Aharon Chechick

The epidemic of ankle fractures in the elderly--is surgical treatment warranted?

Abstract Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%–30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 ± 8.96 in the non-operated group compared with 75.2 ± 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

Localization, detection and guided removal of soft tissue in the hands using sonography.

Abstract Penetrating wounds and lacerations are frequent pathologies treated in the emergency room. The management of hand trauma represents a large part of the work in any surgical practice. Although X-rays are routinely taken, numerous foreign bodies remain undetected, and the wounds are just locally debrided and the lacerations sutured. Unfortunately, as not all foreign bodies are radio-opaque, the radiography results may appear normal, but the patient fails to recover. Patients complaining of persistent wound tenderness were sent for ultrasound investigations, and foreign bodies were detected. Had ultrasonography been carried out initially in the emergency room, the correct diagnosis would have been made, and the sonographic equipment could have helped to guide the physician in his attempt to remove the foreign body. Usually, in response to continued pain, an ultrasound investigation is ordered, and the pathology becomes apparent. A number of examples are briefly described in order to highlight the present inadequacies. It is suggested that hospital administrators consider the need to provide ultrasonographic services as an integral facility of the emergency room.

Ultrasonography: an imaging modality enabling the diagnosis of bipartite patella.

Ultrasound was used to diagnose bipartite patella in seven adolescents with anterior knee pain, and the findings were compared to those from plain radiography and to those of a group of asymptomatic subjects. In all affected individuals the quadriceps and patellar tendons appeared normal on ultrasound. Sonographic examination of the patella demonstrated an irregularity of the bony contour with occurrence of a cleft between the main part of the patellar body and the large superolateral accessory ossicle. The signal detected in the interface between bones was less echogenic than bone reflecting its fibrocartilaginous nature. The correlation with conventional radiography was absolute, as was the inter- and intraobserver reliability. Ultrasound is thus proposed as a simple and reliable imaging modality in bipartite patella. We do not believe that it should replace the initial radiographic, but it can be used to evaluate the contralateral knee for bilaterality and as an adjunct to therapeutic procedures such as local injections to increase the accuracy of treatment.

Biochemical alterations secondary to disuse atrophy in the rat's serum and limb tissues.

Abstract Disuse atrophy has been the subject of research studies of an animal model in which single-limb immobilization induces atrophic changes in the immobilized limb. These reveal systemic changes in the experimental animals that go far beyond the local response expected in that situation and are not fully understood as yet. We therefore performed a biochemical study on the effect of hind-limb immobilization on the serum and tissues of rats. The experiment was carried out on 70 young Sprague-Dawley male rats. In one group of 35 rats, the left hind-limb was immobilized for 3 weeks. Another group of 35 rats served as controls. Serum total protein, albumin, urea, creatinine, and calcium were found to be reduced during immobilization. Serum cholesterol levels, on the other hand, increased to a considerable extent. No changes were recorded with phosphate, bilirubin, and magnesium. Serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were both reduced in activity. The activity of muscle aspartate aminotransferase (AST) and bone alkaline phosphatase (ALP) was also decreased. Lactate dehydrogenase (LDH) remained unchanged in both serum and muscle. We discuss our findings in the light of previous knowledge regarding the atrophic process.

Non-union of undisplaced radial neck fracture in a rheumatoid patient

Abstract Non-union of an undisplaced fracture of the radial neck in a rheumatoid patient is presented. Possible causes are discussed, and the literature reviewed.

ULTRASONOGRAPHIC DIAGNOSIS IN THE EVALUATION OF SHOULDER PAIN

The benefit of adding sonography to the examination of patients suffering from shoulder pain, was examined in this retrospective evaluation. A patient suffering from shoulder pain consults generally his family physician, who sends his patient first to a radiography and not to sonography. In 75% of the patients examined by sonography, shoulder lesions were diagnosed, demonstrated in only 33% of radiographs. Most patients had more than one lesion: 38% had partial or full-thickness tears of the supraspinatus tendon, about one third bicipital tendonitis, 18% irregularities of the humeral greater tuberosity, 10% subdeltoid bursitis and about 10% calcified tendonitis. In about a quarter of the patients, no pathology was found. Many patients had more than one lesion. In conclusion, clinicians encountering shoulder pain should not be content with conventional radiography and are encouraged to make sonographic examinations part of the early diagnostic protocol.

Versatile Utilization of Massive Bone Allografts in Orthopedic Surgery.

The clinical use of massive bone allografts in orthopaedic surgery has become common practice in tumour operations and primary and revision total joint replacement. In certain special clinical situations associated with large bone loss, such as trauma, limb-length discrepancy repair or even infection, massive bone allografts can be successfully used. We present our treatment results of 47 patients who suffered from major bone loss due either to trauma, limb-length discrepancy repair, or infection. Our results (> 2 years minimum follow-up to allow full-bone allograft incorporation) indicate that the use of massive bone allografts in these special and delicate medical conditions is feasible, and have good functional results.

Fixation of humeral surgical neck fracture using contoured pins versus straight pins: a mechanical study

The conventional procedure for displaced fracture of the surgical neck of the humerus uses straight pins inserted from the lateral aspect towards the head of the humerus. The objective of this study was to compare the mechanical properties of fixation by contoured (curved) pins to those fixed with regular straight pins. A transverse osteotomy was made in 30 fresh-frozen sheep humeri in the proximal metaphyseal bone region, and pins were inserted using either three parallel straight pins or three contoured pins in different planes. The assemblies were subjected to bending or rotational stresses at the fracture site. Loads versus deformations were acquired during loading and rigidity was calculated. Results showed that in bending, fixation with straight pins was 31% more rigid compared to contoured pins (p < 0.001), and in torsion, fixation using contoured pins was 21% more rigid compared to straight pins (p < 0.001). A combination of the two fixation types should be considered.RésuméLe procédé conventionnel d’ostéosynthèse des fractures déplacées du col chirurgical de l’humérus utilise des broches rectilignes introduites par la face latérale en direction de la tête humérale. Le but de cette étude était de comparer l’utilisation de broches pré-formées et des broches rectilignes. Une ostéotomie transversale métaphysaire était faite sur 30 humérus de mouton avec montage par 3 broches rectilignes parallèles ou 3 broches incurvées dans différents plans. Ces montages étaient soumis à des forces de flexion et des forces de rotation au niveau de l’ostéotomie. Les résultats montraient qu’en flexion les broches rectilignes étaient plus rigides que les broches incurvées (p < 0,001) et qu’en torsion la fixation avec des broches incurvées était plus rigide que celles avec des broches rectilignes (p < 0,001). Une combinaison des 2 types de fixation paraît interessante.

CHARACTERISTICS OF SOFT TISSUE MASS IN THE HAND BY ULTRASONOGRAPHIC EXAMINATION

Soft tissue masses are amongst the commonest complaints encountered in orthopedic practice. Of these, masses found in the hand and the wrist are presented at higher frequency. They are often painful and may cause limitation of movement. This work describes the prevalence and the nature of soft tissue masses in the hand and wrist encountered in routine practice. This work was performed to assess the characteristics of soft tissue mass in the hand and the effectiveness of ultrasonography in the diagnosis of soft tissue masses and their differentiation from other lesions in the hand and wrist. Orthopedic surgical conditions that involve soft tissue in the hand and wrist may remain a diagnostic challenge when clinical diagnosis is uncertain and standard X-rays are non-diagnostic. High resolution ultrasound is widely available, non-invasive, without damage of radiation, imaging modality that can help the diagnosis. We reviewed retrospectively 25 patients with soft tissue masses. We compared the ultrasound findings with the histological findings in seven operated patients. A substantial majority of these lesions occurred in the right hand: 79% of the lesions were in the dorsal aspect of the hand, of which 37% were distal to the wrist joint, among them 42% at wrist either radial or ulnar; and 21% of the lesions were found in the volar aspect, among them 17% at wrist aspect, either radial or ulnar side. No predisposing factors could be found. The findings of this study reaffirm the utility of ultrasonography as primary diagnostic tool in routine orthopedic practice.

An iatrogenic subtrochanteric fracture —a rare complication of pinning for subcapital fractures of the hip

SummaryWe present a case of a subtrochanteric fracture that occurred 1 week after the surgical treatment of a Garden 1 Type subcapital fracture by way of pinning in situ with multiple Knowles pins. The event took place in the patients bed with no evidence of trauma of any kind. The fracture line went through the insertion site of the lower (distal) pin. This rare type of complication was successfully treated by revision surgery and fixation of both fractures by way of a Richards dynamic hip screw. We review the literature with regard to the incidence, the possible etiological factors involved and the recommended modes or treatment.ZusammenfassungWir stellen den Fall einer subtrochantären Fraktur vor, die sich eine Woche nach der chirurgischen Behandlung einer subkapitalen Garden-Type-1 Fraktur durch In-situ-Fixierung mit mehreren Knowles-Nägeln ereignete. Die Fraktur trat ohne jeglichen Hinweis auf ein Trauma auf, als die Patientin im Bett lag. Die Bruchlinie lief durch den Insertionspunkt des distalen Nagels. Diese seltene Komplikation ließ sich in einer erneuten Operation, bei der beide Frakturen mittles dynamischer Richard-Hüftgelenkschraube fixiert wurden, erfolgreich behandeln.Wir geben einen Überblick der Literatur zu dieser Komplikation, ihrer möglichen ätiologischen Faktoren und der empfohlenen Behandlungsformen.