Assaf Kadar

The effects of ‘old’ red blood cell transfusion on mortality and morbidity in elderly patients with hip fractures – A retrospective study

BACKGROUNDnElderly patients admitted with hip fractures often receive allogenic blood transfusion (ABT) in the perioperative period. We examined the effect of the shelf life of the ABT on mortality and morbidity.nnnMETHODSnA total of 1381 patients with hip fractures were retrospectively analysed. Two groups were compared, group A (new), with an ABT shelf life≤14 days, and group B (old), with an ABT shelf life>14 days. Data collected for both groups included general demographic data, data regarding postoperative infections and other complications rates and data regarding mortality. Kaplan-Meier curves were used to assess difference in survival between the groups. Cox regression was performed to analyse the survival after controlling for age, sex, pre-surgical haemoglobin concentration, pre-surgical creatinine, American Society of Anesthesiologists (ASA) score, surgery type and number of blood units given.nnnRESULTSnHigher mortality was seen in hip fracture patients who received old blood unit compared to new blood unit but the difference was not statistically significant (P=0.5). Cox regression model demonstrated that designation into either young or old groups was not associated with mortality (hazard ratio: 1.14 (confidence interval: 0.85-1.53)). No differences were noted between the groups with regard to infection and other postoperative complication rates.nnnCONCLUSIONnPatients undergoing surgery for hip fractures who received old units of blood did not differ from those receiving new units with regard to mortality and morbidity. Large-scale clinical trials are needed to further investigate this association.

Bilateral total hip replacement: periprosthetic pseudotumor collections are more prevalent in metal-on-metal implants compared to non-metal-on-metal ones

Background Metal-on-metal (MoM) hip prostheses were shown to have high failure rates including the formation of periprosthetic cystic masses called periprosthetic pseudotumor collections (PPCs). Purpose To compare MRI prevalence and size of PPCs in patients after bilateral total-hip-replacement (THR) in which at least one hip was replaced by a MoM prosthesis. Material and Methods All sequential MRI examinations of patients with bilateral THR in which at least one is MoM (2010–2013) were retrospectively evaluated. MRIs were analyzed separately by two readers for the presence and size of PPCs. These were compared between MoM and non-MoM implants and between patients with unilateral or bilateral-MoM prostheses. Blood metal ion levels were also compared. Results Seventy hips of 35 patients (male:female ratio, 9:26; mean age, 64 years; age range, 35–82 years) were assessed. Sixteen patients (45%) underwent bilateral MoM-THRs and 19 (55%) had one MoM and the other non-MoM, yielding 51 MoM THRs and 19 non-MoM THRs. Twenty-eight PPCs were detected in 19 patients (54%): 26 in MoM THRs (51%) and two in non-MoM THRs (10.5%, Pu2009=u20090.00009). The mean PPC volume in the MoM implants (107 mm3) was higher than that of the non-MoM implants (18 mm3, Pu2009=u20090.49). Cobalt/chromium blood levels were 78u2009µg/L/25u2009µg/L for bilateral MoM THRs and 21u2009µg/L/10u2009µg/L for unilateral MoM implants (Pu2009=u20090.1 and 0.16, respectively). Conclusion PPCs are more prevalent in MoM THRs compared to non-MoM THRs. Larger PPC volumes and higher blood metal ion levels were detected in patients with bilateral MoM THRs compared to unilateral MoM THRs (Pu2009>u20090.05).

Protrusion of an Artificial Femoral Head A Rare Complication of Chronic Dislocation of the Prosthetic Hip

Chronic dislocation is considered a rare complication after total hip arthroplasty. We have treated a patient with a complication related to chronic dislocation-protrusion of the prosthetic femoral head through the skin. This 86-year-old bedridden patient with a known dislocated total hip arthroplasty presented with fever and protrusion of an artificial femoral head after 2 months of a nonhealing pressure sore. The care of this patient was partial removal of the prosthetic components and intravenous antibiotics. Chronic dislocation is rarely reported, yet it may cause severe complications in debilitated and demented patients. Special attention should be warranted to these patients as they might benefit from earlier surgical treatment.

Plate Fixation of Proximal Fifth Metatarsal Fracture.

BACKGROUNDnIntramedullary screw fixation of fractures of the proximal fifth metatarsal bone may not be satisfactory in comminuted fractures or when the lateral metatarsal bowing has to be restored. We report our experience with plate fixation in these circumstances.nnnMETHODSnBetween June 1, 2009, and January 31, 2013, 13 patients who had comminuted fracture or nonunion of fracture of the proximal fifth metatarsal bone underwent plate fixation. Study patients were followed up for a mean of 500 days (range, 51-1238 days). Their medical records and radiographs were retrospectively reviewed for demographic and operative data and radiologic evidence of fracture healing. At their most recent follow-up, patients were evaluated for pain levels with a visual analog scale, for foot function with the Foot and Ankle Disability Index, and for quality of life with the 12-Item Short-Form Health Survey.nnnRESULTSnFracture union was evident in 12 patients after a mean of 56.8 days (range, 30-92 days). There was only one major complication of sural nerve neuroma and reflex sympathetic dystrophy. Four patients required reoperation for plate removal. Plate fixation of proximal fifth metatarsal comminuted fractures is associated with high union rates, relief of pain, and patient satisfaction. However, plate removal for various reasons was required in approximately one-third of the study patients. This high revision rate might be avoided by better selection of patients and meticulous intraoperative identification and preservation of the sural nerve.nnnCONCLUSIONSnWe recommend reserving plate fixation for proximal fifth metatarsal fractures for cases of laterally bowed fifth metatarsal or comminuted fractures.

Ochrobactrum anthropi-Caused Osteomyelitis in the Foot Mimicking a Bone Tumor: Case Report and Review of the Literature

Osteomyelitis due to Ochrobactrum anthropi, a new genus Ochrobacterum widely distributed in the environment and occasionally associated with human infection, has been described in only a few case reports. We present a report of an unusual case of osteomyelitis caused by O. anthropi that was identified 9 years after a nail puncture to the lateral cuneiform bone. The patient was an 18-year-old male with a painful foot lesion that had originally been misdiagnosed as an osteolytic tumor. He underwent surgery and 2 firm pieces of rubber measuring 7 and 10 mm were removed from the lower portion of the lateral cuneiform bone, which appeared to be affected by an infection. After surgical debridement, O. anthropi was isolated from the bone cultures. The patient was successfully treated with a 6-week course of oral ciprofloxacin and clindamycin. At 1 year after the corrected diagnosis and appropriate treatment, he was symptom free and had resumed regular activities and an athletic lifestyle.

Musculoskeletal Injuries Among Female Soldiers Working With Dogs.

IntroductionnFemale soldiers serving in the Israeli Defense Forces canine unit may be at increased risk of overuse injuries related to working with military dogs. We hypothesized that this particular type of occupational exposure may lead to an increased strain of the upper extremity due to such non-physiologic motions as pulling the dogs strap or resisting the sudden pulling by the dog, and may result in an increased rate of overuse injuries.nnnMaterials and MethodsnWe compared incidence of overuse injuries in a retrospective cohort of female soldiers who served either in the military working dogs unit (MWD), or in the light infantry battalions (Infantry) from 2005 to 2015. We compared injury incidence of both groups during two periods: 5 mo of basic training (neither worked with dogs) and 19 or more months of combat service. Incidence was calculated as number of diagnoses per person-months (rate ratios, RR); each diagnosis counted once per study subject. We used RR confidence intervals to compare incidence of injuries between groups.nnnResultsnThere were 3,443 person-months in the MWD group and 194,590 person-months in the Infantry group. There was no difference in injury incidence between groups during the initial period of basic training. During the second period, MWDs had higher incidence of upper limb (RR = 1.45, p = 0.048) and hip (RR = 3.6, p < 0.0001) injuries. The association between service with dogs and upper limb injuries remained significant (RR = 1.09, p = 0.005) after adjusting for confounding variables in the multivariate regression analysis. Other independent predictors of the upper limb overuse injuries included each additional month of service (RR = 1.003, p = 0.008), Eastern European origin compared with Israeli-born recruits (RR = 0.97, p = 0.03), increased body weight in increments of 10 kg (RR = 1.008, p = 0.03), anemia (RR = 1.02, p = 0.02) and fatigue (RR = 1.05, p ≤ 0.0001).nnnConclusionsnWe found that service in the MWD unit was associated with increased risk of upper limb injuries. Identification of the exact mechanism of injury and targeted interventions, as well as treatment of anemia and fatigue may lead to reduction of injuries in this unit.

Lower risk of fractures under methylphenidate treatment for ADHD: A dose-response effect: METHYLPHENIDATE AND FRACTURES

Methylphenidate (MP), a widely used and abused stimulant medication for ADHD, negatively affects bone mass. However, previous epidemiological studies demonstrated that MP is not associated with increased incidence of fractures in children, and may even have a protective effect due to behavior modification. This study aimed to investigate the association between MP and fracture risk in a retrospective cohort of healthy military recruits, aged 18–25, with at least 1 year of service between 2008 and 2017. Subjects were divided into five groups: subjects without ADHD; untreated subjects with ADHD; and subjects with ADHD and prescriptions of 1–90, 91–180, or 181+ tablets during the study period. The primary outcome was at least one fracture diagnosis during the study. Among 682,110 subjects (409,175 men [60%]), 50,999 (7.5%) had fractures. MP was used by 1,681 (0.4%) men and 2.828 (1%) women. The fracture rates in the no ADHD, untreated ADHD, ADHD 0–90, ADHD 91–180, and ADHD 181+ groups were 10.4%, 16.4%, 8.7%, 4.8% and 5.8% in men, and 3.6%, 7.1%, 4.6%, 4.4% and 3% in women, respectively. Multivariate regression analysis confirmed an inverse dose–response association between MP and fractures in men (pu2009<u20090.001). In women, untreated ADHD was associated with a significantly higher fracture risk, compared to healthy controls (ORu2009=u20091.82, pu2009<u20090.001). The study confirms previous literature and demonstrates an inverse dose–response association between MP and fracture risk in men.

Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty

Introduction: Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs. Materials and Methods: A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA. Results: One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59). Discussion: Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist—a reduction in the increased mortality risk associated with PHFs. Conclusions: There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Olecranon Bursitis in a Military Population: Epidemiology and Evidence for Prolonged Morbidity in Combat Recruits

INTRODUCTIONnOlecranon bursitis (OB) is a benign but disturbing condition that may adversely affect a military recruits combat preparedness. This study was designed to assess incidence, risk factors, and associated medical burden of OB in the Israel Defense Forces.nnnMATERIALS AND METHODSnThis is a retrospective study drawing on medical records of all Israel Defense Forces soldiers diagnosed as having OB between 2005 and 2015. OB was classified as septic and noninfectious. Crude incidence rates and duty-specific incidence rates were calculated. Medical burden was defined by the number of physician visits, referrals to orthopedic specialist consultations, duration of symptoms, and duration of pharmaceutical treatment. Demographic and occupational information (age, sex, height, weight, socioeconomic status, country of origin, type of military service, time of presentation to medical services) was used to identify risk factors for septic bursitis and longer duration of symptoms. Statistical analysis was performed in R statistical software. Risk factors were evaluated using the Chi-square test for categorical variables and Pearson correlation coefficients were used for continuous variables. The study was approved by the Israeli Defense Force IRB.nnnRESULTSnA total of 2,692 soldiers were diagnosed with OB during the study period. The crude annual incidence rate of OB was 29/100,000 person-years (PY). Combat duty had an incidence of 97/100,000 PY, and noncombat duties had an incidence of 12/10,000 PY (p < 0.001). Female incidence (8.4/100,000 PY) was similar to male incidence (11/100,000 PY) in administrative duties (p = 0.54). More cases were diagnosed during summer and autumn than in other seasons (p = 0.016). Septic bursitis constituted 24% of all cases, was more frequent in combat soldiers (32%), and on average presented earlier in service than noninfectious OB (13 vs. 17 weeks since recruitment). The mean duration of symptoms was estimated at 17.58 weeks, with a mean of 1.75 physician visits per soldier. About 19% received a specialist referral. Origin from the former USSR was associated with a higher duration of symptoms (p = 0.012).nnnCONCLUSIONnType of military service was the principal risk factor for OB, as indicated by a higher incidence of the disorder among combat compared to noncombat units, possibly the result of field training without protective gear and repetitive trauma to elbows. The greater number of diagnoses of OB during summer and autumn, when training is more intensive, support that explanation. Sex did not affect incidence of OB in administrative units. The medical burden appears to be relatively low, since most of the soldiers had only one physician visit. OB is highly prevalent in military compared to civilian populations. Outdoor training involving crawling is a probable explanation for the much higher rates among combat units and increased number of diagnoses during warm summer and autumn months. Prevention by use of protective gear seems to be the most promising intervention.

Adult Closed Distal Radius Fracture Reduction: Does Fluoroscopy Improve Alignment and Reduce Indications for Surgery?

Background: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Methods: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Results: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 (P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters (P > .53) or postreduction alignment of unstable fractures (P = .47). Conclusions: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.