As MMPs são endopeptidases zinco dependentes que, em conjunto, podem degradar todos os componentes da MEC e gerar moléculas bioativas. São as principais responsáveis pelo remodelamento tecidual durante eventos fisiológicos normais como a embriogênese e organogênese e também em eventos patológicos como a invasão tumoral nos tecidos. As pesquisas na área de mineralização biológica têm buscado identificar os genes envolvidos nos mecanismos moleculares que regula o processo de ossificação endocondral. As MMPs e seus inibidores são responsáveis pelo controle da degradação desta matriz, como os inibidores teciduais das MMPs (TIMPs) e a proteína RECK, que, muito provavelmente, determinam o grau de remodelação da matriz extracelular. Desta forma, nosso objetivo foi delinear o perfil temporal e espacial da expressão das MMP-15/MT2-MMP, MMP-16/MT3- MMP, MMP-17/MT4-MMP, MMP-24/MT5-MMP e MMP-25/MT6-MMP durante a ossificação endocondral em embriões de camundongos e em animais recémnascidos através das técnicas de PCR em tempo real e imunohistoquímica. Por imunohistoquímica, nós não encontramos imunomarcação para a MMP-15/MT2- MMP em nenhum dos períodos analisados, apesar da padronização do anticorpo primário. Tanto a MMP-16/MT3-MMP quanto a MMP-24/MT5-MMP foram imunolocalizadas, principalmente, nos osteoblastos do fronte de ossificação da placa de crescimento. Para a MMP-17/MT4-MMP, durante a diferenciação condrocítica (E13) os condrócitos proliferativos foram imunocorados, bem como os condrócitos hipertróficos no centro da cartilagem do molde cartilaginoso (E14). Durante a invasão celular e vascular (E15), as células mesenquimais oriundas do colar ósseo, provavelmente pré-osteoblastos, foram imunocorados na cavidade medular primitiva e osteoblastos fronte de ossificação foram imunocorados, de E16 a PN1. Observamos para a MMP-25/MT6-MMP o mesmo padrão de imunomarcação das demais MT-MMPs, exceto no molde cartilaginoso, onde apenas as células do periósteo e pericôndrio foram imunocoradas, diferentemente da demais que foram localizadas apenas no centro do molde cartilaginoso. A análise da expressão dos transcritos para todas as MT-MMPs revelou o mesmo perfil de expressão, sendo alta durante a fase de diferenciação condrocítica (E13), tendo queda de expressão de E14 a E16. Em E16 há um aumento de expressão até E18 e, novamente, queda até E20 e pouca ou nenhuma expressão em PN7. Apesar deste perfil semelhante, houve uma expressão diferencial entre elas, sendo a MMP-15/MT2-MMP > MMP- 17/MT4-MMP > MMP-16/MT3-MMP > MMP-24/MT5-MMP > MMP-25/MT6/MMP. Os resultados obtidos mostram, pela primeira vez, que as MT-MMPs estão diferencialmente expressas durante a ossificação endocondral normal em camundongos, sugerindo que a atividade biológica destas enzimas esteja atuando na degradação da matriz extracelular pericelular tanto durante a fase de desenvolvimento quanto de formação óssea. / MMPs are zinc-dependent endopeptidases that, collectivelly, degrade all components of the ECM and generate bioactive molecules. They are able to remodelate the ECM during normal developmental processes such as embryogenesis and organogenesis, as well as in pathological processes such as tumoral invasion. The biological mineralization research looking for discovering the genes involved in the molecular mechanisms that control the endochondral ossification process. MMPs and their inhibitors (TIMPs and RECK) are responsable for bone matrix remodeling and, probably, determinate the level of its turnover. Thus, our goal was to evaluate the temporal-spatial expression of MMP-15/MT2-MMP, MMP-16/MT3-MMP, MMP-17/MT4-MMP, MMP-24/MT5-MMP, and MMP-25/MT6- MMP in mice embryos and newborns during endochondral ossification by Real Time PCR and immunohistochemistry. By immunohistochemistry, MMP-15/MT2-MMP signal was not detected. Both MMP-16/MT3-MMP and MMP-24/MT5-MMP were immunostained, mainly in osteoblasts at ossification front of growth plate. For MMP- 17/MT4-MMP, proliferative chondrocytes were immunopositive during chondrocyte differentiation (E13) as well as in hipertrophyc chondrocytes at the middle of cartilaginous template (E14). During cellular e vascular invasion (E15), mesenchymal cells from bone collar, probable pre-osteoblasts, were immunostained at primary bone marrow and osteoblasts at ossification front from E16 e PN1. For MMP- 25/MT6-MMP, perichondrial and periostal cellls were immunostained at cartilaginous template. All MT-MMPs evaluated showed the same transcript levels profile, being high in chondrocyte differentiation (E13), decreasing from E14 to E16. mRNA levels increased from E16 to E18 and, once more, decreasing from E18 to E20. Despite this profile, we observed difference levels: MMP-15/MT2-MMP > MMP-17/MT4-MMP > MMP-16/MT3-MMP > MMP-24/MT5-MMP > MMP-25/MT6/MMP. Our findings show, for the first time, that MT-MMPs are differentially expressed during normal endochondral ossification in mice, suggesting their biological activity act in pericellular extracellular matrix degradation in both development and bone formation.

As MMPs são endopeptidases zinco dependentes que, em conjunto, podem degradar todos os componentes da MEC e gerar moléculas bioativas. São as principais responsáveis pelo remodelamento tecidual durante eventos fisiológicos normais como a embriogênese e organogênese e também em eventos patológicos como a invasão tumoral nos tecidos. As pesquisas na área de mineralização biológica têm buscado identificar os genes envolvidos nos mecanismos moleculares que regula o processo de ossificação endocondral. As MMPs e seus inibidores são responsáveis pelo controle da degradação desta matriz, como os inibidores teciduais das MMPs (TIMPs) e a proteína RECK, que, muito provavelmente, determinam o grau de remodelação da matriz extracelular. Desta forma, nosso objetivo foi delinear o perfil temporal e espacial da expressão das MMP-15/MT2-MMP, MMP-16/MT3- MMP, MMP-17/MT4-MMP, MMP-24/MT5-MMP e MMP-25/MT6-MMP durante a ossificação endocondral em embriões de camundongos e em animais recémnascidos através das técnicas de PCR em tempo real e imunohistoquímica. Por imunohistoquímica, nós não encontramos imunomarcação para a MMP-15/MT2- MMP em nenhum dos períodos analisados, apesar da padronização do anticorpo primário. Tanto a MMP-16/MT3-MMP quanto a MMP-24/MT5-MMP foram imunolocalizadas, principalmente, nos osteoblastos do fronte de ossificação da placa de crescimento. Para a MMP-17/MT4-MMP, durante a diferenciação condrocítica (E13) os condrócitos proliferativos foram imunocorados, bem como os condrócitos hipertróficos no centro da cartilagem do molde cartilaginoso (E14). Durante a invasão celular e vascular (E15), as células mesenquimais oriundas do colar ósseo, provavelmente pré-osteoblastos, foram imunocorados na cavidade medular primitiva e osteoblastos fronte de ossificação foram imunocorados, de E16 a PN1. Observamos para a MMP-25/MT6-MMP o mesmo padrão de imunomarcação das demais MT-MMPs, exceto no molde cartilaginoso, onde apenas as células do periósteo e pericôndrio foram imunocoradas, diferentemente da demais que foram localizadas apenas no centro do molde cartilaginoso. A análise da expressão dos transcritos para todas as MT-MMPs revelou o mesmo perfil de expressão, sendo alta durante a fase de diferenciação condrocítica (E13), tendo queda de expressão de E14 a E16. Em E16 há um aumento de expressão até E18 e, novamente, queda até E20 e pouca ou nenhuma expressão em PN7. Apesar deste perfil semelhante, houve uma expressão diferencial entre elas, sendo a MMP-15/MT2-MMP > MMP- 17/MT4-MMP > MMP-16/MT3-MMP > MMP-24/MT5-MMP > MMP-25/MT6/MMP. Os resultados obtidos mostram, pela primeira vez, que as MT-MMPs estão diferencialmente expressas durante a ossificação endocondral normal em camundongos, sugerindo que a atividade biológica destas enzimas esteja atuando na degradação da matriz extracelular pericelular tanto durante a fase de desenvolvimento quanto de formação óssea. / MMPs are zinc-dependent endopeptidases that, collectivelly, degrade all components of the ECM and generate bioactive molecules. They are able to remodelate the ECM during normal developmental processes such as embryogenesis and organogenesis, as well as in pathological processes such as tumoral invasion. The biological mineralization research looking for discovering the genes involved in the molecular mechanisms that control the endochondral ossification process. MMPs and their inhibitors (TIMPs and RECK) are responsable for bone matrix remodeling and, probably, determinate the level of its turnover. Thus, our goal was to evaluate the temporal-spatial expression of MMP-15/MT2-MMP, MMP-16/MT3-MMP, MMP-17/MT4-MMP, MMP-24/MT5-MMP, and MMP-25/MT6- MMP in mice embryos and newborns during endochondral ossification by Real Time PCR and immunohistochemistry. By immunohistochemistry, MMP-15/MT2-MMP signal was not detected. Both MMP-16/MT3-MMP and MMP-24/MT5-MMP were immunostained, mainly in osteoblasts at ossification front of growth plate. For MMP- 17/MT4-MMP, proliferative chondrocytes were immunopositive during chondrocyte differentiation (E13) as well as in hipertrophyc chondrocytes at the middle of cartilaginous template (E14). During cellular e vascular invasion (E15), mesenchymal cells from bone collar, probable pre-osteoblasts, were immunostained at primary bone marrow and osteoblasts at ossification front from E16 e PN1. For MMP- 25/MT6-MMP, perichondrial and periostal cellls were immunostained at cartilaginous template. All MT-MMPs evaluated showed the same transcript levels profile, being high in chondrocyte differentiation (E13), decreasing from E14 to E16. mRNA levels increased from E16 to E18 and, once more, decreasing from E18 to E20. Despite this profile, we observed difference levels: MMP-15/MT2-MMP > MMP-17/MT4-MMP > MMP-16/MT3-MMP > MMP-24/MT5-MMP > MMP-25/MT6/MMP. Our findings show, for the first time, that MT-MMPs are differentially expressed during normal endochondral ossification in mice, suggesting their biological activity act in pericellular extracellular matrix degradation in both development and bone formation.

<p>Heparan sulfate (HS) is a ubiquitous polysaccharide on the cell surface and in the extracellular matrix. HS is an important actor in the regulation of cell signaling, especially in the developing embryo. In combination with cell culture and biochemical experiments, <i>in vivo</i> studies of genetically modified animals have pointed out the sulfation pattern of HS as highly important for binding of ligands, their receptors and other signaling modulators.</p><p>The sulfation pattern of an HS chain is gained by several modifying steps, performed by multiple enzymes during biosynthesis in the Golgi apparatus. By alterations of sulfation pattern, and the amount of sulfate groups, a cell can regulate the binding properties of its HS to different molecules. The most highly sulfated form of HS is called heparin, and can only be found intracellularly in mast cells.</p><p>This thesis describes the phenotypes and the alterations in HS/heparin biosynthesis of two genetically modified mouse strains deficient in N-deacetylase/N-sulfotransferase-1 (NDST1) and -2 (NDST2) respectively. We have found NDST1 to be important for correct sulfation of HS and that NDST2 is crucial in heparin biosynthesis. NDST2 deficient mice completely lack heparin and therefore have a severe mast cell phenotype. NDST1 deficient mice produce undersulfated HS and show several developmental disturbances. Some NDST1 embryos die in utero while the rest die neonatally due to breathing difficulties. Defect brain, eye and skeletal development has also been observed while some organs, such as the liver, appear to be largely unaffected. Several phenotypes are similar to defects seen in other mouse strains with impaired fibroblast growth factor and bone morphogenetic protein signaling, among others. This suggests the phenotypes of NDST1 deficient embryos to be of a multi factorial origin, in complete accordance to the many signaling pathways HS is suggested to modulate.</p>

Heparan sulfate (HS) is a ubiquitous polysaccharide on the cell surface and in the extracellular matrix. HS is an important actor in the regulation of cell signaling, especially in the developing embryo. In combination with cell culture and biochemical experiments, in vivo studies of genetically modified animals have pointed out the sulfation pattern of HS as highly important for binding of ligands, their receptors and other signaling modulators. The sulfation pattern of an HS chain is gained by several modifying steps, performed by multiple enzymes during biosynthesis in the Golgi apparatus. By alterations of sulfation pattern, and the amount of sulfate groups, a cell can regulate the binding properties of its HS to different molecules. The most highly sulfated form of HS is called heparin, and can only be found intracellularly in mast cells. This thesis describes the phenotypes and the alterations in HS/heparin biosynthesis of two genetically modified mouse strains deficient in N-deacetylase/N-sulfotransferase-1 (NDST1) and -2 (NDST2) respectively. We have found NDST1 to be important for correct sulfation of HS and that NDST2 is crucial in heparin biosynthesis. NDST2 deficient mice completely lack heparin and therefore have a severe mast cell phenotype. NDST1 deficient mice produce undersulfated HS and show several developmental disturbances. Some NDST1 embryos die in utero while the rest die neonatally due to breathing difficulties. Defect brain, eye and skeletal development has also been observed while some organs, such as the liver, appear to be largely unaffected. Several phenotypes are similar to defects seen in other mouse strains with impaired fibroblast growth factor and bone morphogenetic protein signaling, among others. This suggests the phenotypes of NDST1 deficient embryos to be of a multi factorial origin, in complete accordance to the many signaling pathways HS is suggested to modulate.

Με τον όρο «Έκτοπη Οστεοποίηση» περιγράφεται ο σχηματισμός οστού σε σημεία που υπό φυσιολογικές συνθήκες δεν υφίσταται. Τα σημεία αυτά μπορεί να είναι μύες, τένοντες ή σύνδεσμοι και γενικότερα μεσεγχυματικού τύπου μαλακά μόρια, κυρίως γύρω από τις μεγαλύτερες αρθρώσεις. Η επίκτητη μορφή της νόσου, που είναι και η πιο κοινή, εμφανίζεται μετά από μυοσκελετικούς τραυματισμούς, κακώσεις του νωτιαίου μυελού και του κεντρικού νευρικού συστήματος γενικότερα, αλλά και σε περιπτώσεις σοβαρών εγκαυμάτων. Η παθοφυσιολογία της έκτοπης οστεοποίησης παραμένει άγνωστη, αυτό που γνωρίζουμε με βεβαιότητα είναι ότι για τον σχηματισμό της απαιτούνται τρείς βασικές προϋποθέσεις που είναι α) τα οστεοπρογονικά κύτταρα, β) οι κατάλληλοι επαγωγικοί παράγοντες και γ) το ευνοϊκό οστεοεπαγωγικό περιβάλλον. Στην παρούσα εργασία με την χρήση κυτταρομετρίας ροής, δοκιμασιών με ηλεκτροχημειοφωταύγεια, Elisa και ανοσοπροσδιορισμού με χρήση Cytometric Bead Array προσδιορίσαμε τις συγκεντρώσεις των total procollagen type 1 amino-terminal propeptide (TP1NP), osteoprotegerin (OPG), β-isomerized C-terminal telopeptides (β- Crosslaps), soluble receptor activator of nuclear factor kappa-B ligand (sRANKL), N-MID osteocalcin, S100 και των κυτταροκινών IL-2, IL-4, IL-6, IL-10, INF-γ και TNF-a στον ορό ασθενών και υγιών μαρτύρων. Επιπλέον, στο ολικό αίμα προσδιορίσαμε τον πληθυσμό των θετικών στην οστεοκαλσίνη κυττάρων. Όλα τα προς μελέτη μόρια είχαν άμεση ή έμμεση σχέση με την οστική ανακατασκευή και τις φλεγμονώδεις αντιδράσεις. Συνολικά μελετήθηκαν 55 ασθενείς από τους οποίους ελήφθησαν δείγματα καθόλη την διάρκεια νοσηλείας τους. Οι ασθενείς μελετήθηκαν με βάση το είδος του τραύματος, την εμφάνιση ή όχι έκτοπης οστεοποίησης και την έκβαση της κατάστασης τους. Επιπλέον, οι επιμέρους ομάδες ασθενών μελετήθηκαν συναρτήσει του χρόνου. Τα αποτελέσματα μας έδειξαν ότι στο σύνολο των ασθενών παρατηρήθηκαν στατιστικά μειωμένα επίπεδα β- crosslaps, N-MID osteocalcin, sRANKL και S100 συγκριτικά με τους υγιείς μάρτυρες. Αντίθετα, τα επίπεδα των TP1NP, των θετικών στην οστεοκαλσίνη κυττάρων, της OPG, της INF-γ και της IL-6 ήταν στατιστικά σημαντικά αυξημένα. Επιπλέον, στατιστικά σημαντικά αυξημένα παρατηρήθηκαν τα επίπεδα του S100 στους ασθενείς που είχαν υποστεί κρανιοεγκεφαλικές κακώσεις κατά το πρώτο εικοσιτετράωρο μετά την επαγωγή της κάκωσης. Στατιστικά σημαντικά αυξημένο επίσης παρατηρήθηκε και στην ομάδα των ασθενών με κακή έκβαση συγκριτικά με τους υγιείς δότες. Στην ίδια ομάδα ασθενών παρατηρήθηκε μια γενικευμένη αύξηση των επιπέδων των κυτταροκινών που φαίνεται να σχετίζεται άμεσα με την κακή έκβαση της κατάστασης τους. Πιο συγκεκριμένα η αύξηση αυτή ήταν στατιστικώς σημαντική για τις IL-4, INF-γ και TNF-α. / Heterotopic ossification (HO) is the presence of bone in soft tissue where normally does not exist. The acquired form, which is also the most common, develops after musculoskeletal trauma, spinal cord injury or central nervous system injury and severe burns. Pathophysiology of OH still remains unclear, what we know is that the formation of ectopic bone requires three entities which are a) osteogenic precursor cells, b) inducing agents and c) an appropriate environment. In the present study using either flow cytometry, Elisa, electrochemiluminescence immunoassays or cytometric bead array assays we determined the concentrations of the osteoblast progenitors: osteocalcin positive cells in peripheral blood and the serum concentrations of total procollagen type 1 amino-terminal propeptide (TP1NP), osteoprotegerin (OPG), β-isomerized C-terminal telopeptides (β- Crosslaps), soluble receptor activator of nuclear factor kappa-B ligand (sRANKL), N-MID osteocalcin, S100 and the cytokines IL-2, IL-4, IL-6, IL-10, INF-γ and TNF-a. All measured molecules participate directly or indirectly in bone formation and metabolism and in inflammation. Our 55 patients were divided and studied in 3 different ways, regarding the kind of their injury, their outcome and the formation of HO. They were also monitored in course of time. Among our most interesting results is that patients had significantly lower levels of β- crosslaps, N-MID osteocalcin, sRANKL and S100 compared to healthy donors. On the other hand, levels of TP1NP, osteocalcin positive cells, OPG, INF-γ and IL-6 were significantly higher. S100 is significantly increased during the first 24 hours in patients who have sustained traumatic brain injury. In addition, S100 was significantly increased in patients with poor outcome compared to healthy donors. Furthermore, patients with poor outcome seem to develop a cytokine storm which is of great importance for their outcome. All measured cytokine levels were increased compared to patients with good outcome. Especially for IL-4, INF-γ, TNF-α this increase was statistically significant.

Purpose: To determine whether reduced serum levels of AHSG and elevated levels of BMP-2, 4, 7 are associated with post-arthroplasty HO. Patients: Thirty arthroplasty patients were included, 15 with evidence of peri-articular HO and 15 without (NHO). Methods: Blood samples were collected from all patients ≥ 8 weeks after arthroplasty. Analytes were measured using ELISAs. Mann-Whitney U tests were performed to compare serum analyte concentrations between HO and NHO groups, and between arthroplasty patients and healthy humans. Results: There is no difference in serum concentrations of AHSG, BMP-2, 4, 7 between HO and NHO patients. Arthroplasty patients showed significantly higher BMP-2 and BMP-4 and lower AHSG serum levels compared to healthy humans (p < 0.01). Conclusion: Baseline BMP-2, 4, 7 and AHSG serum levels are not markers of acquired HO. However, elevated baseline levels of BMP- 2, 4 and reduced levels of AHSG appear to be markers of severe inflammatory arthritis.

Purpose: To determine whether reduced serum levels of AHSG and elevated levels of BMP-2, 4, 7 are associated with post-arthroplasty HO. Patients: Thirty arthroplasty patients were included, 15 with evidence of peri-articular HO and 15 without (NHO). Methods: Blood samples were collected from all patients ≥ 8 weeks after arthroplasty. Analytes were measured using ELISAs. Mann-Whitney U tests were performed to compare serum analyte concentrations between HO and NHO groups, and between arthroplasty patients and healthy humans. Results: There is no difference in serum concentrations of AHSG, BMP-2, 4, 7 between HO and NHO patients. Arthroplasty patients showed significantly higher BMP-2 and BMP-4 and lower AHSG serum levels compared to healthy humans (p < 0.01). Conclusion: Baseline BMP-2, 4, 7 and AHSG serum levels are not markers of acquired HO. However, elevated baseline levels of BMP- 2, 4 and reduced levels of AHSG appear to be markers of severe inflammatory arthritis.

Diss. (sammanfattning) Linköping : Univ., 2002. / Härtill 4 uppsatser.

O objetivo deste trabalho foi estudar o efeito da radioterapia na profilaxia da ossificação heterotópica (OH) em pacientes com lesão medular traumática. Foram estudados 19 pacientes (15 homens e quatro mulheres), média de idade de 30,4 ± 10,8 anos (19 a 58 anos), com lesão medular traumática. A causa mais freqüente da lesão medular foi acidente de trânsito (42,1%), seguida por queda (26,3%), ferimento por projétil de arma de fogo (21%), mergulho (5,3%) e queda de objeto sobre as costas (5,3%). Dez pacientes eram tetraplégicos (52,6%) e nove (47,4%) eram paraplégicos. Apresentavam lesão medular completa (Frankel A) 14 pacientes (73,7%) e cinco pacientes (25,3%) tinham lesão incompleta (Frankel B). Todos os pacientes incluídos no estudo realizaram cintilografia óssea inicial até um mês após o traumatismo raquimedular e apresentaram diagnóstico negativo para OH. Os pacientes foram divididos em dois grupos: nove pacientes receberam radioterapia em dose única de 8 Gy nos quadris (Grupo Estudo) e 10 pacientes compuseram o Grupo Controle. Após seis meses de seguimento clínico e radiológico, um paciente do Grupo Estudo (11%) e cinco pacientes do Grupo Controle (50%) apresentaram OH. A distribuição da freqüência do desenvolvimento da OH nos dois grupos não mostrou diferença estatística significante, apesar da menor incidência de OH no grupo submetido à radioterapia (Grupo Estudo). Concluiu-se que, com o número de pacientes estudados, não foi possível comprovar a eficácia da radioterapia na prevenção da ossificação heterotópica, ainda que haja uma forte tendência para a correlação estatística / The goal of this study was to evaluate the effect of radiotherapy on the prophylaxis of heterotopic ossification (HO) after spinal cord injury (SCI). Nineteen SCI patients were studied (15 men and four women). The mean age was 30.4 ± 10.8 years (range 19 to 58 years). The most frequent causes of lesion were traffic accident (42.1%), fall (26.3%), shot gun (21%), diving (5.3%) and objects falling on the vertebral column (5.3%). Ten patients were tetraplegics (52.6%) and nine were paraplegics. Fourteen patients (73.7%) had complete lesion (Frankel A) and five had incomplete lesion (Frankel B). All patients realized initial scintigraphy until one month after SCI and showed negative results for HO. The patients were randomized in two groups: nine patients received single dose irradiation with 8 Gy on the hips (Study Group) and 10 patients were the Control Group. After six months of clinical and radiological follow up, one patient of the Study Group (11%) and five patients of Control Group (50%) showed HO. The frequency distribution of the development of HO in both groups showed no significant statistical difference, although there was lower incidence of HO in the radiotherapy group. We concluded that, with the number of patients studied, it was no possible to prove the efficacy of radiotherapy to prevent HO, although had a strong tendency for the statistical correlation

1 PURPOSE OF THE STUDY Heterotopic ossification is frequent and well known complication after primary total hip arthroplasty. Prophylaxis is crucial, ohterwise when ossification is matured, the only treatment option is surgical removal during revision hip surgery. Prophylaxis options are pre, peri- and postoperative modalities. Effectiveness of the profylaxis step sis the aim of this disertation. The goal of Study 1 was to prove the positive side effect of tranexamic acid application to reduce the heterotopic ossification ratio after elective total hip replacement. The goal of Study 2 was to prove the reduction in HO ratio with experimental modification of anterolateral approach with electrosurgery. The goal of Study 3 was to detect the knowledge among czech orthopaedic surgeons in ossification issues and compare the results of questionnaire with german results. 2 MATERIAL AND METHODS Study 1 Cohort of 401 total hip replacements were assessed prospectivelly. Stratification of particular degrees in Brooker scale, sex, laterality and fixation type were evaluated. The average follow up was 6,10 year (40m to 113m). Hips from 2012 are referential and hips from 2016 are administered to tranexamic acid procotol. Other secondary prophylactic modalities (farmacoprophylaxy or radiotherapy), tertiary...