, implant migration. Many patients, almost 50%, received treatment in other wards, mainly the internal diseases ward, 20 patients were treated at the Intensive Care Unit directly after the surgery. This high number of patients requiring treatment in other wards proves that such a heavy injury as PEF fracture requiring a surgery is the reason for the significant deterioration of the general condition of the patients, as well as long-term complications such as heart failure, stroke, digestive tract occlusion. These diseases occur more often than in people without PEF fracture. Directly after the surgery only 5.6% of patients died in hospital, however, within a year after the injury 19.2% of patients died a result similar to the data received from other centers. Conclusions 1. Patients with a fracture of the proximal end of the femur constitute the most numerous group of patients treated in the trauma and orthopedics ward. 2. Women aged 70-89 get injured most often. 3. Almost all patients need a surgery. 4. Many patients after PEF fracture and a surgery require another hospitalization within a year. 5. Despite the small number of perioperative deaths, 1/5 of the patients die within a year. 6. Due to unsatisfactory results of treatment, it seems inevitable to organize a complex care system for patients with PEF fractures. 168

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 165-169 PRACA ORYGINALNA Adam Konik et al., Patient with a fracture of the proximal end of the femur in an urban hospital References [1] Smith R, Harrison J, Cooper C: Osteoporoza. Medycyna Praktyczna, Kraków 2000. [2] Kanis JA: On behalf of the WHO ScientificGroup. Assessment of osteoporosisat the primaryhealth-carelevel Technical report. University of Sheffield, UK 2007. [3] Kanis JA: Osteoporosis. Blackwell Science, Oxford 1994. [4] http://stat.gov.pl/obszary-tematyczne/ludnosc/prognoza-ludnosci/ prognoza-ludnosci-na-lata-2003-2030,1,2.html [5] Rubenstein LZ, Josepson KR: The epidemiology of falls and syncope. ClinGeriatr Med. 2002;18 (Suppl 2): 141-158. [6] Drozdowsak B: Złamania osteoporotyczne. Endokrynologia Polska. Tom 60. Numer 6/2009. [7] Wainwriht SA, Phipps KR, Stone JV,Cauley JA, Vogt MT, Black DM i wsp.: A large proportion of fractures in postmenopausal women occur with base line bone mineral density T-score -2,5. J. Bone Miner. Res. 2001;16:155-155. 169

ISSN 0009-479X Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 170-174 PRACA ORYGINALNA Kręgosłup i klatka piersiowa Survival analysis amongst patients with metastatic spine tumor treated with corpectomy Analiza przeżyć pacjentów po korpektomiach wykonanych z powodu guzów przerzutowych kręgosłupa Piotr Biega, Grzegorz Guzik, Tomasz Pitera Oddział Ortopedii Onkologicznej Szpitala Specjalistycznego w Brzozowie Podkarpacki Ośrodek Onkologiczny Abstract Introduction: Spine metastasis are found In 30% of ontological patients. Approximately 10% of the patients with spine metastasis suffer from decline In neurological function. For those patients surgical decompression is treatment of choice. The vertebral body is common involved by metastatic tumor. Corpectomy allow to remove tumor. However after procedure reconstruction of the vertebral body is necessary. Aim: Aim of the study are analysis of treatment results of the patents with spine metastasis after corpectomy. Material and methods: Retrospective analysis of 51 patients records with metastatic spinal cord compression treated with corpectomy were preformed. Those patients underwent surgical debunking of the vertebral body with implantation of the vertebral body prosthesis. All patients were operated between 2014 to 2015 In The department of Orthopaedic Oncolog of The Podkarpackie Oncological Center In Brzozów. Most of patients were men (61%). Mean age was 61 years. The most common origin of metastasis was Brest. Mean observation time vary from 9 to 920 days. Results: In postoperative period neurological status improve In 71% of patients. Pain reduction was achieve. Mean VAS reduction was 4.26 point. Functional improvement was also noted. Karnofsky score improve by 16 point. Mean survival was 16 month. Complication rate was 16%. One patient (2%) suffer from wound infection. Future neurological impairment was detected In 7% of patients. Conclusion: Corpectomy is safe and sufficient method of treatment for spine metastasis. The origin of cancer and it s advanced influence survival. Multilevel involvement increase operations time and reduce patients survival. Key words: gtumors, spine, metastasis, treatment, survival, corpectomy Streszczenie Wstęp: Przerzuty nowotworów złośliwych do kręgosłupa dotyczą 30% pacjentów onkologicznych. Około 10% chorych z przerzutami do kręgosłupa doświadcza pogorszenia stanu neurologicznego. W tej grupie pacjentów leczenie operacyjne powinno być postępowaniem z wyboru. Większość guzów przerzutowych kręgosłupa lokalizuję się w trzonach kręgów. Korporektomia pozwala na usunięcie guza w całości lub w znacznej części ale wymaga odtworzenia powstałego ubytku kości przy użyciu cementu lub protezy. Cel pracy: Celem pracy była analiza wyników leczenia pacjentów poddanych korporektomii z powodu guzów przerzutowych. Materiały i metody: Wykonano retrospektywną analizę przebiegu leczenia 51 pacjentów z guzami przerzutowymi kręgów powodującymi ucisk rdzenia kręgowego i deficyty neurologiczne. U chorych resekowano przerzuty wraz z trzonami kręgów uzyskując dekompresję rdzenia kręgowego a następnie implantowano protezy kręgów. Materiał obejmuje pacjentów operowanych w Oddziale Ortopedii Onkologicznej w Brzozowie w latach 2014-2015. Większość chorych stanowili mężczyźni (61%). Średni wiek (zarówno mężczyzn i kobiet) wynosił 61 lat. Najczęściej zmiany przerzutowe powodował rak sutka (28%). Czas obserwacji wynosił od 9 do 920 dni. Wyniki: W okresie pooperacyjnym stwierdzono poprawę funkcji neurologicznych u 71% chorych. Uzyskano redukcję natężenia bólu o 4,6 jednostki VAS i poprawę funkcjonalną chorych w skali Karnofsky ego o 16 punktów. Średni czas przeżycia wynosił 16 miesięcy. Odsetek powikłań wynosił 16%. Pooperacyjne pogorszenie funkcji neurologicznych odnotowano u 7% chorych. U jednego (2%) pacjenta stwierdzono opóźnienie gojenia rany operacyjnej. Wnioski: Korpektomia jest skuteczną i bezpieczną metodą leczenia guzów przerzutowych. Przeżycie pacjentów zależy głównie od punktu wyjścia i zaawansowania nowotworu. Zmiany wielopoziomowe powodują wydłużenie czasu operacji i skrócenie okresu przeżycia pacjentów. Słowa kluczowe: guzy, kręgosłup, przerzuty, operacyjne, przeżycie, korpektomia. Author s address: lek. Piotr Biega, ul. Daszyńskiego 3/11, 38-500 Sanok, tel.: 512306782, e-mail: ap.biega@gmail.com Received: 13.10.2017 Accepted: 26.10.2017 Published: 03.11.2017 170

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 170-174 PRACA ORYGINALNA Piotr Biega et al., Survival analysis amongst patients with metastatic spine tumor treated with corpectomy Introduction The spine is the most common site of bone metastasis. While almost every cancer can metastaise to bone. Breast, lung, prostate and kidney account for 80% of all bone lesion. [1,2]. Improvement in diagnostic modalities and systemic treatment had led to increase in survival periods in cancer patients. Therefore metastatic bone disease with led to intractable pain, pathological fracture, spine instability and neurological deficit gain in importance. Surgery can restore and preserve neurological function, spine stability and decrease mortality morbidity and increase quality of life [4,5,6]. Between 2000 to 2009 number of spine surgery due to spine metastatic tumor increase by 60% [7]. Plausible treatment options for metastatic spinal tumor patients include chemotherapy, radiotherapy, vertebroplasty, or operation[8]. Selection appropriate treatment depends on patients general status, origin of metastasis, number of metastasis and its location [9]. To guide treatment recommendation various scale were proposed (Tomita, Tokuhasi, Bauer, van Bollen, Gasbarrini) [10]. Up to 70% of the spine metastasis located in the vertebral body. Therefore only corpectomy or en bloc resection allow to remove tumor. Corpectomy is indicated in patients with single involvement of the 2-3 adjacent vertebral body, and survival prognosis more than 6 mouth. [11]. There are few studies regarding treatment results of corpectomy amongst patients with cancer. Available study analyzed small population of patients, with metastases located in the thoraco-lumbar spine. Moreover patients in these studies had single level involvement, whereas in clinical setting 50% of metastatic tumors had multilevel involvement [12]. In our study we analyzed results, complication, and functional results of corpectomy amongst 51 patients with metastatic bone disease. Material and methods We performed retrospective analysis of the 51 medical records of the patients with metastatic spine tumor, which underwent corpectomy in our hospital. Database include patients receive one or more level corpectomy followed by prosthesis implantation and posterior stabilization in single institution between 2014 and 2015. The indication for surgery was intractable pain, neurological deficit, unstable pathological fracture. Additional all patients were evaluated by multidisciplinary team prior operation to assess possibility of radiotherapy or systemic treatment and predicted survival time. Based on medical documentation and radiological finding clinical characteristics of the patients were created. Preoperative and postoperative pain intensity was assessed by VAS scale (Visual Analogue Scale), functional status was assessed by Karnofsky scale and neurological function was assessed using Frankel grade system. Additional operation time, blood lost, survival, complication and hospitalization time were analyzed. Normally distributed continuous variables were presented as means ± standard deviations. Variables with a skewed distribution were expressed as medians with lower and upper quartiles. The intergroup differences were tested using Student s t-test. The categorical variables were expressed as numbers with percentages. The inter-group differences were tested using the c2 test. Survival analysis was performed by Kaplan-Meier method. A value of p < 0.05 was considered statistically significant. Statistical analyses were performed using the STATISTICA 10 data analysis software system (StatSoft, Inc.). Operation procedure Position of the patient and selected approche depends on tumor localization. The cervical spine lesion (C3-Th2) was managed by anterior approach, with longitudinal incision along sterno-cleido-mastoideus muscle. The upper thoracic spine (Th3-Th6) was managed by posterolateral approach. The thoracolumbar spine lesion (Th7-L5) was managed by thoracophrenico lumbotomy or lumbotomy approach. The reconstruction was performed by placement of an expandable titanium cage (Vlift; Stryker,Kalamazoo, Michigan USA) and lateral stabilization by two pedicle screw above and below a pathologic level in the thoracolumbar spine. Whereas in the cervical spine reconstruction was performed by ECD (Expandable Corpectomy Device Synthes), with anterior plate stabilization. We don t use bone grafts for reconstruction. The drainage was maintained for 5 days in the retroperitoneal space and 7 day in the pleural cavity. The patients were bring to upright posture after two days. Results Most of the patients were men (61%). Mean age of women were 61 + 12,2, and men were 61 + 13,2. Mean observation time was 422 (od 9 do 920) days. Tabel 1 clinical characteristic of the study population. 171

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 170-174 Piotr Biega et al., Survival analysis amongst patients with metastatic spine tumor treated with corpectomy Tabel 1. Clinical characteristic of the patients with the spinal metastatic tumor treated with corpectomy (N=51). Variables Age [years] 60,5±12,7 Operation time [min] 124 (45-315) Volume of blood transfusion [ml] 760 (466-1864) Hospitalization time [days] 14,3±6,72 Observation time [days] 422 (9-1087) Blood transfusion 31 (61) Multilevel involvement 23 (45) Sex [Men] 31 (61) Spine portion Cervical 7 (14) Thoracic 26 (51) Lumbar 18 (35) Origin of the metastasis Myeloma 14 (27) Prostate 9 (18) Kidney 8 (15) Breast 6 (12) Lung 5 (10) Gastrointestinal 5 (10) Larynx 2 (4) Urethra 1 (2) Thyroid 1 (2) The primary sites of the metastatic tumors were as follows: myeloma (27%), prostate cancer (18%), kidney cancer (15%), breast cancer (12%), and lung cancer (10%). In 8% of the patients visceral metastasis were diagnose. The spinal metastases were first sign of cancer diseases in 31% of patients. Localization of the spinal lesion presented as follows: the cervical spine 12%, the thoracic spine 47%, the thoracolumbar spine 6% and lumbar spine 35%. According to Tomita scale most of the spinal tumor were assessed as T6 (76%). After surgery mean VAS score was 3,72 and was decreased by 4.26 point (p>0.05). Functional status of the patient asses according to Karnofsky score was 70 after surgery and rose by 16 point (p<0.05). Neurological status improve in 69% and increased by an average of 2 grade in Frankel scale. Median survival was 483 days (111-920). Overall survival was 36%. Highest survival rate was noted amongst patients with myeloma 54%, and lowest in patients with lung cancer(0%) Figure 1. Number of involved level had no influence on survival. The mean procedure duration was 149 (100-195) minute. Mean blood loss was 1445 (400-2500) mililiter, and was highest in patient with melanoma. Estimated blood loss expressed as a hemoglobin reduction was 2,15 g/dl±1,58. In postoperative period 61% required an average of 2 units (0-8) of blood. Highest hemoglobin reduction was note amongst patients with kidney cancer. In one-way ANOVA analysis of hemoglobin reduction in the patients with different cancer origin did not show significant correlations. However subgroup indicated higher reduction in kidney cancer compared to other groups Figure 2. Fig. 1. Survival time by orygin of the methastasis. Clinical characteristic of the patients by number of involved levels Tabel 2. The patients with multilevel involvement compared to single level metastatic tumor need longer operation. Mean hospitalization time was 14 ± 6,7 days. In eight (16%) patients complication were noted. Declination in neurological function were observed in 4 (7,8%) patients. However despite MRI scans and revision we didn t found underlay condition of it. Two patients had minor wound infection, and one had pleural abscess. One patient died within 30 day after operation. Tabela 2. Clinical characteristic by number of involved level. Variabel [unit] Singiel level N=28 Multi level N=21 Age 60,5 62,23 Main tumor orygin Myeloma 25% Myeloma 33% Main localization Lumbar 50% Thoracic 61% Operation time [min] 102 154* Hemoglobin reduction [mg/dl] 2,08 2,09 Transfusion volume [ml] 652 885 VAS reduction 4,2 4,9 improve- Karnofsky ment 15 16 Hospitalization [days] 13,2 14,89 172

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 170-174 PRACA ORYGINALNA Piotr Biega et al., Survival analysis amongst patients with metastatic spine tumor treated with corpectomy Discussion Corpectomy with subsequent reconstruction of the vertebrae body using prostheses allows to restore height, spine curvature and reduce sagittal deformity. Also significant cytoreduction can be achieved (50-80%)[13]. Compared to posterior decompression, the anterior approach increases the rate of improvement in neurological status, up to 71% of patients[14]. Tomita et al. indicate a prolonged survival of patients treated with corporectomy by 11.4 months[15]. A direct comparison of survival of the patients undergoing different types of surgical treatment is rarely considered because the expected lifetime, estimated using prognostic scales, is one of the main parameters eligible patients for a particular surgical treatment. The quality of life of patients with metastatic spinal tumors correlates with the functional score obtained in the KPS, Frankel scale and the intensity of pain asses by VAS score[5,16]. Corpectomy like other surgical techniques, can achieves a reduction in pain. In the our study pain reduction by 4.26 VAS point was noted. Similar results presents Jouberta et al.[16] and Chonga et al.[17], which had pain reduction ranging from 3.2 to 6.3 in VAS scale. Neurological status was improved in 68% of the patients, whereas in 24% preoperative and postoperative neurologic statuses did not differ. Similar neurological improvement was reported in available in literature range from 20% to 90% [5,18,19,17,20,21]. Ruiter et al. show neurological improvement only in 20% of patients, however in this study patients had more severe spinal cord compression asses according to Frankel system [20]. Only one study of Ruiter et al. assess functional status by Karnofsky score. Similar to his study after operation we noted increased by 16 points in Karnofsky score [20]. Moreover Ruiter et al. indicated that pain asses by VAS, functional status asses by Karofsky and spinal cord injury asses in Frankel grading system correlate with quality of life [20]. Mean survival time was 16 months and these outcomes were comparable with those reported in a literature (Shen et al. 16 months [21], de Ruiter 14 months [20], a Jobert 17 months [16]. At final follow up 35% of patients were alive. Origin of cancer, neurological status and multilevel involvement affect survival [19,23]. Also tumor mass, and pathological fracture has influence on survival [22]. In the our study visceral metastasis do not affect survival. Death within 3 months after surgery range from 6.8 to 17%. In the our study 8% of the patients died within 3 months [17,19,23]. According to literature complication after corpectomy is as high as 60% [23]. With the development of techniques for reconstruction of vertebral body with prosthesis instead bone cement the number of complications systematically decreases [23]. Recently complication rate vary from 4 to 14,3% [5,16,21,]. De Ruiter et al. show reduction of infectious complication from 10% to 4% and neurological complication from 12% to 0% within 3 years [5]. Also mean operation time decrease by 2.2 hours and one hour in Jansson [5,15]. Those observation indicated that corpectomy should be performed by surgeon familiar with that technique. Lau et al. show that complication rate and hospitalization time can by future decrease be employment of mini-invasive technique for corpectomy [23]. The most common complication after corpectomy is infection (2,5-16%) [52]. Compare to posterior stabilization number of infection is similar [5,25,26]. However anterior approach is endangered with vascular insult (7.9-13.8%) [27] and mechanical instability with cage subsidence (1.7-21%) [20]. The risk of infection is associated with blood loss and in posterior stabilization with number of stabilization levels [22,25,26,28]. Mean operation time of 120 minutes and complication rate of 16% is comparable with other study [15,16,21]. The most common complication amongst our patients were neurological deterioration after surgery (7,8%). Jansson et al. reported 4,7% [19], Shen 5% [20], de Rutier 12% [21] of future neurological decline after surgery. However compared to rest of the authors we perform operation in patients with compression lasted longer than 48 hours ( range from 4 days to 2 months). Conclusions 1. Corpectomy is an effective and safe method of treating metastatic spinal tumors. 2. Survival of patients depends mainly on the origin of the tumor. 3. Multi-level changes dominate. There was no effect of the multilevel involvement on the outcome of the treatment, apart from prolongation of the operating procedure. References [1] Zaikova O, Giercksky KE, Fossa SD, et al. A population-based study of spinal metastatic disease in South-East Norway. Clin Oncol (R Coll Radiol). 2009;21(10):753-9 [2] Toma CD, Dominkus M, Nedelcu T, Abdolvahab F, Assadian O, Krepler P, Kotz R. Metastatic bone disease: a 36-year single centre trendanalysis of patients admitted to a tertiary orthopaedic surgical department. J Surg Oncol. 2007;96:404-10 [3] Ibrahim A, Crockard A, Antonietti P, Boriani S, Bünger C, Gasbarrini A, Grejs A, Harms J, Kawahara N, Mazel C, Melcher R, Tomita K. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. J Neurosurg Spine. 2008 Mar;8(3):271-8. [4] Sutcliffe P, Connock M, Shyangdan D, Court R, Kandala NB, Clarke A. A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression. Health Technol Assess. 2013;17:1-274. 173

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 170-174 Piotr Biega et al., Survival analysis amongst patients with metastatic spine tumor treated with corpectomy [5] de Ruiter GC, Nogarede CO, Wolfs JF, Arts MP. Quality of life after different surgical procedures for the treatment of spinal metastases: results of a single-center prospective case series. Neurosurg Focus. 2017;42:E17. [6] Guzik G. Quality of life of patients after surgical treatment of cervical spine metastases. BMC Musculoskelet Disord. 2016;17:315. [7] Fehlings MG, Nater A, Tetreault L, Kopjar B, Arnold P, Dekutoski M,Finkelstein J, Fisher C, France J,Gokaslan Z, Massicotte E, Rhines L, Rose P,Sahgal A, Schuster J, Vaccaro A [2016] Survival and Clinical Outcomes in SurgicallyTreated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study. J Clin Oncol 34:268-76 [8] Guzik G. Treatment of metastatic lesions localized in the acetabulum. J Orthop Surg Res. 2016 Apr 28;11(1):54. [9] Bollen L, Wibmer C, Van der Linden YM, Pondaag W, Fiocco M, Peul WC, Marijnen CA, Nelissen RG, Leithner A, Dijkstra SP. Predictive Value of Six Prognostic Scoring Systems for Spinal Bone Metastases: An Analysis Based on 1379 Patients. Spine. 2016;41:E155-62. [10] Leithner A, Radl R, Gruber G, Hochegger M, Leithner K, Welkerling H, RehakP, Windhager R. Predictive value of seven preoperative prognostic scoring systems for spinal metastases. Eur Spine J. 2008;17:1488-95. [11] Kaneda K, Asano S, Hashimoto T, Satoh S, Fujiya M. The treatment of osteoporotic-posttraumatic vertebral collapse using the Kaneda device and a bioactive ceramic vertebral prosthesis. Spine (Phila Pa 1976). 1992;17:S295-303. [12] D. Togawa and K. U. Lewandrowsky, The pathophysiology of spinal metastases, in Cancer in the Spine, R. F. McLain, Ed., Current Clinical Oncology, pp. 17 23, 2006 [13] White AP, Kwon BK, Lindskog DM, Friedlaender GE, Grauer JN J Am Acad Orthop Surg. 2006 Oct; 14(11):587-98 [14] Kostuik JP, Errico TJ, Gleason TF, Errico CC Spine (Phila Pa 1976). 1988 Mar; 13(3):250-6. [15] Tomita K, Kawahara N, Kobayashi T et al (2001) Surgical strategy for spinal metastases. Spine 26:298 306. [16] Joubert C, Adetchessi T, Peltier E, Graillon T, Dufour H, Blondel B, FuentesS. Corpectomy and Vertebral Body Reconstruction with Expandable Cage Placementand Osteosynthesis via the single stage Posterior Approach: a RetrospectiveSeries of 34 Patients with Thoracic and Lumbar Spine Vertebral Body Tumors. World Neurosurg. 2015;84:1412-22. [17] Chong S, Shin SH, Yoo H, Lee SH, Kim KJ, Jahng TA, Gwak HS. Singlestageposterior decompression and stabilization for metastasis of the thoracic spine: prognostic factors for functional outcome and patients survival. Spine J. 2012;12:1083-92. [18] Chang CC, Chen YJ, Lo DF, Chen HT, Hsu HC, Lin RM. Palliative transpedicular partial corpectomy without anterior vertebral reconstruction in lower thoracic and thoracolumbar junction spinal metastases. J Orthop Surg Res. 2015 17;10:113. [19] Jansson KA, Bauer HC. Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases. Eur Spine J. 2006;15:196-202. [20] de Ruiter GC, Lobatto DJ, Wolfs JF, Peul WC, Arts MP. Reconstruction withexpandable cages after single- and multilevel corpectomies for spinal metastases: a prospective case series of 60 patients. Spine J. 2014;14:2085-93. [21] Shen FH, Marks I, Shaffrey C, Ouellet J, Arlet V. The use of an expandable cage for corpectomy reconstruction of vertebral body tumors through a posterior extracavitary approach: a multicenter consecutive case series of prospectively followed patients. Spine J. 2008;8:329-39. [22] Bauer HC, Wedin R. Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients. Acta Orthop Scand. 1995;66:143-6. [23] Nemelc RM, Stadhouder A, van Royen BJ, Jiya TU. The outcome and survival of palliative surgery in thoraco-lumbar spinal metastases: contemporary retrospective cohort study. Eur Spine J. 2014;23:2272-8. [24] Lau D, Chou D. Posterior thoracic corpectomy with cage reconstruction for metastatic spinal tumors: comparing the mini-open approach to the open approach. J Neurosurg Spine. 2015;23:217-27. [25] Bakar D, Tanenbaum JE, Phan K, Alentado VJ, Steinmetz MP, Benzel EC, Mroz TE. Decompression surgery for spinal metastases: a systematic review. Neurosurg Focus. 2016 ;41:E2. [26] Dunning EC, Butler JS, Morris S. Complications in the management of metastatic spinal disease. World J Orthop. 2012;3:114-21. [27] Vazan M, Ryang YM, Gerhardt J, Zibold F, Janssen I, Ringel F, Gempt J, Meyer B. L5 corpectomy-the lumbosacral segmental geometry and clinical outcome-a consecutive series of 14 patients and review of the literature. Acta Neurochir (Wien). 2017 Jan 31. doi: 10.1007/s00701-017-3084-5. [28] Guzik G. Surgical Treatment in Patients with Spinal Tumors Differences in Surgical Strategies and Malignancy-Associated Problems. An Analysis of 474 Patients. Ortop Traumatol Rehabil. 2015 May- Jun;17(3):229-40. 174

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 ISSN 0009-479X OPIS PRZYPADKU Kończyna górna i dolna Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Wspomaganie zrostu tkanki kostnej za pomocą ultradźwięków studium 4 przypadków Mateusz Stolarz 1,2,3, Robert Hawranek 1,2, Grzegorz Wrzask 1, Marek Hawranek 1, Jakub Hawranek 1, Zygmunt Wróbel 3, 1 Department of Orthopedics and Traumatology, City Hospital in Zabrze, Poland 2 Medict, Gliwice, Poland 3 Department of Computer Biomedical Systems, University of Silesia, Institute of Computer Science, Sosnowiec, Poland Abstract The problems associated with treating bone fractures as well as frequently accompanying complications are still a challenge for modern orthopedics and traumatology. The duration of the healing process is different and depends on numerous individual circumstances. Various methods of accelerating these processes are currently being used; as well, alternative methods of treatment are being sought. Among the ones currently in use, invasive, related to surgery or local injection of various substances, and non-invasive methods, related to physiotherapeutic procedures, can be distinguished. One of the non-invasive methods is low-intensity pulsed ultrasound (LIPUS). This article discusses the use of LIPUS in four cases: nonunion fracture of the clavicle, prolonged healing of a femoral fracture, a tibial stress fracture, and ipsilateral talus and calcaneal fracture. Summing up the discussed cases, the use of ultrasound is a positive and safe method of promoting bone healing. It is worth considering its use, especially in bone nonunion as an alternative to surgical treatment. Key words: bone fracture, nonunion, low-intensity pulsed ultrasound, LIPUS, Streszczenie Problematyka leczenia złamań kości i nierzadkich powikłań wciąż stanowi wyzwanie dla współczesnej ortopedii i traumatologii. Szybkość procesu gojenia jest różna i zależna od wielu uwarunkowań osobniczych. Obecnie wykorzystywane są różne metody przyspieszenia gojenia. Wśród stosowanych można wyróżnić inwazyjne lub nieinwazyjne. Jedną z metod są ultradźwięki o niskim natężeniu (LIPUS). W niniejszym artykule omówiono zastosowanie LIPUS w czterech przypadkach: brak zrostu obojczyka, przedłużający się zrost kości udowej, złamanie przeciążeniowe kości piszczelowej, złamanie ipsilateralne kości skokowej i piętowej. Podsumowując, użycie ultradźwięków stanowi dobrą i bezpieczną metodę wspomagania gojenia kości. Warto rozważyć ich zastosowanie szczególnie przy braku zrostu kości, jako alternatywę do leczenia operacyjnego. Słowa kluczowe: złamanie kości, brak zrostu, ultradźwięki o niskim natężeniu, LIPUS Author s address: Mateusz Stolarz, Department of Orthopedics and Traumatology, City Hospital in Zabrze, Zamkowa 4, 41-803 Zabrze, Poland, tel.: +48500793030, e-mail: matstolarz@gmail.com, Received: 05.09.2017 Accepted: 29.09.2017 Published: 03.11.2017 175

OPIS PRZYPADKU Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Introduction The problem of bone fracture treatment is the subject of numerous studies. The treatment uses conservative and operational methods. Occurring complications, among others, include nonunions, pseudarthrosis in the place of fracture, delayed healing, and others still whose enigmatic etiologies pose a challenge for modern orthopedics and traumatology [1, 2]. A holistic view of the fracture healing process involves both systemic processes and local inflammation processes. Fracture healing can take place directly and indirectly [2]. Subsequent physiological steps combining a junction of broken bone elements include: hematoma formation, recruitment and accumulation of stem cells, angiogenesis, and extracellular matrix formation which is a scaffold for new bone cells that creates a bone scar [3]. The healing process is dependent on biochemical (including pro-inflammatory factors and hormones), nervous and physical regulators [1]. Factors influencing the osseointegration processes also include: sex, age, BMI, nicotine, chronic diseases such as osteoporosis, diabetes as well as genetic predisposition [4, 5]. The duration of the healing process of a bone fracture varies individually between patients. Currently, many enhancement techniques are described in the literature, both invasive and noninvasive. Noninvasive techniques include low-intensity pulsed ultrasound (LIPUS) [6, 7], low-dose laser therapy [8], extracorporeal shock wave therapy (ESWT) [9], and supplementation of parathormon (PTH) [10] or calcium and vitamin D. Minimally invasive techniques are usually associated with local injection of bone marrow [11], FGF-2 factor [15], BMP-2 protein [12], BMP-7 protein [13]. Low intensity ultrasound, which is commercially available, has been proven in many studies to enhance bone healing [6, 14, 15]. Currently it is particularly recommended in the absence or delay of bone healing in stable fixation [16, 17]. Indications also include accelerating the healing of fresh bone fractures treated surgically or conservatively [6, 18], [19]. However, some authors have questioned the use of LI- PUS, indicating moderate to low quality of healing enhancement and contradictory literature data [20]. In the presented article, we have described the use of LIPUS using the system Exogen in 4 medical cases: two patients with nonunion fractures and two with acute fractures. Case studies Medical case 1 A woman, 27 years old, presented with a multifragmentary, unstable fracture of the left clavicle as a result of high-energy trauma. The patient presented with no preexisting diseases and a high level of physical activity. The attempt at fracture repositioning as an application of conservative treatment failed. The patient was approved for an urgent procedure and operated on. An intramedullary nail was implanted (Fig. 1a). Due to the relatively high activity of the patient, it was decided that a Dessault s plaster dressing would be used. At the follow-up examinations at 1 month (Fig. 1b), 7 months (Fig. 1c), 8 months (Fig. 1d), and 9 months (Fig. 1e) after surgery, no satisfactory bone union was achieved. An ache was continuously present in the area surrounding the fracture and a strong pain was felt upon palpation of the clavicle. It was decided that LIPUS would be used for 30 days. A satisfactory bone union (Fig. 1f) was observed a year after injury, and 1,5 months after LIPUS treatment. Complete elimination of pain was achieved. The patient returned to her daily activities. Medical case 2 A 36 year old patient, male, with no chronic diseases, no allergy and no addiction, suffered a fracture of the left femur as a result of a fall. The patient was operated on with a minimally invasive technique using an intramedullary nail (Fig. 2). Early postoperative follow up showed no complications during the postoperative period. Rehabilitation began two days postoperatively. Along with the subsiding of pain, starting the third week after surgery, he gradually increased the load on the limb. Unfortunately, the pain only decreased to a certain level, afterwards plateauing, which interfered with normal daily activity. The radiological examinations were carried out 2 months, 3 months, 4 months and 6 months (Fig. 3) after the operation, and showed bone nonunion. It was decided that performing revision surgery was necessary, carried out 7 months after the initial operation. In one step, the existing fixation material was removed and with the open technique, the fracture was refreshed, and existing fibrous tissue was removed. The fractured part was covered locally with allogeneic bone grafts and a reconstruction plate was fastened (Fig. 4). Postoperative protocol remained the same as after the initial surgery. Postoperatively, the patient complained of stronger pain than that following the first operation which may have been due to more extensive perioperative soft tissue injury. Control tests, including X-rays were taken: 1 month, 3 months and 5 months (Fig. 5) after surgery, showing no satisfactory bone union. Radiographs showed slight signs of bone union and absorption of allografts, after 5 months. Fixation was assessed as stable. When the patient tried to walk, he suffered strong pain, which made his daily activities difficult. Despite intensive rehabilitation and attempts to move with a single crutch, the patient required two elbow crutches. In the fifth month after the operation, LIPUS was applied in 30 cycles at one-day intervals and rehabilitation was continued. Control studies at 8 months (Fig. 6), 10 months, and 18 months (Fig. 7) showed progressive bone union 176

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 OPIS PRZYPADKU Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Fig. 1. Plain 1. Plain radiograph radiograph of left clavicle, in of AP projection. left clavicle, a) 1 day after in surgery, AP projection. b) 1 month after surgery, a) 1 day c) 7 months after after surgery, d) b) 8 months 1 month after surgery, e) 9 months after surgery, f) 12 months after surgery, and 1,5 month after LUPIS treatment. Fig. 2. Plain 2. radiograph Plain radiograph after surgery, a) AP after projection, surgery, b) lateral projection. a) AP Fig. 3. Plain radiograph 6 months after operation: a) AP projection, b) lateral projection. 177

OPIS PRZYPADKU Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Fig. 4. Plain 4. radiograph, Plain radiograph, one day after revision one surgery day (7 months after after revisi first operation), a) AP projection, b)lateral projection. Fig. 5. RTG 5 months after revision surgery Fig. 5. RTG 5 months after revision surgery, a) AP projection, b) lateral projection. Radiographs showed slight signs of bone union and absorption of allografts. with properly formed bone scarring. At the follow-up after 8 months, the patient moved about using his own strength/ bearing his full weight on the injured leg, without crutches, slightly limping. At 18 months, basic treatment was completed. The patient reported periodic discomfort associated with weather changes, but could move without the aid of elbow crutches. Medical case 3 The patient, male, 49 years old, overweight, presented without additional diseases, with no current addictions and a history of cigarette use. After a few months without any sport activity other than daily activities, he started intensive running, every 2-3 days. During one run, he felt a sudden, sharp pain in the distal part of the right leg preventing full weight bearing of the traumatic limb. After a clinical examination and a RTG study (Fig. 8), a stress fracture of the right tibia was diagnosed. Plaster immobilization bandages were used for a month, without weight bearing on the limb, along with the use of 2 elbow crutches. During the immobilization period, antithrombotic prophylaxis was used (deltaparin, 1x1 sc). After 3.5 weeks of immobilization, the plaster brace was removed and replaced with an orthosis ( Walker type ) and 30 cycles of LIPUS were used at one day intervals, along with intensive rehabilitation. In follow-up exams less than 3 months after injury, satisfactory bone union was achieved (Fig. 9). After this period, the patient returned to daily activities, without pain. Medical case 4 The patient, male, 54 years old, had fallen from about 2 meters onto his left lower limb. The Patient suffered from hy- Fig. 6. Radiograph 6. Radiograph 8 months after surgery, 8 months a) AP projection; after b) surgery, lateral projection. Satisfactory bon union a formation. Fig. 7. Radiograph 7. Radiograph 18 months after 18 surgery, months a) AP projection; after b) surgery, lateral projection. Complete bone union. 178

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 OPIS PRZYPADKU Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports pain and swelling after intense physical activity. In the X-ray, bone union in the place of the fractures (Fig. 13) was evident. Additionally, there were symptoms of minor osteoarthritis. Fig. 8. Radiograph of stress fracture of righ Fig. 8. Radiograph of stress fracture of right tibia, a) AP projection; b) lateral projection; c) magnification of AP projection; d) magnification of lateral projection. period, the patient returned to daily activitie Fig. 10. Plain radiograph od ankle joint, with lateral projection, Fracture of talus and calcaneal bone. Fig. 9. Radiograph of right tibia, in the time Fig. 9. Radiograph of right tibia, in the time less than 3 months after fracture. a) AP projection; b) lateral projection. pertension, without additional chronic diseases, without addictions. X-ray examination was performed (Fig. 10) and an ipsilateral fracture of the left talus and calcaneus bone were diagnosed. To precisely illustrate the fracture, computed tomography was performed (Fig. 11). Despite recommendations, the patient did not consent to surgery and decided to undergo conservative treatment - immobilization in a plaster boot, with no weight bearing. During the immobilization period, antithrombotic prophylaxis (deltaparin, 1x1 sc) was used. In the first month after the injury, LIPUS treatment was applied. Rehabilitation included partial weight bearing on the injured limb. After 4 weeks the plaster was changed to a hard ankle orthosis. After control examinations two months later, the orthesis was removed, and gradual loading of the limb was permitted. The X-ray was taken, and satisfactory bone union was confirmed (Fig. 12). On the follow-up, four months after the trauma, the patient moved without elbow crutches and reported periodic Fig. 11. Computed 11. Computed tomography of tomography left angle after injury, of a,b) left AP projections; angle c,d) lateral projections; e,f) oblique projections. 179

OPIS PRZYPADKU Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports Fig. 12. Plain 12. radiograph Plain radiograph of ankle 2 months after of ankle injury, a) AP 2 projection; months b) lateral projection. Fig. 13. Plain 13. radiograph Plain radiograph of ankle 4 months after of ankle injury, a) AP 4 projection; months b) lateral projection. Discussion Low-intensity pulsed ultrasound has been use in orthopedics and traumatology for less than two decades. In many scientific studies, the authors conclude their effectiveness in promoting treatment with moderate or considerable enthusiasm [6, 16-19, 21]. It is worth noting that there are authors who do not recommend using LIPUS [20, 22]. In the first medical case, there was no union after fracture and operative treatment of the clavicle. Despite the young age, lack of chronic diseases and relatively high healing potential, after eight months there was no progressive bone adhesion. This was confirmed by chronic pain, increasing with the movements of the limb and local palpation. Surgical treatment of clavicular fracture, both with plate reconstruction [23], and intramedullary nail [24], decreases healing time and reduces complications. Total treatment time lasts on average 4 months, which is usually radiologically verified [25]. In the absence of union in the presented patient, LI- PUS was chosen as an alternative therapy. As in one article [26] which depicts support for clavicular fracture healing after conservative treatment, a satisfactory union and complete elimination of pain was achieved. The complete healing was radiologically confirmed within a month and a half after LIPUS treatment. In the second case, the patient presented with a stable fixation with an intramedullary nail. Six months after the surgery, the patient felt persistent pain, and could not bear full weight on the limb. The radiographs showed at the edges of bone fragments no progressive bone healing. Due to the incomplete anatomical fixation, as well as a persistent fracture gap in radiological images, it was decided that revision surgery would be performed. The use of an additional fixing plate or a larger diameter intramedullary nail was considered. In the first case the patient would have had a large amount of foreign bodies implanted; in the second case, the fracture gap would have been refreshed and the removal of fibrous tissue would have been difficult. Finally, a single stage operation was performed the fixation nail was removed and then using the open technique, existing fibrous scar was resected. The reconstruction plate and allogeneic bone grafts were implanted. The operation, as well as the postoperative recovery were without complications, with the wound healing well. In spite of this, the patient was not healing properly. In subsequent visits 1, 3 and 5 months after surgery, the pain was reduced but not to a satisfactory level. Sequentially performed X-rays showed bone graft resorption, but a properly progressive union in the place of the fracture gap could not be seen. After discussing the possibility of further treatment with the patient, LIPUS was decided upon. The Exogen system was used for a month, then two months later, a control radiograph was performed (Fig. 6). Radiologically visualized, progressive union of the bone, in particular on the AP projections, was seen. The patient reported pain regression. Subsequent control studies showed a satisfactory union. Ultrasound LIPUS was repeatedly used to stimulate healing of nonunion or delay in the union of the post fracture femoral bone [27, 28]. Authors of the cited publications, as in this case, have used LIPUS for stable fractures with no union, achieving positive results. In this patient, the lack of union after revision surgery was a disturbing symptom. In this and other similar cases, the spectrum of treatment methods is decreasing. In our opinion, the use of ultrasound encouraged the initiation of union at the fracture site. The final effect of the treatment was satisfactory. The advantage of this method is its noninvasive character and that in instances in which it is ineffective, it does not interfere with other treatment methods. The third case concerns a stress fracture of the tibia. This type of fracture is a result of chronic overloading of the skeleton over a given period of time, which prevents proper adaptation of the skeleton to this overload [29, 30]. Recovery time after stress fracture is approximately 12 weeks on average and can be extended up to 19 weeks [31]. Moreover, the risk of re-fracture is as high as 29% [32]. The process is based on conservative treatment, combined with several weeks of immobilisation followed by rehabilitation [31]. Treatment may be supported by physiotherapeutic procedures, such as electrical stimulation [33], shock wave therapy (ESWT) [9] 180

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 OPIS PRZYPADKU Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports or low intensity ultrasound (LIPUS) [34]. The literature presents conflicting studies on the effectiveness of work in the context of the LIPUS treatment of tibia fracture. Some authors in randomized trials have demonstrated that there is no significant reduction in healing time with LIPUS compared to placebo [22], Other authors point to significant acceleration of healing [34]. In the present case the healing process proceeded correctly. Recovery and the return to daily activities lasted 11 weeks, which is a good result, slightly below average. It is difficult to assess whether the use of ultrasound in this case significantly affected the healing process, but certainly the convalescence process was not disturbed and no complications were reported. Ipsilateral fractures of the talus and calcaneus bones are relatively rare and occur in 1% of fractures of the calcaneus and 6% of fractures of the talus [35]. The treatment is still controversial with a lack of generally accepted standards [35-38]. Usually surgical treatment is chosen to reconstruct broken bones or arthrodesis.in rare instances, lower leg/ shin limb amputation is deemed necessary [35, 38, 39]. Conservative treatment, involving immobilisation is least used, only in selected cases [39]. In the fourth case, the patient suffered a fracture of the talus, type 1 by Hawkins and fractures of the calcaneus with preservation of the Bohler angle. Surgery to fixate the fracture was recommended, but the patient did not consent. Due to the fact that the fractures were not significantly displaced, immobilisation, rehabilitation and healing using LIPUS were used. Two months after the injury, the result of the treatment was successful. The control X-ray (Fig. 12) illustrated the progressive union of the bone, along with significant reduction in pain. After 4 months the patient was fully active and returned to pre-injury daily activities. In similar cases the healing and convalescence process lasted from 3 to 20 months [39]. In the absence of prolonged healing and other complications, given the relatively short recovery time, it can be concluded that the use of LIPUS was valuable and effective in the present case. In the cases discussed above, the use of LIPUS bone healing augmentation system was effective in the treatment of union failure or prolonged bone union. Exogen system was used for stable lesions that did not show progressive bone healing. The presented cases are evidence of the effectiveness of acting in accordance with the indications [14, 16, 17]. In the case of healing these fresh fractures, evaluation of the effectiveness of healing is difficult. The course of treatment and recovery was normal. It is not known whether treatment without LIPUS would be similar. In conclusion, the use of low-frequency ultrasound is a positive and safe method to promote the healing of bone. It is worth considering its use, especially in the absence of bone adhesion, as an alternative to surgical treatment. The presented group of cases is small and heterogeneous, but the hypothesis has been confirmed as in many published studies. References [1] I. H. Kalfas: Principles of bone healing. Neurosurg. Focus, vol. 10, no. 4, p. E1, Jan. 2001. [2] R. Marsell and T. A. Einhorn: The biology of fracture healing, Injury, vol. 42, no. 6, pp. 551 555, Jun. 2011. [3] A. Schindeler, M. M. McDonald, P. Bokko, and D. G. Little: Bone remodeling during fracture repair: The cellular picture., Semin. Cell Dev. Biol., vol. 19, no. 5, pp. 459 66, Oct. 2008. [4] S. Jordan, L. Lim, J. Berecki-Gisolf, C. Bain, S. Seubsman, A. Sleigh, and E. Banks: Body mass index, physical activity, and fracture among young adults: longitudinal results from the Thai cohort study., J. Epidemiol., vol. 23, no. 6, pp. 435 442, 2013. [5] B. A. Gower and K. Casazza: Divergent effects of obesity on bone health., J. Clin. Densitom., vol. 16, no. 4, pp. 450 454, 2013. [6] M. D. Schofer, J. E. Block, J. Aigner, and A. Schmelz: Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial, BMC Musculoskelet. Disord., vol. 11, p. 229, Oct. 2010. [7] K.-S. Leung, W.-S. Lee, H.-F. Tsui, P. P.-L. Liu, and W.-H. Cheung: Complex tibial fracture outcomes following treatment with low-intensity pulsed ultrasound, Ultrasound Med. Biol., vol. 30, no. 3, pp. 389 395, Jul. 2015. [8] S. Kazem Shakouri, J. Soleimanpour, Y. Salekzamani, and M. R. Oskuie: Effect of low-level laser therapy on the fracture healing process, Lasers Med. Sci., vol. 25, no. 1, p. 73, 2009. [9] M. K. Shindle, Y. Endo, R. F. Warren, J. M. Lane, D. L. Helfet, E. N. Schwartz, and S. J. Ellis: Stress fractures about the tibia, foot, and ankle, J. Am. Acad. Orthop. Surg., vol. 20, no. 3, pp. 167 176, 2012. [10] Y. M. Alkhiary, L. C. Gerstenfeld, E. Krall, M. Westmore, M. Sato, B. H. Mitlak, and T. A. Einhorn: Enhancement of experimental fracturehealing by systemic administration of recombinant human parathyroid hormone (PTH 1-34)., J. Bone Joint Surg. Am., vol. 87, no. 4, pp. 731 741, Apr. 2005. [11] P. Hernigou, A. Poignard, F. Beaujean, and H. Rouard: Percutaneous autologous bone-marrow grafting for nonunions. Influence of the number and concentration of progenitor cells., J. Bone Joint Surg. Am., vol. 87, no. 7, pp. 1430 1437, Jul. 2005. [12] T. Lyon, W. Scheele, M. Bhandari, K. J. Koval, E. G. Sanchez, J. Christensen, A. Valentin, and F. Huard: Efficacy and safety of recombinant human bone morphogenetic protein-2/calcium phosphate matrix for closed tibial diaphyseal fracture: a double-blind, randomized, controlled phase-ii/iii trial., J. Bone Joint Surg. Am., vol. 95, no. 23, pp. 2088 2096, Dec. 2013. [13] G. E. Friedlaender, C. R. Perry, J. D. Cole, S. D. Cook, G. Cierny, G. F. Muschler, G. A. Zych, J. H. Calhoun, A. J. LaForte, and S. Yin: Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions., J. Bone Joint Surg. Am., vol. 83-A Suppl 1, no. Pt 2, pp. S151 8, 2001. [14] R. Zura, S. Mehta, G. J. Della Rocca, J. Jones, and R. G. Steen: A cohort study of 4,190 patients treated with low-intensity pulsed ultrasound (LIPUS): findings in the elderly versus all patients., BMC Musculoskelet. Disord., vol. 16, p. 45, Mar. 2015. [15] M. Kowal, A. Pozowski, M. Paprocka-Borowicz, A. Kierzek, and J. Kuciel-Lewandowska: Zastosowanie ultradźwięków w leczeniu uszkodzeń i odbudowie kości. przegląd piśmiennictwa, Acta Bio-Optica Inform. Medica. Inżynieria Biomed., vol. 20, no. 3, pp. 172 180, 2014. [16] P. A. Nolte, A. van der Krans, P. Patka, I. M. Janssen, J. P. Ryaby, and G. H. Albers: Low-intensity pulsed ultrasound in the treatment of nonunions., J. Trauma, vol. 51, no. 4, p. 693, Oct. 2001. [17] D. Gebauer, E. Mayr, E. Orthner, and J. P. Ryaby: Low-intensity pulsed ultrasound: effects on nonunions., Ultrasound Med. Biol., vol. 31, no. 10, pp. 1391 1402, Oct. 2005. [18] X. Roussignol, C. Currey, F. Duparc, and F. Dujardin: Indications and results for the Exogen ultrasound system in the management of nonunion: a 59-case pilot study., Orthop. Traumatol. Surg. Res., vol. 98, no. 2, pp. 206 213, Apr. 2012. [19] P. F. W. Hannemann, E. H. H. Mommers, J. P. M. Schots, P. R. G. Brink, and M. Poeze: The effects of low-intensity pulsed ultrasound and pulsed electromagnetic fields bone growth stimulation in acute fractures: a systematic review and meta-analysis of randomized controlled trials, Arch. Orthop. Trauma Surg., vol. 134, no. 8, pp. 1093 1106, 2014. [20] T. A. Einhorn and L. C. Gerstenfeld: Fracture healing: mechanisms and interventions, Nat. Rev. Rheumatol., vol. 11, no. 1, pp. 45 54, Jan. 2015. 181

OPIS PRZYPADKU Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 175-182 Mateusz Stolarz et al., Enhancement of bone fracture healing by ultrasound stimulation 4 case reports [21] S. D. Cook, J. P. Ryaby, J. McCabe, J. J. Frey, J. D. Heckman, and T. K. Kristiansen: Acceleration of Tibia and Distal Radius Fracture Healing in Patients Who Smoke., Clin. Orthop. Relat. Res., vol. 337, 1997. [22] J.-P. H. Rue, D. W. 3rd Armstrong, F. J. Frassica, M. Deafenbaugh, and J. H. Wilckens: The effect of pulsed ultrasound in the treatment of tibial stress fractures., Orthopedics, vol. 27, no. 11, pp. 1192 1195, Nov. 2004. [23] V. Kulshrestha, T. Roy, and L. Audige: Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study., J. Orthop. Trauma, vol. 25, no. 1, pp. 31 38, Jan. 2011. [24] V. Smekal, A. Irenberger, P. Struve, M. Wambacher, D. Krappinger, and F. S. Kralinger: Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial., J. Orthop. Trauma, vol. 23, no. 2, pp. 106 112, Feb. 2009. [25] S. A. Altamimi and M. D. McKee: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Surgical technique., J. Bone Joint Surg. Am., vol. 90 Suppl 2 Pt 1, pp. 1 8, Mar. 2008. [26] P. Lüthje and I. Nurmi-Lüthje: Non-union of the clavicle and delayed union of the proximal fifth metatarsal treated with low-intensity pulsed ultrasound in two soccer players, J. Sports Med. Phys. Fitness, vol. 46, no. 3, p. 476, 2006. [27] I. H. Jeon, C. W. Oh, S. J. Kim, H. S. Kyung, I. H. Park, B. C. Park, J. C. Ihn, and J. Y. Yeo: Treatment of Nonunion in the Long Bone with Low Intensity Pulsed Ultrasound (LIPUS) and LASER, J Korean Soc Fract, vol. 16, no. 2, pp. 177 185, Apr. 2003. [28] S. Jingushi, K. Mizuno, T. Matsushita, and M. Itoman: Low-intensity pulsed ultrasound treatment for postoperative delayed union or nonunion of long bone fractures, J. Orthop. Sci., vol. 12, no. 1, pp. 35 41, 2007. [29] K. L. Bennell and P. D. Brukner: Epidemiology and site specificity of stress fractures., Clin. Sports Med., vol. 16, no. 2, pp. 179 196, Apr. 1997. [30] A. Gam, L. Goldstein, Y. Karmon, I. Mintser, I. Grotto, A. Guri, A. Goldberg, N. Ohana, E. Onn, Y. Levi, and Y. Bar-Dayan: Comparison of stress fractures of male and female recruits during basic training in the Israeli anti-aircraft forces., Mil. Med., vol. 170, no. 8, pp. 710 712, Aug. 2005. [31] K. L. Bennell, S. A. Malcolm, S. A. Thomas, J. D. Wark, and P. D. Brukner: The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study., Am. J. Sports Med., vol. 24, no. 2, pp. 211 217, 1996. [32] J. Ekstrand and M. K. Torstveit: Stress fractures in elite male football players, Scand. J. Med. Sci. Sports, vol. 22, no. 3, pp. 341 346, 2012. [33] B. R. Beck, G. O. Matheson, G. Bergman, T. Norling, M. Fredericson, A. R. Hoffman, and R. Marcus: Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial., Am. J. Sports Med., vol. 36, no. 3, pp. 545 553, Mar. 2008. [34] J. D. Heckman, J. P. Ryaby, J. McCabe, J. J. Frey, and R. F. Kilcoyne: Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound., J. Bone Jt. Surg. Jt. Surg., vol. 76, no. 1, pp. 26 34, Jan. 1994. [35] D. Seybold, T. A. Schildhauer, and G. Muhr: Combined ipsilateral fractures of talus and calcaneus., Foot ankle Int., vol. 29, no. 3, pp. 318 324, Mar. 2008. [36] S. Rammelt and H. Zwipp: Talar neck and body fractures, Injury, vol. 40, pp. 120 135, 2009. [37] E. Guerado, M. L. Bertrand, and J. R. Cano: Management of calcaneal fractures: What have we learnt over the years?, Injury, vol. 43, no. 10, pp. 1640 1650, Oct. 2012. [38] A. Aminian, C. R. Howe, B. J. Sangeorzan, S. K. Benirschke, S. E. Nork, and D. P. Barei: Ipsilateral talar and calcaneal fractures: a retrospective review of complications and sequelae., Injury, vol. 40, no. 2, pp. 139 145, Feb. 2009. [39] P. Gregory, T. DiPasquale, D. Herscovici, and R. Sanders: Ipsilateral fractures of the talus and calcaneus., Foot ankle Int., vol. 17, no. 11, pp. 701 705, Nov. 1996. 182

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 183-187x ISSN 0009-479X PRACA ORYGINALNA Choroby narządu ruchu na tle zapalnym Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications Zespoły hiperandrogenne oraz trądzik jako potencjalne przyczyny powikłań operacji ortopedycznych Szymon Czech 1, Grzegorz Franik 2, Jacek Hermanson 1, Robert Kokot 1, Bogdan Koczy 1, Paweł Madej 2, Michał Mielnik 1 1 District Hospital of Orthopaedics and Trauma Surgery, Piekary Śląskie, Poland 2 Department of Gynecological Endocrynology, Medical University of Silesia, Katowice, Poland Abstract Because of very good clinical outcomes, total hip arthroplasty is currently one of the most common orthopaedic procedures. While there are advantages of treating hip arthritis by performing a total hip arthropasty, there are also complications, which are rare but still pose a great threat. The most severe complications are septic or aseptic loosening of the prosthesis. The cause of aseptic loosening is usually unknown whereas the cause of infectious complications can often be identified. Chronic skin colonisation by different bacterial strains increases the risk of post-operative infections in the area surrounding implanted artificial devices, which are particularly susceptible to bacterial colonization. The risk of infection is thought to be caused by a lack of microcirculation, which plays an important role in the work of the immunological system and the distribution of antibiotics. The disturbance of the physiological bacterial flora in humans is often hard to diagnose; however there are some clinical situations that may suggest it. One of the symptoms of a disturbance in bacterial flora is acne and its co-existing hyperandrogenism syndrome. Propionibacterium acnes plays a vital part in the aetiology of acne skin changes. This bacterium, due to its ability to create biofilm, is a potential source of periprosthetic joint infections. Key words: total hip arthroplasty, periprostetic joint infection, acne, policystic ovary syndrome, septic loosening, aseptic loosening Streszczenie Całkowita endoprotezoplastyka stawu biodrowego ze względu na bardzo dobre wyniki kliniczne jest obecnie jedną z najczęściej wykonywanych procedur ortopedycznych. Rozważając zalety tego sposobu leczenia choroby zwyrodnieniowej stawu biodrowego należy jednak pamiętać o możliwych powikłaniach, które choć występują rzadko, mogą nieść ze sobą poważne konsekwencje. Najpoważniejszym powikłaniem jest obluzowanie protezy, septyczne lub aseptyczne. O ile w przypadku obluzowań aseptycznych przyczyna często bywa nieznana, o tyle w przypadku powikłań infekcyjnych czynnik sprawczy zwykle może być rozpoznany. Przewlekłe nosicielstwo i kolonizacja skóry przez różne szczepy bakterii niewątpliwie zwiększają ryzyko infekcji pooperacyjnych, a sztuczne elementy implantowane do organizmu, ze względu na brak mikrokrążenia umożliwiającego działanie układu immunologicznego oraz dystrybucję antybiotyków, są szczególnie wrażliwe na kolonizację bakteryjną. Fakt zaburzeń fizjologicznej flory bakteryjnej organizmu jest niejednokrotnie trudny do wykrycia, jednak istnieją sytuacje kliniczne mogące to sugerować. Tego typu objawem jest trądzik oraz często współistniejące z nim zespoły hiperandrogenizacji organizmu. W etiologii trądzikowatych zmian skórnych ważną rolę odgrywa z kolei Propionibacterium acnes, która to bakteria dzięki swoim zdolnościom do tworzenia biofilmu, jest także potencjalnym źródłem infekcji okołoprotezowych układu kostnego. Słowa kluczowe: całkowita endoprotezoplastyka stawu biodrowego, infekcja okołoprotezowa, trądzik, zespół policystycznych jajników, obluzowanie septyczne, obluzowanie aseptyczne Author s address: Szymon Czech, District Hospital of Orthopaedics and Trauma Surgery, Bytomska 62, 41-940 Piekary Śląskie, Poland. Tel.: +48 323934323 Mobile: +48 502317437, czechszymon@tlen.pl Received: 16.10.2017 Accepted: 30.10.2017 Published: 03.11.2017 183

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 183-187 Szymon Czech et al., Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications Introduction In contemporary medicine, the use of implants is increasing in many fields and branches, including: neurosurgery, cardiosurgery, ophthalmology, cosmetic surgery, orthopaedics and traumatology. In orthopaedics, the most common indication to use implants is osteoarthritis, and the patients who most often undergo joint exchange are mostly elderly people. However, there is also an increase in the number of young people undergoing joint surgeries for reasons such as traumatic injury. Post-operative infections, both early and late, pose a great threat after surgery, as they may lead serious surgical complications. In all periprosthetic joint infections, the routine procedure of bacteriological examination often does not allow for confirmation of the presence of an inflammatory factor. Such a confirmation is available only after performing additional procedures such as histopathological examinations [1, 2]. The presence of bacteria in symptomatic and asymptomatic people is repeatedly the cause od post-operative infections and complications after bone implant surgeries. One cause of complications is the growth of a bacterial biofilm on the surface of the impanted material [3]. One bacterium that makes up the bacterial flora in humans and that can be the source of many surgical infections is Propionibacterium acnes (P. acnes). This bacterium is also thought to play a role in the pathogenesis of many inflammatory diseases such as infective endocarditis [4,5,6], arthritis [1,7,8], osteomyelitis [9], panuveitis [10,11], inflammatory disease of the central nervous system [12,13], synovitis acne pustulosis hyperostosis osteitis (SAPHO) syndrome [14,15] and acne that develops in women with hyperandrogenism [16]. Propionibacterium acnes and biofilm P. acnes is a relatively aerotolerant, anaerobic, gram-positive rod that produces endospores [6, 17, 18]. It is present in the physiological flora of the skin, digestive system, respiratory system, and genitourinary tracts. This bacterium is capable of using the sudor present in lactic acid and transforming it into propionic acid in order to create an energy source [16]. The metabolic activity of P. acnes around sebum follicles, mainly in the Seborrhoeic dermatitis areas, leads to inflammatory and non-inflammatory acne [19,20]. It has also been shown that P. acnes can exist in the form of biofilm, which is pivotal in the pathogenesis of septic complications that result after the implantation of bone and joint prostheses. Biofilm is created by a population of bacteria that have the ability to adhere to different surfaces. After adhering to the surface, the bacteria release polysaccharides, which have an outer cell layer that makes up about two-thirds of the biofilm surface area. In addition to polysaccharides, the biofilm is also made of water and other factors released by cells [21,22]. he biofilm layer can exist inside cells, most frequently in macrophages, where it can stay for a long time in a latent form. It is this latent bacterial form that can be responsible for chronic biofilm existence and resistance to high doses of antibiotics [23,24]. The presence of P. acnes in the latent form has been noted in patients with meningitis; infective endocarditis; infections of the abdominal cavity, bone, lungs and eye; and prostatitis [25, 26]. P. acnes is also involved in the activation of the complement immune system through the release of proinflammatory factors such as the chemotactic factor for granulocytes, the cytotoxic factor for fibroblasts, vasoactive amines, substances similar to prostaglandin E, and compounds stimulating the release of IL-1, IL-8 and TNF [16,20,27]. Research shows that the presence of P. acnes on skin plays a role in the development of infectious complications after surgery. Taking into consideration early, late and chronic inflammations following hip endoprosthesis surgery, P. acnes was involved in the colonization of the prosthesis in 2% to 14% of cases [27,28]. The biofilm that is created on artificial surfaces by P. acnes contributes to infectious complications by limiting the phagocytic properties of macrophages. This bacterium id able to live inside macrophages what makes it very hard to eliminate from human organism and lowers it susceptibility to antibiotics [29,30]. Hyperandrogenism and acne The infectious complications that result after hip endoprosthetics and other implantation surgeries that involve an orthopaedic device may be related to pathological androgenisation and the presence of acne, which is one of the key symptoms of hyperandrogenism. Current research indicates that the biofilm that is created by P. acnes plays a vital part in the pathogenesis of androgenisation [30]. Women s androgens are physiological progenitors of female sex hormones. Androgens are hormonally active, 19-carbon steroids created as indirect products of cortisol synthesis (in adrenal glands) and oestrogen synthesis (in ovaries). During puberty, the production of ovarian androgens begins, and ovarian oestrogen is released by the stromal cells of the ovary. Androgens can be divided into weak (androstendione [A], dehydroepiandrosterone [DHEA] and its sulfate [DHEA-S]) and strong androgens (testosterone [T] and dihydrotestosterone [DHT]). Dihydrotestosterone, the strongest androgen, is created from testosterone in the skin area and is supported by 5-alpha reductase [31]. Hyperandrogenism is a medical condition that is defined by excessive androgen production in women. In women of reproductive age, excessive androgen production is caused 184

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 183-187 PRACA ORYGINALNA Szymon Czech et al., Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications by polycystic ovary syndrome (PCOS), non-classic adrenal hyperplasia (NCAH), hyperandrogenism together with insulin resistance and acanthosis nigricans (HAIRAN), hormonally active tumours that release androgens and other endocrine disorders such as Cushing s syndrome and acromegaly [31]. PCOS is the most common cause of hyperandrogenism in young women (80% of cases) and, of those cases, acne is present in 10% to 34% of patients. Specifying the frequency of PCOS occurrence in women of reproductive age is difficult due to the use of different diagnostic criteria. Based on a set of European criteria called the Rotterdam criteria, it is estimated that PCOS is present in approximately 12% of women of reproductive age after excluding other endocrine disorders [12]. Endocrine metabolic disorders, among which PCOS plays a vital part. Research results indicate that the etiological factors that cause PCOS are genetic predispositions and environmental factors. With regard to genetic predispositions, the PCOS monogenic inheritance hypothesis has not been confirmed yet, and the results of the majority of research indicate a multigenic pattern of inheritance. There is no doubt that genetic polymorphisms are a predisposing factor; however, the factors responsible for hormonal and metabolic disorders are strictly attributed to environmental factors associated with lifestyle, such as a high-energy diet and low physical activity, which cause obesity[32]. Acne is a physiological phenomenon that occurs most commonly during puberty; however, in some cases it can transform into a chronic dermatosis. Acne is found in 20% of women aged 30 to 39 years, 12% of women ages 40 to 49 years and 7% of women over the age of 50 and can sometimes be caused by genetic conditions. It seems that the etiopathogenesis of acne is extremely complex and not fully explained [13,33]. There are several factors that are thought to play an important role in the development of acne, including seborrhoeic dermatitis, excessive follicular keratinization, increase of P. acnes and the development of counterirritation, hormonal factors, genetic conditions, immunological disorders, excessive follicle reactivity, mental and physical factors and even an iatrogenic background [16,27,33,34]. Total hip arthroplasty and its complications The significance of total arthroplasty in curing hip osteoarthritis is undisputed. Based on positive long-term treatment results and patient reports showing pain relief, this procedure enables patients to return to their daily physical activities and to work very quickly. In recent years, there has been a significant improvement in surgical techniques and longlasting systems of hip osteoarthritis supplementation, such as hip resurfacing, short-stem endoprostheses and new bearings surfaces, such as ceramic on ceramic or oxinium. As a result, there has been a broadened scope within which these medical procedures are performed for example, following arthroses after childhood diseases, post-traumatic injuries, Legg-Carves-Parthes disease and femoral neck fracture which makes total hip arthroplasty available to younger patients and women of reproductive age. Although the percentage of complications after hip prosthesis implantations is relatively low, some complications that do occur may be severe. Some of those severe complications include septic and aseptic prosthesis loosening [3]. A high percentage of people with loosened hip implants do not show any symptoms of inflammation or an increase of bacteria in blood and urine, which places those patients in the category of aseptic loosening. The cause of loosening in this group of patients is not specifically explained; however, many articles suggest that particles created by wear on the prosthetic surface are a major factor in the activation of osteoclasts in the surrounding tissue [35, 36, 37, 38]. Depending on the size and the material (for example, metal, ceramics, polyethylene or titanium), the prosthesis may activate several different processes of humoral and cellular reactions that can lead to the release of proinflammatory cytokines and bone loss. Recent research seems to indicate that aseptic hip prosthesis loosening occurs less frequently than commonly suspected. This is because negative bacterial tests do not always exclude the presence of bacteria on implant surfaces or in tissue taken directly from the area surrounding the prosthesis [39]. In most cases, negative bacterial tests occur due to incorrect test procedures, storage and biological processing of the material and due to the ability of bacteria to form a biofilm on the surface of the implant. The structure of the biofilm protects the bacteria that have developed inside of it from any influence caused by external factors, including the immunological system and antibiotic therapy. Frequently, despite the existence of clinical symptoms of infection in the area of the prosthesis for example, severe tissue inflammation around the endoprosthesis or the occurrence of fistula or pus around the prosthesis the results of a bacterial test may remain negative, which may suggest an error in the bacteriological diagnosis [40]. Hidden infections also occur, for which the only clinical symptom is pain, and results of bacteriological and biochemical tests of the material taken during joint puncture are negative. In those cases, a correct diagnosis may need additional specialized tests such as arthroscopic gathering of the material surrounding the hip endoprosthesis and histopathology or bacteriological tests [41]. The causes of implant infections may be exogenous or endogenous. Despite the use of aseptic rules and surgical preventive treatment with antibiotics, there are many exogenous factors that may penetrate the operating field during the surgery. An example of exogenous factors are microorganisms floating in the air of operating theatres. The endogenous factors complicating the surgeries of hip prosthesis 185

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 183-187 Szymon Czech et al., Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications implantations are mainly chronic and concealed infections of the patients, including respiratory infections, urinary system infections, digestive system infections and bacterial flora existing on the patient s skin which, despite adherence to all the antiseptic procedures during the preparation of the operating field, can contaminate it during the surgery and after the surgery in the recovery stage [42]. The issues that arise from infections following implant surgery suggest the need for a careful, detailed evaluation of patients who are going to undergo severe orthopaedic surgeries, for example, joint arthroplasty. Such a wide evaluation system should include a multi-layered interdisciplinary approach, including internal, dental, dermatological, gynaecological, urological and laryngological examinations before those types of surgeries. The implementation of a detailed evaluation system is not always possible due to the fact that many operations occur under emergency situations because of trauma, for example, a femoral neck fracture. According to the Canadian Joint Replacement Registry, acute hip fractures from 2010 to 2011 and from 2012 to 2013 constituted 6.3% and 13.7%, respectively, of all causes of hip arthroplasty, which makes acute hip fractures the second most frequent cause of orthopaedic surgeries after osteoarthritis [43,44]. The Swedish Hip Arthtroplasty Register states that from 1995 to 2012, proximal femur fractures constituted between 6.3% and 8.2% of urgent alloplasty surgery among men and between 11.3% and 16% among women [45]. In Australian Orthopaedic Association National Joint Replacement Registry from the year 2016 we can find information that the primary diagnosis for total hip replacement surgery was neck of femur fracture on 1.6 to 4.5 % [46]. However, taking into consideration all available registries, still the most common reason for hip alloplasty surgery is osteoarthritis, and patient operations are scheduled after a specialized evaluation. Discussion Taking into consideration the spread of acne in an apparent or concealed form and the significant role of P. acnes in the pathogenesis of acne, it seems that the presence of this bacterium cannot be underestimated when it comes to the success of joint replacement surgeries. Due to the increasing number of patients undergoing joint prosthesis implantations, including young patients, the concealed presence of P. acnes should lead to the increased implementation of detailed objective and subjective examinations before patients undergo surgery. In cases where emergency surgery is required, it is often impossible to exclude all risk factors that contribute to surgical complications. However, when it comes to scheduled surgeries, the occurrence of chronic skin conditions, including acne and diseases associated with hyperandrogenism that contribute to bacterial colonization on skin, should raise the alertness of the doctor performing any evaluations before undertaking a surgery. Such procedures could reduce failures of hip prosthesis implantations, particularly the infectious complications that constitute one of the most severe causes of future surgeries or long-lasting hospitalization. References [1] Borens O, Corvec S, Trampuz A. Diagnosis of periprosthetic joint infections. Hip Int 2012; 22: S9-14. [2] Trampuz A, Steinrücken J, Clauss M, Bizzini A, Furustrand U, Uçkay I, Peter R, Bille J, Borens O. New methods for the diagnosis of implantassociated infections. Rev Med Suisse 2010; 6: 731-734. [3] Szczęsny G, Babiak I, Kowalewski M, Górecki A. Septyczne obluzowania protez stawów biodrowego i kolanowego. Chir. Narzadow Ruchu Ortop. Pol. 2005; 70: 179-184. [4] Delahaye F, Fol S, Célard M, Vandenesch F, Beaune J, Bozio A, de Gevigney G. Propionibacterium acnes infective endocarditis. Study of 11 cases and review of literature. Arch Mal Coeur Vaiss 2005; 98: 1212-1218. [5] Vanagt WY, Daenen WJ, Delhaas T. Propionibacterium acnes endocarditis on an annuloplasty ring in an adolescent boy. Heart 2004; 90: e56. [6] Mohsen AH, Price A, Ridgway E, West JN, Green S, McKendrick MW. Propionibacterium acnes endocarditis in a native valve complicated by intraventricular abscess: a case report and review. Scan J Infect Dis 2001; 33: 379-380. [7] Tunney MM, Patrick S, Curran MD, Ramage G, Hanna D, Nixon JR, Gorman SP, Davis RI, Anderson N. Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rrna gene. J Clin Microbiol 1999; 37: 3281-3290. [8] Yocum RC, McArthur J, Petty BG, Diehl AM, Moench TR. Septic arthritis caused by Propionibacterium acnes. JAMA 1982; 248: 1740-1741. [9] Abolnik IZ, Eaton JV, Sexton DJ. Propionibacterium acnes vertebral osteomyelitis following lumbar puncture: case report and review. Clin Infect Dis 1995; 21: 694-695. [10] Benz MS, Scott IU, Flynn HW Jr, Unonius N, Miller D. Endophthalmitis isolates and antibiotic sensitivities: a 6-year review of cultureproven cases. Am J Ophthalmol 2004; 137: 38-42. [11] Deramo VA, Ting TD. Treatment of Propionibacterium acnes endophthalmitis. Curr Opin in Ophthalmol. 2001; 12: 225-229. [12] Haidar R, Najjar M, Boghossian A, Tabbarah Z. Propionibacterium acnes causing delayed postoperative spine infection: review. Scand J Infec Dis 2010; 42: 405-411. [13] Wong GK, Poon WS, Ip M. Use of ventricular cerebrospinal fluid lactate measurement to diagnose cerebrospinal fluid infection in patients with intraventricular haemorrhage. J Clin Neurosci 2008; 15: 654-655. [14] Kirchhoff T, Merkesdal S, Rosenthal H, Propkop M, Chavan A, Wagner A, Mai U, Hammer M, Zeidler H, Galanski M. Diagnostic management of patients with SAPHO syndrome: use of MR imaging to guide bone biopsy at CT for microbiological and histological work-up. Eur Radiol 2003; 13: 2304-2308. [15] Colina M, Lo Monaco A, Khodeir M, Trotta F. Propionibacterium acnes and SAPHO syndrome: a case report and literature review. Clin Exp Rheumatol. 2007; 25: 457-460. [16] Michalak-Stoma A, Chodorowska G, Juszkiewicz-Borowiec M, Gerkowicz A, Bartosińska J. Rola Propionibacterium acnes (P. acnes) w patogenezie trądziku pospolitego. Nowa Medycyna 2010; 2: 56-59. [17] Portillo ME, Corvec S, Borens O, Trampuz A. Propionibacterium acnes: an underestimated pathogen in implant-associated infections. See comment in PubMed Commons below2013; 2013: 804391. [18] Paściak M, Mordarska H. Rodzaj Propionibacterium - heterogenność taksonomiczna i biologiczna. Post Microbiol 1999; 38: 245-256. [19] Jappe U, Ingham E, Henwood J, Holland KT. Propionibacterium acnes and inflammation in acne; P. acnes has T-cell mitogenic activity. Br J Dermatol 2002; 146: 202-209. [20] Perry A, Lambert P. Propionibacterium acnes: infection beyond the skin. Expert Rev Anti Infect Ther 2011; 9: 1149-1156. 186

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 183-187 PRACA ORYGINALNA Szymon Czech et al., Hyperandrogenic syndromes and acne as potential causes of post-operative orthopaedic complications [21] Coenye T, Peeters E, Nelis HJ. Biofilm formation by Propionibacterium acnes is associated with increased resistance to antimicrobial agents and increased production of putative virulence factors. Res Microbiol 2007; 158: 386-392. [22] Whitchurch CB, Tolker-Nielsen T, Ragas PC, Mattick JS. Extracellular DNA required for bacterial biofilm formation. Science 2002; 295: 1487. [23] Oprica C, Nord CE, ESCMID Study Group on Antimicrobial Resistance in Anaerobic Bacteria. European surveillance study on the antibiotic susceptibility of Propionibacterium acnes. Clin Microbiol Infect 2005; 11: 204-213 [24] Dessinioti C, Katsambas AD. The role of Propionibacterium acnes in acne pathogenesis: facts and controversies. Clin Dermatol 2010; 28: 2-7. [25] Critchley G, Strachan R. Postoperative subdural empyema caused by Propionibacterium acnes - a report of two cases. Br J Neurosurg 1996; 10: 321-323. [26] Alexeyev OA, Marklund I, Shannon B, Golovleva I, Olsson J, Eriksson I, Cohen R, Elgh F. Direct visualization of Propionibacterium acnes in prostate tissue by multicolor fluorescent in situ hybridization assay. J Clin Microbiol 2007; 45: 3721-3728. [27] Zappe B, Graf S, Ochsner PE, Zimmerli W, Sendi P. Propionibacterium spp. in prosthetic joint infections: a diagnostic challenge. Arch Orthop Trauma Surg. 2008; 128: 1039-1046. [28] Zeller V, Ghorbani A, Strady C, Leonard P, Mamoudy P, Desplaces N. Propionibacterium acnes: an agent of prosthetic joint infection and colonization. J Infect 2007; 55: 119-1124. [29] Webster GF, Leyden JJ, Musson RA, Douglas SD. Susceptibility of Propionibacterium acnes to killing and degradation by human neutrophils and monocytes in vitro. 1985; 49: 116-121. [30] Furustrand Tafin U, Corvec S, Betrisey B, Zimmerli W, Trampuz A. Role of rifampin against Propionibacterium acnes biofilm in vitro and in an experimental foreign-body infection model. Antimicrob Agents Chemother 2012; 56: 1885-1891. [31] Skałba P. Endokrynologia Ginekologiczna. PZWL 2008, wyd. III, str..290-294. [32] Orlik B, Madej P, Owczarek A, Skałba P, Chudek J, Olszanecka- Glinianowicz M. Plasma omentin and adiponectin levels as markers of adipose tissue dysfunction in normal weight and obese women with polycystic ovary syndrome. Clin Endocrinol 2014; 81: 529-535. [33] Skałba P. Diagnostyka i leczenie zaburzeń endokrynologicznych w ginekologii. Med Prakt Kraków, 2014. [34] Wolska H, Gliński W, Placek W. Trądzik zwyczajny - patogeneza i leczenie. Konsensus PTD Przegl Dermatol 2007; 2: 171-178. [35] Gallo J, Vaculova J, Goodman SB, Konttinen YT, Thyssen JP. Contributions of human tissue analysis to understanding the mechanisms of loosening and osteolysis in total hip replacement. Acta Biomate 2014; 10: 2354-2366. [36] Hallab NJ, Jacobs JJ. Biologic effects of implant debris. Bull NYU Hosp Jt Dis 2009; 67: 182-188. [37] Ingham E, Fisher J. The role of macrophages in osteolysis of total joint replacement. Biomaterials 2005; 26: 1271-1286. [38] Goodman SB, Gibbon E, Yao Z. The basic science of periprosthetic osteolysis. Instr Course Lect 2013; 62: 201-206. [39] Hoenders CS, Harmsen MC, van Luyn MJ. The local inflammatory environment and microorganisms in aseptic loosening of hip prostheses. J Biomed Mater Res B App Biomater 2008; 86: 291 301. [40] Berbari EF, Marculescu C, Sia I, Lahr BD, Hanssen AD, Steckelberg JM, Gullerud R, Osmon DR. Culture-negative prosthetic joint infection. Clin Infect Dis 2007; 45: 1113-1119. [41] McCarthy JC, Jibodh SR, Lee JA. The role of arthroscopy in evaluation of painful hip arthroplasty. Clin Orthop Relat Res 2009; 467: 174-180. [42] Strzelec-Nowak D, Bogut A, Niedźwiadek J, Kozioł-Montewka M, Sikora A. Mikrobiologiczna diagnostyka zakażeń implantów stawu biodrowego. Postępy mikrobiologii 2012; 51: 219-225. [43] Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry. Annual Report. www.cihi.ca/cjrr, 2013. [44] Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry. Annual Report. www.cihi.ca/cjrr, 2014. [45] Swedish Hip Arthroplasty Register. Annual Report. http://www.shpr. se/en, 2012. [46] Australian Orthopaedic Association National Joint Replacement Registry, 2016 Annual Report. https://aoanjrr.sahmri.com/. 187

ISSN 0009-479X Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 188-193 PRACA ORYGINALNA Prace historyczne Professor Józef Szczekot (1932-1997) In Memoriam Tomasz Mazurek 1, Michał T.W. von Grabowski 2 1 Department of Orthopedics Surgery Medical University of Gdańsk, Polnad 2 Clinic of Orthopaedics, Saarland University, Homburg, Germany The 27th of October 2017 marks the 20 th anniversary of the sudden death of Professor Józef Szczekot (Fig. 1). On October 21, the Pomeranian division of the Polish Orthopedic and Trauma Society organized a commemorative ceremony to honor the Professor. It was held in the Wielka Westa Hall of the Gdańsk City Hall. Fig. 1. Prof. med. Józef Szczekot Józef Szczekot began his work in the Clinic of Orthopedics in Gdańsk in 1955. He gained his 2 nd degree specialization in orthopedics and trauma surgery in 1961. One of the Professor s main field of scientific research was the Developmental Dysplasia of the Hip. Not long after that, already in 1966, he obtained his doctoral degree from the Medical University of Gdańsk. His doctoral dissertation was entitled Early diagnosis and treatment of congenital hip dysplasia [1]. Furthering his scientific interests, in 1972, Professor Szczekot obtained his Doctor habilitatus postdoctoral degree for his work entitled Usefullness of the Salter pelvic osteotomy in treating congenital dislocation and subluxation of hip joints [2]. In 1983 he became associate professor and full professor in 1993. During his 42 years of work at the Clinic of Orthopedics in Gdańsk, the Professor has shown incredible scientific and surgical activity. He devoted most of his time and energy to his surgical practice, as he possessed remarkable aptitude for it always swift, meticulous and methodical, able to keep calm and professional. Professor Szczekot authored and coauthored 58 scientific works (main author in 34 of them) and seven letters and reports. A vast majority of those works were published in the Kinetic Organ Surgery and Polish Orthopedics Journal. The main scientific interests of the Professors included: developmental dysplasia of the hip joint, endoprosthetics of the hip joint, lateral spinal curvature and spondylolisthesis, hand surgery, orthopedic oncology, joint cartilage regeneration, biomechanics. Developmental dysplasia of the hip joint (DDH), then called congenital hip joint dislocation, was undoubtedly the most important research field for the Professor. His doctoral dissertation, postdoctoral degree and 23 scientific works were all in this field [1-25]. The second half of the 20th century marks the orthopedists struggle with DDH. The Professors involvement started with organizing a preluxation clinic and assessing its scientific activity [3]. Professor Szczekot s doctoral dissertation explored a crucial issue, i.e. early diagnosis and prevention of hip joint dysplasia [1]. His subsequent work exposed the ineffectiveness and inadequate results of full reposition-reconstruction of the hip joint in the course of treating DDH [4-7]. It is also worth remembering that the idea behind reposition-reconstruction was the surgical removal of the acetabulum from the Author s address: Tomasz Mazurek, e-mail: mazurek@gumed.edu.pl Received: 10.10.2017 Accepted: 30.10.2017 Published: 03.11.2017 188

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 188-193 PRACA ORYGINALNA Tomasz Mazurek and Michał T.W. von Grabowski, Professor Józef Szczekot (1932-1997) In Memoriam articular cartilage and inserting a femoral head covered in a synovial membrane into the prepared acetabulum. The creators of this method wanted to achieve a metaplasia of synovial membrane to articular cartilage. It did not occur, however. A breakthrough in the surgical treatment of DDH was the introduction of Salter s innominate osteotomy in the 1960s. Professor Szczekot introduced this technique to the clinic in 1967 and consistently proved in his scientific work, that the best results can be achieved not only through open reposition of the joint with pelvic osteotomy, but also through corrective osteotomy of the proximal femur with antetorsion correction. The results of his scientific work were presented in his postdoctoral dissertation and a series of scientific papers from 1972 to 1974 [2, 9, 10, 11, 12, 13, 14]. They were groundbreaking not just for Polish orthopedics. A very important part of this scientific success was a critical assessment of the usefulness of radiological markers for the hip joint in children. This assessment gave the Professor an impulse to create a large control group of healthy children to create a standard for radiological markers of the hip joint in the Polish population. This, in turn, made it possible to effectively treat DDH in children over 2 years old and it remains a surgical treament standard to this day (Fig, 2). A Fig. 2A-B. A. X-ray of a child s right hip with developmental dysplasia of the hip (with dislocation), B. X-ray of the same hip after surgical treatment performed by Professor Szczekot. He performed a straight reposition, Salters pelvic osteotomy and directional osteotomy of the proximal femur. A plate and screws produced in the Research and Development Department of the Clinic of Orthopedics by Janusz Martin M. Eng. were used. Professor Szczekot s next scientific challenge was to treat hip joint subluxation in adolescents with DDH. It turned out that the surgical method of treatment of small children cannot be applied to the treatment of DDH in 15-20 year old patients, as it requires multiple osteotomies, so called triple pelvic osteotomies. The Professor was one of the first in Poland to use the Steele Tönnis pelvic osteotomy to treat DDH. The result of those scientific inquiries were published B in the Kinetic Organ Surgery and Polish Orthopedics Journal [15, 17, 18]. The sudden death of the Professor prevented him from introducing the Ganz osteotomy as a method of treating DDH. The 1980s were marked by the introduction of modern cementless hip joint endoprostheses, such as the Mittelmeier and Parhofer-Mönch, to the Polish orthopedic practice. The Professors scientific activity in this field manifested itself through the introduction and use of central acetabular osteotomy to set the cementless acetabulum and through the modification of surgical access to the hip, which evolved from anterolateral to strictly lateral. This period of activity resulted in more scientific papers and conference communications [26-28]. The Clinic of Orthopedics in Gdańsk has a rich tradition of treatment and scientific activity in the field of the spine. Professor Szczekot practiced the surgical treatment of fractures as well. Mostly of the lateral idiopathic scoliosis and spondylolisthesis. His activity in this field resulted in scientific papers that assess the statistical incidence of scoliosis and the use of lateral spondylodesis in treating spondylolisthesis [29-35]. A separate field of the Professors scientific activity was hand surgery one of the scientific flagship projects of the Clinic of Orthopedics in Gdańsk. The Professor had the honor to take part in a historic II Meeting of the Hand Surgery Section, which took place in Gdańsk on March 18, 1967 (Fig. 3). He was also a member of the Hand Surgery Section of the Polish Orthopedic and Trauma Society. The result of those activities were multiple scientific papers, chiefly on the reconstruction of extensor and flexor tendons. The Professor was also interested in the use of orthopedic apparatuses for treating hand dysfunctions and for potentially treating spastic paresis of the hand [36-43]. Professor Józef Szczekot was the first in Poland to use and describe hemipelvectomy for treating tumors of the pelvis and proximal femur. His paper entitled On Hemipelvectomy is still valid when it comes to indications and surgical technique [44]. Another field, which the Professor was active in, was a clinical study on the regeneration of the articular cartilage using rabbits. The study was performed in the Clinic of Orthopedics in Gdańsk, in the Laboratory of Orthopedic Anatomopathology, in cooperation with its head Professor Weronika Dunaj. This study assessed morphological, histological and histochemical phenomena at different stages of articular cartilage deterioration [45-47]. The last field of the Professor s scientific interest was biomechanics. One of his most interesting study in this field was the use of biological material (buffalo bone) to create screws used in femoral osteosynthesis after an osteotomy. The colorful story the Professor used to tell about the production of those screws in the Clinics Orthopedic Manufactory is truly memorable to this day. The screws came to be used clinically but did not withstand the test of time [8]. It is worth 189

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 188-193 Tomasz Mazurek and Michał T.W. von Grabowski, Professor Józef Szczekot (1932-1997) In Memoriam Ryc. 3. Photograph from the historic II Meeting of the Hand Surgery Section of the Polish Orthopedic and Trauma Society, which took place in Gdańsk on March 18. First from left: Professor Antoni Hlavaty, fifth from the left in the upper row - (then) Józef Szczekot MD. remembering that at that point in time certified companies that produced orthopedic fixtures did not exist. In the Clinic of Orthopedics in Gdańsk, all of the fixtures such as plates, screws, pins and spinal fixtures were produced in the Clinic s Orthopedic Manufactory under the direction of Janusz Martin M. Eng. [48, 49, 50]. Some of those fixtures were still in use in the first decade of this century. Professor Józef Szczekot has been honored for his scientific work by the Rector of the Medical University of Gdańsk. The Polish Medical Alliance also awarded him the Professor Wszelaki price. The Professor supervised nine doctoral dissertations, mainly in the field of the hip joint, wrote 12 doctoral dissertation reviews and one postdoctoral dissertation review. He prepared nine applications for professorial titles and one honorary doctorate degree application. The honorary doctorate degree was awarded to Professor Heinz Mittelmeier on March 26 1993 (the scientific and organizational cooperation between Germany and Poland has been continued in the following years as part of the Polish-German Circle of Friends of Orthopedics and Traumatology [51,52]) (Fig. 4). The Professor also wrote reviews for the Committee of Scientific Research and for Kinetic Organ Surgery and Polish Orthopedics the official journal of the Polish Orthopedic and Trauma Society. He was also a member of the journal s editorial board. Professor Szczekot was great at reconciling many different responsibilities and he was an excellent organizer. He was the regional specialist for orthopedics and trauma surgery for the Bydgoszcz and Słupsk provinces, regional consultant and consultant for the Gdańsk province. He was also a member of the Polish Orthopedic and Trauma Society from 1956, where, in the course of his career, he held all available positions: treasurer, secretary, vice-chairman and chairman of the Gdańsk chapter. From 1978 to 1994, he was a member of the Society s Central Board and from 1990 to 1994 the President of the Society. Ryc. 4. Doctors rounds in the Clinic with Professor Józef Szczekot and Professor Heinz Mittelmeier. On the left Andrzej Baranowski MD, on the right Andrzej Ziętek MD. 190

Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 188-193 PRACA ORYGINALNA Tomasz Mazurek and Michał T.W. von Grabowski, Professor Józef Szczekot (1932-1997) In Memoriam Professor Szczekot was also a member of the Senate of the Medical University of Gdańsk, of many senate, rectorial and departmental commissions. He held the position of Chairman of the Senate Publishing Committee and the University Committee for the organization of post competitions for academic employees. One of the Professor s especially important activities was the organization of symposiums and congresses. He played an active role in all the National Congresses of the Polish Orthopedic and Trauma Society, starting in 1959, through to 1976 and 1992 [48, 49]. The last one, in 1992, with many guests from abroad present, was recognized as the one of the best-organized congresses of the Polish Orthopedic and Trauma Society in its history. The Professor also deserves special appreciation for organizing periodic scientific conferences under the auspices of the Hand Surgery Section in 1967, 1975, 1986 and 1997 as well as Polish-German meetings in 1989 and 1994 (Fig. 5). Throughout his career at the Clinic, the Professor continued to teach 5th year students of the Faculty of Medicine in the form of lectures, practical exercise classes and seminaries. He also carried out exams. He gave lectures at courses organized by the Centre of Postgraduate Medical Education and the Voivodeship Medical Staff Performance Improvement Centre. When Professor Józef Szczekot was President of the Polish Orthopedic and Trauma Society (1990-1994), level two orthopedics exams were carried out in Gdańsk. The Professor was very committed to ensuring that the Chair and Clinic of Orthopedics get a modern office space. His dream was to create a Chair with multiple divisions or clinics that cover all the different fields of orthopedics. There were many attempts at fulfilling those plans, space was sought, amongst others, in the (now) Maritime Medical Center. Ultimately, thanks to Professor Szczekot and with the cooperation of the Governor of the Gdańsk Voivodeship Maciej Płażynski and the Rector of the Medical University of Gdańsk Professor Zbigniew Wajda, the dream started coming true and a plan was formulated to expand the Clinic on the premises of the Voivodeship Hospital. The foundation stone for this construction was laid in December of 1994, and the build was supposed to be finished in 1998. In the end, only a steel construction was erected during the first few years, remaining unfinished for many years. In 2013, the building was finally put into operation but there no longer was a place for the Clinic of Orthopedics on its premises. The culmination of Professor Szczekot s work was his 40th work anniversary celebration organized in the lecture hall of our hospital in 1996 [53]. It seemed then that the Professor would have many long years of work ahead of him. Unfortunately, he died suddenly a year later in 1997 [54]. Ryc. 5. XXXI Symposium of the Hand Surgery Section of the Polish Orthopedic and Trauma Society Jurata 1997. In the middle, Professor Józef Szczekot. 191

PRACA ORYGINALNA Chir. Narzadow Ruchu Ortop. Pol., 2017; 82(5) 188-193 Tomasz Mazurek and Michał T.W. von Grabowski, Professor Józef Szczekot (1932-1997) In Memoriam It is essential to remember Professor Szczekot s extraprofessional passions, especially horseback riding. The Professor was not only an excellent equestrian (Fig. 6) but he also frequently took part in organizing equestrian events or held the position of announcer during riding competitions. Besides having outstanding academic achievements, Professor Szczekot became a role model for every doctor he respected and valued others. Ryc. 6. Professor Józef Szczekot on horseback. References [1] Szczekot J: Zagadnienie wczesnego rozpoznawania i leczenia wrodzonej dysplazji stawów biodrowych. Praca doktorska, AM w Gdańsku,1966 r. [2] Szczekot J.: Przydatność osteotomii miednicy sposobem Saltera w leczeniu wrodzonych zwichnięć i podwichnięć stawów biodrowych. Rozprawa habilitacyjna, AM w Gdańsku, 1972. [3] Szczekot J.: Wstępna ocena wyników pracy przychodni preluksacyjnej. Chir. Narz. Ruchu Ortop. Pol., 1958, t. 23, str.313-316. [4] Faczyński A. Szczekot J., Bela Z., Smoczyński A, Henicz T., Laskowski M.: Analiza odległych wyników czynnościowych pełnej repozycjirekonstrukcji we wrodzonym zwichnięciu stawu biodrowego. Chir. Narz. Ruchu Ortop. Pol., 1969, t.34, str. 271-277. [5] Szczekot J., Faczyński A, Gładkowska E., Wiśniewski T., Mazurkiewicz S., Hać B.: Ocena wyników radiologicznych stawów biodrowych po pełnej repozycji-rekonstrukcji wrodzonego zwichnięcia biodra. Chir. Narz. Ruchu Ortop. Pol., 1969, t.34, str.329-334. [6] Szczekot J., Faczyński A, Gładkowska E., Domańska B.: Martwica jałowa głowy kości udowej po repozycji-rekonstrukcji wrodzonego zwichnięcia stawu biodrowego. Chir. Narz. Ruchu Ortop. Pol., 1969, t.34, str.345-350. [7] Ożga A, Borkowski Z., Szczekot J., Wiśniewski T., Czerepak K., Sadowski 1., Bela Z., Smoczyński A: Odległe wyniki operacyjnego leczenia wrodzonego podwichnięcia stawu biodrowego przy pomocy plastyki dachu oraz osteotomii korekcyjnej górnego końca kości udowej. Chir. Narz. Ruchu Ortop. Pol., 1969, t.34, str.433-437. [8] Szczekot J.: Śruba kostna jako materiał zespalający po osteotomii podkretarzowej w leczeniu wrodzonego zwichnięcia stawu biodrowego. Chir. Narz. Ruchu Ortop. Pol., 1970, t.35, str.485-488. [9] Szczekot J.: Ocena czynnościowa wyników leczenia wrodzonych zwichnięć i podwichnięć stawów biodrowych sposobem Saltera. Chir. Narz. Ruchu Ortop. Pol., 1973, t.38, str.431-437. [10] Szczekot J.: Normy wskaźnikow radiologicznych stawu biodrowego u dzieci. Chir. Narz. Ruchu Ortop. Pol., 1974, t.39, str.67-71. [11] Szczekot J.: Przydatność wskaźników radiologicznych do oceny operowanych stawów biodrowych u dzieci. Chir. Narz. Ruchu Ortop. Pol., 1974, t.39, str.159-168. [12] Szczekot J.: Ocena wyników biomechanicznych panujących w stawie biodrowym po osteotomii miednicy sposobem Saltera. Chir. Narz. Ruchu Ortop. Pol., 1974, t.39, str.279-285. [13] Szczekot J.: Zachowanie się kąta antetorsji po osteotomii miednicy sposobem Saltera. Chir. Narz. Ruchu Ortop. Pol., 1974, t.39, str.621-625. [14] Szczekot J.: Zachowanie się kąta szyjkowo-trzonowego po osteotomii miednicy sposobem Saltera. Chir. Narz. Ruchu Ortop. Pol., 1975, t.40, str.719-724. [15] Szczekot J, Henicz T.: Potrójna osteotomia miednicy w leczeniu podwichnięć stawów biodrowych. Mat. XXI Zjazdu PTO itr, PZWL, W-wa, 1978, str.216-218. [16] Szczekot J.: Ocena wyników czynnościowych po operacyjnym leczeniu wrodzonych zwichnięć i podwichnięć stawów biodrowych sposobem Saltera. Mat. XXI Zjazdu PTO itr, PZWL, W-wa, 1978, str.219-221. [17] Szczekot J.: Ocena aktualnych możliwości leczenia wrodzonych zwichnięć i podwichnięć satwów biodrowych. Chir. Narz. Ruchu Ortop. Pol., 1978, t.43, str.315-319. [18] Baranowski A, Szczekot J., Faczyński A, Gibas L.: Technika i wskazania do operacji typu Wagnera stosowanej w dysplazji stawu biodrowego. Mat.: XXV Zjazdu PTO i Tr, Łódź, 1985, str.440-442. [19] Szczekot J., Faczyński A, Baranowski A, Krzemiński M., Gibas L., Sieliwończyk P. :Ocena odległych wyników leczenia wrodzonych zwichnięć stawów biodrowych sposobem Saltera. Mat. :XXV Zjazdu PTO i Tr., Łódź, 1985, str.447-449. [20] Faczyński A, Szczekot J., Sieliwończyk P., Krzemiński M., Baranowski A: Występowanie i następstwa jałowej martwicy głowy kości udowej po osteotomii Saltera połączonej z repozycją i międzykrętarzową osteotomią detorsyjno-skracającą trzonu kości udowej. Chir. Narz. Ruchu Ortop. Pol., 1987, t.52, str345-349. [21] Szczekot J., Baranowski A. Faczyński A, Krzemiński M., Sieliwończyk P.: Potrójna osteotomia miednicy w operacyjnym leczeniu wrodzonej dysplazji biodra. Chir. Narz. Ruchu Ortop. Pol., 1988, t.53, str. 195-200. Chir. Narz. Ruchu Ortop. Pol., 1988, t.53, str.142-147. [22] Wośko I., Szczekot J., Dugiełło H. : Osteotomia miednicy wg Saltera w leczeniu operacyjnym wrodzonej dysplazji stawu biodrowego. Chir. Narz. Ruchu Ortop. Pol., 1988, t. 53, 142-147. [23] Szczekot J, Dugiełło H., Wośko l.: Wyniki operacyjnego leczenia wrodzonej dysplazji stawu biodrowego osteotomią miednicy wg Saltera. Chir. Narz. Ruchu Ortop. Pol., 1988, t.53, str. 148-153. [24] Dugiełło H., Szczekot J, Wośko I.: Błędy i powikłania w leczeniu operacyjnym 761 dysplastycznych stawów biodrowych operowanych metoda Saltera. Chir. Narz. Ruchu Ortop. Pol., 1988, t.53, str.154-156. [25] Szczekot J, Baranowski A: Uwagi w sprawie organizacji profilaktyki dysplazji stawów biodrowych. Mat. l Symp. Sekcji Ortopedii Dziecięcej, Lublin 1991, str. 14-18. [26] Szczekot J, Faczyński A, Figlewicz B., Urbanowicz R, Szostakowski l, Lorczyński A, Kusiak A, Mazurek T.: Ocena wyników zastosowania cementowych endoprotezoplastyk stawów biodrowych. Pam. XXVII Zjazdu Nauk. PTO i Tr, W-wa, 1988, str.65-71. [27] Szczekot J., Wall A: Technika operacyjna alloplastyki bezcementowej, Pam. XXVII Zjazdu Nauk. PTO i Tr., W-wa, 1988, str. 106-108. [28] Żuk T., Kozak l, Ratomski R, Serafin J., Szczekot J, Wall A, Kosierowski A: Ocena wyników leczenia stawów biodrowych alloplastyką bezcementową wg Mittelmeiera. Pam. XXVII Zjazdu Nauk. PTO i Tr., W-wa, 1988, str.112-117. [29] Patyński l, Szczekot J, Szwaluk F.: Boczne skrzywienie kręgosłupa w świetle statystyki. Chir. Narz. Ruchu Ortop. Pol., 1957, t.22, str.111-114. [30] Hlavaty A, Patyński 1., Wójcik T., Szczekot J., Wojtasik W.: Wstępna ocena wyników operacyjnego leczenia skolioz zmodyfikowanym dystraktorem z jednoczesną spondylodezą. Pam. XVIII Zjazdu PTO i Tr, PZWL, W-wa, 1971, str. 143-147. [31] Hlavaty A, Szczekot J., Wojtasik W., Smoczyński A, Mazurkiewicz S.: Wstępna ocena operacyjnego leczenia kręgozmyku z zastosowaniem dystrakcji oraz tylno-bocznego usztywnienia. Mat. XX Zjazdu PTO i Tr. PZWL, W-wa, 1977, str.276-277. [32] Szczekot J, Małkowski Z., Ziętek A: Ocena niektórych metod operacyjnych stabilizacji kręgosłupa piersiowego i lędźwiowego. Mat. Symp. Stabilizacja operacyjna kręgosłupa piersiowego w leczeniu chorób i uszkodzeń urazowych. Klinika Ortopedyczna AM Lublin, 1991, str. 14-18. [33] Szczekot J, Małkowski Z., Smoczyński A: Wskazania do operacyjnego leczenia bocznych idiopatycznych skrzywień kręgosłupa. Chir. Narz. Ruchu Ortop. Pol., 1992, t.57, supl.1, str. 16-18. 192