Israeli Female Physicians' Motives for Choosing Orthopedics as Their Specialty Choice.

BACKGROUND: Orthopedics is not a popular field of specialization among female medical students. Therefore, the purpose of the study was to examine factors related to women's choice of orthopedics as their field of specialty, compared to those who chose other fields. METHODS: In this cross-sectional survey, 149 female medical residents from Israel-33 specializing in orthopedics and 116 in other fields-completed a questionnaire. A comparison was held between the two groups. RESULTS: Orthopedic residents were more likely to have received clinical training in this field during their medical studies and were more likely to have expressed a desire to specialize in orthopedics before and at the completion of their studies. In addition, orthopedic residents ascribed greater importance to job security when choosing a field of specialty and, in contrast, ascribed no importance at all to lifestyle. No difference was found between the two groups in their level of dissatisfaction as a result of their residency. However, orthopedic residents were more inclined to perceive gender discrimination in the field of orthopedics but, despite this, had a greater intention to recommend a residency in orthopedics. A negative association was found between the level of dissatisfaction as a result of the residency and intention to recommend a residency in orthopedics. CONCLUSIONS: Differences between the two groups point to potential factors that might have been related to women's choice of orthopedics as their field of specialty. The findings may help form strategies for attracting women to specialize in orthopedics.

Should I Ask Doctor Google? Reliability of Israeli Web-based Information Regarding General Orthopedic Injuries and Symptoms.

BACKGROUND: Websites serve as a source of medical information for a large part of the public, some claim to be a substitute for a physician's consultation. Many patients meet a physician after conducting internet research. Medical staff are concerned that internet sources of information are unreliable and may lead to erroneous decisions by patients. OBJECTIVES: To examine the reliability of web-based sources of information (through the Google™ search engine) regarding five common orthopedic complaints and injuries. METHODS: We performed a search of five common orthopedic complaints and injuries using the Google search engine. The reliability of web-based information was measured by the DISCERN tool, which is a valid and verified tool for examining the reliability of medical information sources to the public. The reliability of 47 websites was examined by two orthopedic surgeons and two senior residents. RESULTS: The overall average score given to the sites was 2.8, on a scale of 1 to 5. We found that the higher the site appeared in the search results, the higher the quality of its information. Commercial sites scored higher than general internet information sources. CONCLUSIONS: The internet network is a very broad source of information. For those who lack scientific education and training it is not easy to distinguish between reliable and unreliable or biased sources. The trend of searching for medical information and self-healing is increasing. We must strengthen the network with reliable sources by creating official scientific position papers by medical teams and promoting them online.

Injury and Sociodemographic Characteristics of Intimate Partner Violence in Women in Israel: A Single-Center Retrospective Cohort Study.

BACKGROUND: Intimate partner violence is a growing public health concern worldwide, and nurses are uniquely positioned to help identify and refer patients for services. Yet, intimate partner violence injury patterns and characteristics often go unrecognized. OBJECTIVE: The purpose of this study is to explore injury and sociodemographic characteristics associated with intimate partner violence in women presenting to a single emergency department in Israel. METHODS: This retrospective cohort study analyzed medical records of married women injured by their spouse who presented to a single emergency department in Israel from January 1, 2016, to August 31, 2020. RESULTS: In total, 145 cases were included, of which 110 (76%) were Arab and 35 (24%) were Jewish, with a mean age of 40. Patients' injury patterns consisted of contusions, hematomas, and lacerations to the head, face, or upper extremities, not requiring hospitalization, and having a history of emergency department visits in the past 5 years. CONCLUSION: Identifying intimate partner violence characteristics and patterns of injury will help nurses identify, initiate treatment, and report suspected abuse.

Association Between Type of Face Mask and Visual Analog Scale Scores During Pain Assessment.

AIMS: To examine the association between the type of mask worn by health care professionals and assessment of pain intensity in patients after orthopedic surgery using the visual analog scale (VAS). DESIGN: A nonrandomized controlled trial conducted among 176 patients hospitalized in an orthopedic department of a hospital located in northern-central Israel from January to March 2021. METHODS: In the intervention group (n = 83), pain assessment using the VAS was performed by a health care professional wearing a transparent face mask, while in the control group (n = 93), pain assessment was performed by a health care professional wearing a standard nontransparent face mask. The initial assessment was performed by a nurse, and 15 minutes later, an additional assessment was performed by a physician. RESULTS: Health care professionals wearing a standard non-transparent mask obtained higher VAS scores than health care professionals wearing a transparent mask. In addition, nurses obtained lower VAS scores than physicians. The discrepancy in VAS scores between nurses and physicians was found in 50% of cases. This discrepancy was more prevalent among female patients, patients after knee replacement or spinal surgery, and when health care professionals were wearing a standard nontransparent mask. CONCLUSIONS: This study supports the use of transparent face masks by health care professionals in an orthopedic department, particularly by nurses. In addition, this study supports the assumption of problems involving the reliability of VAS.

[REGENERATIVE MEDICINE IN ORTHOPEDICS - UPDATES AND COMMON USES].

INTRODUCTION: Regenerative medicine is a medical field that aims to heal, rehabilitate, repair, and facilitate the regeneration of diseased and damaged cells, tissues and organs. Regenerative medicine is based on mobilizing the body's self-healing abilities. The use of regenerative medicine to treat various musculoskeletal conditions is an evolving field within orthopedics and sports medicine called 'ortho-biology' or 'ortho-regenerative medicine'. There are currently well-founded findings regarding the safety of ortho-biological treatments, their manner of action, effect, and potential effectiveness. However, there is need for more controlled studies with strong scientific proof in order to better understand the potential of these treatments and how to best use them.

Hip Fracture Following a Fall among Older Adults during the COVID-19 Pandemic.

BACKGROUND: Little is known regarding the impact of the coronavirus disease-2019 (COVID-19) pandemic on the incidence of hip fractures among older adults. OBJECTIVES: To compare the characteristics of patients with a hip fracture following a fall during the COVID-19 pandemic year and during the preceding year. METHODS: We conducted a retrospective cohort study of older patients who had undergone surgery for hip fracture repair in a major 495-bed hospital located in northern central Israel following a fall. Characteristics of patients who had been hospitalized in 2020 (pandemic year, n=136) and in 2019 (non-pandemic year, n=151) were compared. RESULTS: During the pandemic year, patients were less likely to have fallen in a nursing facility, to have had muscle or balance problems, and to have had a history of falls and fractures following a fall. Moreover, the average length of stay (LOS) in the hospital was shorter; however, the average time from the injury to hospitalization was longer. Patients were less likely to have acquired a postoperative infection or to have died. During the pandemic year, postoperative infection was only associated with prolonged LOS. CONCLUSIONS: The COVID-19 pandemic may have had a positive impact on the behavior of older adults as well as on the management of hip fracture patients. However, healthcare providers should be aware of the possible reluctance to seek care during a pandemic. Moreover, further research on the impact of the change in management during COVID-19 on hip fracture survival is warranted.

Assessment of Functional Conservative Treatment of Acute Complete Achilles Tendon Rupture.

BACKGROUND: In recent years, treatment for Achilles tendon rupture (ATR) went through radical changes: from the conservative non-weight bearing approach to a functional protocol. This functional protocol allows complete weight bearing after only 2 weeks by placing the foot in a plastic boot in tapered down equines and using interchangeable wedges under the heel. This change of approach has dramatically lowered the rate of re-rupture. OBJECTIVES: To describe our preliminary results with this functional protocol and to assess outcome measures in the functional conservative treatment. METHODS: The study comprised 15 people who were evaluated clinically and by sonograph. We measured calf circumference, ankle joint range of motion (ROM), and single-leg heel-rise test (SLHRT). In addition, standard scoring methods (Achilles Tendon Rupture Score and Physical Activity Scale) were examined. RESULTS: In our cohort 14 people successfully gained SLHRT. The mean Achilles Tendon Rupture Score functional questionnaire and Physical Activity Scale physical activity questionnaire score was 85.6 of 100, and 4.7 of 6, respectively. There were no significant differences in ankle ROM compared to the uninjured limb. There was statistically significant reduction in the calf circumference and soleus muscle thickness sonographically. CONCLUSIONS: It seems that the conservative functional treatment of ATR demonstrates good functional outcomes, with the patients returning to close to normal activity, although noted muscle wasting and weakness. This protocol presents a true alternative to surgery and should be considered for most non-insertional Achilles tendon tears.

Retrospective study of older patient characteristics that increase the likelihood that a fracture was associated with abuse.

Searching for clinical manifestations of elder abuse may help healthcare professionals identify cases of elder abuse. The aim of the present study was to explore characteristics of older patients with fractures that increase the likelihood that the fracture was associated with abuse. This is a retrospective chart review study of 1,000 patients aged 65 and older who presented to an emergency department in northern-central Israel with a fracture during 2019. The chart review included participant characteristics - sociodemographic data, medical data, data regarding the fracture, and data on the presence of forensic markers of elder abuse in individual patients. Descriptive statistics and regression models were used for the analyses. Older age, presence of dementia, and hand and facial fractures were associated with the presence of forensic markers, and were also found to predict having at least one forensic factor. This study provides further support for the creation of clinical guidelines for identification of elder abuse.

[ANTERIOR APPROACH FOR TOTAL HIP ARTHROPLASTY - THE PREFERRED APPROACH OR A PASSING TREND?]

INTRODUCTION: Both the direct and anterior approach (DAA) for total hip replacement (THR) surgery have gained much popularity in recent years. The suggested benefits of the muscle-sparing and nerve-sparing approach which could lead to a faster and easier recovery process, have led to an increase in the prevalence of the anterior approach in THR. These potential benefits have drawn the attention of both orthopaedic surgeons as well as patients as a faster return to their active lifestyle. While the potential advantages and benefits of the DAA for THR are obvious, several disadvantages have been highlighted over the years including technical pitfalls, a relatively long and steep learning curve and characteristic associated complications. In addition, while there has been a surge in published research involving the DAA in recent years, significant differences in terms of clinical outcomes in the mid and long term have not been evident. The current editorial explores the increasing popularity and utilization of the DAA in THR procedures and the various factors influencing it.

[ROBOTIC TOTAL KNEE ARTHROPLASTY].

INTRODUCTION: Total Knee Arthroplasty (TKA) is one of the most common operations performed in the orthopaedic surgery field. TKA is usually performed as a result of primary osteoarthritis which causes pain and a major decrease in the patient's quality of life. TKA is considered a successful operation with a success rate of 80-85%. In recent years, orthopaedic surgeons have started to perform robotic assisted TKA. In Israel, these operations have been performed since 2019. In this article we reviewed this topic and the latest clinical data comparing a conventional TKA and robotic assisted TKA. In the world, there are several robotic systems in use. Four systems are in use in Israel. The robotic system assists in the pre-operative and intra-operative planning, in order to perform precise cuts of the femur and tibia. The precision helps to achieve better soft tissue balance reconstruction of the lower limb axis. While robotic surgery performed in Israel has been rising since the technology came into use in 2019, the clinical data are not showing a significant advantage to either one of the operations. Recent studies have shown evidence of better imaging results in the robotic-assisted operation, however, the clinical benefits are still in doubt, due to the lack of large and long-term studies.

Hardware Removal and Conversion Hip Arthroplasty via a Single Interval Anterior Approach: Surgical Technique.

The supine 'off-table' anterior-based muscle-sparing (ABMS) approach is an established approach for primary total hip arthroplasty. The approach is performed with the patient positioned supine on a regular operating room table. It combines utilizing the Watson-Jones interval (without disrupting the abductor muscles) with principles of capsular management borrowed from the direct anterior approach. The approach may also be utilized for complex primary and revision hip arthroplasties. One clinical scenario the ABMS approach may be particularly well-suited to is conversion hip arthroplasty when retained hardware requires removal. The approach enables the surgeon to remove proximal femoral hardware and perform hip arthroplasty within the same muscle interval. This is in contrast to direct anterior approach, which entails separate windows being created on either side of the tensor fascia lata muscle to remove hardware and insert hip arthroplasty components, respectively. In this article, we describe our surgical technique for performing conversion total hip arthroplasty with hardware removal (sliding hip screw and plate in the discussed case) via a single interval with the supine off-table ABMS approach.

Combined Effect of Seasonality and Hyponatremia on the Occurrence of Hip Fractures Among Older Adults.

Background: It is unclear whether climate may play a role in the association between hyponatremia on admission and increased mortality risk among hip fracture patients following a hip fracture repair surgery. We aimed (1) to explore if there is any combined effect of seasonality and hyponatremia on the occurrence of hip fractures among older adults and (2) to explore the effect of hyponatremia on admission on mortality rate at latest follow-up among hip fracture patients following a hip fracture repair surgery in the context of the subtropical climate of Israel. Methods: We conducted a retrospective cohort study of older patients who underwent a surgery for hip fracture repair in a major 495-bed hospital located in northern-central Israel in 2017-2020. Patients were divided into two groups: hyponatremic (n = 107) and normonatremic (n = 757) patients. Characteristics of the two groups were compared, as well as their survival probability. Results: Hyponatremic patients were most frequently hospitalized during winter season. Such seasonal variation was observed only among hyponatremic patients. Moreover, patients who were hospitalized during winter season were more likely to be hyponatremic on admission. Hyponatremia on admission was found as a significant independent predictor of mortality rate at latest follow-up (adjusted hazard ratio = 0.377 [0.26-0.52]), when compared to normonatremia. Conclusion: There is a combined effect of seasonality and hyponatremia on the occurrence of hip fractures among older adults, with hyponatremic patients being at a higher risk of sustaining a hip fracture during winter season than during other seasons. In addition, the association between hyponatremia on admission and mortality rate at latest follow-up among hip fracture patients has been confirmed.

Awareness, Knowledge, and Screening for Intimate Partner Violence Among Orthopedic Surgeons in Israel.

This study examines factors associated with screening of female patients for intimate partner violence (IPV) by orthosurgeons in a sample of 100 Israeli orthosurgeons. Findings reveal positive attitudes toward screening female patients but a significant lack of knowledge. Arab orthosurgeons held slightly more negative attitudes toward screening for IPV and had a more prominent lack of knowledge regarding screening for IPV, compared to their Jewish counterparts. Nationality and feeling uncomfortable asking female patients about IPV predicted screening for IPV. The importance of training orthosurgeons on the assessment and treatment of IPV cannot be overemphasized, especially among Arab orthosurgeons.

Reasons for Surgical Delay in Patients With Hip Fracture.

INTRODUCTION: 15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery. METHODS: A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019-2020. Characteristics of patients with early surgery ( n = 40) and patients with delayed surgery ( n = 241) were compared. RESULTS: Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common ( n = 8, 20%). Unavailable operating rooms were another common reason for delays ( n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%). CONCLUSIONS: It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay.

Knowledge, attitudes, detection, and reporting practices of elder abuse among orthopedists.

PURPOSE: The purpose of the present study is to explore orthopedists' level of knowledge regarding laws and directives related to the detection and reporting of elder abuse, their attitudes towards the detection and reporting of elder abuse, detection and reporting practices, and the associations between these variables. METHODS: In this cross-sectional study, 145 orthopedists employed in various Israeli hospitals-senior orthopedists, orthopedic residents, and orthopedic interns-completed a questionnaire. RESULTS: The orthopedists had a medium level of knowledge and held positive attitudes on the detection and reporting of elder abuse, but the actual number of cases they detected and reported was low. Senior orthopedists had the highest level of knowledge and also the most positive attitudes, followed by orthopedic residents, and then orthopedic interns. Common reasons for unwillingness to report cases of elder abuse differed between levels of training. A minority of the orthopedists had received training on the detection and management of elder abuse. Higher knowledge and more positive attitudes were found associated with a higher number of detected and reported cases of elder abuse. CONCLUSIONS: The importance of training orthopedists on the detection and management of elder abuse cannot be overemphasized. It seems that orthopedists should receive such training early in their career. LEVEL OF EVIDENCE: IV.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020.

PURPOSE: Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs. METHODS: This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis. RESULTS: During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed. CONCLUSIONS: Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

Health care professionals' knowledge of commonly used sedative, analgesic and neuromuscular drugs: A single center (Rambam Health Care Campus), prospective, observational survey.

BACKGROUND: Pain management and sedation are important aspects in the treatment of hospitalized patients, especially those mechanically ventilated. In many hospitals, such patients are treated not only in intensive care units, but also in other wards. In the nineteen eighties, numerous studies demonstrated a wide array of misconceptions and inadequate knowledge related to commonly used sedative, analgesics and muscle relaxants which may prevent appropriate treatment. Since these publications, multiple studies have shown that appropriate sedation and analgesia are associated with improved clinical outcomes, educational programs were developed and guidelines published. Whether the personnel's knowledge kept up with these changes is unknown. The aim of this study was to determine the current rate of misconceptions and knowledge gaps regarding commonly used sedative, analgesic and neuromuscular drugs. METHODS: In this prospective, observational, cross-sectional survey, a questionnaire was e-mailed to physicians and nurses routinely treating mechanically ventilated patients in Rambam Health Care Campus (Haifa, Israel). RESULTS: 355 questionnaires were returned. 82.54% knew that midazolam has no analgesic effect. 71-72% were familiar with the sedative effect of opiates. 27% believed that propofol has analgesic properties and 30.52% thought that rocuronium has a sedative effect. CONCLUSION: Our findings demonstrate that although a lot has been done during the last decades in order to improve the treatment of critically ill patients, the rate of misconceptions regarding pharmacological characteristics of commonly used drugs is unacceptably high. We call for performance of similar surveys in other institutes and for immediate action to improve patients' care.

Injuries associated with the use of ejection seats: a systematic review, meta-analysis and the experience of the Israeli Air Force, 1990-2019.

INTRODUCTION: All modern military jet aircraft are equipped with rocket-assisted ejection systems. Jet aircraft operate in the majority of the conflict regions throughout the world, and in nearly all modern countries during peacetime. Civilian and military emergency services may be called upon to treat aircrews that have ejected and should be familiar with the common injury patterns associated with aircraft ejection. METHODS: A systematic review and meta-analysis of the literature were undertaken using the preferred reporting for systematic reviews and meta-analyses (PRISMA) methodology. Peer-reviewed journal and conference papers published between 1 January 1971 and 15 June 2019 were included. Our primary outcomes of interest were mortality and major injury rates. The I2 test was used to assess heterogeneity among the included studies, and data were pooled under random effects models. In addition, all ejection cases in the Israeli Air Force (IAF) between 1990 and 2019 were studied. The data were manually extracted from the accident records and the electronic medical records system. RESULTS: We identified 14 studies that included 1710 aircrew ejections. Heterogeneity was high (I2>75%). Pooled mean mortality and major injury rates were 10.5% (95% CI 6.8-14.8%) and 29.8% (95% CI 20.1-40.6%), respectively. The major injuries included spinal fractures (61.6%), extremity trauma (27.3%), and head trauma (8.9%). During the IAF study period, a total of 37 aircrew ejected from 26 IAF aircraft. The fatality rate was 5.4% and 18.9% suffered major injuries. CONCLUSIONS: Although ejection is lifesaving, it is associated with unique injury patterns that should be addressed during clinical evaluation. Because of their high prevalence, spinal precautions are paramount until spinal injury can be ruled out, generally by advanced imaging. Looking forward, injury patterns will continue to evolve in parallel with improving ejection seat systems.

Spinal cord injury with central cord syndrome from surfing.

INTRODUCTION: Central cord syndrome (CCS) is an injury to the center of the spinal cord. It is well known as a hyperextension injury, but it has never been described as a surfing injury. Our report describes this injury in detail. CASE PRESENTATION: A 35-year-old male novice surfer presented to the emergency department with acute tetraplegia following falling off his surfboard and hitting sea floor at a shallow beach break. He was rescued by a fellow surfer while floating in the sea and unable to raise his head above sea level. Upon arrival at the hospital, tetraplegia and sensory deficits were noted. Radiological investigations showed advanced spinal stenosis at C4-6 levels. T2 magnetic resonance imaging (MRI) demonstrated myelopathy at C5-C6 level. He was diagnosed as having central cord syndrome, treated conservatively, and regained near full neurologic recovery after a month of rehabilitation. DISCUSSION: Unique sport activities lead to unique injuries. It is important to accurately describe these injuries in order to create protective measures against them. Neurologic injuries in surfers are uncommon. With low-energy trauma, surfer's myelopathy is still the most common diagnosis, but central cord syndrome should be in the differential diagnosis.