Alexander Blankstein

Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period. Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine. Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low. Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.

Closing intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: a preliminary report.

The results of treatment of 20 unstable diaphyseal fractures of the forearm in adolescent patients by closed intramedullary nailing are presented. All fractures healed within 4-7 weeks. No cross-union, nonunion, pseudarthrosis, or infection occurred. The advantages of this method are (a) maintenance of accurate reduction, (b) reduction of complication rate, (c) negligible cosmetic defect, and (d) removal of the internal fixation device under local anesthesia.

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations.

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3–5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3–18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.

Congenital muscular torticollis in infants : Ultrasound-assisted diagnosis and evaluation

Ultrasonography is considered the modality of choice for differentiating congenital muscular torticollis from other pathologies in the neck. The authors present their experience with ultrasound examination for the evaluation and management of congenital muscular torticollis. Twenty-six infants, 14 boys and 12 girls, age ranging from 1 to 16 weeks, with torticollis and a palpable mass were examined. Ultrasound showed a well-defined mass in the sternocleidomastoid muscle. The lesions ranged in size from 8 to 15.8 mm on maximal transverse diameter, with length ranging from 13.7 to 45.8 mm. Clinically the torticollis disappeared between 1 to 6 weeks, with complete clinical reduction of the palpated mass between 2 and 8.5 weeks. The ultrasonographic disappearance of the mass was delayed by an average of 2 weeks in comparison to the clinical disappearance of the mass. Ultrasound is advocated for the diagnosis and follow-up of congenital muscular torticollis because it noninvasively provides reliable and dynamic information without sedation.

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.

Septic arthritis of the acromioclavicular joint.

SummaryA patient with isolated pyogenous arthritis of the acromioclavicular joint (A-C joint) caused by Streptococcus viridans is described. The patient had no underlying disease. Minor trauma preceded shortly the development of the septic process. The patient was treated successfully with surgical drainage and antibiotics. To our knowledge this is the first case report of septic arthritis of the A-C joint caused by Streptococcus viridans. The A-C joint is rarely involved in septic processes. Even conditions such as intravenous drug abuse [3, 6] and renal dialysis [4, 7] which tend to infect unusual joints [5] have only rarely been described in association with A-C septic arthritis.ZusammenfassungEin Patient mit einer isolierten pyogenen Arthritis des Acromioclavicular-Gelenks, hervorgerufen durch Streptococcus viridans, wind beschrieben. Der Patient hatte keine zugrunde liegende Krankheit. Ein leichtes Trauma ging den Entwicklung des septischen Prozesses voraus. Der Patient wurde erfolgreich mit chirurgischer Drainage und Antibiotica behandelt. Nach unserem Wissen ist dies der erste Bericht über septische Arthritis des Acromioclavicular-Gelenks, hervorgerufen durch Streptococcus viridans. Das Acromioclavicular-Gelenk ist selten von septischen Prozessen betroffen. Sogar Bedingungen wie intravenöser Drogenmißbrauch und Nierendialyse, die zur Infektion ungewöhnlicher Gelenke führen können, wurden nun selten in Verbindung mit septischen Arthritis des Acromioclavicular-Gelenks beschrieben.

Self-inflicted hand injuries: diagnostic challenge and treatment.

Self-inflicted injuries are probably more common than is generally appreciated. Three patients with self-inflicted hand injuries are described. A delay in making the correct diagnosis resulted in severe hand disability in 2 of the patients. Early diagnosis of this entity, combined with prompt psychotherapy, prevented disability in the third. The pertinent literature is reviewed and the importance of early diagnosis and psychotherapy is stressed.

Disc space infection and vertebral osteomyelitis as a complication of percutaneous lateral discectomy

Percutaneous lateral discectomy (PLD) in a 32-year-old man was followed by postoperative disc space infection and adjacent vertebral osteomyelitis caused by Staphylococcus aureus. The simplicity and decreased morbidity associated with PLD may be offset by severe infections. The small incision made in the annulus during PLD may not allow adequate drainage in the case of infection and may subsequently direct the infective process to the adjacent vertebral endplates. Meticulous aseptic technique, and possibly the use of prophylactic antibiotic therapy, is important in PLD.

Subluxation of the Hip Joint During Femoral Lengthening

Three cases of subluxation of the hip joint occurred during femoral lengthening using the Wagner technique. This infrequent complication, which may result from a conflict of force vectors at the hip joint during lengthening, can, when left untreated, nullify the benefits of such a procedure. We suggest that increased awareness and closer monitoring can improve the prognosis for patients undergoing this course of therapy, especially where a previous hip operation has been performed.

Fishing penetration injuries

Background—Fishing involves millions of people throughout the world and is considered a pleasant and harmless sport. However, many kinds of injury can occur. Penetrating injuries to the extremities by fishing equipment such as hooks and harpoons, and even by scales, or infection from penetration of scales etc are relatively common although hardly ever reported in the literature. Methods—Illustrative cases of penetrating fishing injuries are presented and discussed, with suggestions for the recommended management of these types of injury. Results—Most of these objects are designed to catch and hold resisting fish, so are usually sharp and narrow in the front and wider in the rear with or without spurs. Because of their very irregular shape, simple extraction by pulling is not recommended, because further damage may occur. Conclusions—The use of the appropriate imaging modalities, a full knowledge of the contours of the object, and careful preplanning of the method of treatment are very important.