Nachshon Shazar

Novel classification of knee osteoarthritis severity based on spatiotemporal gait analysis

OBJECTIVE To describe a novel classification method for knee osteoarthritis (OA) based on spatiotemporal gait analysis. METHODS Gait analysis was initially performed on 2911 knee OA patients. Females and males were analyzed separately because of the influence of body height on spatiotemporal parameters. The analysis included the three stages of clustering, classification and clinical validation. Clustering of gait analysis to four groups was applied using the kmeans method. Two-thirds of the patients were used to create a simplified classification tree algorithm, and the models accuracy was validated by the remaining one-third. Clinical validation of the classification method was done by the short form 36 Health Survey (SF-36) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. RESULTS The clustering algorithm divided the data into four groups according to severity of gait difficulties. The classification tree algorithm used stride length and cadence as predicting variables for classification. The correct classification accuracy was 89.5%, and 90.8% for females and males, respectively. Clinical data and number of total joint replacements correlated well with severity group assignment. For example, the percentages of total knee replacement (TKR) within 1 year after gait analysis for females were 1.4%, 2.8%, 4.1% and 8.2% for knee OA gait grades 1-4, respectively. Radiographic grading by Kellgren and Lawrence was found to be associated with the gait analysis grading system. CONCLUSIONS Spatiotemporal gait analysis objectively classifies patients with knee OA according to disease severity. That method correlates with radiographic evaluation, the level of pain, function, number of TKR.

The natural course of bridging osteophyte formation in diffuse idiopathic skeletal hyperostosis: retrospective analysis of consecutive CT examinations over 10 years

OBJECTIVE The aim of this study was to evaluate the natural progression of bridging osteophyte formation in diffuse idiopathic skeletal hyperostosis (DISH) on CT by a newly proposed scoring system. METHODS CT examinations of the thoracic/lumbar spine of DISH patients (Resnick criteria) obtained at two or more time points within a minimum of 3 years were evaluated. Twenty-six patients (mean age at first CT 57 years, 21 males) fulfilled the entry criteria. A semi-quantitative scoring system for osteophyte progression was evaluated for intra- and interreader reliability on 68 vertebral units (VUs) in five patients. CT sagittal reformates of all 26 study patients were scored by two readers in consensus. RESULTS Scoring intra- and interobserver intraclass correlation coefficient values were high (0.971 and 0.893, respectively). The average time points per patient was 3.6 in 398 VUs analysed for 93 time points. The average time between the first and last scans was 5.6 years (range 3-10). The scores of six patients were unchanged. The scores of 20 patients increased by 3 units in 48 VUs over 5.6 (s.d. 3.1) years. The time for a DISH score to increase by 1 scoring unit was 1.6 (s.d. 0.4) years. Two bridging patterns were observed: osteophyte fusion associated with a calcified anterior longitudinal ligament (ALL, 66%) and osteophyte fusion without apparent ALL calcification (33%). Both patterns were observed concomitantly in 15 patients. CONCLUSION The new scoring system may enable earlier diagnosis and help predict disease progression into its final confluent osteophyte form. The two described patterns may indicate an underlying inflammatory rather than a degenerative pathogenesis.

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.

Posterior Malleolus Fractures

Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.

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.

Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures

BACKGROUND Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. Techniques for fixation of displaced fractures of the lateral malleolus have remained essentially unchanged in recent decades. The current gold standard of treating unstable fractures is with open reduction and internal fixation (ORIF), using plates and screws construct. This study evaluates the use of fibula intramedullary nailing based on minimal invasive surgical approach. METHODS Thirty-nine cases treated with fibula intramedullary nailing between the years 2014-2016 were retrospectively studied. A fibular nail was utilized for the treatment of various ankle fractures either as the sole method of fixation or combined with another method. Patient charts were reviewed for fracture patterns, comorbidities, quality of reduction, complications and additional surgeries. RESULTS Out of 39 cases in the study cohort, 37 were closed fractures while 2 had an associated medial malleolus open injury. According to Weber classification of lateral malleolus fractures, 20 cases were type B, 18 cases type C, and one case of a pathologic fracture type B like fracture. Quality of reduction was based on previously published criteria. It was determined to be good in 32 cases, fair in 5 cases and poor in 2 cases that were revised intraoperatively to plate fixation. Overall no systemic complications occurred. Eight patients have undergone additional surgeries, namely hardware removals. In two cases, the nail was later revised to a different fixation method: one case to a plate, due to secondary displacement at 2 weeks, and one to an intramedullary tibiotalocalcaneal arthrodesis secondary to hardware failure and Charcot neuroarthropathy. CONCLUSION Intramedullary fibular nail offers a satisfactory and safe procedure to establish good reduction and fixation of lateral malleoli fractures. It may be considered as treatment of choice for patients with soft tissue problems due to its minimal invasive approach. The current study shows that while good fracture reduction can be achieved, without major complications, more than fifth of patients, required secondary procedures, mainly hardware removals. LEVEL OF EVIDENCE Level IV.

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.

Knee Osteoarthritis Functional Classification Scheme - Validation of Time Dependent Treatment Effect. One Year Follow - Up of 518 Patients

Objective: The purpose of the current study was to validate time dependent changes of a novel functional classification for patients with knee osteoarthritis (KOA), following a home-based biomechanical treatment (HBBT).Methods: A retrospective analysis of 518 patients with KOA was conducted. All patients were classified using a novel knee osteoarthritis functional grade (KOFG) classification for KOA, based on spatio-temporal gait analysis. Patients were re-classified after 3 months and 1 year of HBBT to examine and validate this classification using timedependant changes. The time dependent changes in the classification were compared to gold-standard selfassessment questionnaires, WOMAC and short form 36 (SF-36).Results: The changes in KOFG were demonstrated over time, with most changes occurring after 3 months of treatment with consolidation of the effect at 12 months. For example, of 427 patients that were classified in KOFG 2-4 grade at baseline, 44.9% and 51.5% had lower (better) KOFG grades at 3 and 12 months of treatment, respectively. The changes in KOFG were validated with WOMAC and SF-36 questionnaires showing a significant correlation between KOFG changes and changes in WOMAC and SF-36. SF-36 pain sub-scale showed an improvement of 33.0% and 38.0% following 3 months and 12 months of treatment, respectively (p values <0.0001).Conclusions: The results of the current study validate the knee osteoarthritis functional grade classification scheme as a tool to assess time dependant changes in KOA as well as its sensitivity to assess treatment effect. The KOFG can offer a more robust mode of reporting clinical results in describing the natural history and time-dependent treatment results of patients suffering from knee OA and should be considered as an additional outcome measure in future studies.