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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.

The aim of this study was to assess the suitability of US (ultrasound examination) as an imaging modality in patients with knee pain. US is a sensitive method in demonstrating small bone erosions, fluid accumulation, bursitis changes in the synovia and tendon structure, and changes in the articular cartilage. US was used to assess symptomatic patients. The findings were compared to those of conventional radiographs and to those of an asymptomatic group. In 38 patients of the symptomatic group, US revealed pathological findings. In the asymptomatic group, nine patients revealed pathologic findings. In the symptomatic group, only 12 patients revealed pathological findings in the radiographs. US can provide an early diagnosis by demonstrating joint effusion - synovial thickening - bony changes, patello-femoral changes, articular cartilage changes, meniscal pathologies, such as meniscal cysts and peripheral tears and lesion of tendon, while plain radiographs are still normal and some lesions such as bursitis and tendonitis and in some cases even articular changes, can be reversible. Sonography is an effective tool for the early diagnosis of knee pain. It can detect various soft tissue pathologies as well as early degenerative changes. The examination is inexpensive, non-invasive, dynamic, rapid and avoids patients' exposure to irradiation.

Soft tissue masses are amongst the commonest complaints encountered in orthopedic practice. Of these, masses found in the hand and the wrist are presented at higher frequency. They are often painful and may cause limitation of movement.This work describes the prevalence and the nature of soft tissue masses in the hand and wrist encountered in routine practice. This work was performed to assess the characteristics of soft tissue mass in the hand and the effectiveness of ultrasonography in the diagnosis of soft tissue masses and their differentiation from other lesions in the hand and wrist. Orthopedic surgical conditions that involve soft tissue in the hand and wrist may remain a diagnostic challenge when clinical diagnosis is uncertain and standard X-rays are non-diagnostic. High resolution ultrasound is widely available, non-invasive, without damage of radiation, imaging modality that can help the diagnosis.We reviewed retrospectively 25 patients with soft tissue masses. We compared the ultrasound findings with the histological findings in seven operated patients.A substantial majority of these lesions occurred in the right hand: 79% of the lesions were in the dorsal aspect of the hand, of which 37% were distal to the wrist joint, among them 42% at wrist either radial or ulnar; and 21% of the lesions were found in the volar aspect, among them 17% at wrist aspect, either radial or ulnar side. No predisposing factors could be found.The findings of this study reaffirm the utility of ultrasonography as primary diagnostic tool in routine orthopedic practice.

The benefit of adding sonography to the examination of patients suffering from shoulder pain, was examined in this retrospective evaluation. A patient suffering from shoulder pain consults generally his family physician, who sends his patient first to a radiography and not to sonography. In 75% of the patients examined by sonography, shoulder lesions were diagnosed, demonstrated in only 33% of radiographs. Most patients had more than one lesion: 38% had partial or full-thickness tears of the supraspinatus tendon, about one third bicipital tendonitis, 18% irregularities of the humeral greater tuberosity, 10% subdeltoid bursitis and about 10% calcified tendonitis. In about a quarter of the patients, no pathology was found. Many patients had more than one lesion. In conclusion, clinicians encountering shoulder pain should not be content with conventional radiography and are encouraged to make sonographic examinations part of the early diagnostic protocol.

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.

Chronic exertional compartment syndrome is an uncommon phenomenon first reported in the mid 50's. This condition is characterized by sharp pain during physical activity, causing reduction in activity frequency or intensity and even abstention. This syndrome is caused by elevation of the intra-compartmental pressure which leads to decreased tissue perfusion, thus ischemic damage to the tissue ensues. Chronic exertional syndrome is usually related to repetitive physical activity, usually in young people and athletes. The physical activity performed by the patient causes a rise in intra-compartmental pressure and thereby causes pain. The patient discontinues the activity and the pain subsides within minutes of rest. Chronic exertional syndrome is reported to occur in the thigh, shoulder, arm, hand, foot and gluteal region, but most commonly in the leg, especially the anterior compartment. The diagnosis of chronic exertional syndrome is primarily based on patients' medical history, supported by intramuscular pressure measurement of the specific compartment involved. Treatment of chronic exertional syndrome, especially the anterior and lateral compartment of the leg is mainly by surgery i.e. fasciotomy. If the patient is reluctant to undergo a surgical procedure, the conservative treatment is based on abstention from the offending activity, changing footwear or using arch support. However, the conservative approach is not as successful as surgical 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.

Ultrasound was used to diagnose bipartite patella in seven adolescents with anterior knee pain, and the findings were compared to those from plain radiography and to those of a group of asymptomatic subjects. In all affected individuals the quadriceps and patellar tendons appeared normal on ultrasound. Sonographic examination of the patella demonstrated an irregularity of the bony contour with occurrence of a cleft between the main part of the patellar body and the large superolateral accessory ossicle. The signal detected in the interface between bones was less echogenic than bone reflecting its fibrocartilaginous nature. The correlation with conventional radiography was absolute, as was the inter- and intraobserver reliability. Ultrasound is thus proposed as a simple and reliable imaging modality in bipartite patella. We do not believe that it should replace the initial radiographic, but it can be used to evaluate the contralateral knee for bilaterality and as an adjunct to therapeutic procedures such as local injections to increase the accuracy of treatment.

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.

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 clinical use of massive bone allografts in orthopaedic surgery has become common practice in tumour operations and primary and revision total joint replacement. In certain special clinical situations associated with large bone loss, such as trauma, limb-length discrepancy repair or even infection, massive bone allografts can be successfully used. We present our treatment results of 47 patients who suffered from major bone loss due either to trauma, limb-length discrepancy repair, or infection. Our results (> 2 years minimum follow-up to allow full-bone allograft incorporation) indicate that the use of massive bone allografts in these special and delicate medical conditions is feasible, and have good functional results.

A consecutive prospective series of 19 knees had unicompartmental arthroplasty between 1991 and 1992 for gonarthrosis and AVN. The MOD3TM prosthesis was used in all cases. A total follow-up evaluation was undertaken after 6 to 7.5 years (mean 6.5 years) in 18 patients (1 patient has died during the observation period). Complications included 1 technical failure, 2 cases of thromboembolic phenomena and 1 case of a late deep infection. Knee score averaged 84.3 (pre-operative 54.7) and functional score averaged 68.9 (pre-operative 34.6).

First-ray metatarsalgia is commonly attributed to pathologies of the 1st metatarso-phalangeal joint or the sesamoids. A case of a 50-year-old male patient with 1st ray metatarsalgia caused by a rare benign tumour is presented – a soft tissue chondroma located in the subcutaneous tissue plantar to the head of the 1st metatarsus. The tumour was removed with no evidence of recurrence and the patient is symptom-free ever since. A review of the literature regarding this unusual type of tumour is further presented and discussed.

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.

We present a case of a subtrochanteric fracture that occurred 1 week after the surgical treatment of a Garden 1 Type subcapital fracture by way of pinning in situ with multiple Knowles pins. The event took place in the patient's bed with no evidence of trauma of any kind. The fracture line went through the insertion site of the lower (distal) pin. This rare type of complication was successfully treated by revision surgery and fixation of both fractures by way of a Richard's dynamic hip screw. We review the literature with regard to the incidence, the possible etiological factors involved and the recommended modes or treatment.

Rehabilitation didn't get much attention in animal research as compared to disuse atrophy that has been widely investigated over the years. We therefore performed a combined morphometrical and biochemical study on the effect of recovery from hind-limb immobilization on the tibia and the serum of rats. The experiments were carried out on 42 young Sprague-Dawley male rats. In one group of 32 rats the left hind-limb was immobilized for 2 weeks and then remobilized for another 2 weeks. Another group of 10 rats served as controls. Total body weight was partially restored. Tibia weight (fresh, dry and ash) showed on the other hand no tendency to improve. Serum triglycerides, urea, creatinine, albumin and calcium that were found to be reduced during immobilization returned to normal values during the rehabilitation period. Serum phosphorus that remained normal during limb disuse rose to above normal values in the remobilization phase. Serum alanine aminotransferase levels changed from low to normal. Serum alkaline phosphatase showed a rebound phenomenon from low to above-normal. Both muscle aspartate aminotransferase and bone alkaline phosphatase that were low during immobilization returned to normal in response to rehabilitation. We conclude that biochemical alterations are fast and tend to become fully corrected. Overcoming weight loss is a much slower process and it is unclear whether weight ever returns to pre-atrophic values.

Recently, atypical femoral fractures, especially at the proximal part, were reported in the literature. Most of the reports discussed the relationship between those atypical fractures and chronic use of bisphosphonate drugs as prophylactic treatment for osteoporosis. As a result, the FDA (US Food and Drug Administration) published a statement on October 2010, which was the conclusion of a multidisciplinary working group. The FDA decided to add warnings for every bisphosphonate drug which was given as prophylactic treatment for osteoporosis in the USA. In this review, we will present the bisphosphonate drugs, the presenting symptoms of patients who suffer from the pathologic fracture, the radiologic characteristics and the surgical treatment. We will present the work of a Task Force of the American Society for Bone and Mineral Research and the FDA statements.

Objectives: To enhance the awareness and hence early diagnosis of Freiberg's disease in sportspersons complaining of metatarsalgia. Methods: A case report is presented wherein the correct diagnosis was made late in the natural pathogenesis of the disorder. Results: Salvage surgery was carried out but prevention and preservation of the anatomy would be preferred. Conclusions: Although the exact etiology of Freiberg's disease remains uncertain, early diagnosis and appropriate treatment is desirable rather than a salvage procedure.

Twenty-one cases of clavicular fractures in newborn babies were examined. Ten by radiographic and ultrasonic evaluation and 11 had only ultrasound examination. Clavicle fracture can be diagnosed by ultrasound.

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.

Background: The intention-to-treat principle implies that all patients who are randomized in a clinical trial should be analyzed according to their original allocation. This means that patients crossing over to another treatment group and patients lost to follow-up should be included in the analysis as a part of their original group. This principle is important for preserving the randomization scheme, which is the basis for correct inference in any randomized trial. In this study, we examined the use of the intention-to-treat principle in recently published orthopaedic clinical trials. Methods: We surveyed eight leading orthopaedic journals for randomized clinical trials published between January 2005 and August 2008. We determined whether the intention-to-treat principle was implemented and, if so, how it was used in each trial. Specifically, we ascertained which methods were used to account for missing data. Results: Our search yielded 274 randomized clinical trials, and the intention-to-treat principle was used in ninety-six (35%) of them. There were significant differences among the journals with regard to the use of the intention-to-treat principle. The relative number of trials in which the principle was used increased each year. The authors adhered to the strict definition of the intention-to-treat principle in forty-five of the ninety-six studies in which it was claimed that this principle had been used. In forty-four randomized trials, patients who had been lost to follow-up were excluded from the final analysis; this practice was most notable in studies of surgical interventions. The most popular method of adjusting for missing data was the “last observation carried forward” technique. Conclusions: In most of the randomized clinical trials published in the orthopaedic literature, the investigators did not adhere to the stringent use of the intention-to-treat principle, with the most conspicuous problem being a lack of accounting for patients lost to follow-up. This omission might introduce bias to orthopaedic randomized clinical trials and their analysis.

Noninvasive thermal ablation using magnetic resonance (MR)-guided focused ultrasound (MRgFUS) has been shown to be clinically effective in uterine fibroids, and is being evaluated for ablation of breast, liver, and brain lesions. Recently MRgFUS has been evaluated for palliation of pain caused by bone metastases. We present the clinical results of a multicenter study using MRgFUS for palliation of bone metastases pain. A multicenter study to evaluate the safety and efficacy of MRgFUS palliative treatment of bone metastases was conducted in patients suffering from painful metastatic bone lesions for which other treatments were either ineffective or not feasible. Thirty-one patients with painful bone metastases underwent the MRgFUS procedure in three medical centers. Treatment safety was evaluated by assessing the device-related complications. Effectiveness of pain palliation was evaluated using the visual analog pain score (VAS), and measurable changes in the intake of opioid analgesics. Thirty-six procedures were performed on 31 patients. Mean follow-up time was 4 months. 25 patients underwent the planned treatment and were available for 3 months post-treatment follow-up. 72% of the patients (18/25) reported significant pain improvement. Average VAS score was reduced from 5.9 prior to treatment to 1.8 at 3 months post treatment. 67% of patients with recorded medication data reported a reduction in their opioid usage. No device-related severe adverse events were recorded. The results suggest that MRgFUS has the ability to provide an accurate, effective, and safe noninvasive palliative treatment for patients with bone metastases.

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.

The conventional procedure for displaced fracture of the surgical neck of the humerus uses straight pins inserted from the lateral aspect towards the head of the humerus. The objective of this study was to compare the mechanical properties of fixation by contoured (curved) pins to those fixed with regular straight pins. A transverse osteotomy was made in 30 fresh-frozen sheep humeri in the proximal metaphyseal bone region, and pins were inserted using either three parallel straight pins or three contoured pins in different planes. The assemblies were subjected to bending or rotational stresses at the fracture site. Loads versus deformations were acquired during loading and rigidity was calculated. Results showed that in bending, fixation with straight pins was 31% more rigid compared to contoured pins (p < 0.001), and in torsion, fixation using contoured pins was 21% more rigid compared to straight pins (p < 0.001). A combination of the two fixation types should be considered.

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.