Avraham Garti

Fracture of the Central Polyethylene Tibial Spine in Posterior Stabilized Total Knee Arthroplasty

Between 1993 and 1998, 332 I-BII (Insall Burstein II) prostheses were implanted in our department. We studied 5 cases of tibial polyethylene spine fractures. The fractures occurred 3 to 5 years following the surgery. All cases with fractures had mild medial laxity that was noted on follow-up of 2 to 3 years following arthroplasty. One also developed mild hyperextension. All the patients had a revision surgery. In 2 cases, the polyethylene was changed to a thicker one, together with medial reinforcement. Three cases were revised to a rotating hinge prosthesis.

Fracture of the greater trochanter during hip replacement: a retrospective analysis of 21/372 cases.

We reviewed retrospectively 373 total hip replacements operated on using a lateral approach with the patient in a supine position. We found 21 iatrogenic fractures of the greater trochanter, all in women. 15 cases were diagnosed during the operation and were treated with wire fixation. 6 fractures were diagnosed on radiographs during the first 3 months following the operation. 2 of these 6 cases presented in association with dislocation of the prosthesis; 1 after 6 weeks and 1 after 2 months. Displaced nonunion occurred in 2 cases, 5 healed with minimal displacement and 14 with no displacement. 8 patients limped slightly at follow-up after mean 4 (1-7) years and 4 had some pain over the lateral thigh.

Semimembranosus tendonitis after total knee arthroplasty: good outcome after surgery in 6 patients.

More than 700 total knee arthroplasties were performed in our Department between 1992–2000. 6 patients developed pain on the postero-medial aspect of the knee, within 1 year of surgery. The pain increased during walking and especially on rising from a chair. All patients were women with good knee motion and good alignment of the implanted prosthesis. We found no signs of low-grade infection. Injection of 1% Xylocaine relieved pain for a short time in all patients. They were all treated with excision of the reflected portion of the semimembranosus tendon which was not cut during the arthroplasty. Pain was completely relieved in 5 cases and improvement occurred in 1.

Medial unicompartmental replacement for tricompartmental disease in the elderly

Between 1993 and 1998, we performed 18 unicompartmental arthroplasties of the knee, all on the medial side, in a selected group consisting of 18 elderly patients aged 74-81 (mean 77.2), with severe arthrosis mainly in the medial compartment and mild arthrosis in the lateral compartment and the patellar articular surface mostly covered with articular cartilage. The patients were mainly housebound due to relatively advanced age and severe pain. Unicompartmental arthroplasty was chosen for this group because of a quicker and easier rehabilitation. Two patients had had a high tibial osteotomy 7 and 10 years ago. The average follow up was 5.5 years ranging in age from 5 to 8 years. The average initial American Knee Society Knee Score was 52, ranging from 28 to 70 which improved at follow up to 83 (range 60-92). All prostheses used were Allegretto (Sulzer). The operation was done through short medial arthrotomy. The purpose of this study is to report our results in these low demand patients and although the follow-up was only 5-8 years, the results are promising.

Treatment of anterior tarsal tunnel syndrome through an endoscopic or open technique

Anterior tarsal tunnel syndrome is often underdiagnosed, due to lack of clinical awareness and vague clinical presentation. Most often patients complain of pain located to the dorsum of the foot. The present study is a consecutive series of 13 patients treated according to a fixed protocol followed for a minimum of 24 months. A total of 12/13 cases presented with a bulge in the anterior part of the ankle or the dorsal foot and Tinels sign was positive over it. Only half had decreased sensation. Surgical technique was either endoscopic or open. Endoscopy is preferable when compression is due to an osteophyte (4/13) or an isolated ganglion 2/13). In other cases presenting with synovitis (5/13) or unknown etiology (2/13) performing open surgery was deemed as safer. The American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scores improved from an average of 55 ± 8 to 83 ± 11 at 12 months after surgery and 88 ± 10 at 24 months after surgery. The anterior tarsal tunnel syndrome accounts for approximately 5% of cases complaining of feet numbness, which undergo electromyographic and nerve conduction testing. Reports in the scientific literature are scarce, perhaps due to underdiagnosis, while it is amenable to surgical management. Clinical diagnosis supported by imaging studies demonstrated osteophytes, ganglions or localized synovitis. Endoscopic treatment can be performed safely provided a clear-cut single compressing element is identified.

Hammertoe Correction With K-Wire Fixation Compared With Percutaneous Correction

Background. Kirschner wire (K-wire) fixation for correction of hammertoe deformity is the gold standard for hammertoe surgery fixation, the current study compares it to percutaneous surgery with 3M Coban dressings. Methods. All hammertoe corrections performed were retrospectively reviewed. For the K-wire fixation group: resection arthroplasty of the proximal interphalangeal joint was performed and fixed with a K-wire. The percutaneous technique used involved percutaneous diaphyseal osteotomy of the middle and proximal phalanges combined with tendon release. The toes are then wrapped in 3M Coban dressing for 3 weeks. Follow-up duration, preoperative diagnosis, pin duration, concomitant procedures, visual analogue scale (VAS) pain, recurrence rates, and complications were reviewed and analyzed. A total of 352 patients (87 percutaneous/265 open), in whom 675 hammertoes (221 percutaneous/454 open) were corrected. There were 55.9% females, with an average age of 52.8 years, followed for 6 months. The percutaneous group had more diabetics and multiple toes surgery. Results. Complications of the open surgery group included 5.5% pin migrations, 4.5% infections, and 8 (3%) had impaired wound healing. There were 6.2% recurrent deformities and 2.6% toes were revised. Malalignment was noted in 3.3% toes. Vascular compromise occurred in 0.5%, with 0.25% amputated. Complications of the percutaneous surgery group included 18.4% cases of impaired healing and 2.3% infection. Deep tissue dehiscence occurred in 4.5% of open surgery patients. VAS score decreased in both groups with a more pronounced decline in the percutanteous group (2 ± 2.1 vs 0.5 ± 1.6). The per toe infection rate of patients undergoing open hammertoe correction was 5.3% was significantly higher than with the percutaneous correction group, which was 2.2%. Conclusions. K-wire fixation and percutaneous surgery have similar abnormal healing rates, alignment and patient satisfaction but the latter technique has fewer infections. Levels of Evidence: Level III: Prospective case series with noncontamporenous cohorts

Retentive Cup Arthroplasty in Selected Hip Fracture Patients—A Prospective Series With a Minimum 3-Year Follow-Up:

Objective: To evaluate the efficacy of the use of retentive cup primary total hip replacement (THR) in high-dislocation risk subcapital fracture patients. Methods: During the years 2008 to 2012, 354 patients with displaced subcapital fracture were operated at our institute. The patients were selected to undergo primary constrained THR according to the following criteria: (1) a preinjury grade 4 or more on the Functional Independence Measure mobility item “5. Locomotion: walking/wheelchair” and grade 4 is defined as “4. Minimal assistance Requiring incidental hands-on help only” (patient performs >75% of the task) and (2) a disease leading to poor motor control. Exclusion criteria were normal muscular control and known infection of the involved joint. Results: Of the 354 patients, 87 fulfilled the inclusion criteria and underwent constrained total hip. Average age was 78 years with a female predominance (73%). Fifteen patients had prior hemiparesis, 19 had Parkinson disease, and 35 had generalized sarcopenia. Eighty-five patients had an uneventful recovery, with an average Hip Disability and Osteoarthritis Outcome Score (HOOS) of 76 ± 7 at 2 years. In 2 patients, the prostheses dislocated. In both cases, the dislocation was due to ring displacement and the inner head dislocated. One case was infected and the patient was treated by a Girdlestone procedure. In the other case, the prosthetic head was revised. The patient remained asymptomatic and at 4-year follow-up had an HOOS of 85. Discussion: It appears that constrained prosthesis is a suitable treatment for patients with poor muscular control having subcapital fractures. The functional results appear to be superior to those of bipolar arthroplasty and similar to the results of primary total hip arthroplasty while the dislocation risk is <3%. Conclusion: Semielective total hip arthroplasty using a retentive cup liner appears to offer good functional results with a low dislocation rate in patients with poor muscular control.

The Topaz Micro-Radiofrequency Ablation Achieves Similar Results to Endoscopic Plantar Fascia Release

Plantar fasciitis lifetime prevalence is approximately 10% of the US population creating a significant burden to the health care delivery system. Approximately 90% of patients diagnosed with plantar fasciitis respond to nonsurgical therapy and do not require surgical intervention [1]. However plantar fasciitis has a significant deleterious effect on both foot function and general health overall functional score [2]. Suspected etiologies [3-5] include obesity, overuse due to walking or running or standing, excessive subtalar pronation, seronegative arthritis, and limited dorsiflexion of the ankle joint. Conservative therapy usually entails the use of foot orthoses, stretching exercises, local corticosteroid injection, oral nonsteroidal anti-inflammatory drugs and other physical therapy modalities, and nonweight-bearing status and rest.

Fracture of the Greater Trochanter during Hip Replacement A Retrospective Analysis of 29/688 Cases

Nonunion of the greater trochanter occasionally occurs following trochanteric osteotomy [1] without major consequences. The information regarding the incidence and the consequences of unintended trochanteric fracture is limited. Specifically, it is not clear whether trochanteric non-union or long term trochanteric pain is consequences of such fractures. Trochanteric nonunion may also increase the risk of prosthesis dislocation [2]. Fracture of the greater trochanter rarely occurs after THR surgery without osteotomy [3]. In the current comparative study, the incidence and clinical relevance of iatrogenic greater trochanter fractures in connection with the lateral Hardinge approach [4] were analyzed depending on the patient’s position during the surgery in order to define whether the incidence varies depending on patient positioning.

Effect of Medicinal Cannabis Therapy (MCT) on Severity of Chronic Low BackPain, Sciatica and Lumbar Range of Motion

Background: Anecdotal evidence indicates the possible efficacy of cannabis use as an adjunctive treatment in chronic low back pain. The purpose of the current study was to assess the results of treatment of patients suffering from chronic low back pain by medicinal cannabis (MCT). Methods: A cohort of 46 patients was followed for a minimum of twelve months. They were evaluated at baseline prior to MCT, 3 months later when MCT was begun and up to 12 months of MCT by patient reported outcome questionnaire (SF-12), visual analogue scale (VAS) and the Brief Pain Inventory (BPI), back specific function was assessed using the Oswestry score, range of motion was measured using the Saunders digital inclinometer. Opiate use was assessed using pharmacy dispensation records at baseline and after 12 months of MCT. Inclusion criteria included: Age over 25 years, sciatica with documented treatment for at least 12 months, evidence on CT or MRI scan of disc herniation or spinal stenosis, failure of at least two narcotic drugs, and consent to use medicinal cannabis. Exclusion criteria included evidence of bone cancer, evidence of diabetic neuropathy, and evidence of prior psychotic reactions. Treatment protocol: Cannabis usage was at a fixed dosage of 20 grams per month, dose increase was considered at least after 6 months of treatment. The cannabis was smoked at a recommended rate of 4 dosages per day. Results: After 12 months of MCT BPI VAS decreased from 8.4 ± 1.4 to 2.0 ± 2.0; SF12-PCS improved from 47 ± 14 to 55 ± 12; SF12-MCS improved from 44 ± 6 to 50 ± 10; and sagittal plane active range of motion improved from 34o ± 8o degrees to 48o ± 8o, Conclusion: Short term usage of smoked medicinal cannabis appear to improve both physical and mental function while decreasing pain levels of chronic low back pain sufferers.