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Background Successful treatment of intertrochanteric femoral fractures was reportedly influenced by the position of the fixation devices, by reduction quality and by fracture type. Methods The records of 227 patients with intertrochanteric fractures treated by intramedullary hip screws were analysed retrospectively. The angle and distance from the femur head apex were transformed into Cartesian coordinates. Comparisons were performed between patients with no mechanical failure (207 patients, 90.7%), with cutouts (15 patients, 6.6%) and with secondary loss of reduction (5 patients, 2.2%). Results The standard tip apex distance (TAD) measurement above 25 mm did not predict failure (p = 0.62). Mechanical failure rates increased from 4.8% to 34.4% when the centre of lag screw was not in the second quarter of the head–neck interface line (the so-called “safe zone”) (p = 0.001). Lag screw insertion lower or higher than 11 mm of the head apex line were associated with failure rates of 5.5% and 18.6%, respectively (p = 0.004). Multivariate logistic regression showed that lag screw insertion not within the “safe-zone” was associated an Odds Ratio of 13.4 (95% CI 2.24–81) for mechanical failure (p = 0.004). Conclusions The TAD scale focuses on length measurement and lacks the vector properties of multidirectional measurements. Vector analysis revealed that the caudal-cranial correct lag screw position is the most important factor in preventing mechanical failure.

A 14-year-old boy is reported with bilateral hypoplastic patellae and multiple congenital skeletal anomalies. Since this constellation of bony malformations has not been described previously, we believe this represents a new syndrome most probably of genetic etiology.

Of 2776 intracapsular fractures of the proximal femur, 18% of the patients were treated nonoperatively. Included in the group of patients who were treated conservatively were children, patients with cardiac problems or mental problems, stroke, renal failure, multiple disseminated malignancies, and patients who chose nonoperative treatment. The medical treatment protocol can be divided into two stages: Initially, (1) nursing of a bedridden patient with emphasis on the prevention of complications; and (2) once partial bone union has occurred, the attempted rehabilitation to independent ambulation. Paramedical services provide a major contribution during inpatient therapy and during the preparation for returning the patient to the community. A multidisciplinary medical team evaluates and assesses the patient's needs and rehabilitation potential and in cooperation with the patient and the family, an operative plan then is established.

Penetrating wounds and lacerations are frequent pathologies treated in the emergency room. The management of hand trauma represents a large part of the work in any surgical practice. Although X-rays are routinely taken, numerous foreign bodies remain undetected, and the wounds are just locally debrided and the lacerations sutured. Unfortunately, as not all foreign bodies are radio-opaque, the radiography results may appear normal, but the patient fails to recover. Patients complaining of persistent wound tenderness were sent for ultrasound investigations, and foreign bodies were detected. Had ultrasonography been carried out initially in the emergency room, the correct diagnosis would have been made, and the sonographic equipment could have helped to guide the physician in his attempt to remove the foreign body. Usually, in response to continued pain, an ultrasound investigation is ordered, and the pathology becomes apparent. A number of examples are briefly described in order to highlight the present inadequacies. It is suggested that hospital administrators consider the need to provide ultrasonographic services as an integral facility of the emergency room.

Disuse atrophy has been the subject of research studies of an animal model in which single-limb immobilization induces atrophic changes in the immobilized limb. These reveal systemic changes in the experimental animals that go far beyond the local response expected in that situation and are not fully understood as yet. We therefore performed a biochemical study on the effect of hind-limb immobilization on the serum and tissues of rats. The experiment was carried out on 70 young Sprague-Dawley male rats. In one group of 35 rats, the left hind-limb was immobilized for 3 weeks. Another group of 35 rats served as controls. Serum total protein, albumin, urea, creatinine, and calcium were found to be reduced during immobilization. Serum cholesterol levels, on the other hand, increased to a considerable extent. No changes were recorded with phosphate, bilirubin, and magnesium. Serum alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were both reduced in activity. The activity of muscle aspartate aminotransferase (AST) and bone alkaline phosphatase (ALP) was also decreased. Lactate dehydrogenase (LDH) remained unchanged in both serum and muscle. We discuss our findings in the light of previous knowledge regarding the atrophic process.

Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%-30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 +/- 8.96 in the non-operated group compared with 75.2 +/- 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

Giant cell tumor of the bone (GCT) is a relatively uncommon benign aggressive tumor that occurs near the articular surface of major joints. Standard treatment of GCT is comprised of local resection followed by local adjuvant therapy. Unicondylar osteoarticular resection is usually followed by a reconstructive procedure to restore the biomechanical demands of the joint. The present report describes a patient with satisfactory knee stability and functional outcome 32 years following medial femoral condyle resection with no reconstructive arthroplasty.

AIM: To determine whether ultrasound is useful in detecting cervical rib. Ultrasound was used to diagnose cervical rib in five patients with neck pain and the findings were compared to those from plain radiography. MATERIALS AND METHODS: Ultrasound was used in 34 patients with pain and stiffness in the neck region. The area concerned was scanned sonographically in both longitudinal and transverse planes. In the sitting position, plain radiographs were obtained after ultrasound examination for comparison and verification. The contralateral side of the neck was used as control. RESULTS: Sonography revealed abnormalities in five patients. Sonography and X-ray confirmed the diagnosis of cervical rib in six patients, whereas one patient had a lipoma of the neck. CONCLUSION: Sonography is an additional and easily available diagnostic modality for the detection of cervical rib in cases of pain and stiffness in the neck region.

Background Musculoskeletal ultrasonography (U.S.) is an important imaging technique in the diagnosis of olecranon bursitis, especially for early manifestation. It allows sensitive detection of small fluid collections as well as for differentiation between soft tissue and bone lesions. U.S. examination allows detection of effusions, synovial proliferation, calcifications, loose bodies, rheumatoid nodules, gout tophi and septic processes. Aim To assess the role of ultrasonography in the diagnosis and management of patients with olecranon bursitis. Methods Ultrasound was used in 34 patients with swelling above the olecranon. The opposite asymptomatic side served as a control group. Results 20 patients demonstrated increased fluid collection in the olecranon bursa. 5 had synovial proliferation, 2 cases showed loose body, 5 patients revealed markedly increased blood flow consistent with inflammation, 2 patients had triceps tendonitis with calcifications. Conclusions Sonography is an extremely effective tool for the diagnosis of soft tissue lesions in the olecranon area.

Previously reported results of total hip arthroplasty in patients under the age of 30 indicate a high complication rate and questionable durability.To estimate the results of THA in extremely young patients.We report the results of 69 THA procedures in 56 patients who were under the age of 30 at the time of surgery (mean age 23.23 +/- 4.31 years) and were followed postoperatively for 2-23 years (mean 7.4 +/- 3.79 years).Loosening of the cup (11/69) and early traumatic dislocation (5/69) accounted for the majority of complications.The final average Harris hip scores of 90.59 +/- 9.36 in these patients indicated that THA is a successful and durable treatment modality for young patients with disabling diseases affecting the hip joint. However, due to the likelihood of complications it should be used with caution in this patient group. Efforts should be made to diminish the complication rate.

Scapular pain is a common complaint in daily orthopedic practice. A different type of scapular discomfort, the snapping scapula syndrome that occurs when smooth gliding motion of the scapula upon the chest wall is interfered with is much less common. We studied the syndrome of periscapular pain and discomfort, and present a rare etiology: elastofibroma dorsi, a unique, benign, soft tissue-tumor with unique characteristics. Elastofibroma appears deep to the lower scapular pole, is often bilateral, and consists of a mixture of collagen, elastic fibers and fibroblasts. We present 6 cases, in 3 men and 3 women aged 51-65.

Open reduction and internal fixation are the current trends of treatment for comminuted calcaneal fractures. Assessing treatment results is often difficult due to discrepancy between objective parameters such as range of movement, and subjective results such as pain.To test the reliability of footprint analysis as an adjuvant method of postoperative assessment of patients who sustained calcaneal fractures.Dynamic and static footprint analysis was used as an adjuvant additional method to objectively assess operative results. This method is simple and is independent of the patient's initiatives. This modality was used in 22 patients followed-up 9-90 months postoperatively.We found a good correlation between footprint analysis and objective and subjective parameters of results expressed by American Orthopedic Foot and Ankle Society hind foot score. In certain cases, this method can be used to distinguish between uncorrelated parameter results, such as malingering, and workmens' compensation claims.We recommend the use of this simple, non-invasive objective test as an additional method to assess the results of ankle and foot surgery treatment.

Sonographic examination of the knee has been proposed by several authors in the past as a simple and reliable method to diagnose Osgood-Schlatter disease (OSD). Ultrasound was used to compare the knees of 25 boys and 10 girls with typical OSD with 35 symptom-free knees of an aged-matched group of children. Based on recorded data, patients were categorized (one affected knee in each individual) according to the classification system proposed by De Flaviis et al. in 1989. The results included the following pathological findings: pretibial swelling, fragmentation of the ossification center, insertional thickening of the patellar tendon, and excessive fluid collection in the infrapatellar bursa. Of our patients, 26% fell into the type 1 category, 43% were type 2, 20% type 3, and 11% type 4. This distribution of cases was found to be statistically similar to the initial findings reported by De Flaviis and colleagues. This study therefore supports the validity and reproducibility of their classification method for the ultrasonographic evaluation of children with OSD. This is only the first step, and further assessment of this classification is still required to elucidate its clinical as well as its prognostic value.

When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays.To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon.We conducted a retrospective review of patients presenting at our orthopedic clinics.Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions; a complete rupture in two patients (5%); a partial rupture of the Achilles tendon in 3 (7%); various degrees of calcification of the tendon in 7 (17%); and peritendinous lesions discerned by the tendon's hypoechoic regions with disorganized arrangement of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +/- 2.7 mm, while normal tendons measured 5.2 +/- 0.8 mm (P0.001).As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Foreign bodies are sometimes overlooked in the initial evaluation of soft tissue wounds in the emergency room setting. The physical examination identifies foreign bodies that are superficial enough to be seen or palpated, while radiographs reveal those that are radio-opaque. If these two criteria are not met, however, the foreign body may remain undetected. These patients present later with long-standing pain in the area of penetration sometimes associated with localized tenderness.To assess the role of ultrasonography in the diagnosis and management of patients with a suspected retained foreign body.Ultrasound was used in 21 patients with suspected retained foreign bodies and the diagnosis was positive in 19. Fifteen underwent a surgical exploration in which the ultrasound was used as an adjunctive modality either pre- or intraoperatively to assist in the localization of the foreign body.All procedures were successful. No postoperative complications were recorded at an average follow-up of 2 years. Three patients gradually became asymptomatic and were left untreated. One patient was lost to follow-up.Sonography is an extremely effective tool for the late diagnosis of retained foreign bodies in the soft tissues. We suggest that its availability in the emergency room may decrease the rate of misdiagnosis and avoid these unfortunate cases, although this remains to be proven.

A consecutive series of 16 patients with classical Haemophilia underwent 21 total knee replacements between 1989 and 1997 for haemophilic arthropathy. The patients received Factor VIII replacement therapy via continuous infusion, and fibrin glue was used to facilitate haemostasis. Three different types of prostheses were used. A follow-up evaluation was undertaken between 2 and 10 years after the operation (mean 5.6 years) and two patients with infection were excluded. Knee scores averaged 77.5 (pre-operative 24. 1) and functional scores averaged 84.4 (preoperative 23.2). There were no cases with aseptic loosening of the prosthesis. Complications included one early deep infection controlled by conversion of the TKR into an arthrodesis, one case of late septic loosening that had to be re-operated upon, one case of patellar dislocation, two cases of stiff knee (fibro-arthrosis) that required manipulation under anaesthesia, one postoperative hepatitis, one superficial infection treated by incision and drainage and four febrile patients with no clear source of infection, who responded to antibiotics alone. In conclusion, TKR offers haemophilic patients a long-lasting improvement of their quality of life and we therefore advocate its use with the appropriate indications.

The growth plate increases its activity in response to exercise. Likewise, decreased physical activity exerts a negative effect on bone growth and development, leading to rarefaction of the subepiphyseal bone. Limb immobilization inhibits the growth plate's activity, indirectly shown by a recorded arrest in longitudinal growth of the long bones. However, there is no direct evidence concerning the growth plate itself.To determine whether the growth plate exhibits measurable microstructural changes in response to decreased levels of physical activity.Histomorphometric analysis was used to qualitatively and quantitatively assess the changes in the epiphyseal plate in response to single hind limb immobilization in the rat. In 16 of 25 Sprague-Dawley male rats the left hind limb was immobilized for 3 weeks; the remaining 9 rats served as controls. The left proximal tibia of each animal was examined by computerized image analysis.There was a decrease in epiphyseal height, cell column density and subepiphyseal trabecular area--all indices of growth plate activity. Metaphyseal cortical thickness was also depressed, thereby confirming the efficacy of the immobilization method applied.Limb immobilization in the rat induces inhibitory histological changes in the epiphyseal growth plate, which are in contrast to the excitatory microscopic changes seen with exercise. These changes can be assessed quantitatively. Their potential for reversibility remains to be determined by future experiments.

Disuse atrophy has been the subject of research studies that make the use of an animal model in which single-limb immobilization induces atrophic changes in the immobilized limb. The effect upon the nonimmobilized contralateral limb is, however, still unclear, and findings in the literature are inconclusive. We therefore performed a multidisciplinary study to clear this issue. The experimental population was 70 young male Sprague-Dawley rats. In one group of 35 rats, the left hind limb was immobilized for 3 weeks. Another group of 35 rats served as controls. limb and tibial bone weights (both "dry" and "ash") were found to be reduced in both hind limbs. Bone alkaline phosphatase (ALP) activity was likewise reduced in both limbs. We conclude that the contralateral hind limb in the rat is clearly subjected to atrophic changes that are similar in magnitude or severity to those experienced by the immobilized limb. We further discuss these findings in view of previous knowledge regarding the atrophic process.

Forearm bone fractures are commonly the result of falling on the outstretched hand or of direct injury. The preferred treatment is debated. The possible modalities are: application of a cast, often necessitating repeated manipulations; open reposition and fixation by plates and screws; or closed manipulation and closed intramedullary nailing. We present our favorable results in treating these fractures in young patients by closed intramedullary nailing, and compare them with the unfavorable results of this method in mature adults.

Torticollis results from various pathological mechanisms, and its elucidation depends on identifying diseases of musculoskeletal, neural and ocular tissues. This study characterized the underlying diseases of children hospitalized with torticollis, excluding congenital torticollis. Records of 36 children with torticollis seen during 4 years were reviewed and categorized according to presumed etiology. Most could be classified into 2 categories: in 39% it was due to trauma and in 36% to upper respiratory tract infection. Most girls were in the first group and most boys in the second group. There were 3 cases of ocular torticollis due to superior-oblique muscle palsy, 1 with a post-burn eschar, 2 with neurological disorders (intramedullary cervical astrocytoma and leukodystrophy with macrencephaly), and in 3 no associated cause was found. There was a clear seasonal trend with 58% of cases presenting from November through February, 33% from April through July, and the rest, of neurological or ocular origin, during the rest of the year. In cases of post-traumatic torticollis 21% had neurological symptoms such as weakness of the limbs, headaches or incontinence. Only a few had prior upper respiratory tract infection. All children whose torticollis was assigned to infection had had fever. Only 8% had had neurological complaints or vomiting, half of whom presented with fever exceeding 37.5 degrees C. 46% had restriction of movement and 38% had tenderness. In over 60% of those in this group there were signs of an upper respiratory tract infection, such as lymphadenopathy or a white blood cell count exceeding 15,000/microliter, 3 patients with recurrent torticollis were diagnosed as having severe neurological diseases. Mean hospitalization time was 4 days (range 1-28). Hospitalization periods were similar for all kinds of patients and treatment by traction or fixation did not affect this period.

Familial Mediterranean fever (FMF) is a hereditary disorder affecting people of Mediterranean stock, mainly Sephardic Jews and Armenians. It is characterized by attacks of arthritis, either short, self-limited episodes typically lasting 72 hours or protracted attacks lasting from two weeks to one year. The latter form affects mainly the large joints of the lower limb. The hip joint is the most vulnerable and likely to be affected by the protracted attacks, which may result in destruction of the articular cartilage and, in some cases, aseptic necrosis of the femoral head. Eighteen FMF patients (19-52 years) underwent 22 total hip replacements between 1971 and 1985 at our hospital. Six of the 18 initial prostheses experienced aseptic loosening. This relatively high incidence led us to recommend implantation of cementless hip prostheses following meticulous synovectomy as the treatment of choice. The results of these surgeries and the uniqueness of total hip replacement in FMF patients are presented here and discussed.

Three cases of subluxation of the hip joint occurred during femoral lengthening using the Wagner technique. This infrequent complication, which may result from a conflict of force vectors at the hip joint during lengthening, can, when left untreated, nullify the benefits of such a procedure. We suggest that increased awareness and closer monitoring can improve the prognosis for patients undergoing this course of therapy, especially where a previous hip operation has been performed.

A case of adult cervical trauma that resulted in a clinical picture of Brown-Séquard syndrome and unilateral brachial plexus injury is presented. Rotational hyperflexion of the cervical spine is thought to have resulted in subluxation of C5-6 with root avulsions, leading to this unusual combination of findings.