Paweł Łęgosz

Patient-Specific CT-Based Instrumentation versus Conventional Instrumentation in Total Knee Arthroplasty: A Prospective Randomized Controlled Study on Clinical Outcomes and In-Hospital Data.

Total knee arthroplasty (TKA) is a frequently performed procedure in orthopaedic surgery. Recently, patient-specific instrumentation was introduced to facilitate correct positioning of implants. The aim of this study was to compare the early clinical results of TKA performed with patient-specific CT-based instrumentation and conventional technique. A prospective, randomized controlled trial on 112 patients was performed between January 2011 and December 2011. A group of 112 patients who met the inclusion and exclusion criteria were enrolled in this study and randomly assigned to an experimental or control group. The experimental group comprised 52 patients who received the Signature CT-based implant positioning system, and the control group consisted of 60 patients with conventional instrumentation. Clinical outcomes were evaluated with the KSS scale, WOMAC scale, and VAS scales to assess knee pain severity and patient satisfaction with the surgery. Specified in-hospital data were recorded. Patients were followed up for 12 months. At one year after surgery, there were no statistically significant differences between groups with respect to clinical outcomes and in-hospital data, including operative time, blood loss, hospital length of stay, intraoperative observations, and postoperative complications. Further high-quality investigations of various patient-specific systems and longer follow-up may be helpful in assessing their utility for TKA.

Graphene Nanolayers as a New Method for Bacterial Biofilm Prevention: Preliminary Results

Biofilms are microbial communities of surface-attached cells embedded in a self-produced extracellular matrix. They have been found to play a role in a wide variety of infections, including catheter-related urinary tract and bloodstream infections, and, therefore remain a significant source of morbidity and mortality among the worlds population. Recently, much attention has been devoted to the prevention of biofilm formation on implant surfaces. Nanomaterials such as graphene, characterized by antibacterial activity and low toxicity to human cells, are promising candidates for biomedical applications. This study investigates the antibacterial efficiency of graphene and specially produced graphene decorated with silver nanoparticles, obtained by one of the methods of printed electronics (spray-coating system). These methods are not only economical, but also enable the printing of layers of various thicknesses on different types of materials, including flexible and nonplanar substrates. The aim of the study was to reveal the ability of graphene and graphene-nanosilver layers to prevent the formation of Staphylococcus epidermidis biofilm on the surface of a Foley catheter.

Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial — protocol for an observational cohort study

BACKGROUND Peripheral arterial disease (PAD) is in fact a group of disease entities with different symptoms and course but a common underlying cause, i.e. atherosclerosis. Atherosclerosis is known to be aggravated by several cardiovascular risk factors, including obstructive sleep apnoea (OSA). AIM Following paper is a protocol for the Peripheral ARtery Atherosclerotic DIsease and SlEep disordered breathing (PARADISE) trial, which aims to describe the prevalence of OSA in PAD patients scheduled for revascularisation, and to determine the effect of OSA on the procedure outcomes. METHODS The PARADISE study is an observational cohort trial. It plans to include 200 consecutive patients hospitalised for revascularisation due to PAD. In every patient an overnight sleep study will be performed to diagnose sleep disorders. Accord¬ing to the results of the test, patients will be divided into two groups: group A - patients with OSA, and group B - patients without OSA (control group). All patients will also be screened for classical and non-classical cardiovascular risk factors. In some of the patients, during surgery, a fragment of atherosclerotic plaque will be collected for further testing. Patients will be followed for one year for adverse events and end-points. Primary end-point of the study will be the failure of revascularisa¬tion defined as recurrence or new onset of the symptoms of ischaemia from the treated region, a need for re-operation or procedure revision, or recurrence of ischaemia signs on the imaging tests. DISCUSSION The data obtained will help determine the incidence of OSA in the population of patients with PAD. The au¬thors expect to show that, as with other cardiovascular diseases associated with atherosclerosis, also in patients with PAD the incidence of undiagnosed OSA is high and its presence is associated with elevated cholesterol, inflammatory markers, and higher prevalence of arterial hypertension and poor control of other cardiovascular risk factors. In addition, due to increased oxidative stress and vascular endothelial injury associated with OSA, patients afflicted with this condition will not only have more advanced atherosclerotic lesions, but also in their histopathological examination their atherosclerotic plaque will exhibit evidence of greater instability and adverse morphology. We also expect to show that in patients with OSA, achieving cor¬rect control of cardiovascular risk factors will be more difficult. The study may improve PAD control through assuring better multispecialty care in PAD patients.

Cardiovascular safety of novel non-small cell lung cancer oncotherapy in a patient treated with novel generations of tyrosine kinase inhibitors

Figure 2. Changes in the cardiac parameters during treatment with tyrosine kinase inhibitors; DBP — diastolic blood pressure; HR — heart rate; LVEF — left ventricular ejection fraction; NT-proBNP — N-terminal-pro B-type natriuretic peptide; SBP — systolic blood pressure; UTI — urinary tract infection A Cardiovascular safety of novel non-small cell lung cancer oncotherapy in a patient treated with novel generations of tyrosine kinase inhibitors

Challenges of Heterotopic Ossification ‐ molecular background and current treatment strategies

Heterotopic ossification (HO) is an abnormal formation of mature lamellar bone within extraskeletal soft tissues, such as muscles, tendons, and ligaments. This process is thought to be induced by inflammation associated with tissue injuries. HO is classified using two subtypes: resulting from injury or genetically inherited. HO formation is associated with polytrauma patients with traumatic brain injuries and spinal cord injuries. Moreover, HO is also considered to be a post‐operative risk factor in some orthopaedic procedures. In this review, we summarize our current understanding of the pathology of different types of HO and discuss its current and future therapies. Thus far, research has revealed cellular and molecular pathways leading to HO formation and proposed several possible mechanisms leading to HO and conserved signalling pathways common in the different HO subtypes. Non‐steroidal anti‐inflammatory drug treatment and localized low‐dose irradiation are currently the only available prophylactic treatments for HO. However, they are not always effective and do not target the osteogenic processes directly. New therapeutic strategies targeting the pathological processes of HO, such as bone morphogenetic protein (BMP) inhibitors like noggin, BMP type 1 receptor inhibitor, and nuclear retinoid acid receptor‐gamma (RARγ) agonists, are currently being investigated. In‐depth understanding of the HO pathological process could help to develop effective therapeutic strategies.

Perioperative Physiotherapy for Total Ankle Replacement in Patients with Inherited Bleeding Disorders: Outline of an Algorithm

The treatment of end-stage hemophilic arthropathy of the ankle joint remains a controversial problem, and total ankle replacement (TAR) is considered to be a valuable management option. Physiotherapy continues to be an extremely important part of TAR and has a tremendous impact on the outcomes of this procedure. Given the lack of data on the latter, this study details a protocol of perioperative physiotherapy in TAR in patients with inherited bleeding disorders (IBD). The protocol outlined in this paper was devised via consultations within an interdisciplinary group, the authors’ own experiences with TAR in hemophilic and non-hemophilic patients, previous reports on this issue in the literature, and patient opinions. Our working group followed the criteria of the International Classification of Functioning, Disability and Health. The algorithm includes 4 physiotherapy phases with specified time frames, aims, interventions, and examples of exercises for each phase. We emphasize the importance of preoperative rehabilitation, and recommend introducing intensive physiotherapy immediately after the surgery, with regard to the wound protection and avoiding full weight-bearing in the first weeks. The intensity of physiotherapy should be adjusted individually depending on individual patient progress. This study details a rehabilitation protocol for TAR in patients with IBDs, which can be equally applicable to clinicians and researchers. Further scientific studies are required to investigate the beneficial effect of different protocols as well as to clarify the effectiveness of various frequencies, durations, and intensities of selected interventions.

Revision Knee Arthroplasty in Patients with Inherited Bleeding Disorders: A Single-Center Experience

Background The results of total knee arthroplasty (TKA) in patients with inherited bleeding disorders (IBDs) are poorer when compared with those in the general population, with a notably higher risk of complications and higher revision rates. Thus, revision procedures are becoming a growing concern in this group of patients. The aim of this study was to evaluate the results of revision TKA in patients with IBD. Material/Methods A retrospective cohort study with longitudinal assessment of hemophilia patients scheduled for revision TKA between January 2010 and September 2015 was performed. The clinical status of the patients was assessed based on the Knee Society Score, and the Numeric Rating Scale was used to assess knee pain severity and patient satisfaction with the surgery. Radiological examination, post-operative complications, and reinterventions were recorded and analyzed. Results Very good results were obtained in all patients treated for aseptic loosening of the implant. However, inferior results were found in cases with infection. All patients operated on for aseptic loosening required only single-stage TKA, whereas patients with infection underwent multiple interventions. Complications were observed only in cases with infection. Conclusions Our study clearly outlined the differences in results based on failure mode, with far inferior results obtained in cases with infection. Given the lack of data in this area as well as the high specificity of this population, further high-quality studies are needed.

Assessment of cardiovascular risk in patients undergoing total joint alloplasty: the CRASH-JOINT study.

BACKGROUND Risk assessment is of particular importance for patients undergoing surgical interventions. Orthopaedic procedures, especially total joint alloplasty, are major procedures associated with high perioperative risk, as well as one of the highest rates of complications. AIM The aim of the present study was to establish the prevalence of classical and non-classical cardiovascular risk factors in patients undergoing total hip or knee alloplasty. METHODS The CRASH-JOINT (Cardiovascular Risk Assessment ScHeme in JOINT alloplasty) was a prospective, epidemiological study performed in consecutive patients scheduled for total joint (hip or knee) replacement surgery. Patients enrolled into the study were screened for cardiovascular risk factors and had ambulatory blood pressure performed for the diagnosis of hypertension. RESULTS The present study enrolled 98 patients. During initial screening eight patients were disqualified from the study and the surgery, in the majority due to the cardiac causes. Sixty-five patients had a hip joint replacement and 25 had knee joint replacement (mean age 63.7 ± 12.2 years, 62.2% female). Fifty (55.6%) patients were diagnosed with arterial hypertension in the past, ten (11.1%) patients had diabetes mellitus, two (2.2%) had a history of myocardial infarction, and family history of cardiovascular disease was present in 24 (26.7%) cases. Mean body mass index (BMI) was 28.0 ± 5.1 kg/m² and 39 (43.3%) patients were overweight, while 28 (31.1%) were obese. Patients undergoing hip replacement were significantly younger (61.8 ± 12.6 vs. 68.5 ± 10.0 years; p = 0.02), were more often current smokers (24.6% vs. 4.0%; p = 0.03), had significantly lower BMI (26.8 ± 4.5 vs. 31.2 ± 5.3 kg/m²; p < 0.0001), and were less often obese (18.5% vs. 64.0%; p < 0.0001). There were no significant differences between patients scheduled for primary surgery and reoperation. CONCLUSIONS The study showed that classical cardiovascular risk factors in patients undergoing total hip or knee alloplasty have a higher prevalent than in the general population, which can potentially contribute to the higher risk of development of perioperative complications.

Cardiac approach to a patient with breast cancer and metastases in musculoskeletal system

A 47-year-old, obese female was referred to the orthopaedist by an oncologist. Two years prior to the referral the patient was diagnosed with malignant cancer of the right breast (pT2N0(0/1)M0). Histological diagnosis was invasive carcinoma NST G2, with positive ER, positive PGR, HER2 (0), and Ki67 (30%). She was treated with tumorectomy with a resection of the sentinel node and subsequent hormone therapy and chemotherapy (with doxorubicin and cyclophosphamide). After the tumorectomy she underwent a second operation to resect excessive scare tissue. Following this she did not have signs of local cancer recurrence for over a year. Subsequently she came to the oncologist complaining on limping and pain in the right hip. She had multiple imaging modalities performed that showed signs of metabolically active metastases in the proximal part of the right femur (Fig. 1). In the Harris Hip Score (a questionnaire assessing performance in hip disease) she scored 38 out of 100 points, which is consistent with poor performance. Orthopaedic assessment showed the possibility of a pathological fracture, and the patient was qualified for total hip replacement and subsequent radiotherapy. The patient had never complaint cardiovascular disease in the past. Also, she was never assessed by a cardiologist, even prior to the first round of chemotherapy. Nevertheless, as a part of the standard protocol used in the Orthopaedic Department in patients with malignancy scheduled for hip replacement, she was referred for cardiological evaluation. In addition to a standard follow-up, she had an echocardiography, ambulatory blood pressure (BP) monitoring, and electrocardiogram using telemedical equipment (Fig. 2). All tests showed normal results, except for mild atrial enlargement and inverse dipping BP pattern (mean 24-h BP 120/73 mm Hg). For cardioprotection before operation and oncological treatment the patient was prescribed ramipril 2.5 mg/day, nebivolol 5 mg/day, and rosuvastatin 20 mg/day. Total hip replacement with the use of bone cement was performed (Fig. 3). The patient was rehabilitated and achieved full recovery (Fig. 4). She was scheduled for radiotherapy and underwent another cardiac evaluation. Six months after the surgery she was in good general condition, with no signs of cancer recurrence or cardiac damage. A multi-specialist approach to patient care is currently crucial for modern management of patients. In orthopaedics hip replacement is a procedure associated with one of the greatest risks of periprocedural complications, including cardiovascular complications such as myocardial infarction, stroke, or thromboembolic complications. Also, oncology treatment, including chemoand radiotherapy, is associated with various forms of cardiovascular events. Therefore, proper cardiac evaluation and treatment, in both primary and secondary prevention, should be introduced in all patients with cancer and orthopaedic complications.

Evaluation of the prevalence of periodontal disease as a non-classical risk factor in the group of patients undergoing hip and/or knee arthroplasty

BACKGROUND Periodontal disease is a chronic disease causing an inflammatory process that affects various organs and is as-sociated with an increased risk of many diseases, including bone and cardiovascular disease. AIM The aim of this study was to establish the prevalence of periodontal disease in continuous patients scheduled for hip or knee replacement surgery. METHODS The study was a prospective, epidemiological analysis performed in consecutive patients scheduled for total joint (hip or knee) replacement surgery. Patients enrolled into the study were screened for classical risk factors and had a dental evaluation performed for the diagnosis of periodontal disease. RESULTS The study population consisted of 228 patients. A total of 137 (60.1%) patients were scheduled for a hip replace-ment surgery, while 91 (39.9%) had a knee replacement. The mean age of the study population was 66.8 ± 12.2 years, and 83 (36.4%) patients were male. A clinically significant disease was present in 65 (28.5%) cases, while all (100%) of the patients had at least minimal signs of periodontal disease. In patients with periodontal disease the percentage of tartar involvement of the teeth was 33.1 ± 26.8%, mean dental plaque coverage was 48.1 ± 29.8%, and bleeding occurred at a rate of 35.4 ± 29%. As for the hygiene level, it was generally poor in the majority of patients with periodontal disease. No differences in terms of baseline risk factors were present between patients with and without periodontal disease. CONCLUSIONS In conclusion, periodontal diseases are highly prevalent in patients undergoing hip and/or knee replacement surgery. The presence of the periodontal disease is possibly associated with a worse prognosis and should be treated.