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Over the past four decades, advancements in adjuvant treatments of bone sarcomas have catalyzed development of novel surgical technologies that continue to improve limb salvage surgeries. To date, these technologies have made limb salvage surgery the mainstay of treatment, while limb amputations became negligible. These advancements include pre-and intra-operative imaging technologies enabling accurate 3D-preoperative planning, and intraoperative patient-specific instruments allowing accurate execution of surgical plans. The introduction of customized 3D-printed porous titanium implants gave surgeons more freedom to retain surrounding healthy tissue and optimize reconstruction fit, thereby improving quality of life and reducing comorbidities post-operatively. Creating these custom implants has brought forth novel processes, materials and technologies and given rise to a new era in orthopedic oncology.

Objective To examine the association of color vision deficiency (CVD) with other ophthalmic disorders including ametropia, amblyopia and strabismus in a large population study. Methods The retrospective, cross-sectional study included 916 388 Israeli army male recruits that had their pre-military medical assessment at the age of 16 to 18 years from 2000 to 2020. We examined the prevalence of ophthalmic disorders including amblyopia, strabismus and ametropia in army recruits with CVD compared to all other recruits with normal color vision. Demographic and socioeconomic data were also collected. Results The prevalence of amblyopia (1.12% vs. 0.71%, p

Coronavirus disease 2019 (COVID-19) led to two nationwide lockdowns in Israel, reducing both supply and demand for medical services in the Israel Defense Force (IDF). IDF soldiers serve on bases within Israel, and most of them return home at the end of the day, similar to other armies in the world.To analyze the health services provided by the IDF with regard to policy changes during lockdowns.We compared medical encounters between different services provided by the IDF Medical Corps. We related them to specific time periods: pre-first lockdown, first lockdown (and corresponding timeframes of the previous 3 years), between lockdowns, second lockdown, and post-second lockdown.Compared to past periods, we found a similar reduction of 27-30% in primary care medical encounter rates during the two lockdowns: 42-43% in sick days and 50-54% in referrals to the emergency department. Referral rates to all specialist medical encounters and elective surgeries decreased significantly during the first lockdown period and increased 1.2-3.5 times during the second lockdown.A continuance of the shift to telehealth is required to withstand a future lockdown, with a full supply of secondary medical services attuned to core medical issues relevant for combat personnel. A liberal sick leave policy is required to eliminate unnecessary in-person visits, thus reducing the risk of infection.

Musculoskeletal injuries dominate warfare-related trauma and differ from civilian settings in higher hospitalization costs, morbidity, and mortality. Partly due to introduction of personal protective equipment in the Israel Defence Force (IDF) to minimize head and torso injuries while the extremities remained unprotected. This study describes military extremity injury patterns, prehospital treatment and injury sequela regarding return-to-duty and disability compensation.This retrospective study examined cases of battle and non-battle trauma casualties treated by the IDF Medical Corps from 2013 to 2020. Data from the IDF Trauma Registry (IDF-TR) was merged with The Israeli National Trauma Registry (INTR). Cases with high morbidity discharged from military service were compared with lower morbidity patients who returned to active duty service.Out of 1360 injured soldiers, 280 (20.6%) were found to have isolated limb fractures (ILFs). High morbidity casualties had more open fractures (63% vs. 42%) and higher involvement of lower extremities (79% vs. 58%) (p0.001), higher rates of tourniquets use (28% compared to 9%, p0.001), external fixation (34% vs. 19%, p0.001) and amputations (9% vs. 1%, p = 0.003), required more rehabilitation (34% vs. 7%, p0.001), and had 46% medical disabilities compared to 24% with low morbidity (p0.001).ILFs are associated with significant morbidity and disability. High morbidity is associated with high energy, scar-producing, lower-extremity open fractured limbs treated by tourniquets. Future studies should evaluate whether junctional or extremity protective gear is combat feasible and whether introducing Clinical Practice Guidelines to manage suspected limb fractures can decrease morbidity rates and improve return to duty.

BACKGROUND: Primary bone sarcomas are associated with critically sized bone defects and require complete resection with negative margins. Recent advancements in health care have pioneered novel approaches such as the implementation of 3D surgical technologies. This study presents oncological and functional outcomes following tumor resections of long bones with the use of customized 3D-printed Patient Specific Instruments (PSIs). METHODS: This single-center retrospective study is comprised of seventeen patients who underwent either intercalary (N = 12) or geographic (N = 5) resections with various reconstruction methods including allograft (N = 8), vascularized fibula (Capanna) (N = 7), and 3D printed customized titanium implants (N = 2), between the years 2016–2020. All patients were operated on with a 3D surgical workflow, including intraoperative PSIs, and were followed up postoperatively for at least 12 months (average 31.40 ± 12.13 months) to assess oncological and functional outcomes. RESULTS: All patients demonstrated negative surgical margins, apart from one patient who had planned positive margins. Three patients suffered from short-term complications, and three patients underwent revision surgery due to graft non-union or pathological fracture. One patient suffered from local recurrence and underwent above-knee amputation. Three patients suffered from lung metastasis. MSTS at 12-month follow-up was 26.9.±5.87. CONCLUSION: Customized 3D-printed osteotomy PSIs provide surgeons with a novel tool for optimizing bone resection and reconstruction in long bones surgeries, thus minimizing overall tissue trauma and reducing the risk of damage to nervous and vascular structures. This study demonstrates that the use of PSIs has the potential to improve functional and oncological outcomes. We believe that this technique will become increasingly popular in the future as a widely applicable, highly accurate, cost-effective optimization tool.

Hemostatic dressings are advanced topical dressings designed to control hemorrhage by enhancing clot formation. These dressings may be effective when used on injuries sustained in junctional zones. The Israeli Defense Forces Medical Corps (IDF-MC) chose to equip its medical personnel with the QuikClot Combat Gauze. There is a paucity of data describing clinical use and results of hemostatic dressing especially at the point of injury. The purpose of this article was to report the IDF-MC experience with prehospital use of the QuikClot Combat Gauze in junctional zones in a case series retrieved from the IDF Trauma Registry.All IDF Trauma Registry documented cases of prehospital use of hemostatic dressings in the IDF-MC between January 2009 and September 2014 were retrieved. Data collection included injury mechanism, wound location, reported success of hemostatic dressing, tourniquet use, lifesaving interventions, mortality, and caregiver identity.A total of 122 patients on whom 133 hemostatic dressings were applied were identified. Median age was 22 years. Of the patients, 118 (96.7%) were male and 2 (1.6%) were female (missing, n = 2). Injury mechanism was penetrating in 104 (85.2%), blunt in 4 (3.3%), and combined in 14 (11.5%) patients. Seven patients (5.9%) died. Thirty-seven dressings (27.8%) were used for junctional hemorrhage control (pelvis, shoulder, axilla, buttocks, groin, neck), and 92 dressings (72.1%) were placed in nonjunctional areas (missing, n = 4). Nonjunctional dressings included 63 (47.4%) applied to the extremities, 14 (10.5%) to the back, and 4 (3%) to the head. Hemostatic dressing application was reported as successful in 88.6% (31 of 35 available; missing, n = 2) of junctional hemorrhage applications and in 91.9% (57 of 62 available; missing, n = 1) of extremity hemorrhage applications.Hemostatic dressings seem to be an effective tool for junctional hemorrhage control and should be considered as a second-line treatment for extremity hemorrhage control at the point of injury.Therapeutic study, level V.

Background: Management of combat casualties should optimize outcomes by appropriate patient triage, prehospital care, and rapid transport to the most capable medical facility, while avoiding overwhelming individual facilities. Methods: Planning the medical support for the campaign was done by the medical department of the IDF Southern command in cohort with the medical department of the Homefront command. Data collection and analysis were done by the Trauma Branch of the Medical corp. Results: 339 soldiers were injured, among them were 10 fatalities. Five hospitals received casualties, although the 2 regional hospitals received 84% of the primary evacuation load. The majority of urgently injured soldiers (90%) were evacuated by air, as opposed to 59% of non-urgently injured soldiers. Conclusions: In a cross border setting, airlifting the urgent casualties to farther away level I trauma centers provides appropriate care for them, while not crossing the “surge capacity” line for the near-by medical ...

Summary Introduction Caliper measurement of the excised femoral head is a standard technique for determination of prosthetic head size during hemiarthroplasty for displaced femoral neck fractures. Objectives To evaluate the accuracy of the caliper method of hemiarthroplasty head sizing by comparing it to the native joint congruency (JC) at the weight bearing surface. Materials and methods The diameters of femoral heads in 10 cadaver hip joints were measured by using a caliper at the head equator. Cast moulds were prepared from both the acetabulum and the femoral head in each joint. Every mould's exact spherical diameter at the weight bearing region was measured by a computerised coordinate measuring machine (MNC B231 MITUTOYO). All specimens were coded to ensure that future examination was carried out in a blind manner. Native JC mismatch was determined by subtracting the diameter of the femoral cement mould from that of the acetabular one. Similarly, JC mismatch was calculated for the caliper measurements. Results The average native JC mismatch (0.36 ± 0.29 mm, range 0.03–0.82 mm, median 0.29 mm) was found significantly smaller ( p = 0.03) than following caliper measurements (0.72 ± 0.37 mm, range 0.37–1.46 mm, median 0.6 mm). Routine caliper measured downward size rounding enhanced ( p = 0.004) this mismatch (0.98 ± 0.44 mm, range 0.37–1.96 mm, median 1.01 mm), while upward rounding (0.48 ± 0.46 mm, range −0.06 to 1.15 mm, median 0.41 mm) helped mitigate this tendency. Conclusions Caliper measurements tend to undersize the actual sphere diameter of the femoral head at the weight bearing region. Upward rounded prosthesis should be selected in order to compensate for this propensity.

Background: Gun-shot wound head injury comprises a substantial fraction of combat injuries and a major cause of death in the battlefield. Current shielding gear is totally ineffective against bullets, because bullet-proof materials are too heavy to be worn on the head. The aim of this work was to describe the anatomic distribution of bullet entry wounds to the head in combat fatalities and to discern whether distribution is random (null hypothesis) or not. Methods: We retrospectively examined the forensic external examination reports of all Israeli Defense Forces combat fatalities during the years 2000 to 2004, the Second Lebanon War (2006), and Operation Cast Lead (2009) and mapped the exact anatomic location of all bullet entry wounds to the calvaria. Results: We found 76 gun-shot entry wounds to the heads of 49 fatalities. Among these wounds, the occipital and anterior-temporal regions were found to be hit significantly more often than expected compared with their relative surface area (p < 0.001 and p < 0.001, respectively). Fifty-five percent of all injuries occurred within 15% of the surface area of skull. Conclusions: These findings imply that gun-shot entry wounds to the head are unevenly distributed. A partially bullet-proof protective helmet may prevent a substantial fraction of injuries (and fatalities) without a significant weight addition to the helmet.

Several biomechanics treatments for knee osteoarthritis (OA) have emerged with the goal of reducing pain and improving function. Through this, researchers have hoped to achieve a transition from the pathological gait patterns to coordinated motor responses. The purpose of the study was to determine the long-term effects of a therapy using a biomechanical device in patients with knee OA. Patients with knee OA were enrolled to active and control groups. The biomechanical device used in therapy (AposTherapy) was individually calibrated to each patient in the active group. Patients in the control group received standard treatment. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), Aggregated Locomotor Function (ALF), Short Form 36 (SF-36), and Knee Society Score assessments. The active and control groups were similar at the baseline (group difference in all scores P > 0.05). The active group showed a larger improvement over time between groups in all three WOMAC categories (F = 16.8, 21.7, and 18.1 for pain, stiffness, and function; all P < 0.001), SF-36 Physical Scale (F = 5.8; P = 0.02), Knee Society Knee Score (F = 4.3; P = 0.044 ), and Knee Society Function Score (F = 6.5; P = 0.014 ). At the two-year endpoint, the active group showed significantly better results (all P ≤ 0.001). The groups showed a difference of 4.9, 5.6, and 4.7 for the WOMAC pain, stiffness, and function scores, respectively, 10.8 s in ALF score, 30.5 in SF-36 Physical Scale, 16.9 in SF-36 Mental Scale, 17.8 in Knee Society Knee Score, and 25.2 in Knee Society Function Score. The biomechanical therapy examined was shown to significantly reduce pain and improve function and quality of life of patients with knee OA over the long term.

Background:Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009.Methods:QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation.All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers.Results:Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported.Conclusions:This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.

Background This study examined the effect of treatment with a novel biomechanical device on the level of pain and function in patients with knee OA. Methods Patients with bilateral knee OA were enrolled to active and control groups. Patients were evaluated at baseline, at 4 weeks and at the 8-week endpoint. A novel biomechanical device was individually calibrated to patients from the active group. Patients from the control group received an identical foot-worn platform without the biomechanical elements. Primary outcomes were the WOMAC Index and ALF assessments. Results There were no baseline differences between the groups. At 8 weeks, the active group showed a mean improvement of 64.8% on the WOMAC pain scale, a mean improvement of 62.7% on the WOMAC function scale, and a mean improvement of 31.4% on the ALF scale. The control group demonstrated no improvement in the above parameters. Significant differences were found between the active and control groups in all the parameters of assessment. Conclusions The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients. The study is registered at clinicaltrials.gov, identifier NCT00457132, http://www.clinicaltrials.gov/ct/show/NCT00457132?order=1

Background International social networking is eminent in medical practice, mainly in sharing knowledge and mutual inspiring and in social and professional bonding. Since 2006, the International Medical Course is taking place in Commander Branch at the Military Medicine Academy of the Medical Corps, Israeli Defense Forces; in which medical officers from other military forces are participating along with Israeli officers. One of the course’s objectives is international networking. The purpose of this study was to assess the level of networking in the International Medical Course compared to others means of networking, and to examine which components in the course are the most important in networking formation. Methods Questionnaires were e-mailed to the course participants. Demographic data and data regarding the networking possibilities in the international medical course was collected. Results The answers of 35 participants (17 Majors, 12 Lieutenant-Colonels, and 6 Colonels; mean age of 44.1 years) were included in this study. Response rate was 42%. Of the participants, 24 were Israelis and 11 from other military forces. Most of the responders (88.6%) reported the course is a major networking tool, with no influence of age, sex, rank, education profession or origin. Networking potential among participants from the same origin country was significantly higher in Israeli officers in comparison to officers from other countries (p = 0.001). Clinical practice and research purposes were the reason for communication in one fifth of the participants. Conclusions The International Medical Course fulfils its purpose in forming international military medical networking.