Many orthopedic departments provide their patients with implant-specific identification cards. These cards should assist patients in various security checks and while undergoing revision surgery, especially if performed far from the primary hospital. This retrospective study was performed to evaluate patients’ use of these cards.

In our department, each arthroplasty patient receives an implant-specific identification card. A phone survey was conducted among two groups of consecutive patients who underwent a lower limb arthroplasty – first group consisted of 108 patients operated a year earlier and second – 120 patients operated 3 years earlier. In the first group, 97 patients (90%) replied and in the second group – 83 patients (69%). The patients were asked the following: whether they received the card, where they keep it, what do they know about its purposes, and have they used the card for security or medical reasons.

17 patients (18%) in one-year group and 18 patients (22%) in three-years group didn’t remember the card. The rest of the patients knew the location of the card, but most of them (80% in one-year group and 72%in three-years group) knew only about the security usage of the card and not about the medical one. Many patients complained that they were not given adequate explanations about the card.

Implant-specific identification cards have significant value for arthroplasty patients. However, patients use them mostly for security checks. The medical usage of this card should be explained when they receive it, so the patients can assist their surgeons while performing a revision surgery.

Introduction: The postoperative rehabilitation after a primary knee arthroplasty may be infiuenced by a variety of factors. Nevertheless, only a few studies evaluated the effect of various factors on patients’ short-term outcome. This prospective study was conducted to evaluate the effect of different factors on patients’ function six weeks after the surgery.

Patients and methods. We prospectively recruited 107 patients with osteoarthritis who underwent an uncomplicated total knee arthroplasty, using the same prosthesis and operative technique. Following variables were collected before and after the surgery: age, BMI, visual analogue pain score at rest and during activity, preoperative range of knee motion, involvement of other joints, comorbidities (Katz index), self assessed health status, admission and discharge hemoglobin levels, amount of blood transfusions and intensity of postoperative physiotherapy.

In order to quantify patients’ level of functioning, we used a timed up and go test (TUG) and the Oxford knee score that were collected before and after the surgery. To eliminate the infiuence of postoperative weakness on rehabilitation, hand grip measurements were performed as well. A multivariate regression analysis was performed to examine the infiuence of different peri-operative variables on the outcome measures. Adjusted R2 was measured to estimate the explanatory power of infiuence of these variables.

Results: There was no significant difference between preoperative and postoperative hand grip force measurements, indicating that the general strength of the patients did not deteriorate. A postoperative TUG was worse with higher preoperative TUG and higher rest pain score (adjusted R2=0.53). The amount of improvement in TUG was better only with lower rest pain score (adjusted R2=0.06). A postoperative Oxford hip score was better only with lower rest pain score (adjusted R2=0.30). The amount of improvement in the Oxford score was not infiuenced by any of the variables (adjusted R2=0.01). Only significant infiuences (p< 0.05) are mentioned.

Discussion: Most of preoperative and postoperative measured variables, including age, BMI, comorbidities, hemoglobin concentration and amount of physiotherapy had no significant effect on patient’s functional status after uncomplicated knee arthroplasty. Only the pain at rest had infiuence on the functional result. These results suggest that patient personality has a most significant effect on knee arthroplasty results, either through pain perception or otherwise.

Introduction: Publication rate from orthopedic conferences is reported to be as high as 58% (AAHKS). However, national orthopedic meeting, is a stage where many local papers are presented that do not necessary have an interest to the broad orthopedic forums and thus are not published. We conducted this study to examine the publication rate of papers presented in the National Orthopaedic Association meetings after 5 and 10 years.

Materials and Methods: We reviewed abstract books of National Orthopaedic Association meetings in the year 2003 and years 1998–1999. All invited and plenary lectures were excluded. Pubmed search was performed using authors’ names to find similar publications. The similarity was then rechecked by another author. The specific orthopedic subspeciality was noted; in some cases the same presentation could be classified in two different subspecialities.

Results: 160 works were presented in the years 1998–1999 and 36 of them were published (22.5%). In 2003 27 out of 105 presented works were published (25.7%). In different subspecialities, the publication rate was 48% for pediatric orthopedics, 45% for foot and ankle, 33% for hand, 29% for shoulder and elbow, 27% for basic research, 22% for spine, 21% for trauma, 19% for oncology, 18% for hip and knee and 10% for sports medicine. 14 published papers (22%) were from international institutions. Six papers were published before the presentation at the meeting (two at each year).

Conclusion: The publication rate of papers presented at the National Orthopedic Association meetings is around 24% and most are published at the first five years. However, many of these published papers are not from international institutions. More effort should be put both in better selection of presentations and in supporting young researchers for bringing their work to publication.

Introduction: Distal radius fracture in postmenopausal women is often the first clinical symptom of osteoporosis. Both patients and family physicians are generally unaware of this. It is estimated that only 15–25% of postmenopausal women with a distal radius fracture are further referred to perform a bone density examination. The purpose of the current study was to examine whether a simple intervention by the hospital staff would increase the percentage of patients that undergo diagnostic workup after suffering a fracture in the distal radius.

Patients and Methods: This prospective study included 99 women aged 48–70 seen in the emergency room for a distal radius fracture. All patients were contacted 6–8 weeks after the ER visit and asked as to whether they had received an explanation from the hospital or from the family physician about the significance of the fracture for osteoporosis, and whether they had been referred to a bone density examination. 49 patients served as a control group. The intervention group (50 patients) were then given a detailed explanation regarding the implications of the fracture for osteoporosis, and in addition, received a letter with an explanatory leaflet and an appeal to the family physician with recommendations and an article on osteoporosis.

An additional telephone survey was conducted 6–8 weeks after the first conversation to assess the influence of the intervention.

Results: 15 patients in the intervention group and 14 patients in the control group were lost to follow up or were already treated for osteoporosis before the fracture. At the second phone call 24 patients (72.7%) from the intervention group had contacted their family physician after the intervention, compared to 8 patients (22.9%) in the control group (p=0.0003). 14 patients (42.4%) from this group underwent a bone density examination, compared to 5 patients (14.3%) in the control group (p=0.0003).

Conclusion: It is of great importance that patients understand the connection between the current problem for which they are receiving treatment in the emergency setting and the possibility that there is an underlying cause. In addition the connection between the hospital and the community is very important in increasing the number of patients diagnosed and treated.

Osteoporosis is a very common disease in the elderly, generally undertreated. Hip fracture is often the first clinical painful symptom of osteoporosis. It would seem that hip fracture should be a good opportunity to convince the patient of the importance of osteoporosis treatment. We conducted this study to check whether a simple intervention improved the compliance of osteoporosis treatment.

100 consecutive elderly patients with osteoporotic hip fracture received, during postoperative hospital stay, a 5–10 minutes long explanation about osteoporosis, its sequelae, treatment options and their effectiveness in further fracture prevention. Patients received an explanatory brochure and a letter to family physician that included a recent article on fracture rate reduction with osteoporosis treatment. Compliance was examined by telephone survey 3 and 6 months postoperatively.

100 consecutive patients with similar demographic characteristics who were treated for hip fracture prior to intervention served as a historical control. All patients received a recommendation for osteoporosis treatment in the discharge letter.

At follow up, 40% of patients in the study group were receiving biphosphonates, as opposed to 20% in the control group (p< 0.01). 77% of control patients received no treatment for osteoporosis compared to 37% of patients after intervention (p< 0.01).

Giving the patient a short explanation about osteoporosis combined with a letter to family physician, resulted in a significant improvement in their compliance The orthopaedic surgeon, who treats the patient at the first painful symptom of osteoporosis, has an excellent opportunity to improve patient’s understanding of the disease and her or his compliance to treatment.

Introduction: Currently patients who had undergone lower limb arthroplasty are discharged a few days after surgery, at which stage they still need anticoagulation treatment. The transition from hospital to the community is a sensitive period and is susceptible to mistakes and misunderstandings. Patients may underestimate the importance of the continuing treatment and their inconvenience to self-administrate subcutaneous treatment might decrease their compliance. The purpose of this prospective cohort study was to investigate the continuity of the treatment with subcutaneous low molecular weight heparin at the transition period from the hospital to the community.

Materials and Methods: 209 consecutive consenting patients who had undergone lower limb arthroplasty were recruited. Ten were excluded from the study since they were subscribed oral anticoagulation; 4 patients developed pulmonary embolism and were not included, and 8 patients were lost to follow up. 187 patients were followed weekly by phone and were asked about their adherence to the daily treatment, about clinical signs suggesting a thromboembolic event and whether they sought medical assistance. Three months later there was another clinical follow up.

Results: Of the 187 patients, 174 (93%; 95% CI 88.9% < p < 96.4%) were compliant. The percentage of doctor visits by TKR patients was statistically significantly higher, (p=0.007) than by THR patients. There was no significant difference in the compliance of patients who live with their families and patients who live alone. Patients with 0–6 years of education tend to search medical advice statistically significantly more (p=0.004) than patients with more than 7 years of education.

Discussion: The rate of compliance to anticoagulation treatment with subcutaneous low molecular weight heparin was encouraging. It demonstrates that the patients understand the necessity and importance of the treatment.

Introduction: Several factors render plain X-ray radiographs of the hip unsuitable for bone mineral density measurements, mainly variability in X-ray exposure levels and soft tissue surrounding the bone. We present modification of proximal femur digital radiographs to compensate for these interfering factors.

Methods: The study population consisted of 99 women, in three groups: 1 – elderly, sustaining a fracture of the neck of the femur. 2 – elderly, without a fracture. 3 – young. Each patient’s hip was radiographed with a brass step-wedge for standard reference. Dual-Energy X-ray Absorptiometry (DEXA) of the same hip was performed. On each radiograph, Regions Of Interest (ROIs) of the proximal femur were determined in concordance with ROI of the DEXA, together with three soft tissue regions surrounding the bone. Mean gray level was measured for each ROI.

Results: The difference in gray level of the ROI within the proximal femur was not statistically significant between the groups. Correction of bone gray level to exposure level by dividing the gray level of the ROI to that of the step wedge, resulted in statistically significant difference between group 1 and either group 2 or group 3. Similar results were obtained by correction of bone gray level to soft tissue gray level. Using this method, multiple R² of 0.62 was found predicting the DEXA value from the gray level of each ROI.

Conclusions: After correction to the exposure level and to the soft tissue surrounding the bone, a plain digital radiograph of the pelvis can provide valuable information concerning the bone mineral content of the proximal femur. These preliminary results warrant further research aimed at exploring the potential value of this fast, accessible and relatively inexpensive technique to diagnose osteoporosis and the prediction of future fractures.

Introduction: The most widely accepted method for measuring bone mineral density (BMD) is Dual-energy X-ray Absorptionmetry (DXA). However, the need for relatively expensive equipment and trained personnel lower the accessibility of DXA as a routine screening tool. Plain pelvic X-ray radiography is a simple and inexpensive examination. In principal, the gray level of the bone in the X-ray radiograph is related to BMD. However, several factors render plain X-ray radiographs of the hip unsuitable for BMD measurements, mainly the variability in X-ray exposure levels and the soft tissue surrounding the bone. In this study, we aimed to develop new modifications of plain X-ray radiography of the proximal femur.

Patients and methods: The study population consisted of 18 women with an average age of 77 years (range 57–96 years) who were hospitalized due to a low-energy fracture of the neck of the femur. Each patient’s contralateral hip was radiographed with an aluminium step-wedge positioned near the hip as a standard reference, using a computerized radiography system. A DXA examination of the same hip followed the plain radiograph. On each radiograph, regions of interest (ROI) were determined in concordance with the ROI of the DXA examination. The mean gray level was measured for each ROI. The neck-shaft angle and the femoral head diameter were also measured.

Results: Comparing the gray levels of the plain radiograph with the BMD levels obtained by the DXA revealed a coefficient ratio of R=0.499. Correction of the gray levels using the step wedge as a standard reference revealed a ratio of R=0.576. If further correction was made with measurement of the soft tissue gray levels, a ratio of R=0.708 was obtained. Using the anatomical measurements (neck-shaft angle and femoral head diameter), a ratio of R=0.948 was obtained.

Conclusion: This study shows that a plain digital radiograph of the pelvis can provide valuable information concerning the bone mineral content of the proximal femur, which is comparable to the results of the DXA examination. Ultimately, the research can lead to the development of a fast, available and relatively inexpensive technique to diagnose osteoporosis.

Introduction: Osteolysis is a significant problem associated with hip replacement. In the early stages of osteolysis, when the implant is still stable, formal revision is technically demanding and may result in signififant bone loss. A recently described technique for acetabular component revision addresses osteolysis, retaining the acetabular cup and cementing a new polyethylene liner.

Materials and Methods: Between January 2000 and December 2003, 29 liner cementation revisions in 27 patients were performed. The mean age was 61 years (range 37–77), the mean time elapsed after the original surgery was 6.7 years (3–14). 23 of the hips (79%) were ABG (Howmedica). Only 20 (69%) of the patients were clinically symptomatic. At surgery the polyethylene was removed and osteolytic cysts were debrided. Then, the metal acetabular component was tested for stability. Obviously, only stable metal implants were not revised. The cysts were filled with bone graft or bone substitute and a new polyethylene liner was cemented in with methylmetacrilate augmented gentamicin. The patients were evaluated by modified Harris Hip Score (HHS) and by SF-12 score. The mean follow up was 25 months (10–45).

Results: The average HHS was 86/4 and its pain component was 38.8. The average physical component of SF-12 was 45.9 (19.5–57.2) and the average metal component was 54.6 (29–66.9). The post-operative HHS and the SF-12 scores were high (good or excellent) in all patients reflecting good clinical outcome. In patients who were asymptomatic prior to surgery, both the HHS and the pain score were significantly higher compared to the symptomatic patients (p< 0.01). One patient with extensive bone loss needed revision surgery due to early postoperative fracture of the acetabulum, and another patient had recurrent dislocations that required revision.

Summary: We conclude that revision of the polyethylene liner and cementation of a new one is a safe and useful technique in patients with stable acetabular shell. This is especially true for asymptomatic patients with osteolysis.

Introduction. Osteolysis is a periprosthetic bone loss associated with both cemented and noncemented arthroplasties. It is believed to be caused by cellular reaction to wear particles, especially from polyethylene, and is considered to be a major source of morbidity following total hip replacement. Roentgenographycally it appears as a diffuse cortical thinning or focal cystic lesion, but major bone loss may precede this finding. In advanced osteolysis, implant stability is impaired, and component revision is mandatory. Thus early detection of osteolysis is crucial to allow minor procedure of curettage and insert revision.

Three dimensional imaging tool for early detection and follow up of the osteolytic cysts is needed. The conventional CT incorporates streak artifacts around metallic implants that make the interpretation of the images extremely unreliable. We report our preliminary experience with new 16-slice CT techniques that improve the diagnosis of osteolysis.

Materials and methods. Twenty one patients with suspected osteolysis underwent CT examination of the involved region with a new 16-slice GE Lightspeed scanner. 16 patients had a hip arthroplasty and 5 patients a knee arthroplasty. Different slice thickness was examined. Standard, soft and boneplus filters were tested for the axial images and reconstructions. MPR with 0.625mm, 1.25 and 2.5mm slice thickness, 3D-MIP and VR reconstruction methods were performed for each patient and the best technique for minimizing streak artifacts and evaluation of periprosthetic bone was determined by two radiologists and an orthopedic surgeon.

Results. The axial images in various slice thickness showed massive streak artifacts but the thinner slices of 0.625mm showed better demonstration of fine bony details around the prosthesis. Standard filter was superior compared to the soft and boneplus filters for bony changes. MPR and MIP reconstructions reduced markedly the impact of the metal artifacts but MPR using 1.25mm slice thickness was superior to MIP for appreciation of the texture of the periprosthetic bone.

Conclusions. In our study, a proper technique of 16-slice computerized tomography allows early detection and follow up of osteolytic lesions, that may significantly help in the decision making process, and may enable avoiding major surgery.

Introduction: Decreasing the length of the side plate of the dynamic hip screw (DHS) would theoretically allow a smaller surgical incision, a shorter surgical time, decreased operative blood loss and minimal periosteal stripping. A new design of a very short plate (VSP) dynamic hip screw based on two diagonal screws has been developed. The new design was compared with the four hole side plate regarding its mechanical properties and bio-mechanical outcomes.

Methods: Four pairs of fresh frozen cadaveric femora were extracted from male corpses aged 25–43 (mean 34.8), mechanical loading was applied to four pairs of cadaveric femora which were fixated using the new system on one side and the conventional design on the other. The decline during the periodical loading and the breakage load of the fixated bones were measured. In addition, mechanical performance and probability for failure was assessed by conducting a mathematical analysis using the finite element method.

Results: The average deflection under excessive cyclic loading was 33% higher in bones with the VSP-DHS device than those with regular DHS. The average load failure during the collapse loading test was 312 kg for the VSP-DHS compared to 416 kg for the regular device. The mathematical analysis performed indicated that the maximal stress in the VSP-DHS reached values 3–4 fold higher than in the regular DHS.

Conclusions: Bio-mechanical evaluation was performed both by mechanical testing and theoretically. Although the new design offers a minimally invasive approach to subtrochanteric femur fracture fixation, it was found to have insufficient biomechanical performance resulting in high probability for mechanical failure.

Introduction: Minimally invasive surgery (MIS) is associated with reduced postoperative morbidity and faster recovery of function. The PerCutaneous Compression Plate (PCCP) device was recently developed by Got-fried as a MIS technique for the fixation of osteoporotic hip fractures. PCCP provides rotational stability by means of two hip screws, and lateral cortical support by a proximal extension of the plate and by the relatively small diameter (9.3 mm) of the hip screws. The purpose of this prospective study is to compare the outcome of PCCP to the “gold standard” Compression Hip Screw (CHS) device.

Methods: 104 Patients with intertrochanteric fractures were randomized to be treated by PCCP (50 patients) or CHS (53 patients). One patient was switched from PCCP to CHS during surgery. Inclusion criteria were age above 60, close fracture reduction, no pathological fracture, and no surgical procedure in the same leg in the last year.

Results: The groups were comparable in patient age, gender, ASA, length of surgery and hospital stay. Operative blood loss was 177.8 ml in the PCCP group and 371.3 ml in the CHS group (p< 0.0001). At the 6^th week clinic visit, patients in the PCCP group were able to bear more weight on the injured leg than patients in the CHS group (p< 0.03). Mortality during the first year follow-up period was 10% in the PCCP group and 24.5% in the CHS group (p~0.05). Analysis of X-ray radiographs revealed collapse in 4% of the patients in PCCP group and 19% in CHS group (p< 0.01).

Conclusions: Our results suggest that PCCP provides some of the advantages of MIS: reduced blood loss, as well as improves the stability of fracture fixation, demonstrated by improved early weight bearing and less fracture collapse. We found a trend for decreased first year mortality rate.

We present our experience with 40 infected total knee arthroplasties that were treated in our department during the last 10 years. Three patients suffered from early postoperative infection and were treated by debridement and antibiotic therapy with complete cure.

25 patients had chronic infection with loosening. 17 patients were treated by two-stage revision, six were treated by arthrodesis and in three patients excision arthroplasty was performed due to general poor conditions. 12 patients had late acute hematogenous infection and nine of them underwent debridement, either open or arthroscopic, and antibiotic therapy. Overall, 90% of the patients had no clinical, radiological or laboratory evidence of infection.

Background: Osteoarticular disease is the most common complication of brucellosis and has been described in 10–85% of patients. Spondylitis is the most prevalent clinical form, also arthritis, bursitis, tenosynovitis, sacroileitis and osteomyelitis have been also described.

Method: We describe our experience concerning three patients with brucellar prosthetic joint infection in Israel.

Results

Case 1: A 38 year old artist was admitted for revision of total hip replacement due to increased pain accompanied by loosening of the prosthesis. Four years prior admission total hip arthroplasty was performed due to psoriatic arthritis treated by methotrexate. Revision surgery demonstrated necrotic tissue which grew Brucella melitensis. Doxycycline and rifampicin were administered for 12 weeks. Second stage revision was performed on the 6th week of antibiotic therapy with favorable results.

Case 2: A 62 year old Arab male underwent right total knee arthroplasty 4 years prior admission due to osteoarthritis. Past medical history included hip arthritis. A second TKA was performed due to septic arthritis caused by Staphylococcus epidermidis and Acinetobacter baumanii. The first stage of the arthroplasty grew Brucella melitensis.

Antibiotic treatment and second stage revision surgery were followed successfully.

Case 3: A 67 year old Arab male was admitted due to fever, right pelvic and back pain lasting for 6 weeks. Five years prior admission the patient underwent left total knee arthroplasty. Computerized tomography was normal. Following admission severe left knee pain developed. Joint aspirate grew Brucella melitensis. Antibiotic treatment and two stages revision surgery were performed successfully.

In all three cases consumption of unpasteurized dairy products was documented. All three patients had serum brucella antibody titer of 1:1600.

Conclusion: Brucella melitensis should be added to the differential diagnosis of prosthetic joint infection, mainly in the Mediterranean basin and the Arabian Gulf. Only two other cases of brucella prosthetic joint infections were reported involving prosthetic knees.

Background: Osteoporotic tibial fractures may be a challenge both in diagnosis and treatment. The aim of treatment is obtaining joint congruity and normal alignment, joint stability, adequate soft tissue healing and functional range of motion. The goal is prevention of degenerative osteoarthritis. In the majority of cases the treatment of tibial plateau fractures consists of open reduction and internal fixation.

Objectives: The presentation of two aspects of the osteoporotic fracture – the insufficiency fracture and fixation of the fractures by a more appropriate method.

Patients: We present our experience with 7 cases treated during the past 2 years. Two of these cases presented with no story of trauma, normal X-rays and were diagnosed clinically and on CT and bone scanning. The other 5 cases resulted of minor trauma and operative treatment was in order, using a modified fixation technique – a small fragment plate.

Results: The patients suffering from fractures with normal X-rays suffered from insufficiency fractures and were treated conservatively. The patients suffering from depressed, split or comminuted fractures were treated by open reduction and internal fixation with a small fragment plate.

Discussion and Conclusion: Insufficiency fractures often are misdiagnosed as exacerbation of chronic metabolic or inflammatory diseases and a fracture is not suspected until intense augmentation of radionuclide is seen on bone scan. Screening of patients presenting wit non-traumatic knee pain has shown a prevalence insufficiency fractures of the tibial plateau between 3 to 8% of the cases. These cases may be much more common than we commonly presume.

The fractures in need of reduction and fixation of the plateau fracture involve raising the depressed articular fragment, the possible addition of bone graft augmentation and buttressing of the osteochondral fragment with a plate. These buttress plates may hold the cortical rim of the plateau but many times fail in maintaining the reduction of the intra-articular surface of the plateau. This again results in degenerative changes in the joint and pain.

Internal fixation of these fractures with small fragment plates may be a solution to this problem, as demonstrated by the 5 presented cases treated operatively. The plates are smaller in size and are held by more screws, which are more proximal to the articular surface. This way they allow better control and maintenance of the anatomic reduction and in combination with an a-traumatic dissection and less stress shielding effect, result in a low rate of local complications.

We tested the hypothesis that it is possible to accelerate fracture healing by changing the mechanical environment used in current methods i.e., from initial rigidity or micromovement followed by dynamisation to initial macromovement followed by rigidity (micro-movement).

It is accepted that callus formation requires movement at the fracture site and this callus response is limited to the first few weeks after fracture. Logically, early macromovement at the fracture site would be beneficial for callus formation. Additional callus is not produced by further movement. Indeed, it may be counter-productive, just as continuing movement around two ends of a wooden stick bonded with glue will retard and even prevent “union”. We postulate that continuing movement at the fracture site after the callus response has ceased will also delay union. As a result, rigidity rather than dynamisation is required in the later stage of fracture healing.

After testing an animal model, we built an external fixator which allowed 5 mm of axial movement without “self-locking” and could be compressed at a later date in order to prevent further movement.

A trial containing 15 patients with unilateral tibial shaft fractures (closed or grade 1 open) was undertaken after permission was obtained from the Helsinki Ethical Committee.

So far, 13 patients have been entered into the trial. They have completed therapy and are at least one year post-fracture (12 months to 22 months). Age range is from 20 to 49. The group is composed of nine males and one female.

Under general anaesthetic, an external fixator was applied and the fracture reduced. The patients started ankle exercises (active and passive) the following day, with as much weight-bearing on the fractured leg as possible on the day after. The patients were seen every two weeks and AP and lateral radiographs were taken. The fracture was compressed two to six weeks later. The percentage of body weight that the patient was able to tolerate through the fractured limb was measured by using the scales of Meggit’s step test. The fixators were removed when there was radiographic union and the patient could take at least 80% of body weight through the fractured limb. Mean time duration up to removal of the fixator was 10.8 weeks (range 7 to 15.4 weeks).

We conclude that it is possible to increase the speed of bone healing by changing the mechanical environment to initial macromovement followed by elimination of movement.