Introduction: In 2003 the Ministry of Health in Israel added hip fractures to the DRG listing. The rational behind this move was aiming at the shortening of hip fractures waiting time to surgery and shortening of hospitalization period. Some hospitals in Israel have assigned an additional OR shift for this purpose. Hip fracture patients consist of two main sub-groups: patients who undergo hemi-arthroplasty (HA Group) and those who undergo internal fracture fixation (IFF Group). The new policy determines that DRG of internal fixation patients ends at the fifth day of their initial hospitalization after surgery. The aim of this study was to evaluate the practical effect of this policy on hip fracture management.

Patients and Methods: We retrospectively compared two major groups of patients (total 808) with hip fractures: the first group of patients was treated in 2001 (377 patients) (before the new policy came into effect) and the second in 2005 (431 patients). Each of these groups included the HA group and the IFF group. In each of the groups we compared the time to surgery, length of hospitalization, mortality rates after six months and the diurnal distribution of the operations.

Results: The length of hospitalization in 2005 was found to be shorter in the IFF group by 2.82 days (2001 – mean stay of 12.52, 2005 - 9.7 days) as opposed to the HA group where hospitalization was shorter in 2005 by a mean of only 0.42 day. Mortality rates at six months following surgery, when comparing the two major groups, were 11.3% in 2001 and 7.9% in 2005. 90% of the operations in 2005 were performed between 15:00–19:30 compared to 2001 when 90% of surgeries were evenly distributed between 15:00 and 24:00. We did not find statistically significant differences between the groups in relation to the time to surgery before and after the new policy. There was a trend towards a longer waiting time to surgery in the HA group in 2001 as well as in 2005.

Discussion: The presence of a dedicated shift, according to the new policy, made more room available for other emergency list surgeries. Hospitalization stay became shorter due to the fact that the insurer is committed to discharge patients from the IFF group after 4 days of hospitalization and to finance each additional day. In spite of the fact that waiting time to surgery was not shortened following the new policy, the majority of surgeries were performed during the afternoon sessions. It should be noted that in 2001 waiting time to surgery was already very short. Mortality data are interesting and necessitate further investigation.

Purpose: Fracture reduction (FR) during intra-medullary nailing of long bone fractures requires an extensive use of fluoroscopic radiation. Fluoroscopy based navigation system using custom FR software is introduced of which the main advantage is its ability to track simultaneously the two fracture segments during fracture reduction. The aim of this study was to test the feasibility of this system.

Methods: 26 Patients 17 males and 7 females suffering from 10 tibial shaft and 14 femoral shaft fracture were operated using the FR software. Two trackers were attached to each of the main fracture segments. Image registration was done by acquiring fluoroscopic images including the fracture site and the two metaphysial areas of the long bone on both perpendicular planes. The system uses two cylinder models representing the fracture segments, each defined between two points chosen by the surgeon on the acquired images, these are tracked by the system. Fracture reduction was qualitatively evaluated as well as other features of the system. Overall radiation was registered.

Results: A small number (< 10) of flouroscopic images was acquired; this decreased as we gained more experience. FR software was helpful in all the cases and accomplished good and quick reduction; it reduced the need for added radiation to 2–4 verification images.

The system was utilized as well in all cases for choosing the nail point of entry, in 7 (25%) for blocking screws planning and in 4 (16%) for nail locking successfully.

Conclusion: The FR software enabled and improved significantly the performance of this surgical task with a dramatic decrease in radiation and FR time. The software still lacks the fine tuning needed for best performance.

Background: Surgical approaches to the acetabular fracture present a challenge for most surgeons. The ilioinguinal approach by Letournel has fundamentally contributed to the successful treatment of such fractures. The current tendency is to minimize the approach while maintaining a proper visual field that allows inspection of fracture fragments and the ability to reduce them. The Stoppa approach is a less invasive anterior intra-pelvic approach that could be combined with a lateral window of the ilioinguinal approach, especially helpful in facilitating the approach to the quadrilateral plate.

Aim: To evaluate the efficacy and safety of the Stoppa approach for the treatment of different types of acetabular fractures.

Patients: Between the years 2004 and 2006, 45 patients with acetabular fractures were operated on using the Stoppa approach. Their age ranged between 14 and 73 (average 42). There were 33 males and 12 females whose fractures were classified as anterior column fractures (21) associated both columns (11) transverse (6), T-shape and other various types. They were consecutively operated in two level 1 trauma centers; in 13 the Stoppa approach was used solely and in the others a combination of the Stoppa approach with an iliac window was employed. Patients were followed for an average of 11.4 months (range 2–36 months), and assessed using the Merle d’Aubigné score.

Results: Visualization of the fracture, reduction and fixation were all feasible through the Stoppa approach. The average length of surgery was 4 hours and an average of intraoperative bleeding was 1086 cc. We were able to achieve excellent reduction in 37 patients and a good reduction in the rest of the cases. Clinical outcomes were good to excellent in 90% of the patients. 3 patients underwent hip arthroplasty due to post traumatic osteoarthritis.

Conclusions: The Stoppa approach in combination with an iliac window offers superb visualization of the quadrilateral plate, anterior column and in some cases the posterior column as well and enables excellent reduction. It is a reasonable replacement for the iliuinguinal approach offering less tissue dissection.

Introduction: Reversed oblique subtrochanteric fractures are unstable and pose a surgical challenge. Fixation with Dynamic Hip Screw is prone to collapse with medial displacement and high rate of non or mal union. The use of Proximal Femoral Nails may result in non anatomical reduction which delays union and impedes rehabilitation. PCCP is a percutaneous plate originally designed for fixation of intertrochanteric fractures. However, the plate supports the greater trochanter and can prevent collapse of subtrochanteric fractures and rigidly secure the femoral neck. This study summarized our experience in fixating reversed oblique subtrochanteric fracture with the PCCP technique.

Patients and Methods: Between January 2005 and March 2006 26 patients who sustained reversed oblique subtrochanteric fractures (AO-31A3) were consecutively treated with PCCP. Two patients died and were excluded from this study. Patients’ age ranged between 58 and 93 (average 86, median 80). Follow-up was between 6 to 20 months (average 12). All patients were operated on a standard fracture table with the use of posterior reduction device. An attempt to reduce the fracture was done in each case prior to the surgical incision. In the majority of cases the shaft was displaced medially to the greater trochanter. The PCCP plate was introduced percutaneously and the medially displaced shaft was pulled to the plate using the reduction clamp. The rest of the procedure was done according to the regular technique of the PCCP. All patients were instructed to refrain from weight bearing for six weeks after the surgery and then resume full weigh bearing. Follow-up was in the out patient clinic 6 weeks, 3 months and one year after the surgery.

Results: Time of surgery varied between 35 to 75 minutes. There were no patients who were planned to undergo this procedure and were diverted to a different modality of fixation. All the procedures were done percutaneously. Anatomic or near anatomic reduction was achieved in all cases. All patients resumed full weigh bearing six weeks after the surgery. All but one fracture united. The patient whose fracture did not unite was blind and fell a few times during rehabilitation and eventually suffered from pull-out of the plate from the femur with breakage of the shaft screws. She underwent revision surgery with bone graft and the fracture united. Follow-up radiograms showed that the reduction was maintained in all but three patients. Medial displacement of 8–15 mm occurred in 3 patients. There were no infections.

Conclusions: While there is an ongoing debate among “nailers” vs. “platers” for the fixation of femoral neck fractures, PCCP combines the theoretical advantages of both percutaneous technique and absolute stability. In this study this biological system was found to be a reliable solution for the challenging fixation of reversed oblique (AO-31A3) subtrochanteric fractures, with high union rate, fast recovery and low complication rate.

The importance of mechanism of injury was initially introduced by Holdsworth who made the supposition that all fractures are created when the spine is subject to one of 5 types of violence. It has been our experience that similar injury mechanisms can lead to variable fracture patterns. Alternatively, different injury mechanisms can lead to the same fracture pattern.

Purpose: To evaluate the variation in fracture patterns when a single and uniform force vector is applied to the spine with variable degrees of spinal flexion. Finite element modeling was used for this analysis.

Methods: Three different finite element models were created to represent each accident situation. The straight spine was modeled as a simple column with alternating vertebrae and disc segment. The moderately flexed and significantly flexed spines were modeled as curved cylinders sectioned into vertebrae and discs, then bent around a solid cylinder representing the abdomen. A 1000 N compressive load was applied vertically to the top of the spine. The model was restrained along all bottom surfaces, and the interface between the spine and abdomen sections was defined as frictionless. The model is fixed at the lower end and the area of greatest interest is the transition zone from the most rigid to the less rigid portion. Although no specific area of the spine is intended for purposes of the model, this composition is much like the thoracolumbar junction – the location of the majority of spinal injuries.

Results: The straight spine showed pure compression throughout the length of the spine, while the moderately curved spine showed the posterior elements of the region of interest in tension and the anterior elements in compression. The significantly curved spine was found to be in tension in both posterior and anterior elements.

Conclusion: In a situation where the patient is sitting upright with a straight spine, a compressive load will cause a burst fracture. When the patient is partially bent over, such as with a shoulder seat belt, a flexion distraction injury will occur with the posterior aspect of the spine failing in tension and the anterior in compression. When the patient is fully bent over, such as with a laponly seat belt, a purely distractive fracture can occur.

Introduction: Cigarette smoking is associated with musculoskeletal degenerative disorders and increased risk of fracture delayed- and non-union. A lower-than-average concentration of mesenchymal stem cells may be the reason for the reduced regenerative potential. The aim of this study was to compare the concentration of bone marrow MSC of smokers and non-smokers.

Methods: As part of a larger IRB approved clinical trial, 20ml bone marrow samples were processed and MSC were isolated. FACS analysis was used both to assess the purity of the separation process and to evaluate the number of MSC recovered from each sample. Differences in continuous outcomes between smoking and non-smoking groups were assessed by two tailed t test and difference between categorical outcomes was measured by chi square test.

Results: Twenty six subjects participated in the study. Thirteen were smokers and thirteen were non-smokers. Groups were not significantly different with regard to age and gender. The average concentration of MSC was 352.04x10³/ml for non smokers and 131.23x10³/ml for smokers (SD’s were 245.72 x10³/ml and 161.54 x10³/ ml respectively. The difference between the smokers and nonsmokers was significant (t=3.2 p=0.004).

Discussion: The present study indicates that cigarette smokers have lower-than-average concentration of MSC in their bone marrow. Since MSC are a key element in every regenerative process of the musculoskeletal system, our findings may contribute to understanding and prevention of delayed and non-union. Further investigation is undertaken to address the issue of bone marrow recovery after smoking cessation.

Background: The purpose of this study was to analyze the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with 3-dimensional imaging (SIREMOBIL ISO-C-3D) in fixation of intraarticular fractures.

Methods: Intraoperative CT-quality visualization was performed on a series of 72 closed-intraarticular fractures in 70 patients following fixation. Fracture distribution was; calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle (3), femoral head (l). The mean patient age was 41. Intraoperative revision was performed based on the additional information Iso-C-3D provided beyond routine fluoroscopy used for fracture reduction and fixation. The primary outcome measure was revision rate after final Iso-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for Iso-C-3D use and to determine the rate of further re-do surgeries.

Results: Eight out of 70 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following Iso-C-3D imaging. In 7 cases this was due to hardware misplacement and in 1 this was for intraarticular loose fragment. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using Iso-C-3D was 7.5 minutes. No patient required re-do surgery.

Conclusion: Intraoperative 3-dimensional visualization of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence eliminates the need for re-do procedures. Iso- C-3D adds little operative time and may preclude the need for preoperative and postoperative CT-scans in selected cases.

Introduction: Non union of the humerus in the ostoeportic bone is a great challenge for the orthopedic surgeon. The non weight bearing nature of this bone together with extreme osteoporosis seen in the elderly had rendered a high degree of failure in different modes of internal fixation of established humeral non union. Tantalum is a trabecullar metal with biomechanical properties similar to bone with a high modulus of elasticity and low rigidity. It is proved both in vitro and in vivo to induce excellent bone and vascular in growth and have been used successfully treating other application in orthopedics. We have introduced the tantalum rod for the treatment of humeral non union in the elderly.

Patients and Methods: Six patients with humeral non-union were selected for tantalum rod implantations. All were above 60 years old. All patients had established non and 4 had failures after previous osteosynthesis. The surgical technique was exploration of the fracture site via a posterior or an anterolateral approach, debridement of the fracture site and intramedullary insertion of a 100 mm x 10 mm tantalum rod. No bone grafting was used. Ancillary fixation included a 4.5 broad DCP plate with screws drilled into both bone and rod or screws alone drilled into the bone and tantalum construct. Follow up period was up to one year.

Results: All fractures united clinically and radiographicaly up to 3 months. All patients achieved satisfactory shoulder and elbow range of motion and regained functional activity. No infection or foreign body reaction was noted.

Conclusion: Intramedullary tantalum rodding is a viable treatment option for the cases in both primary and secondary non union of the humeral shaft in osteoporotic bone.

Introduction: Lateral compression (LC) is the most common type of pelvic fracture, however there are no clear clinical or radiologic indications to direct conservative versus operative treatment of this pattern of injury. This study aims to determine if improved characterization of LC fracture patterns is possible through 3D radiological analysis.

Methods: CT scans of 61 patients with unilateral LC pelvic fractures were identified. The scans were segmented to generate a 3D model of the pelvis (Amira, MCS Inc). To quantify displacement of the fractured hemipelvis, the spatial orientation of three distinct anatomical landmarks (anteriof superior iliac, posterior superior iliac and ischial spines) on each side of the 3D hemipelvis were identified. Translational and rotational differences between the intact and fractured sides were compared to determine patterns of displacement with respect to a generated mid-sacral sagittal plane.

Results: 36.6% of the LC fractures were classified as non-displaced, 36.6% had an isolated single axis rotation, in another 13.3% had a pure translation with no rotation. 10% demonstrated pure rotational involvement in extension and the remaining patients, 3.3% had dual axis rotation.

Conclusion and Significance: Using 3D geometric analysis we were able to quantify patterns of LC fracture displacements not previously described. We characterized 5 subgroups of displacement patterns in LC fractures of the pelvis. Our 3D findings demonstrated a spectrum of translation and rotation motivating comparison with clinical outcome.

Introduction: Malrotations following Several complications have been reported in femoral nailing, among them. The aim of this study is to develop an intraoperative method based on cone beam CT (CBCT) to assess comminuted fracture periaxial rotation. We hypothesize that bone surface matching using CBCT image data can precisely predict malrotation in the fractured femur even with severe comminution.

Methods: A mid-shaft osteotomy in a fresh frozen cadaveric femur was performed and a rotational axis was formed. The proximal part of the femur was fixed and the distal part was optically racked for periaxial rotation. At each rotation a CBCT was aquired. The images were segmented at bone threshold. The center of the bone in each axial slice was calculated and the distance from that center to the inner and outer bone surfaces was sampled at 1o intervals (360x). The resulting plot was an unwrapped virtual bone surface consisting of a pattern of ridges and valleys. Fracture gaps were simulated by removing CT slices adjacent to the osteotomy. The fracture gap was reconstituted using an extrapolation algorithm to the midline of the fracture. The two bone surfaces were then continuously shifted relative to one another in order to match the geometric bony features. Calculated malalignments were compared to the measured at each of the 16 rotations with each of the 9 simulated fracture gaps. Three rotational malrotations were tested twice to assess repeatability.

Results: Femoral malrotation was strongly predicted as compared to the rotation measured by optical tracking. The performance was not impacted by gap size up to 100 mm.

Discussion: The high quality of intraoperative CBCT imaging data enables surface matching algorithms to be utilized. The results ratify this novel method for assessing fracture rotation.

With obesity on the rise in Israel, most of the medical staff will probably encounter the unique challenges that result from the pathophysiological changes in this population. Morbid obesity is a chronic disease manifesting itself in a steady and slow-progressive increase in body weight. Currently, BMI is considered the best score for morbid obesity definition and it is calculated by dividing the body weight (kgs) in body surface area (m2). The score for morbid obesity is above 40 kg/m2 and has many systemic implications such as hypertension, diabetes, cardiovascular changes, especially it effects the musculoskeletal system. Complex multiple trauma in morbid obesity patients present a challenge throughout all stages of treatment: assessment of injury, preliminary care, and definitive surgical approach.

In the last two years five morbid obese patients (all weighted more than 150 kgs) sustained various degrees of high-energy multiple-trauma and were operated on in our institution. The patient presented with the following injuries:

Femoral fracture.

The preoperative, operative and post-operative care presented special curative dilemma and pitfalls which required modifications in regular treatment modalities such as improvisation in special equipment and surgical techniques. The operating tables had to be changed so they could sustain the increased patient’s weight and allow, in the same time, modified percutaneous surgical approaches to overcome the anatomical problems. In all patients we were able to achieve the main goal of trauma treatment, i.e. stable fixation of fractures and mobilization.

The experience we have gained in managing and overcoming these obstacles may serve as a basis for devising guidelines for the comprehensive treatment of these patients.