Background: The prevalence and incidence of low back pain in general society is high. Workers whose job involves walking long distances have even a higher tendency to suffer from low back pain.

Purpose: Our goal was to examine the effect of insoles on low back pain among workers whose job involves long-distance walking.

Methods: In this double blind prospective study we examined the effectiveness of insoles constructed in a computerized method to placebo insoles in 58 employees whose work entailed extensive walking and who suffered from low back pain. The evaluation was performed by the MILLION questionnaire.

Results: 81% of the employees preferred the real insoles in comparison to 19% of the users of the placebo insoles (p < 0.05). A substantial improvement in the LBP after the use of the true insoles was noted.. The average pain intensity before the use of the insoles was 5.46. However, after the use of the real insoles and the placebo insoles the average pain intensity decreased to 3.96 and 5.11 respectively. The difference of the average pain intensity at the start of the study and after the use of the real insoles was significant: −1.49 (p=0.0001), whereas this difference after the use of the placebo insoles was not significant: −0.31 (p=0.1189). A level 5 pain and above was reported by 77% of the subjects at the start of the study. After the use of the real insoles 37.9% of the subjects reported a similar degree of pain severity, and 50% of the subjects did so after the use of the placebo (p< 0.05).

Conclusions: LBP decreased significantly after the use of real insoles compared to placebo ones.

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.

Objective: To determine the late (2–5 years) clinical results of surgery for herniated lumbar disc (HLD) as related to duration of preoperative symptoms and type of herniation.

Methods: The study was limited to 63 adult Moslem Arab residents of the hospital’s catchment area. All subjects had been scored for pre and postoperative leg pain and for related disability using a 0–11 visual analog scale and a functional grading system (Spangfort’s), respectively. Relationships between duration of preoperative symptoms and extent of disc herniation with the above scores were statistically analyzed.

Results: The mean overall score for leg pain decreased from 7.2 ± 2.0 (preoperatively) to 3.4 ± 2.4, a mean reduction (ΔVAS) of 3.1 ± 2.7, a 43.3% change (P< 0.001). Patients operated upon within 4 weeks after onset of symptoms attained the highest degree of leg pain relief (ΔVAS 4.3 ± 2.6), those operated within 4–12 weeks reported the least relief of leg pain (ΔVAS 1.7 ± 2.8). Paradoxically, patients who underwent surgery after 12 weeks received better results than the 4 – 12 week group (ΔVAS 3.0 ± 1.3). Patients with non-contained herniation reported a more intense preoperative leg pain than those defined as contained (VAS 8.3 vs. 6.5), were operated earlier (7.4 vs. 15.8 weeks), and their functional outcome was graded as better (Good/Fair in 96.4% vs. 74.3%).

Conclusions: Patients with incapacitating radicular pain, not responding to conservative treatments, are best operated upon within 6 weeks of onset. Surgery for non-contained herniation achieves a higher long-term success rate, probably since severe pain hastens surgical procedure, thereby preventing irreversible root damage.

Purpose: To assess the effect of regional versus general anesthesia on transcranial cerebral oxygen saturation (rSO₂) in elderly patients undergoing fractured proximal femur repair.

Materials and Methods: Prospective, randomized, open-label study. 60 geriatric patients were randomized to receive either general (Group GA) or spinal (Group S) anesthesia. In all cases frontal rSO₂ (INVOS^® 5100, SOMANETICS, Troy, Michigan, USA) was measured for a 10 minute pre-operative control period, throughout the surgical procedure and for 10 minutes postoperatively. If a drop in rSO₂ below baseline occurred, the following were instituted in order to improve cerebral oxygenation: normotension was ensured, the neck vessels were checked and cleared of extrinsic obstruction and the F_IO₂ was increased.

Results: The incidence of a decrease in rSO₂ below base-line preoperative levels was significantly (p < 0.0001) higher in Group S. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups. By contrast, general anesthesia was associated with a significantly higher rSO₂ when compared to spinal anesthesia. This is attributed to the volatile anesthetic agent induced reduction in the cerebral metabolic rate. Logistic regression revealed no correlation between changes in blood pressure, heart rate or peripheral oxygen saturation and the incidence of rSO₂ dips below baseline.

Conclusion: rSO₂ is likely patient specific and independent of the anesthetic technique administered. Therefore we support the utility of cerebral oximetry in this population in order to detect cerebral desaturation and correct reversible causes such as relative hypotension and neck vessel obstruction. Choice of anesthetic technique should still be tailored to individual patient needs.

Introduction: Diffused pigmented villonodular synovitis (PVNS) is a locally aggressive lesion for which surgery provides only marginal resection. An adjuvant treatment modality is therefore required to prevent local tumor recurrence. The authors describe their experience with intra-articular injection of Yttrium⁹⁰ (Y⁹⁰), a radioisotope, as an adjuvant for tumor resection.

Materials and Methods: Between 1989 and 2002, 20 patients with diffuse PVNS were treated with post-operative, intraarticular injection of Y⁹⁰. There were 15 male and 5 female patients who ranged in age from 13 to 67 years (mean, 35 years). Anatomic locations of the affected joints included: knee – 15, ankle – 4, hip – 1. Tumor resection was initially done in all patients: 13 patients required open arthrotomy, the remaining 7 underwent arthroscopic tumor resection. Ten patients were referred for treatment after having operation for a local tumor recurrence: 6 patients had one, 2 had two, 1 had three, and the remaining one had five local recurrences. Six to eight weeks after surgery, intraarticular injection of 15–25 mCi of Y⁹⁰ was done. These procedures were conducted in the operating room under local anesthesia and fluoroscopic guidance. All patients were followed for a minimum of two years (range, 25–168 months; mean, 65 months).

Results: Following Y⁹⁰ injection, all patients reported mild pain around the affected joint. This pain was well controlled with the use of NSAID’s and typically resolved within a few days or weeks. Three patients had superficial skin inflammation and associated blisters around the site of injection, probably the result of Y⁹⁰ effect on the soft-tissues. All were treated conservatively with complete resolution of their symptoms. All patients gained their pre-injection range-of-motion within 4–6 weeks. At the most recent follow-up, five patients had transient post-radiation skin changes (discoloration of the skin and dry and scaly skin) and local recurrence occurred in only one patient (5%) with PVNS around the knee; additional Y⁹⁰ injections were unsuccessful and he eventually underwent knee arthrodesis.

Conclusion: Y⁹⁰ injection is a reliable adjuvant for surgery in the management of diffused PVNS. Local tumor control and good function, associated with only mild morbidity are achieved in the majority of the patients.

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.

Purpose of the study: To evaluate the efficacy and safety of a novel intramedullary, expandable and self-locking system for stabilization of proximal femoral fractures.

Patients and methods: Since October 2001, Fixion ® PF Nails have been implanted in 112 patients (84f / 28m) with mean age of 76.4 years (40–97). Ninety patients were operated for intertrochanteric fractures, and 22 for subtrochanteric fractures. The system consists of a diaphyseal nail and a femoral head peg. The nail is an expandable tube that, once inserted (unreamed) into the medullary canal, expands by 60%, using saline solution under controlled pressure. The expansion causes abutment of the nail longitudinal bars to the inner surface of the canal, resulting in excellent hold. The hip peg includes an expandable distal end, which, once expanded, condenses the travecular bone and enhances the femoral head grip and rotational stability.

Results: Average operative time was 62; minutes (25–90) and average fluoroscopy exposure 1.44 minutes (0.46–4.26). Perioperative blood loss was negligible. Optimal alignment was restored in all cases. No significant operative problems or complications were reported. Union was demonstrated in all cases within 12 weeks, except for two cases of severe osteoporosis, in which delayed cut-out of the implant was reported.

Conclusions: This minimally invasive procedure, requiring no reaming or use of interlocking screws, is user-friendly, safe, reduces the operative and fluoroscopy time, eliminates the risk of postoperative femoral shaft fracture and provides optimal ultimate outcome.

Insertional Achilles tendonitis is an inflammatory disorder affecting mainly active young patients. The etiology is multifactorial and include the combination of anatomical and biomechanical characteristics. One fifth of the tendon injuries in athletes are insertional complaints which includes bursitis and insertion tendinitis.The complex of the insertion of the Achilles tendon includes three main components of fibrocartilage sesamoid, periosteum and enthesis. A conservative regime is recommended as the first line of treatment. In case of failure a surgical decompression of the posterior margin of the calcaneum is indicated.

Nine cadaveric legs were used for the experiment. The leg was mounted on an MTS machine and was axially loaded 360 N. The foot was attached to a plate which enabled dorsal and plantar flexion. The Achilles was sutured twice in an Ethibond No. 5 using the Krakow technique in order to anchor the tendon to an actuator. A thin pressure sensor plate (Teckscan) was inserted into the retrocalcaneal bursa to measure the force, pressure and contact area of the Achilles to the calcaneus in various positions of the foot. The conditions included 90 degrees of the foot, 15 and 30 degrees of dorsiflexion while the tension that was applied on the Achilles was 0, 200 N and 300 N. After resection of the posterior surface of the calcaneus in a 20 degrees inclination.

The mean peak force, pressure and area did not change in Achilles tensioning while the foot was in 90 degrees and were close to zero. In 15 degrees of dorsiflexion there was increase in the mean peak force, pressure and area when the Achilles was tensed to 200 and 300 Newton. Larger increase in these parameters was achieved by further dorsiflexion of the foot to 30 degrees.

After resection of the posterior margin of the calcaneus in an angle of 20 degrees the mean peak force, pressure and area dropped close to zero and remained almost unchanged during the various conditions of the experiment.

Dorsiflexion and tension of the Achilles tendon increases the mean peak force, pressure and area in the Achilles retrocalcaneal bursa. These data may explain the mechanism for insertional Achilles tendinosis. Resection of the posterior surface of the calcaneus in 20 degrees efficiently decompresses the retrocalcaneal bursa in various angles of the foot and in various tensions of the Achilles.

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: Seven cases of osteochondritis dissecans (OCD) of the tarsal navicular bone have been described mainly radiologically.

Aims: We report our experience with additional 6 patients which represent the largest series described, and conclude about the treatment modalities in this unique type of OCD.

Methods: All patients who had OCD of the tarsal navicular bone during the years 1993 and 1998 were evaluated. The parameters which were examined were the age and sex of the patients, the location of pain, duration of symptoms, and any trigger mechanism if this was noted. The various treatments used for these patients as well as their outcome were recorded.

Results: Six patients were treated by us between 1993 and 1998 (follow up 3–7 years). There were 4 males and 2 females aged between 14 and 35 years (mean 21 years). All patients had pain in the dorsal aspect of the midfoot, and painful limitation in midfoot movements. Duration of symptoms varied between 4 months and 1 year. In 3 patients basic training in army service and in one running short distances triggered the pain. In 3 patients an accompanying stress fracture of the navicular bone was developed. Three patients were managed conservatively. Two patients underwent excision, curettage and drilling, and one patient underwent excision and fusion. All patients, whether treated conservatively or surgically, still suffer form pain in activities and painful limitation of midfoot motion.

Conclusions: OCD of tarsal navicular bone affects mainly young patients. Physical efforts are the trigger mechanism for the symptoms. The clinical presentation includes painful limitation in midfoot motion. The outcome is reserved both for conservative or operative treatment.

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.

Background: Osteoarthritis (OA) is a common phenomena in the population. About 80% of the patients more than 55 years of age have reontgenographic signs of OA, while 25% have clinical signs. Eventually OA leads to joint destruction, which may necessitate joint replacement.

Aims: Our goal was to evaluate the synovial reaction in 10 patients who suffered from arthritis and thus underwent total knee replacement operation.

Methods: Ten patients with arthritis of the knee joint (8 with OA and 2 with rheumatoid arthritis (RA) who underwent total knee replacement were evaluated.

Age ranged between 66 and 79 years (mean 71 years). A control group consisted of 6 cadaver knees (mean age 31 years) with no previous history of knee problems.

All the patients in the research group were graded functionally for their knee score by the system of Hospital for Special Surgery Functional Score.

Additional plain X-ray score on a three point scale was performed. During surgery macroscopic changes on the articular surface of all three compartments were recorded on a four point scale. Synovial specimens were taken from each compartment for microscopic examination.

Results: In the research group the average knee score was 54. The macroscopic changes were found predominantly in the medial compartment. No correlation was found between microscopic and histological changes in the synovia. However, a statistically significant correlation between radiological changes in the medial and lateral compartments and macroscopic changes was noted. In the OA patients the ratio of T to B cells was 60% in favor of the B cells, in contrast to RA which was 75% in favor of T cells. In the control group the common find-ing was a thickened sub-synovial fat layer in the patello-femoral (PF) compartment.

Conclusions: Inflammatory reaction in the synovia is graded by the lymphocytic infiltration into the synovia. In OA this is usually mild. However, the predominant reaction is fibrosis. There is no correlation between this fibrotic reaction and overt radiological or macroscopic findings. The thick subsynovial fat layer found in the PF compartment in the control group has not been described previously in the literature and should be the focus of further investigations.

Background: The surgical treatment of extensive diffuse Pigmented Villonodular Synovitis (PVNS) of large joints alone, is unsatisfactory, with high rates of local recurrence. Postsynovectomy adjuvant treatment with external beam radiation therapy or intraarticular injection of Yttrium90 (Y90) yielded better results.

Aims: Experience with 10 cases treated with debulking surgery followed by intraarticular injection of Y90 is reported.

Methods: Between January 1989 and June 1998, 10 patients (8 males and 2 females aged 15049 years) with extensive diffuse PVNS were treated. In 6 patients the knee joint, in 3 patients the ankle joint, and in 1 patient the hip joint were involved. The 10 patients underwent 15 operations, 1 patient had 3 surgical procedures, and 3 patients underwent 2 surgeries (interval between re-operations for local recurrence were 2–4 years). All patients had an intraarticular injection of 15–25 mCi of Y90, 6–8 weeks after the last surgery.

Results: Follow up time was 2.5–12 years (mean 6 years). All patients were followed by repeated computerized tomography (CT) scans, magnetic resonance imaging (MRI), plain X-ray films and bone scans semi-annually. In 9 patients no evidence of disease and no progression of bone or articular destruction have been noted. In 1 patient stabilization of disease was achieved with no further evidence of bony or articular damage. No complications were noticed after surgery, nor after the intraarticular Y90 injection.

Conclusions: A combination of debulking surgery with intraarticular injection of Y90 for extensive diffuse PVNS of major joints is a reliable way of treatment with good results.

The importance of meniscal tears repair is discussed widely in the literature. The repair should be performed if the conditions promise some chance for healing. Due to technical difficulties many orthopaedic surgeons still prefer partial meniscectomy to meniscal repair.

We describe our techniques for meniscal repair. The described techniques could be used by any surgeon with basic skills in arthroscopic surgery. No special equipment is needed.

The basic equipment for this technique is a standard 18 gouge needle. The plastic cup of the needle is cut away in order to overcome the ridge between the plastic and the metal part of the needle, thus making the suture passage easier.

Following the arthroscopic identification of the meniscal tear and preparing the torn parts for repair, the place for the first suture is identified.

A 2–3 mm long skin incision is made. The subcutaneous tissue is bluntly developed to the capsule. The 18 gouge needle is past from outside-in in the desired point through the torn margins of the meniscus. The tip of the needle is emerged above or under the meniscal surface, depends on our decision of suture position.

1st step – Producing a loop outside the joint: Two ends of a nylon 2/0 suture are inserted through the needle into the joint cavity, and pulled out through one of the arthroscopic portals. The needle is removed. The result of this step is a nylon 2/0 suture passing through the torn parts of the meniscus with a loop outside the joint.

2nd step – Producing a double-loop inside the joint cavity: A second nylon 2/0 suture is passed through the first loop. The first suture is pulled into the joint. At this stage, both loops are inside the joint, holding each other. The free ends of the first loop are emerged through one of the arthroscopic portals, while the free ends of the second loop pass through the torn parts of the meniscus and emerge through the capsule.

3rd step – Producing the meniscal suture: A second 19 gouge needle is inserted close to the point of insertion of the first one, directed into the joint. The emerging point of this needle, on the meniscus, should be positioned according to the desired suture direction (transverse, vertical, or oblique). The tip of the needle is then directed into the “2nd” nylon loop (the “1st” nylon loop can assist at this stage). The loop is wrapped over the needle, and the 1st suture is removed.

PDS suture (1/0 or 2/0) is inserted through the needle until a 5 cm free end is positioned intra articular. The needle is removed with caution without pulling the PDS suture, leaving the

PDS free end inside the nylon loop. The nylon loop is used as a pooling tool for the PDS suture. Pulling the free end of the PDS suture out of the joint results in a PDS loop for the meniscal suture (in order to avoid iatrogenic tear of the meniscal tissue while pulling the sutures, a probe should be positioned under the PDS suture during the process). The PDS is tightened over the capsule. The technique is repeated as much as necessary for perfect repair of the meniscus.

The advantage of this method is that it does not necessitates unique equipment, but rather uses the ordinary arthroscopic tools and sutures. This method was used successfully upon large number of meniscal tears. We recommend its use routinely.

Background: Female recruits are known to have a relatively high incidence of stress fractures (SF). This has been apparent also when female recruits entered the Israel Border Police training program.

Aims: To examine the influence of various interventions including shoe modification, nutrition, controlled training program and pre-recruit course on the incidence of SF.

Methods: Between February 1996 and February 1998, five courses of female recruits were held with a total of 229 participants. The four later courses were controlled and strictly documented. These included 203 recruits. The total number of SF was recorded using bone scintigraphy. “Dangerous SFX” was described as those SF including the long bones of the lower limb and the navicular bone. Due to high number of SF the organic medical team introduced various interventions: 1. Shoes were replaced with lither and flexible shoes with soft absorbing soles (course I onward). 2. Nutrition was modified (course II onward). 3. A training scale was programmed and introduced (course III onward). 4. Selecting candidates six months before recruitment and running a three-month preparation course (course IV onward).

Results: 1) 55 recruits (of 203) or 27.1% suffered SF grade I or more (2.9 SF for injured recruit or 0.78 SF for each recruit in the course. 2) 36 recruits (of 203) or 17.7% suffered SF grade II or more (2.1 SF for injured recruit or 0.37 SF for each recruit in the course. 3) The data concerning 229 recruits along the 5 courses was recorded and found that the incidence of number of recruits suffering dangerous SF in all grades, or grade II or higher, and the number of dangerous SF per recruit was reduced gradually from course to course.

Conclusions: The incidence of stress fractures in female recruits during basic training is high, ranging in the series for the various courses from 23% to 35% for all grades and from 8.3% to 19% for “dangerous” SF (basically of the long bones) graded II onward. Various interventions including shoe modification, nutrition, controlled training program and pre-recruit course seems to have a possible combined effect in reducing the incidence and severity of stress fractures, especially those termed “dangerous stress fractures”.