Ilan Cohen

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.

Ultrasonography: an imaging modality enabling the diagnosis of bipartite patella.

Ultrasound was used to diagnose bipartite patella in seven adolescents with anterior knee pain, and the findings were compared to those from plain radiography and to those of a group of asymptomatic subjects. In all affected individuals the quadriceps and patellar tendons appeared normal on ultrasound. Sonographic examination of the patella demonstrated an irregularity of the bony contour with occurrence of a cleft between the main part of the patellar body and the large superolateral accessory ossicle. The signal detected in the interface between bones was less echogenic than bone reflecting its fibrocartilaginous nature. The correlation with conventional radiography was absolute, as was the inter- and intraobserver reliability. Ultrasound is thus proposed as a simple and reliable imaging modality in bipartite patella. We do not believe that it should replace the initial radiographic, but it can be used to evaluate the contralateral knee for bilaterality and as an adjunct to therapeutic procedures such as local injections to increase the accuracy of treatment.

Biochemical alterations secondary to disuse atrophy in the rat's serum and limb tissues.

Abstract Disuse atrophy has been the subject of research studies of an animal model in which single-limb immobilization induces atrophic changes in the immobilized limb. These reveal systemic changes in the experimental animals that go far beyond the local response expected in that situation and are not fully understood as yet. We therefore performed a biochemical study on the effect of hind-limb immobilization on the serum and tissues of rats. The experiment was carried out on 70 young Sprague-Dawley male rats. In one group of 35 rats, the left hind-limb was immobilized for 3 weeks. Another group of 35 rats served as controls. Serum total protein, albumin, urea, creatinine, and calcium were found to be reduced during immobilization. Serum cholesterol levels, on the other hand, increased to a considerable extent. No changes were recorded with phosphate, bilirubin, and magnesium. Serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were both reduced in activity. The activity of muscle aspartate aminotransferase (AST) and bone alkaline phosphatase (ALP) was also decreased. Lactate dehydrogenase (LDH) remained unchanged in both serum and muscle. We discuss our findings in the light of previous knowledge regarding the atrophic process.

An iatrogenic subtrochanteric fracture —a rare complication of pinning for subcapital fractures of the hip

SummaryWe present a case of a subtrochanteric fracture that occurred 1 week after the surgical treatment of a Garden 1 Type subcapital fracture by way of pinning in situ with multiple Knowles pins. The event took place in the patients bed with no evidence of trauma of any kind. The fracture line went through the insertion site of the lower (distal) pin. This rare type of complication was successfully treated by revision surgery and fixation of both fractures by way of a Richards dynamic hip screw. We review the literature with regard to the incidence, the possible etiological factors involved and the recommended modes or treatment.ZusammenfassungWir stellen den Fall einer subtrochantären Fraktur vor, die sich eine Woche nach der chirurgischen Behandlung einer subkapitalen Garden-Type-1 Fraktur durch In-situ-Fixierung mit mehreren Knowles-Nägeln ereignete. Die Fraktur trat ohne jeglichen Hinweis auf ein Trauma auf, als die Patientin im Bett lag. Die Bruchlinie lief durch den Insertionspunkt des distalen Nagels. Diese seltene Komplikation ließ sich in einer erneuten Operation, bei der beide Frakturen mittles dynamischer Richard-Hüftgelenkschraube fixiert wurden, erfolgreich behandeln.Wir geben einen Überblick der Literatur zu dieser Komplikation, ihrer möglichen ätiologischen Faktoren und der empfohlenen Behandlungsformen.

Subcapital fractures complicating pertrochanteric fractures treated by internal fixation

Three female patients over 70 years of age were treated surgically for a pertrochanteric fracture of the hip. In 2 of them internal fixation was achieved by way of a dynamic screw-plate assembly while intramedullary Ender nails were used in the 3rd patient. All 3 patients were readmitted a couple of months after discharge from hospital due to a new subcapital fracture that occurred ipsilaterally through the tip of the fixation device after the primary pertrochanteric fracture had already reached a solid union. None of these cases resulted from inadequate placement of the fixation device: 1. The neck-shaft angle had been correctly restored. 2. The metals were centrally positioned in the femoral head and neck as documented in both the AP and axial views. 3. The distance between the subchondral bone and the tip of the device was consistently less than 10 mm. Neither X-rays nor histology showed any evidence of AVN or other pathologic processes (other than osteoporosis).This rare complication which requires immediate reoperation with removal of the metals and some form of arthroplasty of the hip joint has been reported 27 times following different types of internal fixation methods. The etiology of these interesting cases is still unclear and multiple theories have been proposed to explain this phenomenon. Among these the most popular is that of a technical error consisting of inserting the nail not deeply enough into the subchondral bone thus exposing the cancellous femoral neck to strong forces that tend to deform the femoral head into a varus position, with the metallic tip acting as a stress riser. Our own observations hereby presented challenge this theory as we have found no evidence to support it. The fact that perfect positioning of the device is not enough to guarantee a successful outcome raises the issue of whether it is justified to consider a second operative intervention for early removal of the metals as a preventive measure.

Unicompartmental arthroplasty of the knee with the cemented MOD3TM prosthesis

A consecutive prospective series of 19 knees had unicompartmental arthroplasty between 1991 and 1992 for gonarthrosis and AVN. The MOD3TM prosthesis was used in all cases. A total follow-up evaluation was undertaken after 6 to 7.5 years (mean 6.5 years) in 18 patients (1 patient has died during the observation period). Complications included 1 technical failure, 2 cases of thromboembolic phenomena and 1 case of a late deep infection. Knee score averaged 84.3 (pre-operative 54.7) and functional score averaged 68.9 (pre-operative 34.6).There were no cases with aseptic loosening of the prosthesis.It is concluded that with the appropriate indications, the unicompartmental arthroplasty of the knee is an effective and predictable procedure to achieve pain reduction and improved quality of life in patients with monocompartmental arthritis. Furthermore, the cemented MOD3TM prosthesis yields results that are comparable to other unicompartmental prostheses in current use.ZusammenfassungIn einer prospektiven Serie in den Jahren 1991 and 1992 wurden 19 unikompartimentelle Kniegelenkprothesen bei Gonarthrose und avaskulärer Knochennekrose durchgeführt. In allen Fällen wurde die MOD3TM-Prothese eingesetzt. Die Nachuntersuchung bei 18 Patienten (ein Patient verstarb his zur Nachuntersuchung) erfolgte nach durchschnittlich 6,5 Jahren (sechs bis 7,5 Jahre). Als Komplikationen wurden ein technischer Fehler, zwei Thromboembolien und eine späte tiefe Infektion beobachtet. Der Knie-Score hatte im Mittel 84,3 Punkte (präoperativ 54,7 Punkte), und der Funktionsscore betrug im Mittel 68,9 Punkte (präoperativ 34,6 Punkte). Aseptische Prothesenlockerungen wurden nicht beobachtet.Die Untersuchungsergebnisse legen nahe, daß bei regelrechter Indikation der unikompartimentelle Kniegelenkersatz ein effektives und vorhersehbares Verfahren zur Schmerzlinderung und Verbesserung der Lebensqualität darstellt. Darüber hinaus sind die Ergebnisse mit der zementierten MOD3TM-Prothese vergleichbar mit anderen derzeit verwendeten unikompartimentellen Prothesen.