Osteoporotic tibial plateau fractures: an underestimated cause of knee pain in the elderly.
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Biomedical subjects
Meir Liebergall
Publications and source records attributed to Meir Liebergall.
Pelvic fractures in a level I trauma center: a test case for the efficacy of the evolving trauma system in Israel.
BACKGROUND: Pelvic fracture is a severe and life-threatening injury that requires treatment by a dedicated team. One of the goals of a nationwide trauma system is to provide appropriate medical care for such injuries. OBJECTIVES: To use pelvic fractures as a test case for the efficiency of the Israeli trauma system, as reflected in the experience of our medical center. METHODS: Data were obtained from the medical charts of all cases of pelvic fractures admitted to our medical center between 1987 and 1999. We obtained demographic data, information on the cause of injury, fracture classification, co-injuries and Injury Severity Score, treatment strategies, and mortality rate. RESULTS: Altogether, 808 patients with pelvic injuries were treated in our medical center. The most common cause of injury was motor vehicle accidents (51%). Pelvic fractures without acetabular involvement were diagnosed in 58% of patients and isolated acetabular fractures in 32%, while 10% sustained combined injuries to the pelvic ring and the acetabulum. The overall rate of operative stabilization was 34%. The majority of patients had associated injuries, mostly additional musculoskeletal injuries. Altogether, 13% were referred from Level II/III trauma centers. We observed an increase in the total number of local admissions, in the percentage of referred patients and in the percentage of operated patients during the study period. The observed mortality rate was 5%. CONCLUSIONS: Our results show a more than twofold increase in the percentage of referred patients following the designation of a Level I trauma center. These referrals are due not only to the designation as a Level I trauma center, but also to the presence of a dedicated team of pelvic fracture specialists, available 24 hours a day. In addition, a larger percentage of patients undergo surgery for internal fixation of pelvic fractures, in accordance with current worldwide trends.
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Human mesenchymal stem cells alter antigen-presenting cell maturation and induce T-cell unresponsiveness.
Infusion of either embryonic or mesenchymal stem cells prolongs the survival of organ transplants derived from stem cell donors and prevents graft-versus-host-disease (GVHD). An in-depth mechanistic understanding of this tolerization phenomenon could lead to novel cell-based therapies for transplantation. Here we demonstrate that while human mesenchymal stem cells (hMSCs) can promote superantigen-induced activation of purified T cells, addition of antigen-presenting cells (APCs; either monocytes or dendritic cells) to the cultures inhibits the T-cell responses. This contact- and dose-dependent inhibition is accompanied by secretion of large quantities of interleukin (IL)-10 and aberrant APC maturation, which can be partially overridden by the addition of factors that promote APC maturation (ie, lipopolysaccharide [LPS] or anti-CD40 monoclonal antibody [mAb]). Thus, our data support an immunoregulatory mechanism wherein hMSCs inhibit T cells indirectly by contact-dependent induction of regulatory APCs with T-cell-suppressive properties. Our data may reveal a physiologic phenomenon whereby the development of a distinct APC population is regulated by the tissue's cellular microenvironment.
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The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits.
When subjected to strains or strain rates higher than usual, the bone remodels to repair microdamage and to strengthen itself. During the initial resorption phase of remodeling, the bone is transitorily weakened and microdamage can accumulate leading to stress fracture. To determine whether short-term suppression of bone turnover using bisphosphonates can prevent the initial loss of bone during the remodeling response to high bone strain and strain rates and potentially prevent stress fracture, we conducted a randomized, double-blind, placebo-controlled trial of 324 new infantry recruits known to be at high risk for stress fracture. Recruits were given a loading dose of 30 mg of risedronate or placebo daily for 10 doses during the first 2 weeks of basic training and then a once a week maintenance dose for the following 12 weeks. Recruits were monitored by biweekly orthopedic examinations during 15 weeks of basic training for stress fractures. Bone scans for suspected tibial and femoral stress fractures and radiographs for suspected metatarsal stress fractures were used to verify stress fracture occurrence. By the intention-to-treat analysis and per-protocol analysis, there was no statistically significant difference in the tibial, femoral, metatarsal, or total stress fracture incidence between the treatment group and the placebo. We conclude that prophylactic treatment with risedronate in a training population at high risk for stress fracture using a maintenance dosage for the treatment of osteoporosis does not lower stress fracture risk.
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First generation computerized fluoroscopic navigation in percutaneous pelvic surgery.
Percutaneous internal fixation of pelvic fractures has gained popularity allowing rapid mobilization with reduced surgical related morbidity; however, this method depends on conventional fluoroscopy, which exposes the patient and the surgeon to a significant amount of radiation. The use of computerized fluoroscopic navigation systems enables the simultaneous use of several radiographic projections. These preliminary fluoroscopic views are taken when the operating team stands at a distance from the radiation source. No further fluoroscopic radiation is used later during the surgical procedure. Computerized fluoroscopic navigation was used in the percutaneous insertion of 45 cannulated screws in 29 patients, including sacroiliac screws, pubic ramus screws, posterior column screws, and a supraacetabular transverse screw. Fluoroscopic verification of screw placement demonstrated a deviation <or=2 mm and <or=5 degrees. We believe the system saves fluoroscopic radiation time, yet improves the precision of the procedure. We believe that the use of this system is adequate for a selected patient population with pelvic fractures amenable to percutaneous screw fixation.
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The use of computerized navigation in the treatment of gunshot and shrapnel injury.
OBJECTIVE: Trauma surgeons encounter numerous penetrating injuries nowadays. In some cases, missiles causing infection, pain and discomfort, or those retained within joints, bursae and other strategic sites, must be removed. This paper describes an innovative high-tech modality for use in the immediate removal of shrapnel and bullets from strategic anatomical sites. METHODS: Surgical computerized navigation based on real-time acquisition of fluoroscopic data was employed. Several fluoroscopic images of the required anatomical site were obtained. The accurate spatial location of the foreign object could be seen on the images displayed on the computer screen. No further fluoroscopic radiation was necessary. During surgery, the infra-red camera tracked the position of a surgical probe on the patient's anatomy and continuously updated its three-dimensional position simultaneously on all displayed images until the missile's location was reached. RESULTS: The use of percutaneous fluoroscopic navigation to remove retained metal objects, including bullets and shrapnel, has proved itself in 12 cases as an accurate measure involving reduced exposure to radiation. In contrast to CT- or MRI-based navigation, computerized fluoroscopic navigation does not require long preliminary preparation. Thus, it is highly efficient in the treatment of acute trauma victims. CONCLUSIONS: The use of this accurate technique in complex and dangerous situations where the foreign body is located in proximity to blood vessels, nerves and narrow 'safe-zones', is promising. This innovative technique reduces surgical time and radiation exposure. In our experience, it has rendered percutaneous missile removal much safer, even in hazardous situations.
Adult↗
Using computerized fluoroscopic navigation to remove pelvic screws.
Orthopedic surgeons have recently recognized the benefits of using percutaneous fixation to treat pelvic-ring disruption. Surgical removal of pelvic internal fixation is performed in an anatomically "crowded" area, with no direct vision, and harbors its own risks. Computerized fluoroscopic navigation, which makes implant location easier and reduces radiation exposure, operative time, and soft-tissue damage, can make this procedure short and relatively safe.
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Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia.
BACKGROUND: Perioperative myocardial ischemia occurs in 35% of unselected elderly patients undergoing hip fracture surgery. Perioperative epidural analgesia may reduce the incidence of adverse cardiac events. METHODS: The effect of early administration of epidural analgesia during the stressful period, on cardiac events was evaluated in a prospective randomized study in 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. On admission to the emergency room, patients were assigned to receive a usual care analgesic regimen (intramuscular meperidine, control group, n = 34) or continuous epidural infusion of local anesthetic and opioid (epidural group, n = 34). Monitoring in the preoperative period included a preoperative history and physical examination, daily assessment of cardiac adverse events, serial electrocardiograms, cardiac enzymes, and pain scores. RESULTS: Preoperative adverse cardiac events were significantly more prevalent in the control group compared with the epidural group (7 of 34 0 of 34; = 0.01). Adverse cardiac events included fatal myocardial infarction in three, fatal congestive heart failure in one, nonfatal congestive heart failure in one, and new onset atrial fibrillation in two. The incidence of intraoperative and postoperative adverse cardiac events was similar for the two groups. The significant difference between groups in the incidence of preoperative cardiac events prompted interruption of the study after the planned interim analysis. CONCLUSIONS: The authors' data indicate that compared with conventional analgesia, early administration of continuous epidural analgesia is associated with a lower incidence of preoperative adverse cardiac events in elderly patients with hip fracture who have or are at risk for coronary artery disease. Preoperative epidural analgesia may be advantageous for this surgical population.
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Quantification of guided regeneration of weight-bearing bones.
An accurate histological evaluation system was established to improve and quantify the compatibility of membranes to provide bone regeneration in a large mid-diaphyseal bone defect, complementing radiographic evaluation. New bone formation obtained in critical segmental defects covered with tubular ethyl cellulose membranes was examined. Computerized radiography showed gradual new bone formation, which slows after 6 weeks. In a parallel histomorphological assessment, a characteristic process of new bone formation occurs inside the confined space and surrounding tissues. Histological findings are summarized according to the new scoring system, which clarifies the mechanism and provides complementary quantification of guided bone regeneration.
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Revision total knee arthroplasty.
BACKGROUND: Revision total knee arthroplasties are performed with increasing frequency due to the increasing numbers of primary arthroplasties. OBJECTIVES: To retrospectively analyze 71 patients who underwent 78 revision total knee arthroplasties during the years 1991 to 1999 METHODS: We evaluated the revised knees using the Knee Society Clinical Rating System after an average follow-up period of 3 years and 9 months (2-10 years). The indications for revision included pain and instability, deep infection of the joint, complaints linked to the patella, or post-trauma to the operated knee. RESULTS: The average knee score (evaluation of the knee joint itself) calculated after the revision was 74.5. The results on the knee score were excellent (> 85) in 48% of patients and poor (< 60) in 22%. The functional results (patient's ability to walk and climb stairs) were only 48.3. CONCLUSION: Although the revision of total knee replacements is known to be problematic, most patients show good results on knee examination, and reasonable functional results given the factors involved.
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Maneuvering the retrograde medullary screw in pubic ramus fractures.
This report describes an improved percutaneous insertion technique of a retrograde medullary screw in pubic ramus fractures. This improved technique enables the use of a relatively thick retrograde medullary screw in difficult anatomical variations such as narrow or curved pubic ramus. Maneuvering of the retrograde medullary screw gives control of the proximal fragment and can assist in fracture reduction.
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Symmetric bilateral transverse fracture of the iliac wings: chance fracture of the pelvis.
An extremely rare "transverse fracture" of the pelvis is presented. This fracture is not yet classified in currently used classifications of pelvic fractures. A fully detailed description of the fracture is given, along with a possible explanation of the mechanism of the injury.
Adolescent↗
Myositis ossificans circumscripta of the sacrotuberous ligament: a case report and review of the literature.
Soft tissue ossification is a well-known phenomenon in various pathologic conditions. Myositis ossificans circumscripta refers to posttraumatic calcification of soft tissue, including various ligaments. However, posttraumatic calcification of ligaments in the pelvis is a rare complication described only anecdotally in the past. We present a rare case of posttraumatic calcification of the sacrotuberous ligament in a patient, several months after suffering a pelvic trauma. This is one of the differential diagnoses of soft tissue pain and tenderness after trauma.
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Percutaneous plating of distal tibial fractures.
This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12 degrees and average plantiflexion 18 degrees). Two fractures united with mal-union: one with an 8 degrees valgus deformity and another with a 7 degrees varus deformity. Both cases, which had a metaphyseal component, were treated by means of a "soft" (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either "soft" or "rigid" plates, and type A and C fractures with a metaphyseal component should be fixed with "rigid" plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.
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Avascular necrosis and related complications following healed osteoporotic intertrochanteric fractures.
BACKGROUND: Femoral hip fractures are a common occurrence in the elderly. Of the various fracture patterns, intertrochanteric injuries have the lowest rate of complications. Case reports of ensuing subcapital fracture have all been linked to incorrect placement of fixation devices or to osteomyelitis, white cases of avascular necrosis have only been reported rarely in the literature and are considered to occur at the rare rate of 0.8%. OBJECTIVES: To check the incidence and outcome of AVN in intertrochanteric hip fractures. METHODS AND RESULTS: In a retrospective analysis of patients who had surgical treatment for intertrochanteric fractures. 10 patients (0.5%) underwent dynamic hip screw fixation for intertrochanteric fractures and subsequently developed painful AVN as their primary presentation. Three of these patients were also found to have subcapital fractures. On revision of the primary fixation no fault was found with nail placement. CONCLUSIONS: The reported rate of AVN may be understated since many patients have limiting factors that prevent them from consulting a physician when in pain, and one-third of these patients die within 2 years. Therefore, we suggest that hip pain following fixation of an intertrochanteric fracture should prompt the clinician to consider the rare possibility of AVN or subcapital fracture.
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The influence of surgically-induced weight loss on the knee joint.
BACKGROUND: The causal relationship between obesity and osteoarthritis (OA) of the knee is generally accepted. Weight loss has been shown to reduce the development of OA and improve the radiological parameters of existing disease. However, inducing weight reduction is difficult, and thus the number of patients studied has been small. We wished to determine the effects of surgically-induced weight loss on objective, radiological evidence of OA in the knee joint. METHODS: 64 consecutive patients that were referred to the Bariatric Surgical Unit were enrolled in the study. The only exclusion criterion was the prior diagnosis of OA. Knee pain alone did not exclude patients from the study. The study was performed in a prospective manner as a before-after trial. Radiographic data was evaluated by an independent radiologist not involved in the patient care or follow-up. Upright film of the knee was taken prior to surgery and 3 months following surgery. Minimal medial joint space width (JSW) was measured by a digital image computer. In addition, patients were clinically assessed using the American Knee Society Score (AKSS) at these times. RESULTS: 59 of 64 patients were available for followup. BMI decreased from 43.4 to 36.9 (P<0.01). The medial joint space increased from 4.6 mm to 5.25 mm (P<0.001). The AKSS improved from 78.5 points (perfect function = 100 points) to 90.69 points (P<0.01). CONCLUSION: Surgically-induced weight loss is an effective, rapid and dependable means of reversing the radiological signs of early changes associated with OA.
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