At long-term follow-up many first-time male traumatic shoulder dislocators remain symptomatic.

OBJECTIVES: To assess the status at 13 to 17 years follow-up of a cohort of young male traumatic shoulder dislocators. STUDY DESIGN: Prospective cohort study. METHODS: A prospective study of first-time young male traumatic shoulder dislocators, began in 2004. Subjects were evaluated by the apprehension test after completing rehabilitation 6 to 9 weeks post dislocation. Between March 2021 and July 2022, a telephone questionnaire was administered to ascertain their current shoulder status. Subjects were questioned about avoidance of activities of daily living and sport, participation in sports, current instability, and self-assessed shoulder function by the SANE score. RESULTS: 50/53 (94.3%) of the study subjects, mean age 20.4 years, completed a mean follow-up of 181.8 ±â€¯12 months. The non-redislocation survival was 13% for those with a positive apprehension test and 49% for those with a negative test (p = 0.007). SANE scores were 64.3 ±â€¯23.7 for those with a positive apprehension test and 83.7 ±â€¯19.7 for those with a negative test (p = 0.001). In the year before the follow-up, 33.3% of those treated conservatively and 42.9% treated surgically experienced subluxation (p = 0.5). Fifty-seven percent of those who were treated conservatively and 56% of those who underwent surgery avoided some ADL or sports because of their shoulder. CONCLUSIONS: For young male first time traumatic shoulder dislocators a positive apprehension test after rehabilitation is associated with a high risk for reoccurrence and poorer long-term results. Most subjects were still dealing with shoulder symptoms at long-term follow-up.

Significance of tibial MRI findings of special forces recruits at the onset of their training.

INTRODUCTION: MRI is commonly used to evaluate medial tibial stress syndrome (MTSS), based on grading assessments developed in civilian populations. When MTSS represents stress fracture, rest is required to allow for bone remodelling to occur. False positive evaluations can lead to unnecessary recruit attrition. METHODS: Thirty randomly selected new recruits to a special forces training unit underwent MRI of their tibias using the T2-Dixon sequence at the onset of training. Evaluation was according to the Fredericson MTSS grading system. Prior to undergoing MRI, anthropomorphic measurements, a survey of sports history and an orthopaedic examination of subject tibias were performed. Orthopaedic follow-up was through 11 weeks of training. RESULTS: Medial periosteal oedema without the presence of bone marrow oedema, corresponding to a grade 1 stress reaction, was present on MRI in 10 recruits (17 tibias). In only one case did the periosteal oedema include the posterior aspect of the medial cortex where medial tibial stress fractures usually occur. Tibial tenderness was present in seven tibias on examination done just prior to the MRI studies, but none were symptomatic and only one had periosteal oedema present on MRI, but without anatomical correlation between the site of the tenderness and the periosteal oedema. During subsequent training, five tibias in four recruits developed pain and tenderness. Two had periosteal oedema in their prior MRIs, but the location did not coincide anatomically with that of the tibial tenderness. The time from stopping sports before induction and the presence of periosteal oedema was not significant. CONCLUSION: Periosteal oedema, one of the hallmarks used in MRI grading systems to evaluate MTSS, was found to have a 37.7% false positive rate for anatomically corresponding tibial tenderness at the time of the examination and during subsequent training, indicating the grading systems' low utility for the military.

In vivo strains at the middle and distal thirds of the tibia during exertional activities.

There is a known variance in the incidence and anatomical site of tibial stress fractures among infantry recruits and athletes who train according to established uniform training programs. To better understand the biomechanical basis for this variance, we conducted in vivo axial strain measurements using instrumented bone staples affixed in the medial cortex, aligned along the long axis of the tibia at the level of the mid and distal third of the bone in four male subjects. Strain measurements were made during treadmill walking, treadmill running, drop jumps from a 45 cm height onto a force plate and serial vertical jumps on a force plate. Significance levels for the main effects of location, type of activity and their interaction were determined by quasi-parametric methodologies. Compared to walking, running and vertical jumping peak axial tensile strain (µÎµ) was 1.94 (p = 0.009) and 3.92 times (p < 0.001) higher, respectively. Peak axial compression strain (µÎµ) values were found to be greater at the distal third than at the mid tibia for walking, running and vertical jumping (PR = 1.95, p-value<0.001). Peak axial compression and tension strains varied significantly between the subjects (all with p < 0.001), after controlling for strain gauge location and activity type. The study findings help explain the variance in the anatomical location of tibial stress fractures among participants doing the same uniform training and offers evidence of individual biomechanical susceptibility to tibial stress fracture. The study data can provide guidance when developing a generalized finite element model for mechanical tibial loading. For subject specific decisions, individualized musculoskeletal finite element models may be necessary.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

Differences in the principal strain angles during activities performed on natural hilly terrain versus engineered surfaces.

BACKGROUND: Tibial stress fractures in military recruits occur beginning with the fourth week of training. In and ex vivo tibial strain experiments indicate that the repetitive mechanical loading during this time may not alone be sufficient to cause stress fracture. This has led to the hypothesis that the development of tibial stress fracture is mediated by the bone remodeling response to high repetitive strains. This study assesses the differences in the strain and angle of the principal strain during military field activities versus common civilian activities. METHODS: In vivo strain measurements were made from a rosette strain gauge bonded to the midshaft of the medial tibia. Measurements of principal strains and their angles were made while performing level and inclined walking and running on an asphalt surface, while fast walking up and down stairs, while performing a standing vertical jump and while zig-zag running up and down a 30° inclined dirt hill. FINDINGS: The angle of the principal strain varied little (5.40° to +2.74°) during activities performed on engineered surfaces. During zig-zag running on a dirt hill the strain levels were higher (maximum shear = 4290 µÎµ). At the pivot points of zig-zag running the angle of the principal strain varied between -115° to -123° downhill and between -32.8° to -51° uphill. INTERPRETATION: Activities that mimic those performed by infantry recruits on irregular hilly surfaces result in higher tibial strains and have more variation in principal strain angles than activities of ordinary civilian life performed on engineered surfaces.

Pathological fracture risk assessment in patients with femoral metastases using CT-based finite element methods. A retrospective clinical study.

Physician recommendation for prophylactic surgical fixation of a femur with metastatic bone disease (MBD) is usually based on Mirels' criteria and clinical experience, both of which suffer from poor specificity. This may result in a significant number of these health compromised patients undergoing unnecessary surgery. CT-based finite element analyses (CTFEA) have been shown to accurately predict strength in femurs with metastatic tumors in an ex-vivo study. In order to assess the utility of CTFEA as a clinical tool to determine the need for fixation of patients with MBD of the femur, an ad hoc CTFEA was performed on a retrospective cohort of fifty patients. Patients with CT scans appropriate for CTFEA analysis were analyzed. Group 1 was composed of 5 MBD patients who presented with a pathologic femoral fracture and had a scan of their femurs just prior to fracture. Group 2 was composed of 45 MBD patients who were scheduled for a prophylactic surgery because of an impending femoral fracture. CTFEA models were constructed for both femurs for all patients, loaded with a hip contact force representing stance position loading accounting for the patient's weight and femur anatomy. CTFEA analysis of Group 1 patients revealed that they all had higher tumor associated strains compared to typical non-diseased femur bone strains at the same region (>45%). Based on analysis of the 5 patients in Group 1, the ratio between the absolute maximum principal strain in the vicinity of the tumor and the typical median strain in the region of the tumor of healthy bones (typical strain fold ratio) was found to be the 1.48. This was considered to be the predictive threshold for a pathological femoral fracture. Based on this typical strain fold ratio, twenty patients (44.4%) in Group 2 were at low risk of fracture and twenty-five patients (55.5%) high risk of fracture. Eleven patients in Group 2 choose not to have surgery and none fractured in the 5month follow-up period. CTFEA predicted that seven of these patients were below the pathological fracture threshold and four above, for a specificity of 63% Based on CTFEA, 39% of the patients with femoral MBD who were referred and underwent prophylactic stabilization may not have needed surgery. These results indicate that a prospective randomized clinical trial evaluating CTFEA as a criterion for determining the need for surgical stabilization in patients with MBD of the femur may be warranted.

Should Patients With Frozen Shoulder Be Screened for Diabetes Mellitus?

BACKGROUND: Idiopathic frozen shoulder (nontraumatic) is commonly encountered in patients between the ages of 35 and 60 years in general orthopaedic practice. While the prevalence of frozen shoulder among the general population is estimated to be between 2% and 4%, a significantly higher prevalence of 10% to 22% has been reported in patients with diabetes mellitus. Since diabetic patients are more prone to develop frozen shoulder than nondiabetics, the question arises as to whether patients diagnosed as having idiopathic frozen shoulder are at greater risk to develop diabetes mellitus and should be routinely screened for this condition. PURPOSE: To compare the prevalence of diabetes mellitus and prediabetes among patients diagnosed with idiopathic frozen shoulder who are not known to have either diabetes mellitus or prediabetic conditions with that of an age-matched group from the general population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients at a shoulder clinic with a diagnosis of idiopathic frozen shoulder were asked to participate in the study if they were aged between 35 to 60 years and had no known previous diagnosis of diabetes mellitus or prediabetic conditions. These patients underwent a 2-hour oral glucose tolerance test. According to their fasting and 2-hour plasma glucose levels, patients were diagnosed as normal glucose tolerance, prediabetic, or diabetic. Findings were matched with the prevalence in an age-matched general population. RESULTS: Fifty patients completed the test. Four patients with idiopathic frozen shoulder (8%) were found to be prediabetic. No patient was found to be diabetic. All 4 patients reported a history of diabetes in their parents or siblings. CONCLUSION: Patients diagnosed with idiopathic frozen shoulder who are 60 years or younger and are not known diabetics have a similar probability of having diabetes or prediabetes to an age-matched population. No routine diabetic workup is warranted specifically for these patients.

The effect of stress fracture interventions in a single elite infantry training unit (1983-2015).

Stress fractures can be seen as an undesired byproduct of demanding physical training. The threshold value of stress that places an individual bone at high risk for stress fracture has not been identified. In a prospective study of stress fractures in 1983, a 31% incidence was found during demanding Israeli infantry basic training by bone scan criteria. Within a subgroup of these recruits, an elite infantry unit was found to have a 40% incidence. Since then and until 2015, eight additional induction companies of the same elite infantry unit were prospectively monitored for stress fractures during their basic training. In all of the studies, stress fracture surveillance and the examining orthopedist were the same. A retrospective review of all nine studies and of eight training changes was performed to look for a temporal trend in stress fracture incidence and to see if these might be related to training changes. There was a statistically significant trend for lower radiological proven stress fractures (p=0.0001) and radiological proven stress fractures plus clinical stress fractures (p=0.0013), as well as lower stress fracture severity by radiological criteria (p=0.0001) between 1983 and 2015. The only training change that was associated, by multivariate logistic regression, with a decreased incidence of stress fracture was restricting training to the authorized training protocol (odds ratio, 3874; 95% CI, 1.526 to 9.931; p=0.004). Increased recruit weight was found by multivariate analysis to be associated with lower stress fracture incidence (odds ratio 1.034; 95% CI, 1.00 to 1.070; p=0.051). Moving the training to a base with flatter terrain and reducing the formal marching distance by 1/3 was associated with a decrease in high grade stress fractures (odds ratio, 10.03; 95% CI, 3.5 to 28.4; p=0.0001). Neither the combined changes of enforcing a seven hour a night sleep regimen, training in more comfortable boots and adding a physical therapist to the unit nor stopping specific running exercises and adding lower body strengthening exercises were associated with a decrease in stress fracture. 67% of recruits who sustained stress fractures and 69% who did not sustain stress fracture finished their military service as combat soldiers in the unit (p=0.87). There are no magic bullets to prevent stress fractures. Stress cannot be lowered beyond the level which compromises the training goals. It is a problem that can be managed by awareness that identifies and treats stress fractures while they are still in the micro stage and not in the more dangerous macro stage.

The search for the best infantry boot.

BACKGROUND: The combat role of the twenty-first century infantry soldier has changed and accordingly their boots should evolve to meet these new needs and maximize soldier performance. OBJECTIVE: To evaluate injuries and durability of the hot weather infantry boots (HWIB) in elite infantry training and assess the initial performance of newly designed Israeli infantry boots (NDIB). METHODS: In Phase 1, the durability of the HWIB during elite infantry training was evaluated at weeks 10, 19 and 64 in a cohort of 67 recruits. At each exam recruits removed their boots which were assessed for wear and integrity and photographed. The number of times recruits changed their boots was recorded. In Phase 2, foot injuries were assessed in a cohort of 73 elite infantry recruits wearing HWIB. In Phase 3, 65 infantry recruits were issued the NDIB. Recruits feet were measured for width and shoe size using the Brannock device and then followed for problems associated with their boots. Foot lesions were document by photographs. RESULTS: Phase 1: The mean longevity of HWIB in training was 5.2 ± 0.2 (SE) months, (95 % CI 4.83-5.61). Phase 2: 38 % of the elite infantry recruits wearing HWIB had at least one complaint and 31 (42 %) were found to have boot related injuries in a total of 56 injured areas. Phase 3: The mean predicted boot size (42.8 ± 1.7) based on Brannock measurements, was less than the size of the NDIB actually worn, 43.1 ± 1.6. Only 34.8 % of the feet were width D (the standard shoe width). At 9 day follow up, 55 of the 65 recruits who wore NDIB reported at least one problem with them (85 %, p < 0.0001, compared to HWIB). By 3 weeks, all but five recruits had returned to wearing the HWIB. Of the recruits wearing NDIB, 47 (72 %) were found to have had at least one boot related injury with a total number of 180 injured foot areas (p = 0.0004, compared to HWIB). CONCLUSIONS: The HWIB was well tolerated by the elite infantry recruits and associated with significantly less foot injuries than the NDIB. The longevity of the HWIB in demanding elite infantry training was five months. Trial registration: NCT02810002 retrospectively registered June 22, 2016.

Understanding the etiology of the posteromedial tibial stress fracture.

Previous human in vivo tibial strain measurements from surface strain gauges during vigorous activities were found to be below the threshold value of repetitive cyclical loading at 2500 microstrain in tension necessary to reduce the fatigue life of bone, based on ex vivo studies. Therefore it has been hypothesized that an intermediate bone remodeling response might play a role in the development of tibial stress fractures. In young adults tibial stress fractures are usually oblique, suggesting that they are the result of failure under shear strain. Strains were measured using surface mounted unstacked 45° rosette strain gauges on the posterior aspect of the flat medial cortex just below the tibial midshaft, in a 48year old male subject while performing vertical jumps, staircase jumps and running up and down stadium stairs. Shear strains approaching 5000 microstrain were recorded during stair jumping and vertical standing jumps. Shear strains above 1250 microstrain were recorded during runs up and down stadium steps. Based on predictions from ex vivo studies, stair and vertical jumping tibial shear strain in the test subject was high enough to potentially produce tibial stress fracture subsequent to repetitive cyclic loading without necessarily requiring an intermediate remodeling response to microdamage.

Cardiovascular and bone health of former elite infantry soldiers at middle life.

BACKGROUND: The long term implications of elite infantry service on cardiovascular health and cortical bone width at middle age has not been studied. The purpose of this study was to compare the cardiovascular health and cortical bone thickness of former elite infantry soldiers at middle life with a sedentary population of religious scholars using seven factors associated with cardiovascular risk and QCT tibial cross sections 8 cm above the ankle joint. RESULTS: Torah scholars had a higher 5 year risk for a fatal or non fatal cardiovascular event (p = 0.008) than former elite infantry soldiers. The former elite infantry soldiers had wider tibia cortices than Torah scholar (p = 0.003). CONCLUSIONS: This study shows that former elite infantry soldiers who performed strenuous physical activity during their military service and continued physical activity in their subsequent life, had stronger tibias based on increased cortical width and a modest decrease in cardiovascular risk at middle life compared to sedentary Torah scholars.

Participation in ball sports may represent a prehabilitation strategy to prevent future stress fractures and promote bone health in young athletes.

Sports participation has many benefits for the young athlete, including improved bone health. However, a subset of athletes may attain suboptimal bone health and be at increased risk for stress fractures. This risk is greater for female than for male athletes. In healthy children, high-impact physical activity has been shown to improve bone health during growth and development. We offer our perspective on the importance of promoting high-impact, multidirectional loading activities, including ball sports, as a method of enhancing bone quality and fracture prevention based on collective research. Ball sports have been associated with greater bone mineral density and enhanced bone geometric properties compared with participation in repetitive, low-impact sports such as distance running or nonimpact sports such as swimming. Runners and infantry who participated in ball sports during childhood were at decreased risk of future stress fractures. Gender-specific differences, including the coexistence of female athlete triad, may negate the benefits of previous ball sports on fracture prevention. Ball sports involve multidirectional loading with high ground reaction forces that may result in stiffer and more fracture-resistant bones. Encouraging young athletes to participate in ball sports may optimize bone health in the setting of adequate nutrition and in female athletes, eumenorrhea. Future research to determine timing, frequency, and type of loading activity could result in a primary prevention program for stress fracture injuries and improved life-long bone health.

The supine apprehension test helps predict the risk of recurrent instability after a first-time anterior shoulder dislocation.

BACKGROUND: We previously identified the positive result of the supine apprehension test after completion of rehabilitation following a first dislocation as a possible predictor of high risk for redislocation. We extend the follow-up of a previous cohort of patients with first-time shoulder dislocations to better assess this test. METHODS: Fifty-three men aged 17 to 27 years who sustained a first traumatic shoulder dislocation were treated by shoulder immobilization for 4 weeks and then rehabilitated with a standard physical therapy protocol. At 6-week follow-up, a supine anterior apprehension test was performed to assess the risk of redislocation. The patients were observed prospectively for a minimum of 75 months. RESULTS: Of the 53 participants, 52 (mean age, 20.2 years) completed the study follow-up. Of the 52 subjects, 41 (79%) were combat soldiers. Follow-up was between 75 and 112 months. Of the 52 subjects, 31 (60%) redislocated at a range of 3 to 70 months after the initial dislocation. Eleven of 14 subjects (79%; confidence interval, 52%-92%) with a positive anterior apprehension test result redislocated, compared with 20 of 38 patients (53%; confidence interval, 37%-68%) with a negative test result. Patients with a positive test result redislocated more and earlier (P = .02, PROC LIFETEST, SAS). CONCLUSIONS: The results of the supine apprehension test after a first shoulder dislocation and rehabilitation can help predict risk for recurrent instability. It potentially may be included as a variable in decision analysis models.

Predicting the stiffness and strength of human femurs with real metastatic tumors.

BACKGROUND: Predicting patient specific risk of fracture in femurs with metastatic tumors and the need for surgical intervention are of major clinical importance. Recent patient-specific high-order finite element methods (p-FEMs) based on CT-scans demonstrated accurate results for healthy femurs, so that their application to metastatic affected femurs is considered herein. METHODS: Radiographs of fresh frozen proximal femur specimens from donors that died of cancer were examined, and seven pairs with metastatic tumor were identified. These were CT-scanned, instrumented by strain-gauges and loaded in stance position at three inclination angles. Finally the femurs were loaded until fracture that usually occurred at the neck. Histopathology was performed to determine whether metastatic tumors are present at fractured surfaces. Following each experiment p-FE models were created based on the CT-scans mimicking the mechanical experiments. The predicted displacements, strains and yield loads were compared to experimental observations. RESULTS: The predicted strains and displacements showed an excellent agreement with the experimental observations with a linear regression slope of 0.95 and a coefficient of regression R(2)=0.967. A good correlation was obtained between the predicted yield load and the experimental observed yield, with a linear regression slope of 0.80 and a coefficient of regression R(2)=0.78. DISCUSSION: CT-based patient-specific p-FE models of femurs with real metastatic tumors were demonstrated to predict the mechanical response very well. A simplified yield criterion based on the computation of principal strains was also demonstrated to predict the yield force in most of the cases, especially for femurs that failed at small loads. In view of the limited capabilities to predict risk of fracture in femurs with metastatic tumors used nowadays, the p-FE methodology validated herein may be very valuable in making clinical decisions.

Achilles tendons hypertrophy in response to high loading training.

BACKGROUND: Whether the human Achilles tendon undergoes hypertrophic changes as measured by an increase in cross-sectional area, in response to endurance training exercise remains in question. We investigated the hypothesis that transition from civilian life through 6 months of elite infantry training would induce adaptive Achilles tendon hypertrophy. METHODS: Seventy-two new elite infantry recruits had the cross-sectional area of their Achilles tendons measured at a point 2.5 cm proximal to the Achilles insertion by ultrasound before beginning elite infantry training. Measurements were repeated by the same ultrasonographer for those recruits who were still in the training program at 6 months. Prior to beginning the study the intraobserver reliability of the ultrasonographer's Achilles tendon measurements was calculated (intraclass correlation coefficient = .96). Fifty-five recruits completed 6 months of training. RESULTS: The mean cross-sectional area of their right Achilles tendon increased from 47.0 ± 11.2 to 50.2 ± 9.6 mm(2) (P = .037) and the left Achilles tendon from 47.2 ± 8.9 to 51.1 ± 8.3 mm(2) (P = .013). The change in cross-sectional area did not correlate with subject height, weight, prior sport history, or jumping and running abilities. CONCLUSIONS: An abrupt stimulus of 6 months of elite infantry training was adequate to induce hypertrophic changes in the Achilles tendon. This is the first human prospective study showing an increase in the Achilles tendon cross-sectional area in response to rigorous endurance type training. The finding supports the hypothesis that the Achilles tendon in response to sufficiently high and sustained loading can remodel its morphological properties and thereby strengthen itself. LEVEL OF EVIDENCE: Level II, etiology study.

Evaluation of the performance of females as light infantry soldiers.

A few countries permit women to serve in combat roles, but their long term performance in these positions has not been reported. The incidences of overuse injuries and attrition of 85 male and 235 female recruits in a light infantry brigade was followed in a three-year prospective study. Females were shorter (162 cm, CI 161-163 cm) than males (174 cm, CI 173-176), had more body fat (18.9 kg, CI 18.2-19.6 kg) than males (12.6 kg, 11.3-13.8 kg), had lower [Formula: see text]O2max (36.8 mL·min(-1) ·kg(-1), CI 35.8-37.78 mL·min(-1) ·kg(-1)) than males (50.48 mL·min(-1) ·kg(-1), CI 48.4 to 52.48 mL·min(-1) ·kg(-1)), had more stress fractures (21.0%, 95% CI 16.2-26.5%) than males (2.3%, CI 0.3-8.2%), and had more anterior knee pain (41.2%, CI 34.9-47.7%) than males (24.7%, CI 16.0-35.2%). Three-year attrition was 28% CI 22-34% for females and 37% CI 26-48% for males. The females in this study successfully served as light infantry soldiers. Their lower fitness and high incidence of overuse injuries might impede service as regular infantry soldiers.

Patient-specific FE analyses of metatarsal bones with inhomogeneous isotropic material properties.

The mechanical response of human metatarsal bones is of importance in both research and clinical practice, especially when associated with the correction of Hallux Valgus. Verified and validated patient-specific finite-element analysis (FEA) based on CT scans developed for human femurs are extended here to the first and second metatarsal bones. Two fresh-frozen metatarsal #1 and five metatarsal #2 bones from three donors were loaded in-vitro at three different angles. Holes typical to Hallux Valgus correction were then drilled in the bones, which were reloaded until fracture. In parallel, high-order FE models of the bones were created from CT-scans that mimic the experimental setting. We validated the FE results by comparison to experimental observations. Excellent agreement was obtained with R(2)=0.97 and slope of the regression line close to 1. We also compared the FE predicted fracture load and location for the second metatarsal bones with these measured in the experiment, demonstrating an excellent prediction within 10% difference. After validation of the FE predictions, they were used to investigate the effect of drilled hole position, dimension and the insertion of a metallic device on the mechanical response so to optimize the outcome of the Hallux Valgus correction. This study further substantiates the potential use of FEA in clinical practice.

Comparison of knee SPECT and MRI in evaluating meniscus injuries in soldiers.

BACKGROUND: Medical evaluation of a suspected meniscus injury begins with a history-taking and physical examination. Suspected meniscus injuries not responding to treatment are usually sent for imaging to confirm the diagnosis before arthroscopy. Tc-MDP bone single photon emission computed tomography (SPECT) scan has been suggested as an alternative to magnetic resonance imaging (MRI) in evaluating suspected knee meniscus tears. OBJECTIVES: To examine the accuracy of knee SPECT as a tool to identify meniscus tears versus that of MRI as compared to the gold standard of arthroscopy. METHODS: The Israel Defense Forces database for 2005 through 2009 was searched using the key words: knee MRI, knee SPECT and knee arthroscopy. We identified 330 subjects who had undergone both a single knee SPECT and a single knee MRI prior to knee surgery. The medical files of 193 of the 330 subjects were randomly selected for review. A comparison was made between the preoperative SPECT and MRI studies and the arthroscopic finding. The sensitivity, specificity and accuracy were calculated. RESULTS: The subjects' age was 21.3 ± 3.9. The agreement between SPECT and arthroscopy was 0.14 forthe medial meniscus and 0.29 for the lateral meniscus. The agreement between MRI and arthroscopy was 0.59 for the medial meniscus and 0.69 for the lateral meniscus. SPECT scan was found to be 61% sensitive, 54% specific and 58% accurate in detecting common knee pathology, whereas MRI was found to be 95% sensitive, 67% specific and 85% accurate. CONCLUSIONS: Knee SPECT has a lower sensitivity, specificity and accuracy than MRI in evaluating meniscal injuries and its use can result in increased unnecessary surgery.

The case for orthopaedic medicine in Israel.

BACKGROUND: Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists. METHODS: In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel's large non-profit HMO's, and the domains of the visits to an orthopaedic surgeon. RESULTS: Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO's. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training. DISCUSSION: While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the "Orthopaedic Medicine Lacuna" is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.