Amir Herman

Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches.

Objective: To compare the reduction quality, surgery time, and early postoperative complications between the 2 following surgical approaches: the ilioinguinal and the anterior intrapelvic (AIP or modified Rives–Stoppa). Design: Retrospective study. Patients: Comparison of 122 patients operated in our center between 1996 and 2003 with the ilioinguinal approach and 103 cases operated between 2004 and 2011 with the AIP approach. Setting: Level 1 trauma center, acetabular fracture surgery referral center. Outcome Measurement: The patients demographics, fracture type, fracture reduction quality, surgery time, and postoperative complications were compared. Results: Anatomic reduction was achieved in 84 patients (68.9%) treated by the ilioinguinal approach and in 85 patients (82.5%) treated by the AIP approach (P = 0.018). In both the columns, acetabular fracture type anatomic reduction was achieved in 54.2% of the ilioinguinal group and 79.4% of the AIP group (P = 0.018). In the ilioinguinal group, surgery time decreased as the number of surgeries increased (P = 0.021), whereas a similar trend was not found in the AIP group. Fracture type distribution and complication rates were similar for both the groups. Conclusions: The AIP approach is a safe alternative that offers better exposure and possibly improved reduction quality of acetabular fractures compared with the ilioinguinal approach. We believe that the major advantage of the AIP approach is that it enables reduction of the posterior column and the quadrilateral plate from the contralateral side and enables application of a buttress plate below the pelvic brim. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteosynthesis of unstable intracapsular femoral neck fracture by dynamic locking plate or screw fixation: early results.

Objectives: The purpose of this study was to compare the postoperative radiologic and clinical outcomes of telescopic femur neck screws and small locking plate device (Targon FN) (group 1) with multiple cancellous screws (group 2) for displaced intracapsular femoral neck fractures. Design: Comparison of a prospective collected data to a historical control group (retrospective). Setting: One community teaching hospital. Patients: Seventy-eight patients (group 1, 31; group 2, 47) underwent reduction and internal fixation of displaced intracapsular femoral neck fractures with either Targon FN device or multiple cancellous screws from March 2000 to July 2010. Their mean age was 53.7 years (SD: 16.4), and the mean follow-up period was 28.6 months. Main Outcome Measures: Treatment failure was considered to be either a nonunion, osteonecrosis, or revision surgery of any type. Treatment was regarded as successful in patients who did not show failure and had at least 1-year follow-up. Results: One patient in group 1 (3.2%) and 22 (46.8%) in group 2 had a nonunion (P = 0.0001). Four (12.9%) group 1 patients and 16 (34.0%) group 2 patients underwent revision surgery (P = 0.036). Four (12.9%) patients in group 1 and 4 (8.5%) group 2 patients had osteonecrosis of the femoral head (P = 0.531). Multivariate logistic regression showed that internal fixation by the fixed-angle fixation device decreased the odds ratio for overall complication by a factor of 0.23, for example, by 77% (P = 0.018). Conclusions: Performing internal fixation by a fixed-angle fixation device decreased nonunion rates and revision rates. It did not affect the rate of osteonecrosis. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Erythropoietin Induced Tumour Mass Reduction in Murine Lymphoproliferative Models

leukocyte (PBL) counts begin to increase a few weeks following injection, exceeding 20 ! 10 6 cells/ml. Mice were injected (subcutaneously) with 10 4 MOPC-315 tumour cells in the abdomen area as described [7] . The rHuEPO (epoetin alfa, Eprex®; Janssen-Cilag, Baar, Switzerland) treatment (rHuEPO 30 U) was administered daily for 10 consecutive days, followed by three times per week for an additional 2–3 weeks to the MOPC-315-bearing mice as described [7] . The linear mixed effect (repeated measures) model was used to determine the effect of EPO on tumour size. Variance among mice was taken into account in the analysis by considering the mice to be randomly selected from a larger population. Starting 9 days after tumour cell injection, 28 MOPC315-bearing mice were injected with rHuEPO or albumin (control). The survival curve, shown in fi gure 1 d, demonstrates approximately 50 and 15% survival of the EPOtreated and control mice, respectively, which is in line with our previously documented observations [7] . Tumour growth kinetics in each of the EPO-treated and albumin-treated mice are presented in fi gures 1 a and b, respectively. Statistical analysis of the tumour size of 7 EPO-treated and 11 control progressor mice, which displayed only one localized tumour, using the linear mixed effect (repeated measures) model, yielded an R value of 0.875 ( fi g. 1 c). The predicted mean rate of tumour growth was 0.539 and 1.238 mm/day for EPO and albumin-treatRecombinant erythropoietin (rHuEPO) is widely used in clinical practice in the treatment of several types of anaemia [1–4] . We observed that patients with end-stage multiple myeloma (MM) treated with EPO live longer than expected, despite their original poor prognostic features [5, 6] . BALB/c mice in which MM was induced by transplantation of mineral oil-induced plasmacytoma cells (MOPC-315) showed complete T cell-mediated tumour regression in 30–60% of the animals after treatment with EPO [7] , suggesting that EPO may also act as an antitumour immunotherapeutic agent. Here, we raised a question regarding the effect of EPO on tumour load, rather than on the ultimate survival, by studying two lymphoproliferative murine models, MOPC-315 MM [8] and B cell leukaemia/lymphoma (BCL1) [9] . BCL1 is a B-cell leukaemia/lymphoma that developed spontaneously in a 2-year-old female BALB/c mouse [10] ; its advantage as a model is due to its analogies to human chronic lymphocytic leukaemia/lymphoma. In both models, we focused on tumour-bearing mice that did not achieve complete tumour regression after EPO treatment (‘progressors’). Female inbred BALB/c mice, aged 6–8 weeks, were obtained from the Tel-Aviv University Breeding Center. BCL1 tumour cells (10 4 cells), derived from spleens of tumour-bearing BALB/c mice, were injected intra-peritoneally into syngeneic mice. Typically, peripheral blood Received: January 18, 2005 Accepted after revision: May 9, 2005

The Percutaneous Surgical Approach for Repairing Acute Achilles Tendon Rupture A Comprehensive Outcome Assessment

BACKGROUNDnTreatment modalities for acute Achilles tendon rupture can be divided into operative and nonoperative. The main concern with nonoperative treatment is the high incidence of repeated ruptures; operative treatment is associated with risk of infection, sural nerve injury, and wound-healing sequelae. We assessed our experience with a percutaneous operative approach for treating acute Achilles tendon rupture.nnnMETHODSnThe outcomes of percutaneous surgery in 29 patients (25 men; age range, 24-58 years) who underwent percutaneous surgery for Achilles tendon rupture between 1997 and 2004 were retrospectively evaluated. Their demographic data, subjective and objective evaluation findings, and isokinetic evaluation results were retrieved, and they were assessed with the modified Boyden score and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale.nnnRESULTSnAll 29 patients demonstrated good functional outcome, with no- to mild-limitations in recreational activities and high patient satisfaction. Mean follow-up was 31.8 months. Changes in ankle range of motion in the operated leg were minimal. Strength and power testing revealed a significant difference at 90 degrees /sec for plantarflexion power between the injured and healthy legs but no difference at 30 degrees and 240 degrees /sec or in dorsiflexion. The mean modified Boyden score was 74.3, and the mean Ankle-Hindfoot Scale score was 94.5.nnnCONCLUSIONSnPercutaneous surgery for Achilles tendon rupture is easily executed and has excellent functional results and low complication rates. It is an appealing alternative to either nonoperative or open surgery treatments.

Magnetic resonance imaging of pelvic entheses—a systematic comparison between short tau inversion recovery (STIR) and T1-weighted, contrast-enhanced, fat-saturated sequences

ObjectiveTo assess the contribution of contrast material in detecting and evaluating enthesitis of pelvic entheses by MRI.Materials and methodsSixty-seven hip or pelvic 1.5-T MRIs (30:37 male:female, mean age: 53xa0years) were retrospectively evaluated for the presence of hamstring and gluteus medius (GM) enthesitis by two readers (a resident and an experienced radiologist). Short tau inversion recovery (STIR) and T1-weighted pre- and post-contrast (T1+Gd) images were evaluated by each reader at two sessions. A consensus reading of two senior radiologists was regarded as the gold standard. Clinical data was retrieved from patients’ referral form and medical files. Cohen’s kappa was used for intra- and inter-observer agreement calculation. Diagnostic properties were calculated against the gold standard reading.ResultsA total of 228 entheses were evaluated. Gold standard analysis diagnosed 83 (36xa0%) enthesitis lesions. Intra-reader reliability for the experienced reader was significantly (pu2009=u20090.0001) higher in the T1+Gd images compared to the STIR images (hamstring: ku2009=u20090.84/0.45, GM: ku2009=u20090.84/0.47). Sensitivity and specificity increased from 0.74/0.8 to 0.87/0.9 in the STIR images and T1+Gd sequences. Intra-reader reliability for the inexperienced reader was lower (pu2009>u20090.05).ConclusionsEvidence showing that contrast material improves the reliability, sensitivity, and specificity of detecting enthesitis supports its use in this setting.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVEnTo evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.nnnDESIGNnRetrospective review (Canadian Task Force classification II-2).nnnSETTINGnMaccabi Outpatient Womens Health Center.nnnPATIENTSnOne thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.nnnINTERVENTIONnOffice diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.nnnMEASUREMENTS AND MAIN RESULTSnHysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.nnnCONCLUSIONnThe combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.

The correlation between radiographic knee OA and clinical symptoms--do we know everything?

This study aims to evaluate the correlations between common clinical osteoarthritis (OA) diagnostic tools in order to determine the value of each. A secondary goal was to investigate the influence of gender differences on the findings. Five hundred and eighteen patients with knee OA were evaluated using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire, short form 36 (SF-36) Health Survey, and plain radiographs. Analysis of variance (ANOVA) was used to compare the different domains of the WOMAC and SF-36 questionnaires between genders and the radiographic scale. Higher knee OA x-ray grade were associated with worse clinical outcome: for women, higher scores for the WOMAC pain, function and final scores and lower scores in the SF-36 final score; in men, lower SF-36 overall and physical domains scores. Gender differences were found in all clinical scores that were tested, with women having worse clinical scores for similar radiographic grading (p values <0.001). Knee radiographs for OA have an important role in the clinical evaluation of the patient. Patients with higher levels of knee OA in x-ray have a higher probability of having a worse clinical score in the WOMAC and SF-36 scores. The gender differences suggest that for similar knee OA x-ray grade, women’s clinical scores are lower.Trial registration: NCT00767780

Pediatric Nonaccidental Injury: Are Orthopedic Surgeons Vigilant Enough?

Background: Nonaccidental pediatric injuries are major cause of morbidity and mortality, with fractures being second to soft-tissue injuries as the most common presentation. As the orthopedic surgeon might be the only physician an abused child would encounter, the role of the orthopedic surgeon is of great importance. It includes recognition, treatment, and appropriate report of suspected child abuse. The purpose of this study is to examine the attitude and knowledge of orthopedic surgeons treating suspected nonaccidental injuries. Methods: Evaluation of orthopedic surgeons included level of knowledge regarding pediatric nonaccidental injury, common practice, and reporting attitudes to Child Protection Services. We specifically examined whether seniority and professional experience had effect on knowledge and performance. Data were collected by a questionnaire distributed to orthopedic surgeons. Results: The study cohort includes 130 orthopedic surgeons. As much as 62.3% of participating physicians had 10 years or less experience practicing as orthopedic surgeons, and 37.7% had more than 10 years of experience. A mean of 2.39 cases of suspected child abuse was treated over the last year by the physicians that completed the questionnaire. Thirty-five percent of the responders had specific targeted training with respect to the “violence toward minors or helpless reporting obligation law.” Of the participating physicians, 89.2% stated that they thought it is the responsibility of the orthopedic surgeons to raise the suspicion for child abuse and refer the child and his/her parents to Child Protection Services. When treating a case of suspected nonaccidental injury, 61.2% of experienced physicians stated that they try to find out what caused the symptoms as opposed to 81.5% of less-experienced physicians (P=0.011). Conclusions: The study findings suggest that many orthopedic surgeons—both senior physicians and less-experienced physicians—can benefit by improved education and training modality related to pediatric nonaccidental injury. More-experienced physicians had lesser awareness and tendency to further investigate cases with suspected nonaccidental injury compared with less-experienced physicians. Level of Evidence: Level III—retrospective study.

Sonographic findings following appendectomy for uncomplicated appendicitis in children

BackgroundLittle is known about ‘normal’ local sonographic changes occurring in the postoperative period after an uneventful appendectomy.ObjectiveTo analyse the local changes on US examination occurring after uneventful open (OA) or laparoscopic (LA) appendectomy in children with normal histology and with nonperforated acute appendicitis.Materials and methodsUS was prospectively performed in 82 children (54 boys and 28 girls) aged 1–16xa0years (mean 11.6±3.2xa0years), 3xa0days following LA (n=51, 62%) or OA (n=31, 38%) for nonperforated appendicitis. Multivariate analysis was performed using stepwise logistic regression, with the following starting variables: surgical technique, gender, pathological finding, appendix location, and histology.ResultsOf the 82 patients, 35 (42.7%) had postoperative pathological US findings such as peritoneal fluid, oedematous mesenteric fat and thickening of the bowel wall. While the overall incidence of pathological US findings between OA and LA groups was not significantly different, multivariate logistic regression analysis showed that OA is associated with a reduction by a factor of 0.35 in the odds ratio of postoperative pathological US findings (P=0.007).ConclusionPathological US findings are common in children after appendectomy, particularly after LA. Awareness of these pathological findings might prevent unnecessary postoperative treatment.

Acetabular Greenstick Fracture and Iliac Crest Osteotomy: An Earlier Undescribed Acetabular Fracture Type and its Surgical Management

In this communication we characterize and name an earlier undefined type of acetabular fracture—the acetabular greenstick fracture. This is a subtype of fracture in which the anterior column component is incomplete, that is, the anterior column is fractured only in its inferior part (iliac body), whereas its superior part (the iliac crest) is intact. These fractures are characterized by an external rotation of the anterior acetabular dome on the axis of the intact iliac crest. The intact iliac crest might prevent anatomic reduction. Iliac crest osteotomy is proposed as a novel surgical technique to assist reducing this type of fractures. The fracture type and surgical techniques are shown by an illustrative case.