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The aim of the paper was to present the results achieved with triple pelvic osteotomy in the treatment of residual hip dysplasia, with special interest in identifying recurrences and complications and how to avoid them. 60 patients (76 hips) with developmental dysplasia of the hip (DDH), treated by the triple pelvic osteotomy according to Tönnis and modified by Vladimirov, were included in the study. Hips were evaluated radiologically with the center-edge (CE) angle, break of the Shenton-Menard arch and index of acetabular depth by Heyman-Herndon, and functionally using the Harris Hip Score (HHS). The postoperative results showed an average increase of the CE angle by a mean of 23.5±9.28 degrees, with a highly significant difference between the preoperative and final postoperative findings (t-test, t=-20.85, p<0.01). The mean HHS significantly improved (p<0.01). Total complication rate was 13,1%, divided in: 1,3% (one case) of triple nonunion of iliac, pubic and ischial bones, 7,9% (six cases) of double nonunion of pubic and ischial bones, 2,6% (two cases) of peroneal palsy and 1,3% (one case) of infection. In this study the triple pelvic osteotomy showed to be reliable for acetabular dysplasia in adolescent and young adult, alone or in association with proximal femoral osteotomy and/ or great trochanter distal advancement. [ABSTRACT FROM AUTHOR]

Serbia, a middle-income country, is located in southeastern Europe, with territory of 88,361 km(2) and 9,400,000 inhabitants. Average month salary is US$542 and the registered unemployment rate is 22%. The country is administratively divided into 30 districts (193 municipalities). The healthcare system is territorially organized. In the state capital there are five clinical hospitals with musculoskeletal traumatology departments, as well as one in each of the four university centers. In addition, there are orthopaedic departments in 40 smaller hospitals throughout the country and in three military hospitals, along with several pediatric surgical departments involved in managing musculoskeletal trauma. There are 524 orthopaedic trauma surgeons (1:18,000 people), with a minor number of additionally trained general and pediatric surgeons who care for musculoskeletal problems. Bonesetters are neither recognized nor included in the healthcare system. Orthopaedic traumatology services are well organized, with variable accessibility depending on the distance between injury site and nearest medical facility. Preventive strategies are well developed and mainly consider agricultural, industrial, and traffic injuries. Distribution of medical institutions is satisfactory. Future activities should include continuing medical education of specialists, exclusion of inappropriate specialists, improvement of preventive strategies and medical transport facilities, as well as standardization of medical equipment, diagnostics, and treatment protocols. [ABSTRACT FROM AUTHOR]

Laboratory and clinical muscle analysis has revealed that even in the absence of bioelectrical and motor activity, skeletal muscles have certain basic level of tension. This is called Human Resting Muscle Tone (HRMT). It results from viscoelasticity of connective tissue, titin action in muscle fibers and the trixotrophy of muscle tissue (nonlinear relation between muscle viscosity and shear force) and in Hill's muscle model it is represented by parallel elastic component. HRMT is a source of significant force across the musculoskeletal system, exerting an average pressure on growth cartilages larger than 0.3MPa, for more than 96,53% of time and participating in the development of orthopedic deformities. The intensity of HRMT is under the influence of many factors: emotional, constitutional, reflex activity, physical activity, skeletal growth and other. Direct measurement of HRMT by NMR, US elastography, EMG analysis, mechanomiography or myotonometry is complicated and expensive, therefore it is reserved mostly for scientific investigation. Clinical assessment of HRMT can be done by reverse engineering approach: the analysis of consequences. CoreFitMax method provides an analysis of postural data (43 static and 40 dynamic), using a discrete finite element analysis algorithm to calculate relative HRMT levels of 62 major muscles important for posture and locomotion. CoreFitMax algorithm uses myofascial, chains-based, kinesiological analysis. Results contribute to establishing an etiological diagnosis of structural and functional deformity of the human body. Restitution of adequate HRMT improves muscular balance and posture. It can be achieved by exercise, physical therapy and rehabilitation, using immobilization or medication, or even by surgical procedures. Biomechanical integration of connective tissue into myofascial chains brings HRMT into focus in therapeutic and preventive measures in everyday orthopaedic and physiatric practice.

Introduction. Congenital pseudarthrosis of tibia is a rare congenital deformity with progressive evolution. Treatment is vague and difficult, and many methods have been used - from once mandatory early amputation to contemporary operative (Ilizarov method, free microvascular fibular graft) and adjuvant methods (electrostimulation, biphosphonates, bone morphogenetic protein). We present the usage of once popular method of homologous graft insertion and intramedullary fixation. Case Outline. This is a case report of male patient with pseudarthrosis involving both crural bones (Boyd type 5), diagnosed in neonatal age. Early conservative treatment was unsuccessful, so child never initiated gait. At the age of three and a half years, operative treatment was applied: resection of pseudarthrosis on both tibia and fibula, and osteoplasty of tibia using cylindric homologous graft and intramedullary fixation with transtarsal Steinman pin, followed by long leg cast immobilization. Pin was removed after ten months, and physical therapy was initiated 1.5 year after surgery, with initial to partial weight bearing and short leg cast throughout another year. Two and a half years after surgery complete union of graft was documented, and then full weight bearing was allowed. At final visit, five years and three months after surgery, shin axis was correct, leg lengths were equal, and child had normal walk with full range of motion. X-ray showed complete union of both tibia and fibula. Conclusion. Despite bad prognostic factors (young age, severe deformity), utilization of obsolete and almost forgotten treatment methods can provide excellent result. [Projekat Ministarstva nauke Republike Srbije, br. III 41004]

Introduction. Modified, reversal technique of fixation in digital replantation using K-wires was analyzed. The results obtained from the standard technique and reversal technique of fixation using K-wires were compared. Objective. The aim was to compare the results of osteofixation using K-wires in digital replantation when either standard or reversal, modified technique was used. Methods. A retrospective study included 103 replanted fingers in 72 patients. The first group included standard fixation using K-wires and the second group included fixation using K-wires, but with a modified technique. Modification consisted of the opposite order of moves during the phalanges fixation compared to the standard technique: first, K-wire was introduced intramedullary in the proximal phalanx and the top of the wire was drawn out through the skin in proximal part of the finger or hand. Second, distal part of the wire was introduced in the phalanx of the amputated part of the finger intramedullary until the wire entered the cortex. Results. Duration of bone healing after digital replantation was shorter in cases where reversal technique was used in comparison with standard technique (7.2 weeks compared to 7.5 weeks). Conclusion. The comparison of standard and reversal technique of phalangeal fixation with K-wires in digital replantation shows that both techniques are useful. Reversal technique expands the choice of operative techniques for bone fixation during the replantation. It shows some advantages and enables avoidance of vein injuries. [Projekat Ministarstva nauke Republike Srbije, br. III 41004 i br. 175095]

Introduction. Perthes disease is idiopathic avascular osteonecrosis of the hip in children, with unknown etiology. Inflammation is present during development of Perthes disease and it is known that this process influences bone remodeling. Objective. Since genetic studies related to inflammation have not been performed in Perthes disease so far, the aim of this study was to analyze the association of frequencies of genetic variants of immune response genes, toll-like receptor 4 (TLR4) and interleukin-6 (IL-6), with this disease. Methods. The study cohort consisted of 37 patients with Perthes disease and 50 healthy controls. Polymorphisms of well described inflammatory mediators: TLR4 (Asp299Gly, Thr399Ile) and IL-6 (G-174C, G- 597A) were determined by polymerase chain reaction restriction fragment length polymorphism method. Results. IL-6 G-174C and G-597A polymorphisms were in complete linkage disequilibrium. A statistically significant increase of heterozygote subjects for IL-6 G-174C/G-597A was found in controls in comparison to Perthes patient group (p=0.047, OR=2.49, 95% CI=1.00-6.21). Also, the patient group for IL-6 G-174C/G- 597A polymorphisms was not in Hardy-Weinberg equilibrium. No statistically significant differences were found between patient and control groups for TLR4 analyzed polymorphisms. A stratified analysis by the age at disease onset also did not reveal any significant difference for all analyzed polymorphisms. Conclusion. Our study revealed that heterozygote subjects for the IL-6 G-174C/G-597A polymorphisms were significantly overrepresented in the control group than in the Perthes patient group. Consequently, we concluded that children who are heterozygous for these polymorphisms have a lower chance of developing Perthes disease than carriers of both homozygote genotypes. [Projekat Ministarstva nauke Republike Srbije, br. III41004]

Introduction. Pelvic ring injuries usually result from high­energy trauma, and cranial and abdominal multiple injuries are frequently present. Malgaigne fracture is referred to pelvic ring disruption at two sites, and is often treated surgically for its instability. We present a case of nonoperative treatment of Malgaigne pelvic fracture. Case Outline. A 17­year­old girl sustained a Malgaigne fracture falling off a horse. After ruling out urgent multiple trauma in local hospital, she was then transferred to Pediatric Orthopedic and Trauma Service at the Institute of Orthopedic Surgery «Banjica» Belgrade, with provisional cutaneous traction of 2 kg applied to her right leg. After the status evaluation, the supracondylar femoral traction was applied for three months, combined with pelvic cradle for first 73 days. Weight of traction was gradually adjusted according to x­ray check­up, ranging from 1­16 kg (1/4 of body weight). Antibiotic prophylaxis was administered for 10 days, and thromboprophylaxis for two months. After the removal of traction, physical therapy was applied and the patient achieved full weight bearing four months after the injury. Treatment outcome was a symmetric and stable pelvic ring, equal leg length, full range of motion in both hip joints and normal walking. Conclusion. Traction therapy, combined with gravitational suspension in pelvic cradle, resulted in excellent clinical result. Although significantly longer and more loaded than usual, normal weight bearing and walking were promptly achieved using intensive physical therapy. [Projekat Ministarstva nauke Republike Srbije, br. III 41004]

Introduction. Associated bone tissue defect and infection, commonly result in non-healing, i.e. by the development of infected tibial nonunion. Objective. The aim of the paper was to present experiences acquired in the treatment of this problem by the application of the Ilizarov method. Methods. The analyses enrolled 16 patients diagnosed with infected tibial nonunion. The Ilizarov method was used in all the patients, of type bilocal synchronous compressive-distractive or bilocal alternating compressive-distractive. Bone and functional results were classified as excellent, good, fair and poor. Total follow-up period of the patients was 48.77±41.57 months on the average. Results. Fifteen (93.75%) cases of nonunions were successfully healed. According to the laboratory findings of inflammation, the same patients were also successfully treated for local infection. The inequality of the lower limbs was also resolved by new bone formation of average length of 5.75±3.29 cm. Poor result was verified in one (6.25%) patient only. The patient satisfaction was scored 3.73±1.33 and physician’s satisfaction 4.33±1.11. Conclusion. The Ilizarov method with bone transport, because of being capable to solve simultaneously a local infection and tibial malalignement, and by substituting bone and soft tissue defects, thus enabling healing of until then unhealed bone, has shown as the best method in the treatment of this complex problem, infected tibial nonunions.

Femoroacetabular impingement is an undesirable contact between acetabular rim and femoral neck and presents abnormality of proximal femoral part and acetabulum, as well. Two forms may appear: cam impingement and pincer impingement. Femoroacetabular impingement related to Legg-Calvé-Perthes disease may be caused by various reasons, as the consequence of the disease itself, and as the consequence of its treatment. Coxa magna deformity (large femoral head and neck) and coxa brevis deformity (shortened femoral neck) may produce cam femoroacetabular impingement during hip flexion. After the disease, the flattened femoral head (coxa plana) may persist. Chiari pelvic osteotomy is the only treatment option for such femoral head deformity. Acetabular labrum squeezed continuously between the femoral head and the non-articular part of the cut iliac bone lead to cam femoroacetabular impingement, as well. If Salter or triple pelvic osteotomy is used that may cause a very large iatrogenic acetabular retroversion, we can also refer to radial type pincer femoroacetabular impingement. Treatment of Legg-Calvé-Perthes disease should be conducted according to the natural course of the disease and prognosis. Treatment should start on time, well before a crushed femoral head develops, because it is the easiest way to establish hip spherical congruency at the end of treatment. This is the best option to prevent secondary hip arthrosis caused by femoroacetabular impingement or by insufficient head coverage at the end of remodelling. In each case of delayed hip pain, followed by a limited range of movements, femoroacetabular impingement should be taken into consideration, confirmed, and treated by some of the available therapeutic methods.

The aim of this prospective control study was a quantitative evaluation of the activity of rheumatoid arthritis (RA) in certain time intervals, using articular indexes (set of 28 sensitive and 28 swollen joints), laboratory parameters (Hb, Hct, Er, Le and Plt) and acute phase reactants (ESR, RF, CRP); to determine which of the acute phase reactants is the most useful biochemical marker for the evaluation of disease activity in RA; to quantify the therapeutical and laboratory differences in certain time intervals in the group with and without immunomodulatory therapy with Methotrexate. Sixty patients with RA were included, 27 of who were treated with non-steroid antiinflammatory drugs (NSAIDs) and Methotrexate (MTX). The control group consisted of 33 patients treated only with NSAIDs because of irregular controls. In the first group of patients the disease activity was estimated at four time intervals, and in the control group of patients at three time intervals following the scores of the articular indexes, blood cell counts, ESR and CRP in every patient. In the first group of patients decreased activity of RA was found upon every following control with a consecutive decrease in mean values of the scores of articular indexes with statistically significant differences at the four time intervals. Considering laboratory parameters, there were statistically significant differences in the mean values of Hb, Er, Plt, ESR, (p=0.0462, p=0.0076, p= 0.0058, p= 0.0003). Mean values of CRP did not show statistically significant differences, but the number of patients who were CRP negative increased (there were great standard deviations). In the group of patients treated only with NSAIDs, there were statistically significant differences in the mean values of the scores of articular indexes with an increase at every following control (in favour of progression of the disease). There were no statistically significant differences considering blood cell counts, ESR and CRP (in favour of permanently active disease). In conclusion, CRP is the most useful marker for the prospective follow-up of patients with RA.

Introduction. Ultrasound represents a method of examination of hips of newborn babies capable of defining hip condition and distinguishing stable and unstable hips based on morphological elements. It is accepted in a large number of countries as a method of examination of high risk newborns, or as a method of systematic screening. Objective. The objective of this study was to investigate correlation between ultrasonically estimated hip maturity and respective gestation maturity both in premature and term-born babies, and to investigate the influence of different delivery types on hips condition. Methods. In our study 2045 patients, 1141 males and 904 females, were examined in at the Institute of Neonatology over a period of 5 years. The average age was 34.04 gestation weeks. There were significantly more premature (1698 or 83.03%) than term-born babies (347 or 16.97%). Ultrasound hip examination, as a screening method, was carried out according to Graf. It was followed by clinical examination. Results were analyzed by appropriate statistical methods (χ2-test, one-way ANOVA, multifactor ANOVA). Results. The overall frequency of unstable hips was 3.2%, 1.88% in males and 4.87% in females (p

Introduction. Insufficient femoral head coverage is found in a variety of diseases, with acetabular dysplasia as the most frequent disorder and triple pelvic osteotomy as the most recently introduced surgical treatment. Objective. This study analyses pre- and postoperative pathoanatomic characteristics of triple in comparison to Salter and Chiari osteotomies, with a logistic regression analysis of outcome predictor and effect explanator factors in relation to the chosen type of operation. Methods. The study involved 136 adolescents treated with Salter and Chiari osteotomies or a triple pelvic osteotomy at the Institute of Orthopaedic Surgery 'Banjica' in Belgrade. The patients were between 10-20 years old at the time of operation. We collected and analyzed data from all the patients: illness history, operative parameters, preoperative and postoperative pathoanatomic data. The data was statistically processed using the statistical software SPSS, defining standard descriptive values, and by using the appropriate tests of analytic statistics: t-test for dependent and independent variables, χ2-test, Fisher's exact test, Wilcoxon's test, parameter correlation, one-way ANOVA, multi-factorial ANOVA and logistic regression, according to the type of the analyzed data and the conditions under which the statistical methods were applied. Results. The average CE angle after triple pelvic osteotomy was 43.5°, more improved than after the Salter osteotomy (33.0°) and Chiari osteotomy (31.4°) (F=16.822; p

Introduction. The Institute for Orthopaedic Surgery 'Banjica' in Belgrade provides tertiary healthcare services on national level. After decades of constant development, a recent decline coincided with the decade of great social and governmental disturbance, the transition period after the dissociation of former Yugoslavia. Objective. In order to overcome the crisis, we used modern management methods to define problems in the institution management, and to propose appropriate strategies. Methods. A survey that included 100 employees (17.67%) was carried out, followed by descriptive statistical analysis, PEST and SWOT analyses. Results The impact of political fluctuations, ageing of population, financing model, obsolete medical technology was evaluated. Various personal and interpersonal factors were assessed: the quality of medical service (3.59±0.76, mark 1-5); relations among health service participants (3.39±0.78); occupational conditions (not good-91%); human, financial and other resources; professional cooperation, stimulation; rivalry and mobbing (declared in 56%); public informing, institution image (rank 3.70±0.88) and PR activities (new to 78%). 93% declared to give maximum effort at work. Conclusion. Using these results, we defined several strategic objectives. These include strengthening scientific activities, general orientation to specific and exclusive pathological conditions and treatment methods, improvement of management transparency, introduction of quality-based stimulation of workers, support of promotional and PR activities.

The purpose of this research is to evaluate the values of alanine aminopeptidase (AAP), γ-glutamyl transferase (γ-GT), and β2-Microglobulin in urine (β2-M), in untreated rheumatoid arthritis (RA) and to define the effect of untreated rheumatoid arthritis on the tubular function and brush border region. We used a kinetic assay for AAP, standard methods by the IFCC for γ-glutamyl transferase and MEIA for the determination of β2-Microglobulin in urine in 70 participants (35 untreated RA patients, 35 healthy individuals). From the total of 35 RA patients, 24 patients had AAP (sensitivity of the test 68.57%), 16 patients had γ-GT enzymuria (sensitivity of the test 45.71%), while the presence of β2-Microglobulin in urine was found in a very low percentage. Out of 18 RF negative patients, 14 patients are AAP positive, 10 patients were γ-GT positive, while the presence of β2-Microglobulin in urine was not detected. Among 17 RF positive RA patients, the presence of AAP was noticed in 10, the presence of γ-GT in 6 patients, while the presence of β2-Microglobulin in urine was not detected. AAP has higher sensitivity than γ-GT and β2-Microglobulin in the detection of asymptomatic renal lesions in untreated RA.

INTRODUCTION Paget disease, localized on thoracal vertebrae, presents a significant challenge in diagnostics and treatment. Presenting with progressive neurological symptoms, it has a broad differential diagnostic spectrum and requires additional radiological, neurological and endocrinological evaluation. Besides drug therapy, an operative decompression of nerve elements is performed when indicated. CASE OUTLINE We present a case of an older male patient complaining of chronic progressive pain localized at fourth and fifth thoracal vertebrae, with slight but progressive hypertonus and hyperreflection of leg muscles, including no plantar response. Vertebral biopsy indicated parathyreoid disturbance, excluded by further endocrinological analyses. At that point a corporectomy of fourth and fifth vertebrae and titanium cage spondylodesis of adjacent levels was performed, with pathological findings suggesting Paget disease. Postoperatively, there was initial significant neurological improvement; unfortunately, 2.5 years after the operation a relapse of the disease developed with gibbus deformity. Further treatment was surgical in two stages (first by decompression, and later by broad laminectomy), resulting in partial neurological recovery. CONCLUSION Spinal localization of Paget disease as a monoostotic form must be considered in all cases of progressive neurological impairment accompanied by biochemical disturbances in blood and urine, and with radiologically evident deformity, pathological fracture or neoplastic destruction of vertebra. A combination of medicamentous and surgical treatment should significantly improve neurological condition.

The aim of this study was to evaluate the activity of rheumatoid arthritis (RA) by hand radiography (Sharp's radiographic index), and assessment of acute phase reactants - erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and rheumatoid factor (RF), and to determine their value as prognostic markers for disease outcome in patients with early RA treated with disease modifying antirheumatic drugs (DMARDs)-Methotrexate (MTH); to register and quantify clinical, radiographic and laboratorial differences in certain time intervals in a group of patients treated with immunomodulation therapy with MTH; to determine which of the acute phase reactants would be the most useful marker for evaluation of disease activity in long-term follow-up in RA patients; to select high-risk groups with aggressive course of disease, in order to emphasize the necessity of early and aggressive treatment. Thirty patients with early RA (disease evolution up to 1 year) were evaluated in several time intervals. The score of the Sharp's index showed greater radiographic progression of the joint damage of hands in time intervals between 0-time and 12 months (p=0.0167) and between 0-time and 18 months (p=0.0089). Statistical analysis showed differences in values of CRP in four time intervals (p=0.00002). Considering CRP, there were statistically significant differences among mean values in four time intervals (p=0.0428) (standard deviations showed greater variations). There were no statistically significant differences among mean values of RF in four time intervals (p=0.573). At 0-time in 3 (10%) patients progression of the Sharp's index was found, after 6 months in 13 (39%) patients, while after 12 and 18 months progression of the Sharp's index was found in an identical number of patients, 15 (50%). In most patients high values of CRP and RF were found. Progression of the radiographic damage is especially expressed in patients with high values of ESR, CRP, RF and existence of previous erosions of hands, which are predictors for aggressive course of disease. CRP is the most useful marker for the evaluation of RA activity in the long-term follow-up of RA patients.

The purpose of this research was to compare the diagnostic values of laboratory variables, to present quantitative evaluations of the diagnostic test with reference to sensitivity, and specificity, the predictive value of the positive and negative test and precision of the test for anti-cyclic citrullinated peptide (anti-CCP 2) antibodies, rheumatoid factor (RF), C-reactive protein (CRP), DAS 28 index, in early diagnosis of untreated rheumatoid arthritis (RA). Using the ELISA technology of DIA-STATTM Anti-CCP (Axis-Shield Diagnostics), the serum has been examined in 70 participants (35 RA who were not treated, 35 healthy controls). RF was defined with the test for agglutination (Latex RF test) in the same participants. In 23 of the 35 examined patients with RA, we found presence of anti-CCP 2 antibodies (sensitivity of the test 65.71%), while RF appeared in 17 patients (sensitivity of the test 48.57%). Twelve patients were anti-CCP 2 and RF positive, 11 were anti-CCP 2 positive but RF negative. Five patients were anti-CCP 2 negative and RF positive. Out of 18 RF negative patients, 11 were anti-CCP 2 positive. In 17 RF positive patients, anti-CCP 2 antibodies were positive in 12 patients. In the healthy control group, 1 patient was anti-CCP 2 positive, while 2 patients were RF positive. Anti- CCP 2 antibodies have higher sensitivity and specificity than RF in RA.

Legg-Calvé-Perthes disease represents avascular necrosis of the femoral head in a growing child. It commonly affects children aged 2-14 years, mostly boys, and has familiar pattern. The etiology of this disease is unknown. It is based on avascular necrosis due to variations of the femoral head vascular supply, trauma, coagulation of endocrine disturbances. The disease presents with limping and pain localized in the hip with projection to thigh and knee, frequently accompanied by the limitation of abduction and internal rotation, as well as slight limitation in flexion of about 20 degrees. Plain radiography is most informative additional diagnostic procedure, enabling assessment of the stage of disease, containment of the femoral head within the acetabulum, acetabular coverage and the extent of disease. Main treatment goal is obtaining the spherical congruity of the hip joint. This can be achieved by abduction bracing, varization femoral osteotomies and various innominate osteotomies (sometimes combined with femoral osteotomies). Children younger than four years of age, with minimal femoral head involvement, do not need any treatment. These children with a larger involvement, older than four years of age, with possible containment in hip abducion, should be treated by one of the following procedures: Salter innominate osteotomy, Salter innominate osteotomy with femoral shortening, or triple pelvic osteotomy. The patients with containment of the hip is not possible in abduction (related to subluxation and femoral head crush), should be treated by Chiari pelvic osteotomy.

The purpose of this research was to compare the diagnostic values of laboratory variables, to present quantitative evaluations of the diagnostic sifted test with reference to sensitivity and specificity, the predictive value of the positive and negative test and precision of the test for N-acetyl-β-D-glucosaminidase (NAG), microalbumin, rheumatoid factor (RF), Creactive protein (CRP), DAS 28 index, in early diagnosis of untreated rheumatoid arthritis (RA), and to define the effect of untreated rheumatoid arthritis on glomerular and tubular function. Using a colorimetric assay for the determination of Nacetyl- β -D-glucosaminidase and an immunoturbidimetric assay for the determination of urinary albumin, the samples of serum and urine have been examined in 70 participants (35 RA who were not treated, 35 healthy controls). RF was defined with the test for agglutination (Latex RF test) in the same participants. Out of 35 examined patients with RA, in 13 we found the presence of NAG enzymuria (sensitivity of the test 37.14%), while microalbuminuria appeared in 4 patients (sensitivity of the test 11.42%). RF appeared in 17 patients (sensitivity of the test 48.57%). Four patients were NAG and RF positive, while 3 patients were microalbuminuria and RF positive. Among 18 RF negative patients, 9 patients were NAG positive, and 1 patient presented with microalbuminuria. Among 17 RF positive RA, the presence of NAG was found in 4 patients, and the presence of microalbuminuria in 3 patients. Among 18 RF negative RA, NAG enzymuria appeared in 9 patients. Microalbuminuria was present in 1 patient. In the healthy control group, 8 patients were NAG positive, 2 patients were positive for microalbuminuria. RF appeared in 2 patients. NAG has higher sensitivity than microalbuminuria in the detection of asymptomatic renal lesions in untreated RA.

The purpose of this investigation was to evaluate epidemiologic features of Ewing sarcoma in children treated in the Institute for Orthopedic Surgery "Banjica", as well as to establish relation of these features to clinical findings. Study involved 78 patients treated over 20-year period (1980-2000). Analysis included standard epidemiologic data (age, sex, tumor localization) and diagnostic clinical features on presentation (major symptoms, time elapsed between presentation and diagnosis, presence of metastases). Most of the patients were in the age group of 15-18 years (50.0%), predominantly males. In general, the results of our study were consistent with data reported in literature. Nevertheless, this investigation revealed slightly higher incidence in patients younger than four years of age (5.1%); localization on the upper extremity was found to be more frequent (upper to lower extremity ratio was nearly 3:1 in our study), and the time lost between presentation and diagnosis was markedly reduced (average time elapsed between presentation and diagnosis was 2.5 months). The results of our study may improve efficiency and success of treatment, thus providing the basis of better prognosis in management of such a serious illness.

Ewing’s tumor of bone is the second primary malignant bone tumor. Localized lesion is found in nearly 80% of cases and metastatic lesions are present in 20% at the time of diagnosis. Treatment protocols were analyzed, prognostic parameters were evaluated, and overall survival as well as survival until relapse of disease was studied. Prognostic features included age and sex, localization of tumor, type of applied surgical resection and treatment protocol, and presence of necrosis after neoadjuvant therapy as well as morphological characteristics of the tumor. Wide surgical resection (χ2=7.855; p

Authors reviewed their eight-year long experience with triple pelvic osteotomy. They explained the way of introduction of this procedure into everyday clinical practice. Seventy hips were operated using Tonnis-Vladimirov method in fifty nine patients of an average age of 15 years and one month. Treatment results were evaluated, both anatomically and functionally. Anatomic improvement was recorded by measuring the CE angle of Wiberg. Preoperatively, it ranged from -6 to 33 degrees (16.1±10.2 degrees), and at the end of treatment, it ranged from 15 to 68 degrees (43.1±11.1 degrees) - the difference proved to be highly significant (Student test t=-14.27, p

The paper presented the results of diagnostics and treatment of patients with diagnosis of chondroblastoma, treated at the Institute of Orthopedic Surgery "Banjica", Belgrade. A total of 30 patients were analyzed, involving the period from 1975-2004. All important data were obtained using the complete medical documentation, physical examination, radiographic findings and available additional diagnostic procedures. The proximal part of tibia, the proximal part of humerus and the distal part of femur were the most common sites of tumor, accounting for 63% of cases. Higher incidence of chondroblastoma was found in male patients, especially in the second decade of life. Pathohistological tumor verification was done in all patients. The patients were then treated by different surgical procedures, both on account of primary lesion and recurrence. Curettage and osteoplasty using the auto- and homograft were carried out in 21 patients, wide resection in nine cases, and amputation was performed in three cases. One patient had radiotherapy due to recurrence of lesion, nevertheless malignant transformation of chondroblastoma occurred in time. Seven patients manifested local recurrence, and one of them even had relapse on two occasions and malignant transformation of chondroblastoma. Malignant lesions were found in three cases (10% of patients); one lesion was diagnosed as primary while other two malignancies were detected only after recurrence, and the treatment was completed by lower leg amputation.

The objective of this study was to estimate the incidence of hip fractures in Belgrade for the period 1990-2000, and to determine distribution of fractures according to sex, age, and causes of injuries. Data based on medical records of the National Health Service in Belgrade were collected from all orthopedic hospitals and departments in Belgrade. A total number of 8904 hip fractures were included in the analysis, out of which 64.7% occurred in women. During the survey period, the estimated average annual incidence rate of hip fractures was 51.7/100 000 (95% Cl= 48.1-55.4); 66.2/100 000 (95% Cl= 60.8-72.1) in women and 35.3/100 000 (95% Cl= 31.4-40.1) in men, respectively. In the age group s50 years, the incidence rates standardized by the 1985 US population were 228 and 96 per 100 000 female and male population, respectively. An exponential increase in the incidence of hip fractures with age was observed in both sexes, especially in women. The number of trochanteric fractures was 4718 (53.0%), compared with 4186 (47.0%) cervical fractures. Observation at three time points, in 1990,1995,2000, indicated the pronounced increase of trochanteric fractures in women and less distinctive in men. Fall on the flat ground resulted in 70.3% of hip fractures among persons aged 50 years or older, and traffic accidents were recorded as the major cause in 59.7% of patients under 50 years of age.

Background/Objectives : Numerous studies have demonstrated the safety and efficacy of intraarticular stem cell injections for treating osteoarthritic knee joints, reporting symptom reduction and pain relief within a few months of treatment. Here, we report the results of a 7-year follow-up after a single intraarticular injection of 0.5-1 × 10 7 autologous adipose tissue-derived mesenchymal stem cells in patients with OA (Kellgren-Lawrence grade 2 to 4). Methods : Nine patients were treated, and two patients had bilateral disease. Patients were evaluated clinically and radiologically using X-ray and MRI. A comprehensive statistical analysis was undertaken to evaluate the obtained results. Results : All clinical scores and range of motion significantly improved within the first six months after injection. At the 18-month time point, a significant improvement in cartilage structure was observed on MRI while X-ray showed no changes in subchondral bone of distal femur and proximal tibia. At the 60-month time point, the clinical scores were still improved compared to baseline, except for the range of motion, which decreased almost back to the baseline level. At 84 months, the clinical scores decreased significantly toward the baseline level, but the MRI structural characteristics of cartilage still remained significantly better than those measured at baseline. Conclusions : Adipose tissue-derived stem cell therapy has substantial long-term clinical effects on patients with knee osteoarthritis.

Background: Perthes disease is a juvenile form of osteonecrosis of the femoral head that affects children under the age of 15. One hundred years after its discovery, some light has been shed on its etiology and the biological factors relevant to its etiology and disease severity., Methods: The aim of this study was to summarize the literature findings on the biological factors relevant to the pathogenesis of Perthes disease, their diagnostic and clinical significance, and their therapeutic potential. A special focus on candidate genes as susceptibility factors and factors relevant to clinical severity was made, where studies reporting clinical or preclinical results were considered as the inclusion criteria. PubMed databases were searched by two independent researchers. Sixty-eight articles were included in this review. Results on the factors relevant to vascular involvement and inflammatory molecules indicated as factors that contribute to impaired bone remodeling have been summarized. Moreover, several candidate genes relevant to an active phase of the disease have been suggested as possible biological therapeutic targets., Conclusions: Delineation of molecular biomarkers that underlie the pathophysiological process of Perthes disease can allow for the provision of earlier and more accurate diagnoses of the disease and more precise follow-ups and treatment in the early phases of the disease., Competing Interests: The authors declare no conflicts of interest.

Aim : Cushing's syndrome (CS) is associated with weight gain and extreme central, visceral, abdominal obesity which is confirmed with dual-energy X-rays absorptiometric (DXA) diagnostic cut-off point (CP) values of central obesity indexes (COI), determined as an android to gynoid tissue and fat mass ratios. These best differentiate CS from non-CS obese women matched with CS according to their age and BMI. The aim of this study was to determine the CP values of new DXA indexes of central, abdominal obesity as a ratio of android and trunk to legs as well as trunk and legs to total tissue and fat mass that best differentiate CS and matched non-CS obese women in order to confirm central abdominal obesity, and to determine their normal CP values that best differentiate healthy non-obese women from CS and non-CS obese women, and to exclude abdominal obesity completely. Material and Methods : DXA indexes of abdominal obesity, calculated as а ratio of regional body fat and tissue mass compartments android to legs (A/L), trunk to legs (Tr/L), trunk to total (Tr/To) and legs to total (L/To) values were determined among 4 groups. Each group consisted of 18 women: 1 st group of CS, 2 nd group of obese women (O 1 ) not different according to their age and BMI from CS, 3 rd group of obese women (O 2 ) with higher BMI of 35 ± 1.2 kg and a 4 th group of non-obese, healthy women (C) with a normal BMI. Diagnostic accuracy (DG) of CP values of DXA indexes of abdominal obesity and indexes of normal body fat distribution (BFD) were determined. Results : A/L, Tr/L, Tr/To, and L/To DXA indexes were significantly different between CS and O 1 as well as between non-CS women O 2 compared to O 1 and C. These indexes had a highly significant correlation among each other and also in relation to their BMI (p < 0.0001). A/L-Tm CP value of 0.3 best differentiated the CS from group O 1 , with the highest DG of 100 % and an A/L-Fm CP value of 0.26 differentiated them with a DG of 94.44% and sensitivity of 100 %. An A/L-Tn CP value of 0.23 and an A/L-Fn CP value of 0.25 best differentiated CS and C as well as O 2 and C for the highest DG of 100 %. Conclusions : DXA indexes A/L, Tr/L, Tr/To and L/To values were significantly different among the four groups. These values correlated significantly among them and with their BMI in non-CS groups, thus confirming a BMI increase association with a more pronounced abdominal BFD. An A/L-Tm CP value of 0.3 and an A/L-Fm CP value of 0.26 were discovered as the best DXA diagnostic indexes of extreme abdominal obesity in CS and these could also be used in discovering abdominal BFD in non-CS obese women with metabolic syndrome (MS). An A/L-Tn CP value of 0.23 and an A/L-Fn CP value of 0.25 were discovered as the best DXA diagnostic indexes of normal BFD which completely excluded abdominal obesity., (© 2021 Slavica Shubeska Stratrova et al., published by Sciendo.)

Background: Osteoarthritis (OA) is a chronic degenerative joint disease and is considered to be the fourth leading cause of disability and the second cause of inability to work in men. Recently, adipose-derived mesenchymal stem cells (AD-MSCs) came into focus for regenerative medicine as a promising tool for the treatment of OA. The administration of stem cells into impaired joints results in pain relief and improves quality of life, accompanied by restoration of hyaline articular cartilage., Methods: In the present study, nine patients (including two patients with bilateral symptoms) diagnosed with osteoarthritis (International Knee Documentation grade B in 5 and grade D in six knees) were treated using a single injection of AD-MSCs at a concentration of 0.5-1.0 × 10 7 cells and were followed up for 18 months. During follow-up, all the cases were evaluated clinically by Knee Society score (KSS), Hospital for Special Surgery knee score (HSS-KS), Tegner-Lysholm (T-L) score and visual analogue scale (VAS) of pain, as well as by plain radiography and by magnetic resonance imaging visualization with 2D Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score assessment., Results: Significant improvement of all four clinical scores was observed within the first 6 months (KSS for 41.4 points, HSS-KS for 33.9 points, T-L score for 44.8 points, VAS of pain from 54.5 to 9.3) and improvement persisted throughout the rest of the follow-up. MOCART score showed significant cartilage restoration (from 43 ± 7.2 to 63 ± 17.1), whereas radiography showed neither improvement, nor further joint degeneration., Conclusions: The results obtained in the present study provide good basis for prospective randomized controlled clinical trials with respect to the use of AD-MSCs in the treatment of osteoarthritis., (Copyright © 2017 John Wiley & Sons, Ltd.)

Unlabelled: Perthes disease is one of the most common forms of pediatric femoral head osteonecrosis with an unknown etiology. Coagulation factors were the first genetic factors suspected to have a role in the pathogenesis of this disease, but studies showed inconsistent results. It is described that inflammation is present during early stages of Perthes disease, but its genetic aspect has not been studied extensively. Little is known regarding the status of apoptotic factors during the repair process that leads to the occurrence of hip deformity in patients. Therefore, the aim of this study was to analyze major mediators involved in coagulation, inflammation, and apoptotic processes as possible causative factors of Perthes disease. The study cohort consisted of 37 patients. Gene variants of TNF-α, FV, FII, and MTHFR genes were determined by PCR-RFLP, while IL-3 and PAI-1 were genotyped by direct sequencing. The expression level of Bax, Bcl-2, Bcl2L12, Fas and FasL was analyzed by quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) technique. Our results showed a significantly increased level of expression of pro-apoptotic factor Bax along with significantly higher Bax/Bcl-2 ratio in the patient group., Conclusion: The results presented indicate that apoptosis could be one of the factors contributing to the lack of balanced bone remodeling process in Perthes patients.

Background: Accurate prediction of a patient's prognosis is useful to define the risk posed by the disease. Age, gender, peripheral blood cytopenia, proportion of bone marrow (BM) blasts, performance status, comorbidities, transfusion dependence, specific karyotype abnormalities and molecular biomarkers can refine the prediction of prognosis in MDS., Aim: to assess the influence of the some prognostic factors like age, gender, cytopenia, BM blast percentage, transfusion dependence, ferritin, hemoglobin (Hb), lactate dehydrogenase (LDH), albumin and specific karyotype abnormalities in myelodysplastic syndromes on overall survival (OS)., Patients and Methods: we retrospectively analyzed the cohort of 108 patients diagnosed between 1.1.2011 and 31.12.2013 at the University Clinic of Hematology, Ss Cyril and Methodius University, Skopje, Macedonia. They were evaluated for clinical and hematologic features at diagnosis and at leukemic transformation., Results: in the study group 62 were man and 46 women. Male to female ratio was 1.35 to 1. The differences in OS between men and women were significant (p = .03015). The mean age at diagnosis was 66,6 years. According to the age OS was 16,4 months. FAB subtypes influenced OS significantly (p = .03015). OS inversely correlated with BM blast percentage (p= .02327). Cytopenia had no impact on OS (p=.33755). Hb as a whole and groups with different levels of Hb had no influence on OS (p = .12142) and (p= .07535), respectively. The group with ferritin <500 µg/L had better OS (p=.04720). Transfusion dependence, LDH and albumin had no impact on OS. Leukemic transformation was noticed in 10 (9,3%) patients. Mortality was 36,1%., Conclusion: gender, FAB subtypes, BM blast percentage and the serum levels of ferritin had an influence on OS, while age, hemoglobin level, transfusion dependence, LDH and albumin had no impact on OS.

Introduction. To compare the diagnostic values of laboratory variables, to present evaluations of the diagnostic test for asymmetric dimethyl arginine (ADMA), rheumatoid factor (RF), C-reactive protein (CRP), and DAS28 index, and to define the effect of untreated rheumatoid arthritis on endothelial function. In order to determine whether ADMA changes depending on the disease evolution, ADMA was used as an indicator for endothelial dysfunction. Methods. Using an ELISA technology of DLD-Diagnostika-GMBH for the detection of ADMA, the samples of serum and urine have been examined in 70 participants (35 RA who were not treated, 35 healthy controls). RF was defined with the test for agglutination (Latex RF test) in the same participants. Results. Out of 35 examined patients with RA, RF appeared in 17 patients (sensitivity of the test, 51.42%). In 20 of the 35 examined patients with RA, we found the presence of ADMA (sensitivity of the test, 57.14%). Anti-CCP antibody was present in 24 examined patients with RA (sensitivity of the test, 68.57%). Conclusion. ADMA has equal or very similar sensitivity and specificity to RF in untreated RA (sensitivity of 57.14% versus 48.57%, specificity of 88.57% versus 91.42%) in the detection of asymptomatic endothelial dysfunction in untreated RA.

Background: The aim of this study was to determine the effect of initial therapy with some disease modifying antirheumatic drugs (DMARDs) (Methotrexate and Ketoprofen) on glomerular and tubular integrity in patients with Rheumatoid arthritis (RA)., Objectives: To determine whether there is a change in clinical and laboratory indicators of renal function in course of the follow up of treatment and whether that change correlates with the dynamics of the quantity of enzymes excreted in urine and reactants of the acute phase., Materials and Methods: Using colorimetric method for determination of NAG, samples of 70 participants were examined (35 RA patients treated with Ketoprofen only, 35 RA patients treated with combined use of Methotrexate and Ketoprofen). The follow up was 5 time-intervals in the course of 24 weeks., Results: There was moderate correlation between NAG and microalbuminuria (r=0,34) in the group of patients treated with Ketoprofen only, while statistically significant correlation (r=0,21) was seen in group of patients with combined use of Methotrexate and Ketoprofen. NAG enzymuria in size, number of patients registered, and time of appearance were greater and appears earlier in the group with the combined use of Methotrexate and Ketoprofen compared with the mono-therapy with Ketoprofen. Mean urinary NAG induction was increasing with the concomitant use of Methotrexate and Ketoprofen., Conclusions: Methotrexate is more potent NAG inductor than Ketoprofen and provokes greater tubular enzymuria than Ketoprofen.

Purpose: We studied changes of contact stress distribution in the hip joint after Tonnis triple pelvic osteotomy applied in the treatment of dysplasia and hip joint incongruence in adolescents., Methods: In a group of 75 patients, 54 (72 %) female, who underwent surgery by triple pelvic osteotomy in adolescence for developmental disorder of the hip and avascular necrosis of the femoral head, a three-dimensional hip joint model was used based on the radiography of the pelvis with hips. The following biomechanical parameters were calculated: resultant hip force normalised to body weight (R/Wb), inclination of the resultant hip force (θ-R), the position of the stress pole (θ), peak contact hip stress (Pmax), and peak contact hip stress normalised to body weight (Pmax/Wb). Gait quality was also assessed., Results: After surgery the Wiberg CE angle was increased by 17.85° (114 %), resultant hip force normalised to body weight (R/Wb) was decreased by 0.107 (3.3 %), the position of the stress pole was shifted medially by 27.59° (63.5 %), and peak contact hip stress normalised to body weight (Pmax/Wb) was decreased by 2249.74 (55.9 %). Waddling gait was reduced from 17 (23.9 %) to four cases (5.6 %). All changes were statistically highly significant (p<0.01)., Conclusions: The effect of Tonnis triple pelvic osteotomy lies in the improvement of stress distribution across the acetabular cartilage of the hip joint, thus slowing down the degenerative damage of the hip joint.

Introduction: The aim of the study was to determine the validity of acetabular component position of the noncemented total hip endoprosthesis after Chiari pelvic osteotomy., Material and Methods: The study involved 75 patients operated on at the Institute of Orthopedic Surgery "Banjica" in the period from 1990-2009. The first group consisted of 39 patients (46 hips) who underwent Chiari pelvic osteotomy and also later the implantation of a noncemented total hip endoprosthesis. A control group consisted of 36 patients (47 hips) who underwent total hip arthroplasty due to degenerative hip dysplasia., Results: In the previously operated patients the centre of rotation of the hip was on the average placed more proximally, while in the control group of patients the position of the acetabular component was closer to the anatomical one. In the group of patients after Chiari osteotomy the mean acetabular cup abduction angle rated 41.8°±9.8°, while in the control group this value was on the average higher (45.4°±8.6°)., Discussion: There was a significant difference between the studied groups in relation to the distance between the acetabular component of endoprosthesis and the acetabular teardrop (t=-2.763; p=0.007). No statistically significant difference was determined in the mean value of the angle of acetabular abduction component of endoprosthesis between the studied groups of patients (t=1.878; p=0.064)., Conclusions: Acetabular component position of the total hip endoprosthesis was not compromised by anatomic changes of the acetabulum caused by Chiari pelvic osteotomy.

Femoroacetabular impingement is an undesirable contact between acetabular rim and femoral neck and presents abnormality of proximal femoral part and acetabulum, as well. Two forms may appear: cam impingement and pincer impingement. Femoroacetabular impingement related to Legg-Calvé-Perthes disease may be caused by various reasons, as the consequence of the disease itself, and as the consequence of its treatment. Coxa magna deformity (large femoral head and neck) and coxa brevis deformity (shortened femoral neck) may produce cam femoroacetabular impingement during hip flexion. After the disease, the flattened femoral head (coxa plana) may persist. Chiari pelvic osteotomy is the only treatment option for such femoral head deformity. Acetabular labrum squeezed continuously between the femoral head and the non-articular part of the cut iliac bone lead to cam femoroacetabular impingement, as well. If Salter or triple pelvic osteotomy is used that may cause a very large iatrogenic acetabular retroversion, we can also refer to radial type pincer femoroacetabular impingement. Treatment of Legg-Calvé-Perthes disease should be conducted according to the natural course of the disease and prognosis. Treatment should start on time, well before a crushed femoral head develops, because it is the easiest way to establish hip spherical congruency at the end of treatment. This is the best option to prevent secondary hip arthrosis caused by femoroacetabular impingement or by insufficient head coverage at the end of remodelling. In each case of delayed hip pain, followed by a limited range of movements, femoroacetabular impingement should be taken into consideration, confirmed, and treated by some of the available therapeutic methods.

Ninety-nine hips treated by the Chiari pelvic osteotomy were included in this study designed as a retrospective review. The group consisted of 36 male and 50 female patients, with mean age of 15.6 years. Each was diagnosed with developmental dysplasia of the hip (DDH) or avascular necrosis of the femoral head--Legg-Calve-Perthes disease (LCP)--and postreduction avascular necrosis (PAN). Five hip parameters (the acetabular angle of Sharp, the center-edge (CE) angle of Wiberg, the percentage of femoral head uncoverage, the acetabular depth ratio, and the Shenton-Menard arch continuity) were evaluated. Functional outcome was assessed according to Harris hip score (HHS) and McKay criteria for clinical evaluation. The postoperative results showed improvement in all the radiographic parameters. The angle of Sharp showed a decrease of 8.62º (p < 0.01). The CE angle of Wiberg showed an increase of 28.76º (p < 0.01), and the uncoverage of the femoral head showed a decrease of 51.51% (p < 0.01). The improvement of HHS was 11.93 (p < 0.05). The patients' satisfaction was indicated by grade 4.1 ± 0.94 and the doctor's satisfaction by grade 3.7 ± 1.16. The Chiari pelvic osteotomy, in spite of the development of biologically better procedures, has retained its position in the treatment of adolescent hip disorders.

Background: Proximal tubules of the kidney have a dominant function in the excretion of different enzymes in the urine. These enzymes can be used as markers for secondary renal damage under the action of different diseases, medicines, and toxins. The aim of this study was to evaluate the values of alanine aminopeptidase (AAP), gamma-glutamyl transferase (gamma-GT), and beta2 microglobulin (beta2m) in urine of patients with untreated rheumatoid arthritis (RA) and to define the possible association between untreated rheumatoid arthritis and tubular function at the brush border region., Methods: We used a kinetic assay for AAP, standard methods by the International Federation for Clinical Chemistry (IFCC) for gamma-GT and Microparticle Enzyme Immunoassay (MEIA), (Abbott A(x)SYM System) for the determination of beta2m in urine of 70 participants (35 untreated RA patients and 35 healthy volunteers (HC))., Results: From the total of 35 RA patients, AAP enzymuria was found in 24 patients with test sensitivity (68.57%), gamma-GT in 16 patients with test sensitivity (45.71%), while the presence of urinary beta2m was found in a very low percentage of cases. Out of 18 rheumatoid factor (RF) negative patients, 14 patients were AAP and 10 patients were gamma-GT positive, while the presence of beta2m in urine was not detected. Among 17 RF positive RA patients, the presence of AAP and gamma-GT was noticed in 10 and 6 patients, respectively, while the presence of beta2m in urine was not detected., Conclusions: In conclusion, AAP had a higher sensitivity than gamma-GT and beta2m in detection of asymptomatic renal lesions in untreated RA.

Hairy cell leukemia (HCL) is a very rare type of leukemia, in which abnormal B lymphocytes, present in the bone marrow, spleen, and peripheral blood stream, get worse slowly or do not get worse at all. HCL is the disease where patients have pancytopenia with splenomegalia over 90% percent, palpable lymphadenopathy occur in 35% of patients, some form of serious infection eventually developed in over 50% of patients and was the most common cause of death in patients. HCL is dominantly a male disease, with the male-female ratio, ranging from 4:1 to 7:1. Treatment and prognosis of HCL depends on: the number of HC in the peripheral blood or bone marrow, if the spleen is enlarged and on the existence of the visible leukemia infection symptoms. Prognostic factors are similar to the above mentioned and also if the basic disease HCL is aggressive or the number of HC grow slowly and there is no need for treatment. Starting from September 1985 till September 2010, we observed a group with total number of 28 patients (22 males and 6 females) at the age of 30-76 (median range 46 years), all with HCL disease. From the total number of participants, 20 patients (71,43%) received hemotherapy, Cladribine and 8 patients (28,57%) received different type of therapy, such as immunomodulator therapy, surgery or combination of both, without Cladribine. Most effective therapy for HCL, from all of the above mentioned was definitely Cladribine which is dominant with a resulting response rates of 80-100%, where 70-90% of patients were achieving a complete remission, as defined by a complete disappearance of hairy cells in the bone marrow.