[The use of antibiotic prophylaxis prior to dental procedures for the prevention of prosthetic joint infection].

Prosthetic joint infection (PJI) is a severe illness which may cause pain and discomfort, may damage the quality of life and may even be life-threatening. A variety of studies have demonstrated the presence of bacteria in a small but potentially dangerous number of prosthetic joint infections that may have originated in the oral cavity. Some dental treatments such as calculus removal, extractions, dental implants placements etc. and daily oral hygiene routines such as tooth brushing may cause bacteremia. Recently the American Academy of Orthopaedic Surgeons (AAOS) published updated guidelines for antibiotic prophylaxis to prevent prosthetic joint infections. These guidelines suggest a direct and established connection between dental treatments and prosthetic joint infections, and expand the criteria to prescribe antibiotic prophylaxis prior to dental procedures associated with bacteremia. The purpose of this review is to introduce these new guidelines, and to review the literature regarding the relationship between dental care and prosthetic joint infections.

Synovial osteochondromatosis of the shoulder joint.

A case of synovial osteochondromatosis in a synovial recess of the shoulder joint, which is considered to be a very rare condition, is presented. Different clinical and pathologic aspects of this condition are reviewed and discussed. Treatment consists of a surgical removal of the free loose osteocartilaginous bodies with a partial excision of the affected synovia. The condition did not recur.

Acute rupture of the lateral ligaments of the ankle joint, diagnosis and surgical treatment.

A useful method for the diagnosis of acute rupture of the lateral ligament of the ankle joint is presented. Twenty-three patients with ruptures of the lateral ligament of the ankle joint were treated surgically with suture of the lateral ligaments of the ankle. Accurate preoperative diagnosis with stress films and arthrography under local anesthesia of the ankle joint is imperative. No instances of infection or other complications were observed. All patients achieved a normal range of ankle function within three to six months. Radiograhs of the injured ankle in the forced inversion position following operation showed full stability of the ankle joint. In our opinion, all ankle injuries should be examined roentgenographically with forced inversion of the foot. Tilting of the talus of at least 10 degrees must be followed by arthrography of the ankle joint under local anesthesia. If there is leakage of contrast material along the peroneal tendon sheaths and around the joint cavity, the lateral ligament of the ankle must be sutured immediately in order to regain stability of the ankle joint.

Complete displacement of the femoral stem during dislocation of a THR.

We report an unusual complication of late dislocation of a total hip replacement. The femoral stem had completely migrated from the shaft. The insertion of a new long-stem prosthesis was successful.

Degenerative arthritis after intra-articular fractures of the knee. Long-term results.

We reviewed 31 of 33 consecutive patients with intra-articular fractures of the knee at 6 to 22 years (average 14). Of these, 77% had excellent or good results; the others had various degrees of degenerative osteoarthritis. There was no significant difference between the results after surgical or conservative treatment. Secondary degeneration was not related to cause or type of fracture, but its incidence increased with the patient's age at the time of injury, though not with the length of follow-up. Early mobilisation appeared to be beneficial in preventing later degenerative changes.

Distribution of alkaline phosphatase activity in experimentally produced callus in rats.

Experimentally produced fractures in long bones studied by light and electron microscopic histochemistry were found to heal by a process of enchondral calcification. There was intense proliferation in the cells of the cambium layer of the periosteum, with differentiation to chondroblasts and osteoblasts, suggesting that this layer was the primary tissue responsible for development of the callus. Cytoplasmic processes of the hypertrophic chondrocytes appeared to bud and produce matrix vesicles. Alkaline phosphatase activity was detected along the plasma membrane of the hypertrophic chondrocytes and around the matrix vesicles, before any signs of mineral deposition. Calcification took place by deposition of hydroxyapatite crystals in and around these matrix vesicles which frequently showed alkaline phosphatase activity. It is suggested that there is a close functional association between alkaline phosphatase activity and calcification in the process of fracture healing, which is another type of enchondral calcification mediated by matrix vesicles.

Muscle recovery after immobilisation by external fixation.

We immobilised the right hindlimbs of six-month-old female Wistar rats for four weeks using a biplanar external fixation bridging the knee. The untreated left limbs served as a control group. An additional group of rats was allowed to recover for four weeks after removal of the frame. Immobilisation caused reduction in the wet weights of approximately 50% in the gastrocnemius, quadriceps, soleus and plantaris muscles; this was not restored completely after remobilisation. There was an increase in the activity of acid phosphatase of approximately 85% in the gastrocnemius and quadriceps muscles whereas that of creatine phosphokinase was reduced by about 40%. These values returned to nearly normal after remobilisation. Histological and ultrastructural examination showed a marked myopathy of the gastrocnemius muscle after immobilisation although the morphology was largely restored after remobilisation. We conclude that after four weeks of remobilisation, hind-limb muscles do not return to preimmobilisation weights, although biochemical activities and ultrastructural appearance are largely restored.

Complete infraclavicular brachial plexus palsy with occlusion of axillary vessels following anterior dislocation of the shoulder joint.

Two cases of complete infraclavicular brachial plexus palsy after anterior dislocation of the shoulder joint are reported. Both patients had transient motor brachial plexus paralysis and extensive anesthesia of the whole upper limb. Additionally, one of them had occlusion of the axillary vessels. Vascular recovery occurred immediately after manipulation and reduction of the affected shoulder joint. Neurological recovery occurred 9 to 12 months later in both cases without surgery, other than closed reductions. Such neurological and vascular complications after anterior dislocation of the shoulder joint are unique.

Stress fractures of the femoral neck following strenuous activity.

Stress fractures of the femoral neck following sustained strenuous physical activity are uncommon. In 194 military recruits in elite basic training who had sustained 257 stress fractures, most of them in long bone diaphyses, nine such fractures were located in the femoral neck. Seven of these fractures were transverse and undisplaced, and were treated successfully by bed rest and non-weight bearing for 6-8 weeks. The other two fractures displaced into a varus position. One of them was treated successfully by manipulation and plaster of paris spica immobilization. Solid union of the fracture followed within 3 months. The second displaced fracture was treated by two successive procedures of internal fixation because it did not unite after the first intervention and slipped again into varus position. It is therefore suggested that unstable stress fractures of the femoral neck should be initially operated on and stabilized by rigid internal fixation, in order to avoid displacement and severe disability.

Cytological diagnosis of primary leiomyosarcoma of bone: case report.

We report on a case of primary leiomyosarcoma of the bone in a 77-yr-old man. The patient presented with a painful, enlarging mass in the left shoulder of 6 mo duration. Radiography and computed tomography (CT) revealed a large destructive intramedullary lesion of the proximal humerus, with massive extension into the surrounding soft tissues. CT-guided fine-needle aspiration biopsies (FNAB) of both the bony and soft-tissue lesions were performed. Cytological examination showed a neoplastic process composed of spindle cells mixed with pleomorphic cells. The smooth muscle origin of the neoplastic cells was confirmed by immunocytochemical analysis. We describe the cytological features of this rare primary tumor of bone, and consider the differential diagnosis of spindle-cell neoplasms.

Osteomyelitis of the femoral neck caused by a pencil stab wound.

A unique case of osteomyelitis of the femoral neck of an eleven-year-old boy, following a stab wound by a lead pencil, with reactive synovitis of the hip joint is presented. The clinical course simulated that of acute septic arthritis and was diagnosed by various imaging modalities. Following operation and systemic antibiotic treatment, the patient improved dramatically. The role of sonography in the presence of inflammatory conditions around the hip joint is emphasized.

Hand infections due to non-cholera Vibrio after injuries from St Peter's fish (Tilapia zillii).

We report 49 patients with a wide variety of hand infections, which developed after injuries from St Peter's fish (Tilapia zillii). Twenty-eight of 36 patients who had been operated on had non-cholera Vibrio infections, all identified as Vibrio vulnificus. The course in these patients was characterized by rapid spread of the infection with progressive necrosis of the tendon sheath, subcutaneous tissues and the skin. Two of them required amputations but the others had satisfactory functional results. Thirteen other patients were managed nonoperatively with intravenous antibiotics and all of them recovered completely.

Anterior interosseous nerve palsy associated with Galeazzi fracture.

Galeazzi fracture is more common in adults than in children. Associated neurologic deficits are rare and easily missed at the first clinical examination. The authors describe a case of anterior interosseous nerve palsy after closed Galeazzi fracture. Conservative treatment resulted in complete return of normal nerve function, suggesting that this is a neurapraxia type of injury.

Lower limb pain and disability following strenuous activity.

One hundred five military recruits were evaluated in our outpatient clinic for pain in the lower limb following prolonged sustained physical effort and strain. Plain x-ray investigations augmented by technetium-99m polyphosphate demonstrated the presence of 80 stress fractures in 52.4% of the patients. None of the patients had any anatomical abnormalities of the lower limbs. Of the stress fractures seen, 82.5% were located in the tibial and femoral diaphyses and 16.2% were in the small bones of the foot. Plain radiography gave false negative results in 87.3% of documented fractures. The remaining 47.6% of these recruits had no evidence of stress fractures. However, 74% of them had various anatomical deformities of the lower limb, mainly of the feet. Correction of these deformities enabled these patients to return to previous strenuous activities of their basic military training. The pathogenesis of stress fractures is still not understood. However, the development of persistent pain in the lower limb following prolonged sustained intensive physical activity needs further investigation. Anatomical deformities may be associated with development of stress fractures.

[Impingement syndrome following direct injuries of the shoulder joint].

Impingement is the most common cause of pain and limitation of movement in the shoulder, with painful arc syndrome its major clinical sign. It usually becomes manifest at between 70 degrees-120 degrees of abduction, but in severe cases, this may be reduced to only 50 degrees-70 degrees. We studied 22 patients who had developed shoulder impingement following direct injuries and who had been treated by anterior acromioplasty and decompression, with an average follow-up of 32 months. 5 had sustained fractures of the greater tuberosity of the humerus at the time of injury, 14 had tears of the rotator cuff of various sizes (1 in both shoulders) and 3 had developed fibrotic scars of the subacromial bursa. Excellent or good results were achieved in 86.6%. Healing time was shorter, and there was return of full range of shoulder movement in those with subacromial scars, undisplaced fractures of the greater tuberosity, or those with a small tear of the rotator cuff. Recovery took longer in those with larger tears of the rotator cuff and in those with displaced fractures of the greater tuberosity. Recovery time was proportional to the size of the rotator cuff tear. It is concluded that direct trauma to the shoulder bears a direct relationship to the development of impingement syndrome, and that at surgery a concomitant tear in the rotator cuff is seen more than 2/3. Because of the high rate of success in surgical treatment of this syndrome, operation is indicated when a few months of physical therapy and analgesics fail to provide relief. In the presence of fractures, decompression surgery should be postponed until the fracture has united.

[Conservative therapy in carpal tunnel syndrome].

A prospective study was designed to determine which patients with carpal tunnel would respond to conservative therapy (splinting and local injection of corticosteroids). The study included 50 hands of 34 patients, aged 25-80 years, with a mean follow-up of 18 months. Conservative therapy was effective in 82% of hands after 8 weeks, but symptoms subsequently recurred, so that by the end of a year only 20% remained asymptomatic. Failure of conservative therapy was predicted by long duration of symptoms, older age, permanent paresthesia, 2-point discrimination threshold above 6 mm, positive Phalen test within 30 seconds, and long motor and sensory distal latency.

[Nerve palsies in a soldier with penetrating injuries following prolonged use of limb tourniquets].

Nerve paralysis following the use of tourniquets, regular or pneumatic, for limb surgery is rare. We describe a 19-year-old male soldier who had tourniquets applied for 3 1/4 hours to his arm and both legs due to penetrating injuries. As a result, he suffered palsy of the radial nerve and both common peroneal nerves. Nerve palsy in such cases has not been described in the literature. It is not clear whether the cause is direct mechanical pressure on the nerve, nerve ischemia, or a combination of both. We recommend that tourniquets should not be used continuously for more than 2 hours. If evacuation of the injured is delayed, the medical team should consider loosening tourniquets for short intervals or changing for a pressure bandage. This is providing the patient's condition is stable and bleeding does not start again on release of the tourniquet.

[Injury from fireworks and firecrackers during holidays].

BACKGROUND: Every year during the holidays of the Arab and Druze population, and especially during Id el-Adha, scores of injured from firecrackers, crackers, skyrockets and other homemade explosive devices arrive at the Western Galilee Hospital. Similar casualties present during the Jewish Purim Festival. OBJECTIVES: To characterize the population of the injured and to analyze various aspects of this kind of accidents, in order to reduce injury and minimize disability. METHODS: A retrospective survey of records of all injured from firecrackers and similar devices during holidays that arrived at our hospital between 1999 and 2003 was conducted. Between 2001 and 2002 the trauma team, in cooperation with the local leadership, directed an education and information campaign in the community, in an attempt to reduce these injuries. RESULTS: During the study period, a decrease in the rate of injury was observed, which in the year 2003, reached a level of 50% of the 1999 figures. Of the injured, 53% were children (< or = 15 years old), 93% were Arab or Druze, and 93% were males. The rate of injuries from fireworks in 2003 was significantly lower than the mean rate of the years 1999, 2001, 2002 (p=0.045). The major cause of injury was firecrackers (67%) followed by fireworks (21%). Major injuries were to the extremities (58%), followed by facial and eye trauma (24%) and burns (11%). Of the casualties, 54% were lightly injured, 46% were hospitalized, 24% required surgical intervention and 7% lost fingers. Two individuals lost eyesight in one eye, but no fatalities occurred. CONCLUSIONS: The reduced rate of injury from fireworks and similar devices can be attributed to two major reasons: intervention by the trauma team and enforcement by the police and the Ministry of Trade and Industry. We recommend conducting a combined campaign of education and parental guidance with the involvement of community leaders and local media, and to increase law-enforcement. The organization of central firework displays in each community during this holiday should be considered.

[Ilizarov reconstructive surgery--a solution for complex problems of the musculoskeletal system].

The Ilizarov technique is an important modality of reconstructive surgery for limb deformities, such as malunion and nonunion of fractures, persistent osteomyelitis, and bone loss following complex limb injuries, as well as in limb-lengthening procedures. It has received wide recognition in the Western world over the past decade. In MEDLINE we found 537 articles published between 1971-1995 that describe the use of this technique. Of these, only 18 were published between 1971-1975, while 261 were published between 1991-1995. The present paper describes the developments and updates in this method, as a result of the large experience gained by the authors in a number of centers in Israel using this technique. The Ilizarov apparatus is a circular frame that allows accurate control, much more than any other external fixator, during correction of limb deformities and limb-lengthening. It is minimally invasive, and open techniques and use of internal hardware and bone grafts are not needed. Based on our experience, we suggest that this method requires careful preoperative planning and meticulous surgical technique. More important, cooperation between surgeon and patient throughout the lengthy treatment is a prerequisite to ensure complete success, even in the most complicated cases.

Results of early and delayed surgical fixation of hip fractures in the elderly: a comparative retrospective study.

The postoperative course of 555 elderly patients with fractures of the femoral neck was reviewed. Of these, 89% were surgically treated within 24 hours following injury and the remaining within 2-7 days. The postoperative results of patients who underwent reconstructive surgery within 24 hours were significantly better than of those treated later. The overall immediate postoperative mortality in these surgically treated patients was 1.6%, whereas in 56 patients who were treated conservatively the mortality rate was 8.9%. This markedly low mortality was observed in spite of a high percentage of associated diseases in 71.2% of the surgically treated patients. These findings suggest that whenever possible, immediate or early reconstructive surgery of femoral neck fractures in the elderly is the preferred treatment of choice. Early surgical intervention should be pursued and performed following immediate medical evaluation, even in the presence of multiple associated diseases. The contraindication to surgical treatment must be well defined and kept to a bare minimum, since conservative treatment appears to bear a high mortality risk in geriatric patients.