Background

Hip fractures affect annually over 350,000 people in the USA and over 1.6 million worldwide. About 50% of these numbers are intertrochanteric fractures,

The surgeon should be able to minimize the morbidity associated with the fracture by: recognizing the fracture pattern, choosing the appropriate fixation device, performing accurate reductions with ideal implant placement and being conscious of implant costs. In this study we assessed the ability of the orthopaedic surgeons to recognize fractures pattern, and choosing the ideal implant for the recognized fracture.

Purpose: Describe our experience with our new approach for treating displaced subcapital femoral fractures in our active patients.

Materials and Methods: From August 2005 till January 2008, 79 active patients were treated for displaced Sub-capital Femoral fracture by close reduction and internal fixation with Short Trochanteric Antegrade Nail (T.A.N.) (Smith& Nephew).

Mean age 74.5 (range 38–93),

Partial weight bearing began 0–4 weeks post operation and Full Weight Bearing 4–8 weeks post operation.

Patients were evaluated at 1,2,6,12& 24 months after the operation.

Results: All patients returned to walk on their feet.

The patients were scored by modified lower extremity questionnaire with mean results 4.1 (scale of 1–5, 1-poor, 5-excellent).

There were no cases of implant failure. No cases of infections.

Two patients had a cut-out of the implant and two other patients had a nonunion of the fracture. Those 4 patients (5.06%) were converted to a THR.

There were no cases of avascular necrosis.

Conclusions: Our complications rate for displaced sub-capital fractures treated by C.R.I.F. were lower than that reported for the alternative treatment modality. Our findings show that these fractures can be treated with a high rate of success by closed reduction and internal fixation with an intramedullary biaxial fixation in all age groups. With this simple and minimally invasive operation and the nail’s biaxial angular stability, we can achieve stable fixation.

This procedure offers several advantages over hemiarthroplasty, by lowering the risk of immediate complications such as prolonged anesthesia, bleeding, infection, periprosthetic fractures and dislocations. Furthermore, the use of the short TAN preserves the femoral head and the normal anatomy in active patients in order to avoid the late complications of hemiarthroplasty.

The Purpose: To compare clinical results of proximal humerus fractures following internal fixation with proximal humeral locked plate versus conservative treatment.

Materials and Methods: 25 patients sustained 3-part fractures of the proximal humerus. 8 were internally fixed and 17 were treated conservatively in two different centers.

Mean age: 65.4±12.7 Gender: 22 females, 3 males. Age and gender were similar in both groups. Follow up was longer in the conservative group (23.8 m ±7.5) compared to the operated one (11.1 m ±8.3).

All the patients were evaluated clinically using Constant’s score.

Statistical analysis was performed using Fisher’s exact test (examination rates differences), Mann-Whitney test (examination means difference) and Spearman’s test (evaluation of the correlation coefficient between two continuous variables).

Results: Constant’s score in the operated group was 57.1±19.3 and 58±21.5 in the conservative group. Union was noticed in all the operated patients, and there was one case of nonunion in the conservative group. There were no cases of AVN in any group.

Statistical Analysis: No significant difference between the two groups was found for total Constant’s score. ROM was similar in both groups except for the rotations, which tended to be better in the operated group: IR 7.6±2.6 versus 5.4±3.3 (p=0.103) respectively, ER 7.7±3.1 versus 6±2.6 (p=0.169) respectively.

Conclusions: Clinical results are similar for operative and conservative treatments in 3 part fractures of the proximal humerus. There are better results for rotations in the operated group. Strength in abduction is superior in the conservative group.

The difference could be influenced by the shorter follow–up period in the operated group.

Purpose: The elderly population is increasing in the modern world. Societies in general and medical personnel are facing new ethical and medical dilemmas when treating extremely old patients. Elderly patients have osteoporotic bone and hence a high incidence of fractures. Evaluating this unique group of patients who have hip fractures is our goal.

Materials and Methods: A retrospective analysis of all patients who had hip fractures between January 1990 and December 2001 and were beyond 100 years old was handled.

Data was collected from the medical files (hospitalization and out-patient charts) for age, sex, type of fracture, type of treatment, background disease, rehabilitation and time until death. The latter was confirmed by data from ministry of home office.

Results: 23 patients (17 females and 6 males) were found. Ages ranged from 100 and 107 (mean: 101.78). They had 4 subcapital and 19 per-subtrochanteric fractures. The patients had between 1–5 major background diseases. 4 patients were treated conservatively (1 due to major pneumonia and 3 refused the operative procedure). All these patients died at the same month of admission. Among the 19 patients who underwent operation, 12 patients have died and lived between 0–34 months (mean: 7.43) post-operatively, and 7 are still alive for 4–75 months (mean: 34.43) post-operatively. No differences between the operative and conservative groups in terms of major background disease were found.

Conclusions: Most of hip fractures in the extreme old age are per-subtrochanteric. Operative treatment yielded better results and should be the treatment of choice.

Purpose: To evaluate the use of locked Compression Plate (L.C.P.) in metaphyseal long bones fractures, and report our preliminary results.

Materials and Methods: 23 patients 14–82 years old with long bones metaphyseal fractures underwent surgery with the use of L.C.P. between January 2004 and August 2004. Four patients were adolescents.

7 patients had Supracondylar femoral fracture. One of them had the fracture at the tip of IMN. 11 patients had distal Tibia, one had proximal+midshaft tibia and 4 had distal humerus fractures. All plates were prebended to fit the area of the fracture using a skeleton model. The plates were inserted percutaneously with reduction of the fracture.

Partial weight bearing started after 6 weeks and full weight bearing started after 12 weeks.

Results: Unuion was seen in x-ray after 6 to 12 week in 95% of patients. 20 patients regained full range of motion of the adjacent joints at 3 months follow-up.

Complications: One patient developed compartment Syndrome in a high energy tibial fracture. One patient developed deep infection at the site of fibular plate not affecting the L.C.P. at the tibia. One patient developed temporary weakness of extensor Hallucis longus.

Conclusions: L.C.P. proved to be effective in fixation of meta-epiphyseal zones which are difficult in IMN fixation. The use of this plate enables fixation of long bones in adolescents with open growth plate. The locking system enables good fixation of osteoporotic bones and in periprosthetic fracture. The high primary stability in combination with newly developed minimal-invasive techniques (MIPO = minimal invasive plate osteosynthesis) are the bases for a rapid bony consolidation, a low complication rate and good functional results.

Purpose: Evaluating the rate of complications with the use of Proximal femoral nail (P.F.N.), and discuss the reasons for the complications and their solution.

Material and Methods: During last 4.5 years 308 patients underwent P.F.N. for unstable proximal femoral fracture. The average age of the patients was 75.6 (range 20–96).

A.O. classification. A1: 27. A2: 180. A3: 96. In 7 patients a failed dynamic hip screw (D.H.S.) was changed to P.F.N. All the patients were allowed to begin full weight bearing immediately. In 81% of patients short femoral nail was inserted and in the rest long one.

Results:

Complications:Malfixation(internal-rotation, varus, valgus, shorting, bad position of the screw in the neck) – 10%

Deep infection 0.7%, nonuonion 1%, cut out 2%,

Nail breakage 0.6%, Broken drills, bad position of locking screws.

Solutions:

Re-operation 1.6%, T.H.R. 1.3 %, removal of nail 1.6%, nail change 0.9%.

During the last year we began to use a new and improved insertion set with less complications.

Conclusions: P.F.N. is a valid solution for unstable proximal femoral fractures enabling immediate full weight bearing. P.F.N. may be used as a good salvage procedure for failed dynamic hip screw. The procedure demands accurate and meticulous operative technique in order to avoid technical complications. In cutout nails T.H.R. is a good salvage procedure in older patients.

The treatment of OA of the ankle is similar to any other large joint and includes conservative and surgical treatment. The surgical treatment is fusion or replacement but conservative treatment is limited and include mainly ankle supports and physiotherapy. Hyaluronic acid was discovered by Meyer and Palmer in 1934 and recently is widely used in the treatment of knee osteoarthritis. We evaluated the efficacy of intra-articular preparation containing Sodium Hyaluronate, in the treatment of OA of the ankle.

A group of 16 patients suffering from ankle osteoarthritis were selected for the study. The mean age was 43 years (range 31–79 years) and the duration of pain from nine months to 27 years. Twelve patients had ankle fractures and four had no trauma history. The clinical presentation included at least one or more of the following conditions of the ankle joint: pain in motion or at rest, swelling and tenderness for over than nine months. The radiographic severity of the ankle osteoarthritis was grade II, III or IV according to Kellgren and Lawrence. Intra-articular injections of 25 mg Sodium-hyaluronate (Adant) were administered on five consecutive weeks. Follow-up visits were perfumed one, two, three, four and seven months post treatment and included clinical evaluation and score scale.

Global assessment showed, in 13 out of 16 patients, improvement in the range of motion by 20%. Significant reduction of the OA symptoms according to the score: two to three points improvement on each scale. According to the osteoarthrithis ankle score scale: up to 20 points. Improvement continued for seven months follow-up after the treatment; no decrease in the treatment efficacy has been shown. Global assessment of two patients did not show any significant improvement after the treatment. One patient dropped off the study due to other operation.

Symptomatic relief of OA of the ankle can be achieved by injection of intraarticular preparation containing Sodium Hyaluronate.

Background: Osteoarthritis (OA) may affect large and small joints and is common final pathway of large array of conditions. OA of the large joints includes mainly hip, knee, shoulder and ankle. The treatment of OA of the ankle is limited and the surgical treatment is usually salvage procedure as fusion. Therefore there is a need for an efficient conservative treatment of the ankle OA.

Aims: The objective of this clinical trial was to evaluate the symptomatic efficacy of intraarticular preparation containing Sodium Hyaluronate, in the treatment of OA of the ankle.

Methods: The study was conducted on patients who visited our out-patients clinic under the direct supervision of the principle investigator. The male or female patient aged between 30 and 80 suffering from osteoarthritis of the ankle joint of radiographic severity II or III or IV according to Kellgren and Lawrance, suffering from one or more of the following conditions of the ankle joint: swelling, tenderness or pressure, and/or pain on motion or at rest, who have clinical history of ankle pain for over 6 months.

Intraarticular injections of 25 mg Sodium-hyaluronate in 5 following weeks were administrated to 16 patients, 31–79 years old (average 43 years) suffering from pain in the ankle, 9 months to 27 years. 12 patients after operation, 4 with no trauma history.

Follow-up visits were performed 1,2,3,4,7 months post treatment and included clinical evaluation and score scale.

Results: Global assessment showed in 13 out of 16 patients improvement in the motion range (20%) and significantly reduction of the OA symptoms according to the score: 2–3 points improvement on each scale and according to the osteoarthritis ankle hindfoot score scale (100 points total): up to 20 points improvement. Seven months after the treatment, no decrease in the treatment efficacy has been shown.

Global assessment of 2 patients did not show any significant improvement after the treatment. One patient dropped off the study due to other operation.

Conclusions: Symptomatic relief of OA of the ankle can be achieved by admission of intraarticular preparation containing Sodium Hyaluronate.