Background The PROSPECT (Procedure-Specific Postoperative Pain Management) Group recommended a single injection femoral nerve block in 2008 as a guideline for analgesia after total knee arthroplasty. Other authors have recommended the addition of sciatic and obturator nerve blocks. The lateral femoral cutaneous nerve is also involved in pain syndrome following total knee arthroplasty. We hypothesized that preoperative blocking of all four nerves would offer superior analgesia to femoral nerve block alone. Methods This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 107 patients were randomly assigned to one of three groups: a femoral nerve block group, a multiple nerve block group, and a control group. All patients were treated postoperatively using patient-controlled intravenous analgesia with morphine. Pain intensity at rest, during flexion and extension, and morphine consumption were compared between groups over three days. Results A total of 90 patients completed the study protocol. Patients who received multiple nerve blocks experienced superior analgesia and had reduced morphine consumption during the postoperative period compared to the other two groups. Pain intensity during flexion was significantly lower in the “blocks” groups versus the control group. Morphine consumption was significantly higher in the control group. Conclusions Pain relief after total knee arthroplasty immediately after surgery and on the first postoperative day was significantly superior in patients who received multiple blocks preoperatively, with morphine consumption significantly lower during this period. A preoperative femoral nerve block alone produced partial and insufficient analgesia immediately after surgery and on the first postoperative day. (Clinical trial registration number (NIH): NCT01303120)

In order to reduce the magnitude of the force applied to skull for treatment of acute cervical spine dislocation, we developed a method of skeletal traction based on reduction of friction forces under the patient’s head. Traction force was applied to sculls of five patients with cervical fracture-dislocations. A difference in friction interface between the patient’s head and shoulder girdle was created. The traction weight required for the reduction of the vertebral dislocation was significantly lower than an expected minimal traction weight in the commonly used techniques (p = 0.013). The presented method permits an effective and safe reduction of dislocated cervical vertebra by a relatively low traction force.

Purpose: The predicted increase in primary and revision total knee arthroplasty (TKA) for knee osteoarthritis is a major concern. The demand for primary TKA in the United States alone is expected to grow by 673% (3.48 million annual procedures) by 2030 and the demand for TKA revisions is expected to grow by 601%. Yet, up to 50% of patients continue to suffer from pain and disability following the surgery. In most of the cases those finding cannot be explained by implant factors or surgical technique. Additionally, physiotherapy functional exercises after discharge result in small to moderate effect sizes with no long-term benefits. Evidence shows that gait patterns after TKA do not return to healthy ranges. These pathological gait patterns may partially explain the difficulty in postoperative recovery in pain and function, as well the wear and tear of the TKA implant in the long-term. In this study we applied a biomechanical therapy program after surgery aimed at reducing pain, improving function and correcting gait patterns. Methods: We conducted a randomized, controlled, double-blind trial involving fifty patients after unilateral TKA for end-stage knee OA. The active group underwent a therapy program using a biomechanical foot-worn device, while the control group received a similar training program with a sham walking shoe. Treatment was initiated 6 weeks postoperatively. Patients were examined at baseline, 3 months, 6 months, 9 months and 12 months postoperatively. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and three-dimensional gait analysis measurements in the frontal and sagittal planes. Comparisons of categorical variables between the intervention groups (active vs. control) were carried out with the chi-square tests. Comparisons of continuous variables such as demographic data and baseline gait data between the groups were done by the Wilcoxon-Mann-Whitney rank-sum test. A linear mixed effect model was used to determine the effect of the treatment over time in each parameter. Results: There were no differences between groups at baseline. Both groups improved with time after surgery, but the active group consistently showed significantly better outcomes in WOMAC pain (Figure 1; 91% reduction compared to 33%), function (Figure 2; 93% reduction compared to 21%) and stiffness (85% reduction compared to 32%) sub-scales (all p = 0.001), in SF-36 physical score (107.3% increase compared to 59%) and mental scores (51% increase compared to 45%) (all p<0.001). Patients from the active group also showed lower second peak knee adduction moment (Figure 3; p = 0.007) and greater peak knee extension moment (p = 0.009). Linear mixed effect models over time showed faster improvements in the active group in all clinical parameters, stride, cadence, double-limb-support, step-length, knee range of motion and impulses of the knee flexion and extension moments, as well as slower regression of the knee adduction impulse (all p<0.01). The knee varus angle did not differ between groups over time. Conclusions: A patient-specific biomechanical therapy program applied to patients after unilateral TKA may lead to a greater improvement and more rapid recovery time in pain and function, as compared to regular rehabilitation protocols after TKA. Furthermore, this biomechanical training program may lead to healthier loading patterns on the knee joint.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

There is a controversy whether the comminuted calcaneal fractures should benefit more from conservative or from surgical treatment. Aiming to contribute to this unsolved clinical question we reviewed the long-term outcome (up to 96 months) of in 44 patients (mean age 35 years) with 47 calcaneal fractures who were treated surgically. In these patients open reduction and internal fixation were performed using a calcaneal reconstruction plate. The functional outcome was measured according to the Rowe Score and the level of pain by Visual Analog Scale. The objective outcome was estimated by the current radiographs. The clinical results were good to excellent in 69% of patients. Poor outcome observed in one patient who developed Complex Regional Pain Syndrome in his foot. The radiographic evaluation showed satisfactory reconstruction (according to the Boehler angle measurements) in 35 of operated calcanei. These results indicate on the satisfactory outcome of surgical treatment in the majority of the patients who were diagnosed with comminuted fracture of calcaneus.

Joint arthroplasty is one of the commonest surgical procedures in orthopedic surgery. In recent years there was an increase in the number of procedures, patient satisfaction and implant survival. Originally, these operations were designed for old patients in order to relieve pain and to enable ambulation. Over the past few years, these operations have become common in younger patients which desire to return to activity, including sports activities. The importance of physical activity is a well known fact. In recent years it became clear that with the proper physical activity the outcomes of the operations are better. There are several types of arthroplasty. Many factors influence the outcome of the operation apart from the post-surgery physical activity. These factors include patient factors, surgical technique and type of arthroplasty. This review summarizes the recommendations for sports activities after hip and knee arthroplasties. These activities are evaluated according to surgeons' recommendations, stress applied on the implant and long term outcomes. The recommended sports activities after joint arthroplasties are walking, swimming and cycling. Soccer, basketball and jogging are not advised. Tennis, downhill skiing and horse riding are recommended with previous experience. There are many more sports activities that patients can participate in, and it is important that the patient discuss the different options prior to the operation. Since these operations are so common, many non-orthopedic physicians encounter these patients in their practice. They should be acquainted with the recommendations for sports activities and encourage them.

Rapidly destructive hip disease is a rare condition, the cause of which is yet to be clarified, and is described in the literature by scant case reports. The disease was first described by Forestier in 1957, and since then many names have been proposed to describe the rapid vanishing of the femoral head, and occasionally the acetabulum. This condition initially represents as acute hip pain, and rapidly progresses to complete vanishing of the proximal femur, within a few months. We briefly discuss the literature regarding this phenomenon, and describe a case of a female patient who suffered from complete disappearance of the femoral head within 9 weeks.

ObjectivesThe most prevalent disorders of the shoulder are related to the muscles of rotator cuff. In order to develop a mechanical method for the evaluation of the rotator cuff muscles, we created a database of isometric force generation by the rotator cuff muscles in normal adult population. We hypothesised the existence of variations according to age, gender and dominancy of limb.MethodsA total of 400 healthy adult volunteers were tested, classified into groups of 50 men and women for each decade of life. Maximal isometric force was measured at standardised positions for supraspinatus, infraspinatus and subscapularis muscles in both shoulders in every person. Torque of the force was calculated and normalised to lean body mass. The profiles of mean torque-time curves for each age and gender group were compared.ResultsOur data showed that men gradually gained maximal strength in the fifth decade, and showed decreased strength in the sixth. In women the maximal strength was gained in the fourth decade with gradual decline to the sixth decade of life. The dominant arm was stronger in most of the tested groups. The torque profiles of the rotator cuff muscles in men at all ages were significantly higher than that in women.ConclusionsWe found previously unrecognised variations of rotator cuff muscles’ isometric strength according to age, gender and dominancy in a normal population. The presented data may serve as a basis for the future studies for identification of the abnormal patterns of muscle isometric strength in patients with pathology of the rotator cuff muscles. Cite this article: Bone Joint Res 2013;2:214–19.

The most prevalent group of disorders of human shoulder is related to the muscles of the rotator cuff. In order to develop a mechanical method for rotator cuff muscles' evaluation, we hypothesized that measurement of the isometric force generated by the individual muscle of the rotator cuff might detect the variations, which are characteristic to the different disorders of rotator cuff muscles in adults. The isometric force of supraspinatus, infraspinatus and subscapularis muscles were measured in patients with rotator cuff tears, calcific tendinitis and subacromial impingement syndrome, 30 patients with each disorder, and compared to the normal values from our previous study. Torque of the force was calculated and normalized to lean body mass. The profiles of the mean torque-time curves of each group were compared statistically. We found the expected significantly lower profiles of the torque-time curves of all the tested rotator cuff muscles in comparison to the normal values. The best resolution between the curves of different study groups was found in the testing of the infraspinatus muscles. Therefore the previously unrecognized variations of rotator cuff muscles' isometric strength build up patterns in the common disorders involving the rotator cuff muscles were revealed. The presented data might be a basis for the future development of a simple mechanical diagnostic method for identification of the abnormal patterns of muscle isometric strength in patients with rotator cuff muscles' pathology.

The rationale for mobile bearing design of knee replacement prosthesis is to increase its survival by reducing the rate of aseptic loosening and to improve the range of movement of the treated knee. The theoretical basis for the achievement of the first goal is the expected lower rates of the polyethylene insert wear in the mobile design in comparison to a fixed design, due to lower contact and constraint forces. A better range of movements following mobile bearing arthroplasty is expected as the result of additional moving surface between to fixed planes at the ends of the articulating bones, allowing mobility with congruency.These expected advantages of the mobile bearing design should be judged cautiously since the initial mobile bearing implants caused higher rates of breakage and disarrangement of the polyethylene inserts, when the implantation method wasn’t strictly followed. In order to resolve these technical problems the rotating platform mobile prosthesis was developed. Mobile bearing concept was implemented in a three compartment replacement prostheses and also in unicompartamental designs, especially for the medial compartment of the knee. Currently, following the more than two decades of the rising experience with implantation of a large number of mobile bearing prostheses, there is a significant amount of data for evaluation of the survival of these prosthetic designs. In order to declare on their higher expected efficiency these implants should show higher than 96-97% of ten year clinical survival, which should remain relatively stable up to 20 years of follow up, as reported in the several of fixed bearing designs. Unfortunately this data is not readily available, because only few well designed survivorship reports on mobile knee implants have been published yet. Furthermore the published data failed to provide a clear evidence of the superiority of mobile bearing design. The endoprosthetic arthroplasty is the most popular surgical modality for treatment of advanced knee joint disease, either degenerative or inflammatory. The reason for this clinical trend is the ability to reduce pain and to restore the patient’s ability to walk.

High frequency electromagnetic field in the range of 4 - 33 kHz given in low frequency bursts of 7-15 Hz (PEMF) is efficient in stimulating osteoblast proliferation and differentiation in vitro. We hypothesize that osteoblast cell cycle changes following this stimulatory PEMF. In order to explore this effect we used primary explant cultures of human osteoblast-like cells. These cells were subjected to low frequency of 20-30 Hz, higher frequency of 5-15 kHz electromagnetic fields and to PEMF (5-15 kHz basic frequency in pulses of 20-30 Hz) with maximal magnetic flux of 10-12 Gauss. The maturation state of the cells was estimated by the measurement of cellular alkaline phosphatase activity and the overall cell death by the LDH activity in culture media. The cell cycle was analyzed by cytometry. The PEMF stimulation significantly increased the proportion of cells in the G1 phase (p<.001) and decreased the proportion of apoptotic and necrotic cells (p<.001), with parallel decrease in cellular alkaline phosphatase and media LDH activities. Pure 20-30 Hz or 5-15 kHz electromagnetic stimulations had no effect on these parameters. Therefore we show that PEMF with a basic frequency in the kHz range provided in pulses in the infrasonic range alters human osteoblast cell cycle by reducing cell death and cellular maturation.

Bone structural integrity and shape are maintained by removal of old matrix by osteoclasts and in-situ synthesis of new bone by osteoblasts. These cells comprise the basic multicellular unit (BMU). Bone mass maintenance is determined by the net anabolic activity of the BMU, when the matrix elaboration of the osteoblasts equals or exceeds the bone resorption by the osteoclasts. The normal function of the BMU causes a continuous remodeling process of the bone, with deposition of bony matrix (osteoid) along the vectors of the generated force by gravity and attached muscle activity. The osteoblasts are derived from mesenchymal stem cells (MSCs). Circulating hormones and locally produced cytokines and growth factors modulate the replication and differentiation of osteoclast and osteoblast progenitors. The appropriate number of the osteoblasts in the BMU is determined by the differentiation of the precursor bone-marrow stem cells into mature osteoblasts, their proliferation with subsequent maturation into metabolically active osteocytes, and osteoblast degradation by apoptosis. Thus, the two crucial points to target when planning to control the osteoblast population are the processes of cell proliferation and apoptosis, which are regulated by cellular hedgehog and Wnt pathways that involve humoral and mechanical stimulations. Osteoblasts regulate both bone matrix synthesis and mineralization directly by their own synthetic activities, and bone resorption indirectly by its paracrinic effects on osteoclasts. The overall synthetic and regulatory activities of osteoblasts govern bone tissue integrity and shape.

Objective: The aim was to develop a reporting system for collecting human factors problem reports to establish a database to guide activities for improving health care quality and patient safety. Background: The current error and incident report systems do not provide sufficient and adequate coverage of the factors contributing to impaired safety and care quality. They fail to examine the range of difficulties that clinical staff encounters in the conduct of daily work. Method: A voluntary problem-reporting system was developed to be used by hospital wards’ clinicians and was tested in four wards of two hospitals in Israel. The system is based on human factors–formatted problem reports submitted by physicians and nurses on difficulties and hazards they confront in their daily work. Reports are grouped and evaluated by a team of human factor professionals. Results: A total of 359 reports were collected in the wards during 12 weeks, as compared with a total of 200 incidents reports that were collected during a period of 5 years with the existing obligatory incident reporting system. In-depth observational studies conducted on the wards confirmed the ability of the new system to highlight major human factors problems, differentially identifying specific problems in each of the wards studied. Problems reported were directly related to general factors affecting care quality and patient safety. Conclusion: Validation studies confirmed the reliability of the reporting system in pinpointing major problems per investigated unit according to its specific characteristics. Application: This type of reporting system could fill an important information gap with the potential to be a cost-effective initial database source to guide human factors efforts to improve care quality, reduce errors, and increase patient safety.

Exposure to nicotine causes a broad range of biological and molecular effects on osteoblasts which are known to play a crucial role in bone metabolism and fracture healing. Most effects of nicotine on the osteoblasts are long-term adaptations at the genomic level. To identify the nicotine-regulated genes, the Agilent technologies whole human genome gene expression microarray was performed on RNA samples from osteoblast-like cells, MG-63, exposed to 100 μM nicotine. Repeat and cross-controlled microarray analyses revealed 842 genes whose expression was consistently altered at P<0.05 level following nicotine treatment. Gene ontology analysis suggested effects of nicotine on various biological and cellular processes which were associated with survival, proliferation, differentiation and apoptosis processes within the cell. Quantitative real-time reverse transcriptase PCR analysis confirmed altered expression in 7 out of 9 genes tested. The identified genes tested in the current study support our previous report that nicotine regulates the expression of genes that promote osteoblast proliferation and/or anti-apoptosis processes. Furthermore, using nicotinic acetylcholine receptor antagonists blocked the majority of the nicotine effects, indicating that these changes are dependent on nAChR activation. These results established a novel and consistent nicotinic activation of nAChR in osteoblast cells which has a broad role affecting cellular physiology through modulation of gene expression.

The major factor determining the outcome in high-energy combat injuries to the limbs is the severity and extension of the soft tissue damage. Primary radical debridement is a crucial phase in the management of patients after open high-energy injuries. Inadequate tissue debridement remains the major cause of acute and chronic infection after severe trauma. Often, this important first surgical procedure determinates the long-term outcome of severe trauma. Repeated serial debridements are required for patients with high-velocity war injuries, especially those suffering from explosive and crush injuries with large zones of injury and skeletal muscle defects. This chapter will focus and outline the general principles and techniques of primary wound inspection and surgical debridement after combat trauma.