David Hendel

Functional gain of hip fracture patients in different cognitive and functional groups.

Objective: To follow up six months post hip fracture and to compare functional gain of patients in different cognitive and functional groups. Design: Prospective longitudinal study of hip fracture patients with functional evaluation pre-fracture, prior to discharge from orthopaedic department and one, three and six months post fracture. Setting: Department of Orthopaedics, Rabin Medical Center, Golda Campus with follow-up at Beit-Rivka Geriatric Rehabilitation Hospital, both in Petach Tikvah, Israel, with a minority of patients followed at home or nursing home. Measurement: Cognition evaluated by Mini-Mental State Examination, prefracture functioning by Functional Independence Measure and Katz Index of ADL. Functional outcome assessed by Functional Independence Measure gain defined as the difference between Functional Independence Measure scores at six months and just prior to discharge from the Department of Orthopaedics. Results: Moderately cognitively impaired and normal patients had the same Functional Independence Measure – A (self-care) and Functional Independence Measure – B (motor) gains. Pre-fracture independent patients had significantly higher Functional Independence Measure – A and Functional Independence Measure – B gains. A multiple regression analysis examining age, sex, Mini-Mental State Examination score, Katz score, type of fracture, surgery versus conservative treatment and the pre-fracture Functional Independence Measure score showed that only the pre-fracture Functional Independence Measure – B scores and Katz scores are the independent variables for motor and self-care gains, respectively. Conclusions: Pre-fracture motor and not cognitive level has been the most important predictive factor for motor gain after hip fracture. Cognitively impaired hip fracture patients can achieve and maintain the same motor functional gain as normal patients, if they were mobile pre-fracture.

Different C-Reactive Protein Kinetics in Post-Operative Hip-Fractured Geriatric Patients with and without Complications

Background: Hip fracture is a frequent injury in the elderly, and is associated with a high incidence of functional impairment, complications and mortality. Objective: To determine kinetics of C-reactive protein (CRP), fibrinogen and erythrocyte sedimentation rate (ESR) in hip-fractured patients over a 1-month post-operative period; to examine the relationship of these parameters to cognition, operation type, post-operational complications, functional level 1 month post-operatively and 6-month mortality. Methods and Subjects: 32 aged patients operated on for hip fracture were prospectively followed-up for 6 months. Fracture, type of operation and anesthetic risk were recorded. Cognition was evaluated by the Mini-Mental State Examination and pre-fracture functional level evaluated by the Katz Index of ADL. Follow-up included complications, mortality and functional outcome. CRP, fibrinogen and ESR were assessed during the first 10 h post-fracture; 48–60 h, and 7 and 30 days post-operatively, respectively. Results: Only CRP kinetics were found to differ in patients with complications vs. those without, as a group (p = 0.006), and in patients suffering infections, delirium and cardiovascular complication vs. patients with no complications (p = 0.06, 0.03, 0.02, respectively). Mean (±SEM) CRP 48–60 h post-operatively was 20.9 ± 2.1 and 13.1 ± 1.6 mg/dl in complicated and uncomplicated patients, respectively (p = 0.002). The mean CRP 48–60 h post-operatively was highly correlated with the CRP area under the curve, R = 0.88 (p < 0.001). A cut-off level of 15 mg/dl for CRP, 48– 60 h post-operatively, was calculated for patients with complications (sensitivity 93%, specificity 65%, p = 0.003). CRP, fibrinogen and ESR were not related to fracture or type of operation, cognition, anesthetic risk, 1-month post-operative functioning and 6-month mortality. Conclusions: CRP measurement in elderly patients operated for hip fracture may be valuable in assessing and monitoring complications.

Dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture.

Abstract Fifty-three elderly patients with intracapsular hip fracture were hospitalized in the Department of Orthopaedics. Forty-two underwent operations: 38 hemiarthroplasty; 2 total hip replacements and 2 closed reduction interior fixation. They were followed up and assessed prospectively five times for 6 months post-fracture. Cognition was evaluated by the Mini-Mental State Examination. Pre-fracture functioning was determined by the Functional Independence Measure (FIM) and the Katz index of activities of daily living (ADL). The functional outcome was assessed by the FIM gain defined as the difference between FIM scores at 6 months and just prior to discharge. FIM gain, length of stay, complications and mortality rates were not significantly different between three cognitive groups: normal, moderately and severely demented patients. The majority of patients were independent and partially dependent in their ADL. We conclude that dementia does not significantly affect complications and functional gain in elderly patients operated on for intracapsular hip fracture if they were mobile before the fracture.

Degenerative tear of the tibialis anterior tendon after corticosteroid injection-augmentation with the extensor hallucis longus tendon, case report

A 52-year-old physician, active in recreational sport, suffered pain for 2 months in the dorsum of his left foot. Bethamethasone 7 mg was injected in the anterior tibialis tendon sheath. 4 months later and 2 weeks before his admission, when climbing stairs, his left foot hit the stair’s edge, sharply plantiflexing the foot. The pain increased and he could not extend the foot. The tibialis anterior tendon was tender and a gap was felt. A presumptive diagnosis of tear of the tibialis anterior tendon was suggested and confirmed by MRI. We decided to repair the lesion. During the operation, it became clear that a direct repair was not feasible due to severe degeneration of both stumps. The extensor hallucis longus tendon was transferred and sutured parallel to the tibialis anterior proximal stump. The conjoint tendon was passed through a tunnel in the medial cuneiform bone and then sutured back to itself. Thus, the extensor hallucis longus bridged the gap, while keeping the important insertion of the tibialis anterior tendon into the medial cuneiform bone. The extensor hallucis brevis was cut A ct a O rt ho p D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y 16 3. 12 5. 96 .4 1 on 0 5/ 20 /1 4

Rupture of the pectoralis major muscle in nursing home residents

Pectoralis major rupture is relatively rare; only about 150 cases have been reported (1,2). The injury can occur in men from infancy to old age, but is most frequent between the ages of 20 and 40 years (1,3). It usually occurs during sports activity (e.g., weight lifting, wrestling, football, and rugby), or at work (2), after extreme muscle tension or direct trauma (2,4,5), although spontaneous rupture has been reported (6). We report a series of cases involving nursing home residents who had rupture of the pectoralis major muscle.

Pectoralis major rupture in the elderly:Clinical and sonographic findings

We describe clinical and sonographic features of pectoralis major rupture in the elderly, which is relatively rare and unknown. Patients presented with a large pectoral ecchymosis extending to the axilla, chest wall, breast and arm. The pectoral area was sensitive, sometimes with a visible and palpable defect in the axilla. Ultrasound examination showed a large hypoechoic, well-circumscribed structure representing a hematoma within the pectoralis major muscle, partially replacing the normal echo muscle pattern. Ultrasonography is a useful, low cost diagnostic tool, and is recommended in the investigation of pectoralis major rupture in the elderly.

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.

Sonographic features of dialysis-related amyloidosis of the shoulder.

This study evaluated the diagnostic role of ultrasonography in dialysis‐related amyloidosis in shoulders of chronically hemodialyzed patients. Fourteen shoulders of 12 long‐term hemodialysis patients were examined. All patients had been on dialysis for at least 10 years. All patients had varying degrees of pain and limitations of movement in the studied shoulders. Dialysis‐related amyloidosis was the presumed diagnosis in all patients. Any patient with a history of any disease, other than dialysis‐related amyloidosis, capable of producing a pathologic shoulder condition was excluded. The following parameters were studied: supraspinatus and biceps tendon thickness, tendon tears, synovial thickening, and the presence of hypoechoic material around tendons and within bursae. All shoulders had a nonhomogeneous thickening, greater than 7 mm, of the supraspinatus tendon. Seven shoulders (50%) had abnormal thickening of the biceps tendon (4 mm or greater), and two shoulders had abnormal thickening of the subscapularis tendon. Hypoechoic deposits were seen in the subdeltoid bursae and biceps sheaths in five and six shoulders, respectively. Three shoulders showed partial tears of the supraspinatus tendon, one shoulder showed a tear in the biceps tendon, and one shoulder had a tear in the subscapularis tendon. Ultrasonography is an excellent imaging modality in diagnosing the presence of dialysis‐related amyloidosis in symptomatic shoulders of long‐term hemodialysis patients, without having to resort to invasive procedures. The results of previous studies have been confirmed and new ultrasonographic findings described. Of particular interest is the involvement of the subscapularis tendon in dialysis‐related amyloidosis. Repeat ultrasonography can become an important way to follow‐up progression of shoulder dialysis‐related amyloidosis in hemodialyzed patients.

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.

Increased median nerve latency at the carpal tunnel of patients with trigger finger : Comparison of 62 patients and 13 controls

An association between symptomatic compression neuropathy of the median nerve at the carpal tunnel and trigger finger has been reported in endocrine and metabolic disorders. We assessed the incidence of increased median nerve latency in subjects with trigger finger. 62 consecutive patients with trigger finger and no signs or symptoms of median nerve compression underwent nerve conduction studies of the median nerve. 13 healthy adults served as controls. 39/62 patients had increased distal motor latency in the median nerve. Only 1 of 13 subjects in the control group had a borderline value of distal motor latency.