Introduction: Various techniques have been described for cup position in deficient acetabuli. Medialization allows an optimal cup position in the true acetabulum affording cover of the implant in the superolateral area by the bony roof and avoiding the need for a structural graft to cover the protruding lateral edge of the cup.

Materials and Methods: During the last 5 years 51 cases of cup medialization have been done during Resurfacing Replacement or THR with hard-hard bearing surfaces (mean follow up 35.2 month). 15 cases were done with the medial acetabuloplasty technique and 36 cases were done by simple over-reaming the medial wall and morselized bone grafting. The mean followed up was 16 months.

Surgical technique: Medial Acetabuloplasty: After a cartilage removal, we drill perforations in a horizontal line to weaken the central area of the medial wall. Using an impactor the medial wall is fractured and shifted medially for a few millimeters and the cavitation so produced is filled with morselized bone graft. This technique preserves a shell of bone medially which together with the graft brings about medial bony wall preservation. In extreme acetabular deficiency, this technique is also useful by minimizing the extent of morselized bone grafting needed in the superolateral area for lateral roof bone formation.

Results: The medial wall defect was consistently reformed during the first year. In neither the over-reaming with morselized bone graft nor in the group using the medial acetabuloplasty was the stability of the cup compromised.

Conclusion: The lateral structural graft techniques are more cumbersome, take more time and the results are less certain.

In the short term there was no difference in hip scores or in the radiological assessment between medialization with or without acetabuloplasty. We suggest this technique seems to have the potential for very good long term results.

Purpose: To study the frequency and the type of pathogen contaminating the surgical wound during total joint replacement in a standard operating theatre

Type of Study: A prospective study.

Material and Methods: 100 patients, mean age 67 years, 56 females and 44 males, were available for 5 years follow-up after total joint replacement, of the 100 patients 13 underwent total hip replacement and 87 total knee replacement for osteoarthritis, 1 gram of cefazolin was given with induction of anesthesia and a further three doses of 1 gram i.v. cefazolin were given every 8 hours after surgery. The following swab cultures were taking from: skin knife, deep soft tissue knife, joint prosthesis after implantation, orthopaedic lavage fluid, suction tip, lamp hundle, operator gown, deep facia suture, skin (after removal of steridrape), surgical gloves, ambient air. Altogether 1100 cultures were taken. At five years 20 patients were lost to follow up. Ptients of the contaminated groupe were all available for follow up.

Results: 8 patients ( 8%) had one or more positive culture. Non was from ambient air, suction tip, orthopaedic lavage fluid and gloves. Four skin knife had positive cultures ( all with Staph. Coag. Negative ), and 4 deep soft tissue knife cultures ( 2 Staph. Coag. Neg., 1 Staph. Coag. Positive and one Klepsiella). Two facial sutures cultures were positive ( both alfa hemolytic strep.) One lamp hundle positive culture ( Staph. Coag. Neg. ). One joint prosthesis positive culture ( Staph. Coag. Neg. ). One gown positive culture ( Alpha. Hemolytic Strept. ). One skin positive culture (Staph. Coag. Neg.). No clinical signs of infection were seen in any case in the first year. During the second and the third year two patients showed increasing pains due to septic loosening with Staph. Coag. Neg. ( the same contaminating microorganism).

Conclusions: Microbial contamination of the wound is common. Cefazolin seems to be an effective prophylactic, but despite the antibiotic treatment 20% of the contaminated patients developed late low grade infection, loosening of the prosthesis and needed revision surgery, therefore cultures should be taken during joint replacement surgery and antibiotic treatment should be continued in case of positive culture.

Introduction: Extracorporal Shock Wave Therapy (ESWT) has become a useful adjunct for the treatment of various musculo-skeletal inflammatory conditions.

The aim of the study is prospective assessment of the efficacy of ESWT for the treatment of recalcitrant greater trochanteric bursitis (GTB).

Material and Methods: Prospective evaluation and follow-up of fourteen patients with persistent GTB two of them with bilateral problem. All the patients failed to response to conventional treatment with oral NSAID’s, physiotherapy, US and more than one steroid injection to the grater trochanter region. All patients underwent compete physical examination. A Comprehensive VAS Score (grading from 0–10) which were obtained prior to therapy and at follow-up. ESWT was applied in six consequitive courses each of 1500 impulses of 0.32mj/mm^2 to the lateral side of the grater trochanter region.

Results: Mean age of 60.6 ± 11.6 (mean ± SD) years (range 81 to 38 years). Mean duration of symptoms 14.2 ± 8.1 months, up to 37 months. Mean VAS dropped from 7.9 ± 0.9 to 1.6 ± 0.8 (p< 0.0001). There were no side effects except minimal local discomfort during the session time.

Conclusion: ESWT is an effective treatment for recalcitrant GTB, with minimal side effect.

During the second Lebanon war, between 12/07/06 to 14/08/06, 241 war injuries were admitted to Rambam Medical Center emergency room: 202 soldiers and 39 citizens. (Post traumatic stress disorders victims were not included). Majority of the injured soldiers (98%) were mobilized by the Israeli Air Force helicopters. More then 40 helicopters had landed in the hospital heliport during the war. Distribution of injuries according to the injury type:

110 patients (44% of all injured) had Orthopedic injuries (including hand injuries)

Distributions of soldier’s injuries among soldiers were similar to the above :

81 soldiers (41%) Orthopedic injuries (including hand injuries)

About 75 % of the injured soldiers suffered from orthopedic injuries. Vast majority of the injuries were shrapnel injuries, which were divided to 3 levels:

Mild soft tissue damage due to few or superficial shrapnel injury – 107 (49%) soldiers.

Organs injury distribution:

24 Patients total of 54 fractures, 24 of those had been long bone fractures

Amputation – 5 soldiers were underwent completion of traumatic lower limb amputation. One soldiers had bilateral below knee amputation, 1 above knee amputation and 3 unilateral below knee amputation.

Two hundred and three orthopedic surgery interventions were done by Orthopedics’ B’ department in Rambam Medical Hospital, during the Second Lebanon War.

Background: The occurrence of osteomyelitis in diabetic foot often dictates different treatment approach. The diagnosis of osteomyelitis, though, is sometimes difficult. When X rays are not diagnostic or equivocal, a nuclear medicine studies are often performed. In common practice bone scan with Tc⁹⁹m-MDP combined with In¹¹¹ labeled leucocytes scintigraphy are used. Although highly sensitive, these procedures may be hampered by coexisting pathological processes such as neuroarthropathy, trauma, or cellulites. In addition, poor resolution of the In¹¹¹ images, complicates the interpretation weather the observed uptake (e.g. infection) is in the soft tissue or within the bone. Positron emission tomography (PET) using 2-Deoxy-2-[18F]-Fluoro-D-Glucose (FDG) is a useful clinical tool for the assessment of malignancies. FDG, a nonspecific tracer of increased intracellular glucose metabolism, accumulates in sites of infection and inflammation as well. PET is highly sensitive but may lack the ability to define the anatomic location of a focus of increased FDG accumulation. The hybrid PET/CT technology, providing precise registration of metabolic and structural imaging data, obtained in one session on a single device, may improve diagnosis and localization of infection.

Goals: The present study assesses the role of PET/CT imaging using FDG for the diagnosis of diabetic foot osteomyelitis.

Methods: Fourteen diabetic patients (M=10, F=4; age range 29–70 years) with 18 clinically suspected sites of infection underwent PET/CT following the injection of 185–370 MBq FDG for suspected osteomyelitis complicating diabetic foot. PET, CT and hybrid images were independently evaluated for the diagnosis and localization of an infectious process. Additional data provided by PET/CT for localization of infection in the bone or soft tissues was recorded. The final diagnosis was based on histopathological findings and bacteriological assays obtained at surgery or clinical and imaging follow up.

Results: PET detected 14 foci of increased FDG uptake suspected as infection in 10 patients. PET/CT correctly localized 8 foci in 4 patients to bone, indicating osteomyelitis. PET/CT correctly excluded osteomyelitis in 5 foci in 5 patients, with the abnormal FDG uptake limited to infected soft tissues only. One site of mildly increased focal FDG uptake was localized by PET/CT to diabetic osteoarthropathy changes demonstrated on CT. Four patients showed no abnormal increased FDG uptake, and no further evidence for an infectious process in the foot on clinical and imaging follow up.

Conclusion: FDG-PET can be used for diagnosis of diabetes-related infection. The precise anatomic localization of increased FDG uptake provided by PET/CT enables accurate differentiation between osteomyelitis and soft tissue infection.

Introduction: In avascular necrosis [AVN] of the femoral head the dead bone undergoes osteoclastic osteolysis and is replaced by newly synthesized, immature, weak bone, which cannot withstand the daily loads. The articular surface might caves in because of these changes, and osteoarthritic joint changes can develop. Alendronate interferes with the osteoclastic activities, it can slow-down the bone turnover of the necrotic bone and can differ these changes.

The aim of this study is to delay the speedy renewal of living epiphyses by alendronate medication in order to describe the effects of it on the fate of the necrotic femoral heads in rats.

Methods: Sixty female sprague-dawley rats, 6-month old weighing about 400–500 grams, underwent surgical AVN of the right femoral heads. Forty-four rats, the treated group, were treated with alendronate 200 μgm/kg/day. Sixteen rats, the control group, were treated with saline. Both groups were daily injected subcutaneously for six weeks and sacrificed. Both femoral heads were harvested and were evaluated microscopically and stained by H& E.

Results: The necrotic femoral heads of the control group, which were not treated by alendronate, were severely distorted with osteoarthrosis features as; collapse of the epiphysis, pannus formation, filling of spaces by chronically and mildly inflamed densely textured fibrous tissue which was polluted by numerous tiny particles of necrotic bone. Additionally, large chunks of necrotic articular cartilage were haphazardly scattered in the fibrous tissue. All hematopoietic and fat cells of the intertrabecular spaces of the epiphysis were replaced by fibrous tissue. More often than not, the cartilage of the physis was focally or entirely absent such that osseous trabeculae of the epiphysis and metaphysis linked with each other, forming so-called epiphyseal-metaphyseal bridges. The above described alterations were encountered in all animals, yet their severity varied.

The decisive difference between the necrotic femoral heads of otherwise untreated in opposition to the alendronate-medicated rats was the preservation of a hemispherical configuration of the femoral heads. There was no distortion of the femoral heads in the alendronate-treated animals and the femoral heads preserved their roundness.

All femoral heads of the non-operated left hips were microscopically normal.

Discussion: It has become clear that the degree of architectural distortion of the femoral epiphyses depends on the extent of bone turnover leading to resorption of all debris and its replacement by living osseous and soft tissues. The more rapidly and more extensively the reconstruction of living epiphyses progresses, the smaller is the prospect of reshaping a hemispherical or near-hemispherical femoral head. The recently rebuilt epiphyses cannot carry daily transarticular loads without caving in. The revascularization-related reconstitution of weak bony trabeculae is blamed for the collapse of the femoral heads. If this indeed is the case, the remodeling of the necrotic femoral heads should be delayed, rather than sped-up. Alendronate interferes with the osteoclastic activities and hence, slowing-down the bone turnover.

The osteoclastic activity is detrimental for the conservation of a hemispherical femoral head because of the rapidly occurring replacement of the necrotic bone by living tissues. Halting the activities of the osteoclasts by a biphosphonate would stop the hasty osteoneogenesis, which is responsible for the early femoral capital disfigurement and might delay the regeneration of osteo-arthiritic changes of the joint later on.

Introduction: The aim of the current investigation to study the inherent ability of biomaterial scaffolds to regenerate bone defects without osteoinductive growth factors. We have developed a biosynthetic hybrid scaffold that mimics the biofunctionality of the provisional fibrin matrix which regulated the initial stages of in vivo bone regeneration. The material is comprised of a fibrinogen backbone and polyethylene glycol (PEG) cross-links that regulate the strength, durability, and degradation of the matrix during the healing process. Precise control over the degradability of the hydrogel scaffold provides the ability to systematically regulate the cellular infiltration associated with fracture healing. Furthermore, improved physical strength (over purified native fibrin clots) enables superior handling properties and stable in situ fixation.

Materials & Methods: In the current study, a 7-mm critical size defect is created in the right tibia of female Sprague-Dawley rats (age 3–4 months); an external fixator is placed proximal and distal to the mid-section of the tibia. Pre-cast fibrinogen-PEG cylindrical hydro-gels (3-mm dia, 7-mm long) are placed into the site of the defect. Three different hydrogel compositions are tested: 1:1, 1:2, and 1:3 fibrinogen to PEG. Independent experiments demonstrate that higher concentrations of PEG give the hydrogels slower degradation kinetics. Radiographs, post operative and during follow-up, and histological evaluation were done.

Results & Discussion: Both radiography and histological evaluation reveals extensive and widespread periosteal new bone formation. Post-operative radiographs show the formation of a periosteal callus in the gap region of treated animals after five weeks compared to immediately following excision (Figure 1, right). Five weeks post-operatively, histological sections stained with H& E reveal a thick covering of newly formed and moderately differentiated lamellar-fibred bone alongside lengthy stretches of the original cortex. There are large amounts of closely packed trabeculae of recently deposited, woven-fibered bone wherever there are empty spaces of the hydrogel scaffold. These trabeculae join at their perimeters with the preexisting bone. We also demonstrate a clear relationship between the composition of the hydrogel and the synthesis of new bone in the defect site. In conclusion, we demonstrate the formation of newly synthesized bone in critical size defects in the rat tibia using a biomimetic hydrogel scaffold without the use of exogenous growth factors.

Purpose: Midterm follow up of complete knee dislocation and clinical outcome evaluation.

Materials and Methods: Between 1990–2004, we retrospectively reviewed the records of patients with complete knee dislocation. Eighteen patients, 19 knees were followed. Twelve males and 6 females. The average age at follow up was 40.7 years. Treatment consisted of primary knee stabilization with tutor cast in 10 knees and 9 by external fixation for 6 weeks. Following rehabilitation program, further surgical treatment was according to clinical relevancy. Functional and subjective evaluation was registered by the WOMAC questionnaire.

Results: Eleven were multiple trauma patients, involved in RTA, 2 had a crush injury, one patient involved in aviation accident had bilateral dislocation and 4 patients had low energy injury. Out of 7 patients, 8 knees had isolated dislocation. One died, 3 were not available for clinical follow up. Twelve patients returned the questionnaire. The average result of the WOMAC score was 46.5, range 7–91. Four knees presented advanced osteoarthritis with painful stiffness. Eight knees presented at the end of the follow up with instability as chief compliant. Five patients underwent later reconstructive procedures. One patient underwent knee arthrodesis.

Conclusion: In patients with knee dislocation, associated polytrauma should be regarded as a bed prognostic sign. The results suggest the need to revaluate the initial treatment strategy. The overall outcome shows that nearly all patients were able to perform daily activities, no patients in our study attempted any strenuous activity.

Purpose of Study: Assessing short and long term eficacy of Extracorporal Shock Wave Therapy (ESWT) as a treatment for recalcitrant plantar fasciitis (PF).

Methods: Prospective follow up of 63 heels among 50 patients with persistent PF patients, (mean age 57.2±10.5); symptoms’ duration 15.8±14.3 months, resistant to non-operative treatment modalities including steroid injections.

All patients underwent thorough physical examination and AOFAS Hindfoot score was obtained before treatment and a follow-up examination one week and one year after applicaton of ESWT course. Pain was assessed by Visual Analog Scale (VAS) relating to six parameters: pain on first step in the morning, maximum pain intensity, pain during prolonged walking, standing, at the end of the day and night pain. ESWT was applied in five consecutive courses of 1500 impulses of 0.32mj/mm² once a week in a routine previously described manner.

Results:. All the six VAS parameters decreased significantly post treatment. The Vas parameter of the first steps in the mornining was the most severe before 8.6±1.8 and after treatment 4.2±2.0 and 1.4±1.9 one year after tretment (p< 0.0001). Night pain was the less intenes before treatment 3.9±3.7 and was nearly eliminated to 0.9±1.6 and 0.2±0.8 after one week and a one year post treatment (p< 0.0001). AOFAS hind-foot Score increased from 49.7±15.8 before ESWT to 87.7±10.9 and 86.3±10.7 one week and year after the courses (p< 0.0001). Three patients couldn’t complete the ESWT course one, one of them with bilateral PF. From those patients two had tarsal tunnel syndrome and one with the tibial nerve first branch which was fassing through the plantar fascia. There were no side effects other than minimal local discomfort during the session time.

Conclusion: ESWT is a safe, efficient treatment modality for resistant PF.

Introduction: Conventional total hip replacement has a high rate of failure in young or high demand patients due to polyethylene wear, therefore, we perform a metal on metal hip resurfacing in these patients. Materials and Methods: The cup is all chrome cobalt alloy, with HA coating and the beads of the porous ingrowth surface are integrated with the substrate metal. The metal head is þxed with low viscosity cement, after careful precise preparation of femoral head.33 hybrid hip resurfacing in 29 patients. Average age was 42.8 years. Results: Harris Hip Score: 34.2 points average preoperatively and 97.1 points at the last examination. The average follow-up was 14.7 month. Discussion: The advantages: Minimal bone resection which makes for easier future revision, normal proximal femoral loading that hence avoidance of the stress shielding present in standard hip replacements, less risk of dislocation with greater range of motion, the physiological biomechanics of the joint is maintained, proprioception is maintained and we have noted that the postoperative recovery is extremely smooth and quick.

The disadvantages: Leg length and neck version cannot be altered. Hip resurfacing is, technically, a demanding procedure.

Contraindications: osteoporosis, varus neck.

Conclusions: Our early results are encouraging. We believe that metal on metal hybrid resurfacing is a legitimate alternative for active patients who require hip arthroplasty.

A vascular necrosis (AVN) of the head of the femur is a potentially crippling disease which mainly affects young adults. Although treatment by exposure to hyperbaric oxygen (HBO) is reported as being beneficial, there has been no study of its use in treated compared with untreated patients. We selected 12 patients who suffered from Steinberg stage-I AVN of the head of the femur (four bilateral) whose lesions were 4 mm or more thick and/or 12.5 mm or more long on MRI. Daily HBO therapy was given for 100 days to each patient. All smaller stage-I lesions and more advanced stages of AVN were excluded. These size criteria were chosen in order to compare outcomes with an identical size of lesion in an untreated group described earlier. Overall, 81% of patients who received HBO therapy showed a return to normal on MRI as compared with 17% in the untreated group. We therefore conclude that hyperbaric oxygen is effective in the treatment of stage-I AVN of the head of the femur.

Fractures of the proximal humerus account for 4 to 5% of all fractures. Most occur in elderly individuals caused in part by osteoporosis.

Conservative treatment frequently led to poor clinical results because of the inability to gain and maintain satisfactory reduction.

The preferred method for these fractures was open reduction and internal fixation especially in those fractures with displacement and in young patients.

In 18 patients the fracture was operatively reduced and was secured with a plate and screws.

Methods of plating: T plate, clover leaf plate or blade plate modified. Delayed union and non-union of humeral head fracture is also an indication for open reduction and internal fixation by plate and screws.

A consecutive series of 18 patients with displaced fracture and fracture dislocation, followed for a minimum period of one year were analyzed.

The age of the patient range from 16 to 62 years.

The fractures were classified according to Neer 91970).

The aim of treatment was accurate reduction and stable fixation of the fracture with plate and screw.

The most common technical error was a too high positioning of the plate caused implant impinged under the acromion during abduction. No aseptic necrosis of the humeral head was observed. There was no deep infection.

11 patients had an excellent or good result, 7 had a fair result, and 1 had a poor result.

Koval in a biomechanical cadaver study was to compare the mechanical stability of ten different fixation, techniques used of stabilize surgical neck fractures of the proximal humerus in both osteopenic and non osteopenic bone.

The AO five holes T plate provided significantly greater resistance to displacement than all other methods tested the fresh-frozen specimens. Their effectiveness diminished in the presence of osteopenia.

Introduction: The regulation of balance during upright standing involves continuous muscular activity, associated with body sway. In single stance standing, the base of support is narrower compared to double stance, resulting in an increased body sway and emphasizing the role of individual muscles in regulating the sway motion. In this study, we investigated the effect of Tibialis Anterior (TA) fatigue on body sway during standing on one leg on ten able-bodied subjects.

Methods: Foot ground reaction forces, goniometry of the ankle joint, and EMG of the TA were all measured simultaneously in two tests. Each test lasted 30 sec. During which the subjects were required to stand as still as possible with their dominant leg on a forceplate and the contralateral knee flexed upward at 90 deg approximately, and their hands resting on their waists. The tests were separated by a 4 min isotonic fatiguing effort of the TA, indicated by a significant decrease of the mean power frequency (MPF).

Results: The EGM root mean square (RMS) started off at 45% MVC but, towards the end of the effort, significantly increased to 52% MVC, the latter determined in non-fatigue condition. Compared to the non-fatigue state, the following significant (p< 0.05) sway changes took place in the fatigue state: force RMS increased from 2.61 to 3.90 N and from 3.77 to 5.01 N in the mediolateral (ML) and vertical directions, respectively. The center of pressure (CoP)

RMS in the ML direction increased from 0.57 to 0.68 cm. The EMG RMS in the TA increased from 4.15 to 5.58 and the MPF decreased from 107.6 to 96.7 Hz in the fatigued state.

Discussion: An interesting finding was revealed by comparing the variations of the ankle angle to those of the center of pressure in the anterior-posterior direction taking place during standing. During the non-fatigue test the CoP moved gradually posteriorly, while the goniometer indicated an ankle change towards dorsiflexion. These obviously two opposing trends necessitate compensatory angular adjustments at the knee and/or hip joints. However, during the fatigue test, the posterior excursion of the CoP was accompanied by a consistent change in the ankle, towards plantar flexion. This seems to suggest that in the fatigue state the redundancy of the musculoskeletal system is reduced, increasing the degree of correction between ankle angle and CoP.