Paweł Małdyk

Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis

Introduction. Radical procedures like calcanectomy and amputation performed for calcaneal osteomyelitis are regarded as effective in eradication of infection even though potentially functionally disabling. Bone sparing procedures offer better functional result at the expense of potentially worse infection control. The aim of the study has been to assess the influence of the surgical radicalism as much as the extent of bone infection on the final outcome in the surgical therapy of chronic calcaneal osteomyelitis (CO). Material and method. 32 patients with chronic CO have comprised the group under study: 8 with superficial type, 12 localised type and 12 with diffuse type according to Cierny-Mader classification. The aim of the treatment was to heal infection, preserve the heel shape and achieve good skin coverage over the calcaneus. The therapy consisted of 9 debridement surgeries with or without flaps, 8 drilling-operations of the calcaneus with application of collagen-gentamicin-sponge in bore holes, 15 partial and 2 total calcanectomies, and 4 below-the knee amputations. Results. The healing of infection and wound has been achieved after 7 of 9 debridements, 6 of 8 drilling-operations, 13 of 15 partial and all total calcanectomies. Conclusion. Bone preserving operations in chronic calcaneal osteomyelitis provided inferior infection control (76,47% vs 88,24%) and worse patient satisfaction (88,24% vs 100%) and almost camparable ambulation (100% vs 93,33%). Drilling of the calcaneus with application of collagen sponge containing gentamicin performed in chronic diffuse calcaneal osteomyelitis seems to offer a viable alternative to partial or radical calcanectomy. Level of evidence: V.

Failures of Operative Treatment of Comminuted Fractures of Proximal Humerusin in Own Material

BACKGROUND Fractures of the proximal humerus make up 4 to 10% of all fractures. Their incidence increaseswith age, usually affecting individuals over 40 years old, reflecting the mineral status of the bone, Material and methods. Out of a group of 131 patients operated on due to comminuted proximal humeral fractures, 25 cases presenting inappropriate postoperative results were selected for further analysis. RESULTS Failures were found in 16 cases, but affected the final outcome in seven cases only (lack of anatomical repositioning of bone fragments, including one that was stabilized at the fifth postfracture week, in whom a severe contracture of the supraspinatus muscle dislocated the major tubercle, or conflict of the implant with the acromion), and were negligible in the other nine. In two, properly stabilized major tubercles were dislocated due to their bearing the body weight immediately after the procedure. Another two developed necrosis of the humeral head, and in one the fracture was revealed to be pathological, requiring further oncological treatment. In four cases, ostensible false stabilizations were recorded as a consequence of inappropriate patient positioning for x-rays. CONCLUSIONS 1. Our observations indicate that anatomical repositioning of bone fragments, especially those containing articular surface and muscle attachments, and their firm stabilization as well as proper implant positioning are crucial for the final result. 2. In some cases objective and unpredictable factors influencing the type and time of intervention affect the final results. 3. In those cases the decision to operate seems to be controversial. 4. The possibility of a pathological fracture should also be remembered, as such fractures require an appropriate oncological treatment.

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.

Comminuted Fractures of the Distal Femur Treated with Ilizarov External Fixator. Case Series Study

BACKGROUND Distal femoral fractures constitute a type of lower limb injuries that is rare and difficult to treat. Despite advances in surgical technique and development of implants used for internal fixation of fracture fragments, the treatment continues to result in numerous complications. The Ilizarov External Fixator reduces the risk of complications and allows for bone union. MATERIAL AND METHODS Six men with distal femoral fractures resulting from multisite and multiorgan injuries were treated at the Department of Orthopaedics and Musculoskeletal Traumatology of the Medical Uni-versity of Warsaw between 2008 and 2016. Mean age of the patients was 42.6 years. Four of them were mana-ged with the Ilizarov method as a primary treatment and two wore the apparatus as a second-line treatment following unsuccessful plate osteosynthesis. RESULTS Mean treatment duration with the Ilizarov apparatus was 29 weeks. Bone union was achieved in all patients. After the treatment, the patients ambulated unassisted, without orthopaedic aids. All patients re-turned to work. CONCLUSIONS 1. The Ilizarov method allows for efficient fixation of comminuted distal femoral fractures, in-clud-ing C2 and C3 intra-articular fractures (AO/ASIF classification). 2. The use of the Ilizarov apparatus re-duces soft tissue laceration, preserves blood supply to the bone fragments, and allows for easier skin care, which is particularly important in the case of open fractures. 3. Early rehabilitation with the patient fully loading the operated limb reduces muscle atrophy and stimulates bone union.

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.

Stress Fractures of Tibia Treated with Ilizarov External Fixator.

BACKGROUND Stress fractures are the result of cyclic loading of the bone, which gradually becomes damaged. Most often they are treated by rest or plaster cast and, in rare cases, by internal fixation. There is little published data on initial reposition followed by stabilization with the Ilizarov apparatus in such fractures. MATERIAL AND METHODS Six patients were treated with an external fixator according to the Ilizarov method for a stress fracture of the tibia between 2007 and 2015. Three patients were initially treated conservatively. Due to increasing tibial deformation, they were qualified for surgical treatment with external stabilization. In the other patients, surgery was the first-line treatment. All patients demonstrated risk factors for a stress fracture. After the surgery, they fully loaded the operated limb. RESULTS No patient developed malunion, nonunion, infection or venous thrombosis. The average time from the first operation to the removal of the external fixator was 19 weeks. Radiographic and clinical outcomes were satisfactory in all patients. CONCLUSION 1. The Ilizarov method allows for successful stabilization of stress fractures of the tibia. 2. It may be a good alternative to internal stabilization, especially in patients with multiple comorbidities which affect bone quality and may impair soft tissue healing.

Epidemiology of arterial hypertension in patients scheduled for elective hip replacement

Background: Assessment of blood pressure values and early diagnosis of hypertension are especially important in high-risk group, including patients in preoperative and postoperative period. The aim of the current study was the assessment of blood pressure values and prevalence of hypertension in patients undergoing elective hip replacement surgery — an orthopedic procedure associated with one of the highest cardiovascular complication rate. Material and methods: Two hundred and eighty-four consecutive patients admitted for elective hip replacement surgery were screened for arterial hypertension. All patients had their medical records reviewed for prior diagnosis and had their blood pressure measured on admission by a qualified physician prior to the procedure, according to the current guidelines. Results: The mean age of the study population was 62.2 ± 13.9 years and 42.7% of the patients were male. The body mass index (BMI) in the study population was 27.0 ± 4.2 kg/m 2 . Fifty-eight point two percent of patients were diagnosed with arterial hypertension previously. Mean blood pressure values on admission for systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 134.5 ± 20.4 and 78.6 ± 13.1 mm Hg, respectively. In 43.2% of patients, the on admission blood pressure values exceeded the threshold of ≥ 140 and/or 90 mm Hg. Arterial hypertension was diagnosed de novo in 33 (15.0%) patients. Patients with the disease were older (67.5 ± 12.3 vs. 54.4 ± 13.9 years; p < 0.0001), and had higher BMI (27.6 ± 4.3 vs. 26.2 ± 3.8 kg/m 2 ; p = 0.05) than patients without the diagnosed disease. Diabetes mellitus was more often found in hypertensive patients (13.3% vs. 3.3%; p = 0.02), they also more often had history of myocardial infarction (p = 0.02), stable coronary artery disease (p = 0.001) and heart failure (p = 0.006) compared to patients without the diagnosis. Conclusions: The majority of patients scheduled for elective hip replacement surgery is diagnosed with arterial hypertension. The disease is also diagnosed de novo in 15% of these patients. Screening for arterial hypertension is important in this group of patients and can potentially reduce the complication rates of the hip replacement surgery.

The relationship between the use of cement during total hip replacement and blood pressure values

Background Total hip replacement is a common orthopaedic procedure associated with an elevated cardiovascular risk. There are several methods for total hip replacement, including whether or not to use cement for the prosthesis fixation. The aim of the study was to compare clinical characteristics, including blood pressure, in patients undergoing total hip replacement with and without the use of cement. Material and methods The study included patients with elective total hip replacement surgery, who were divided into those in whom the procedure was performed with or without the use of medical cement. The criteria for using cement were assessed during operation by the operator, according to the current protocol. All patients were interviewed, screened, and had their medical records checked for the prior diagnosis of cardiovascular risk factors. Blood pressure values were measured before and after the procedure according to the current guidelines. Results The study population consisted of 65 patients in whom the total hip replacement was performed (mean age 61.5 ± 15.0 years; 50.8% male). 60% of patients had the hip replacement without cement and 40.0% had a procedure with the use of cement. Patients in whom the cement was used were significantly older (75.0 ± 8.5 vs. 53.0 ± 11.5 years; p < 0.0001) and more often diagnosed with arterial hypertension (61.5 vs. 33.3%; p = 0.04), than those in whom it was not used. Systolic blood pressure values were significantly higher before and after the procedure (138.8 ± 18.2 vs. 130.8 ± 21.5 mm Hg, p = 0.04; 122.6 ± 13.3 vs. 113.8 ± 14.1 mm Hg, p = 0.03; respectively) in the group which required cement. Conclusions Patients with hip replacement using cement have higher systolic values before, and after the surgery than in patients in whom cement wasn’t used. Therefore careful management and risk assessment is especially important in patients receiving the total hip replacement with the use of cement.

Open Trimalleolar Fractures Treated with Ilizarov External Fixator.

BACKGROUND Open trimalleolar fractures are some of the most severe fractures of the ankle joint region and some of the most difficult in trauma surgery. Repositioning with internal fixation is the most common surgical treatment method. There is little published data on primary repositioning and external fixation. MATERIAL AND METHODS Five patients with open trimalleolar were fitted with Ilizarov external fixators in single-stage procedures. RESULTS Full weight bearing was possible following surgical treatment in all five patients. None of the patients developed malunion, infections or vein thrombosis. For all patients, the Ilizarov apparatus was remodelled after six weeks to allow movement in the ankle. Three patients developed posttraumatic arthrosis requiring joint fusion. Arthrodesis was performed in two patients, and another patient will require it in the future. None of the patients developed any inflammatory complications. The mean duration of treatment with an external fixator was 11.6 weeks (range: 9-15 weeks). Radiological and clinical outcomes were satisfactory in all patients. CONCLUSIONS The Ilizarov method allows for early and definitive treatment of open trimalleolar fractures with a low risk of complications and a good clinical outcome.