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Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance.To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery.We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage.We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation.Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Background Supracondylar humerus fractures (SCHF) are the most common elbow fractures requiring surgical treatment in the pediatric age group. Most fractures are reduced and stabilised adequately. Yet, post-surgical malunion may occur. The purpose of this study is to evaluate our results of early revision surgery in 21 surgically treated pediatric SCHF with immediate postoperative loss of alignment and compare them with previous reports of late corrective osteotomies. Methods Twenty-one pediatric SCHF patients that underwent revision surgery for malalignment within 3 weeks of the initial reduction and fixation consisted the study group. Indications for revision were unacceptable radiographic alignment diagnosed within the first 3 weeks after the index surgery. Clinical outcome included pain, range of motion (ROM) and appearance of the elbow. Radiographic outcome was defined as fracture healing and final alignment, assessed in both coronal and sagittal planes. Results The average time interval between index and revision surgery was 7.6 days (range 3–18). In revision surgery, closed reduction was performed in 17 out of 21 patients, and open reduction was required in four. In one patient, an external fixator was added. In the most recent follow up, all patients but three regained full ROM. The remaining three had a deficit of 10° or less. Two patients had cubitus varus of 10° or less. All patients had a marked radiographic improvement after revision, especially in the sagittal plane increasing the humero-capitaller flexion angle by an average of 20°. Discussion Malunion after reduction and Kirschner wires (KW) fixation of SCHF is an uncommonly reported phenomenon. When malunion is recognised after fracture healing, corrective osteotomies may carry a significant complications rate. We describe our favourable experience with early diagnosis and revision surgery of malaligned SCHF.

Background Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population. Methods Study design: retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27–60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores. Results All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome. Conclusion Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.

Operative fixation of distal radius fractures using fixed-angle devices has become increasingly common. Although good to excellent results have been reported in acute fractures, little is currently known regarding the fixation of healing displaced distal radius fractures that were presented late. The aim of this study was to evaluate the results of internal fixation of distal radius fractures presented late (21 days) as compared with an acute-care control group.Forty patients operated on for displaced distal radius fractures, presenting more than 21 days after injury (delayed treatment (DT) group), were compared with 75 age-matched controls with acute fracture repair (≤21 days). The same surgical approach was used in both groups, together with dorsal soft-tissue and brachioradialis release. No osteotomy was required. Direct and indirect reduction aids were used. A fixed-angle device (DVR; Biomet Inc., Warsaw, IN, USA) was used in both groups. Mean follow-up was 3.4 years. Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Short Form 12 scores were used to evaluate outcome, as well as radiographic analysis for Arbeitsgemeinschaft für Osteosynthesefragen(AO)/Orthopaedic Trauma Association(OTA) classification, volar tilt, radial inclination and radial length.Average age was 53 years in both groups and male to female (M/F) ratio was similar in the study groups. Mean time to surgery was 30 days in the DT group and 8 days in the control group. There were significantly more type C (91.5% vs. 67.5%) fractures in the control group. The average quick DASH score was 27.1 in the DT group as compared with 6.3 in the control group (p0.03); however, when controlling for two outlier cases with complications (hardware irritation and a sensory neuropathy) there was no significant difference. Volar tilt, radial inclination and length were similar in both groups and were within normal anatomical values.Delayed primary operative fixation of displaced unstable distal radial fractures is a viable option for cases that were presented late, with predictable, favourable results. Neither extensile approaches nor formal osteotomies are required.

Introduction Angiographic embolisation (AE) is a successful treatment for haemodynamically unstable pelvic ring injuries. However, recent evidence has shown a significant complication rate following AE together with a lower success rate than previously reported. The aim of the current study was to review and indentify the factors predicting success or failure of AE. Patients and methods 651 patients with high energy (ISS > 16) pelvic ring injuries were treated in our institution between the years 1997 and 2009. Mean patient age was 37 (range 5–89) years, and the average ISS 33.4 (range 16–66). Patients’ information was collected from the institution's trauma registry as well as from the patient's medical chart and radiographs. Data included age, ISS, length of stay, ICU stay, initial blood pressure and pulse, blood products consumption, blood creatinine levels, fracture type and treatment, embolisation details, complications and mortality. 61 patients (9.3%) underwent urgent angiography due to haemodynamic instability. Angiography was positive (PA) in 38 patients (62.3%) and was negative for haemorrhage (NA) in the remaining 23 (37.7%). Results Ten patients required a branch vessel embolisation while 17 patients required major vessel embolisation, 11 required bilateral internal iliac embolisation and three patients underwent multiple vessel embolisation. Overall mortality rate was 26%. 32 patients required surgical intervention for pelvic ring stabilisation. Significant reduction in blood transfusion was seen in patients with an APC fracture type following AE. No significant correlation was found between fracture type and mortality. Multiple vessel embolisations were associated with increased surgical complications and mortality. Discussion Angiographic embolisation provides a reasonable option for haemodynamically unstable pelvic ring injured patients with an acceptable outcome, supporting previously reported literature. Patients with unstable APC type pelvic fracture may benefit the most from early angiographic embolisation. Patients requiring multiple vessel embolisation have a guarded outcome.

Distal tibial fractures tend towards delayed- or nonunion. The purpose of this study was to evaluate the safety and efficacy of early minimally invasive intervention (MII) in the treatment of these fractures. A total 24 consecutive patients who underwent operative treatment for distal tibial fractures were randomized into a control and an intervention group. MII entailed aspirating iliac crest bone marrow and peripheral blood, yielding mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) respectively, that were mixed with demineralized bone matrix (DBM) and injected under fluoroscopic control into the fracture site. No complications occurred in either group. The median time to union was 1.5 months in the MII group and 3 months in the control group. MII was found to be a safe and efficient procedure.

Distal radial fractures are common. Modern trends favour operative treatment in many instances, providing stable fixation and early functional recovery. Recent biomechanical evidence suggests that volar locking plates (VLPs) enable adequate stability for dorsally displaced fractures, both in dorsally intact (DI) and in dorsally comminuted (DC) fractures. The aim of the study was to compare the clinical outcome of these two fracture groups treated with a VLP.Retrospective case-control analysis of 91 distal radial fractures treated surgically using VLP by a single surgeon between the years 2006 and 2008 was carried out. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthes/Orthopaedic Trauma Association (AO/OTA) classification. Based on initial pre-reduction X-rays and computed tomography (CT) scans, fractures were classified into two groups of DI and DC fractures. The patients were re-evaluated at 2 and 6 weeks, 3 and 6 months and 1 year.Forty-one fractures (45%) were dorsally comminuted. Patients in the DC group were significantly older (mean 59 vs. 46 years, p0.01) and included more female patients, as well as significantly more C3 type fractures than the DI group (p0.04). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year postoperatively was 6.3±2.3 for the DC group, as compared with 6.6±2.02 for the DI group (p=0.64). Average time to return to work was longer in the DC group (81.2 vs. 63.6 days, p=0.05). Range of motion, volar tilt, and radial inclination were within clinically acceptable values and did not differ significantly among the two groups.VLP fixation of DC distal radial fractures results in the maintenance of reduction and comparable functional and radiographical outcome with respect to DI fractures.

Background: Rotator cuff tears are the most frequent tendon injury in the adult population. However, the natural history of nonoperatively treated full-thickness tears is poorly defined. Knowledge of the expected evolution in tear size is important when considering nonoperative versus surgical care, especially in relatively young, active patients. Purpose: To evaluate the size change of nonoperatively treated full-thickness rotator cuff tears over 2 to 3 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: The authors prospectively followed patients 60 years old or younger who had a full-thickness rotator cuff tear equal to or larger than 5 mm, as diagnosed by bilateral shoulder ultrasound, and who were treated nonoperatively. At 2 to 3 years after the index ultrasound examination, a repeat ultrasound examination was performed by the same ultrasonographer. Results of the follow-up ultrasound examinations of both shoulders were compared with those of the index ultrasound examinations for change in rotator cuff tear size. The correlations were examined between these changes and age, sex, history of initial trauma, size of tear on the index ultrasound, and current shoulder symptoms. Results: Fifty-one patients with 61 rotator cuff tears were evaluated. At a follow-up of 25 to 39 months (mean, 29), 49% of the tears (30 tears) increased in size, 43% (26 tears) had not changed, and 8% (5 tears) decreased in size. For 25% (10 shoulders ) of initially intact shoulders (41 shoulders), a new full-thickness rotator cuff tear was diagnosed. No correlation was found between the change in tear size and age of the patient ( P = .85), sex ( P = .93), existence of a prior trauma ( P = .63), size of tear at index ultrasound ( P = .62), and bilateral tears ( P = 1.00). There was a correlation between the existence of considerable pain at the time of the follow-up ultrasound and a clinically significant increase in tear size ( P = .002). Conclusion: Full-thickness rotator cuff tears tend to increase in size in about half of patients aged 60 years or younger. Surgery should be initially considered in these patients to prevent a probable increase in size tear. Patients treated nonoperatively should be routinely monitored for tear size increase, especially if they remain symptomatic.

The most commonly used imaging device for assessment of fracture reduction is the two-dimensional X-ray fluoroscope. Two recently introduced 3D fluoroscopic devices, the Siremobil ISO-C3D (Siemens) and the C-InSight (Mazor Surgical Technologies), enable the surgeon to obtain spatial information for the assessment of articular reduction and hardware placement. The purpose of this study was to assess the reliability and accuracy of these two 3D fluoroscopic systems in measuring articular reduction in a cadaveric tibial plateau fracture.Six cadaveric knee specimens were osteotomized at the lateral tibial plateau and fixed with a maximal articular step-off of 0, 1, 2.5, 5 and 7.5 mm. Each specimen was scanned 10 times with two 3D fluoroscopes, the Siremobil ISO-C3D and the C-InSight. The resulting images were reformatted and interpreted for articular displacements at four different locations at the plateau level and were compared with high-resolution CT scans by an independent observer.For the non-displaced fracture, no displacement (mean0.1 mm) was observed in either modality. The mean scanning time for the ISO-C3D was 2 min, while each C-InSight scan took 20 s. The readings at four different points along the malreduced fractures were similar for most measurements with either of the two modalities. The C-InSight readings were less accurate than those of the ISO-C3D, relative to the CT scan, but most errors were within clinically acceptable limits (2 mm) and used less radiation.Intraoperative 3D fluoroscopes can detect clinically significant intra-articular step-off with acceptable measurement errors, using newer devices that enable the use of a conventional C-arm and reduced radiation.

Hydatid disease is prevalent throughout much of the world, mainly in the developing world and unprivileged areas. There are twelve subtypes of Echinococcus known today. However, in humans there are two main types of infection—Echinococcus multilocularis causing alveolar and Echinococcus granulosus which causes the cystic echinococcosis. The incidence of bone disease, caused by echinococcus is rare as only 0.5–4.5% of cases of echinococcosis have bony involvement. Primary hydatid disease of bone, is caused by E. granulosus, occurs when a bloodborne scolex settles in bone. In bone involvement, pericyst formation of the echinococcus does not occur, thereby allowing aggressive proliferation in an irregular branching fashion along the line of least resistance, especially the bone canals. When this proliferation causes damage severe enough to create a compromise in the solidity of the bone, a pathological fracture may occur. However, very few reports deal with the treatment of pathological long bone fractures, especially as the sole presentation of the echinococcus usually with a grim outcome. We present a case of a pathological femur fracture non-union caused as an isolated bony infection of echinococcus, treated successfully with serial debridements, antibiotics and fixation with a locked plate construct.

Terror-related injuries are becoming more prevalent. The predominant mechanism of damage is related to blast effects. These include penetrating injury due to material in the explosives and blunt trauma due to objects falling after detonation. However, the more commonly encountered severe trauma in civilian centres is related to motor vehicle accidents. A comparison between the two, although problematic, might enhance the knowledge of orthopaedic traumatologists dealing with these injuries. Thus 1072 in-patients, treated in levels I and II centres in Israel for orthopaedic injuries due to terrorist attack from November 2000 to December 2003, were compared with 9714 similar in-patients injured in motor vehicle accidents (controls). Analysis included age, gender, severity of injuries, diagnoses, lengths of intensive care unit and hospital stay, operations and mortality. The victims of terrorist attack included significantly more young adults, males, severe associated injuries and operations, and increased lengths of stay and mortality. Prompt recognition and awareness of the unique character of terror-related injuries is required.

Objective: Fluoroscopy-based computerized navigation systems enable accurate implant placement while reducing radiation exposure. The navigation process normally requires the attachment of a dynamic reference frame (DRF) to a bone, causing additional surgical trauma. The aim of this study was to compare the accuracy of navigation with the DRF either attached to the bone or mounted on the fracture table. Methods: We conducted a prospective study on 10 consecutive patients who underwent operative fixation of femoral neck fractures with cannulated screws using computerized navigation. After insertion of the three guide wires, the DRF was moved from the patient’s bone to the fracture table. For each screw, angular and translational deviations of the navigated images as compared to the conventional fluoroscopic images were analyzed. Results: The accuracy of navigated Kirschner wire placement was similar with both techniques, resulting in an average translational error of less than 2 mm in both groups and around 1 in angulation error – both of these accuracy measurements are acceptable and sufficient for the insertion of cannulated screws into the femoral head. Conclusion: Our study suggests that attaching the DRF to a fracture table during navigated femoral neck fixation allows for acceptable accuracy with the possible added benefit of reducing patient morbidity.

In situ pinning with a single screw is the treatment of choice for symptomatic slipped capital femoral epiphysis (SCFE). Some technical features are critical and include proper screw entry point, screw direction in relation to the epiphysis, and the length of screw. These are complicated by the deformity created as a result of the posterior slip of the epiphysis. Fluoroscopic based computerized navigation system can increase precision in screw placement while performing the surgical task, and markedly reduce radiation. By using real fluoroscopy-based navigation, the screw can be placed with only two fluoroscopic images. Entry point, length, and precise direction can all be easily determined through this technique.

Anatomische Reposition und minimalinvasive Stabilisierung pertrochantarer Frakturen mit der perkutanen Kompressionsplatte (PCCP™). Sofortige postoperative Vollbelastung. Pertrochantare Frakturen. Pertrochantare Frakturen, die nicht geschlossen reponiert werden konnen, subtrochantare Frakturen und „reverse oblique fractures“ (AO/OTA 31-A3). Der Patient wird auf einem Extensionstisch gelagert. Das Femur distal der Fraktur wird durch eine dorsale Repositionshilfe (PORD™ [„posterior reduction device“]) unterstutzt. Reposition der Fraktur durch geschlossene Manipulation. Perkutanes Einfuhren der Platte uber eine proximale laterale Inzision. Die Platte wird mit Hilfe einer Zange uber eine zweite, mehr distal gelegene Inzision an den proximalen Femurschaft angelegt. Einbringen der Gleitschrauben durch die Platte in den Schenkelhals und Sicherung der Platte am Femurschaft mit drei zusatzlichen Schrauben. Abschliesend Vervollstandigung der Frakturstabilisierung mit einer zweiten Schenkelhalsschraube. Von 130 Patienten mit einer pertrochantaren Fraktur, die zwischen Mai 2000 und Dezember 2001 mit der beschriebenen Technik in der Hadassah-Universitatsklinik fur Orthopadische Chirurgie, Jerusalem, Israel, behandelt wurden, konnten 108 in diese Studie eingeschlossen werden. Das Patientenalter lag bei durchschnittlich 81 Jahren (± 8 Jahre). Die durchschnittliche Operationszeit betrug 67 min, der Krankenhausaufenthalt lag bei 11,5 Tagen. 40% der Patienten benotigten wahrend des Krankenhausaufenthalts keine Bluttransfusion, wohingegen 8,3% mehr als drei Erythrozytenkonzentrate erhielten. Komplikationen traten bei vier Patienten auf: in zwei Fallen Implantatversagen, das erfolgreich mit Kompressionshuftschrauben (CHS) behandelt wurde, und eine Pseudarthrose, die mit einer Arthroplastie behandelt wurde. Der vierte Patient hatte eine Beinverkurzung von 3 cm, die mit einer Schuherhohung ausglichen wurde. Drei Patienten entwickelten eine Infektion, wovon eine ein chirurgisches Debridement erforderte.

Percutaneous internal fixation of pelvic fractures has gained popularity allowing rapid mobilization with reduced surgical related morbidity; however, this method depends on conventional fluoroscopy, which exposes the patient and the surgeon to a significant amount of radiation. The use of computerized fluoroscopic navigation systems enables the simultaneous use of several radiographic projections. These preliminary fluoroscopic views are taken when the operating team stands at a distance from the radiation source. No further fluoroscopic radiation is used later during the surgical procedure. Computerized fluoroscopic navigation was used in the percutaneous insertion of 45 cannulated screws in 29 patients, including sacroiliac screws, pubic ramus screws, posterior column screws, and a supraacetabular transverse screw. Fluoroscopic verification of screw placement demonstrated a deviation

We report 3 cases of Brucella melitensis infection of prosthetic hips and knees, and we summarize data about 4 cases reported in the literature. Six of the 7 affected patients were men. The median duration from prosthesis implantation to the onset of symptoms was 38.7 months. Five patients had only local symptoms. Preoperative joint aspirates yielded negative culture results for 3 patients, and blood culture results were negative for 6 patients. Excisional arthroplasty was the initial intervention for 3 patients. Three others responded well to medical therapy alone. One patient had relapse while receiving tetracycline and underwent total hip replacement. All patients were treated with combined antibiotic therapy for 6 weeks to 19 months. All had favorable long-term responses. The 3 patients we treated underwent a 2-staged resection arthroplasty. Antibiotics alone can be used to treat Brucella prosthetic joint infection, but loosening of the joint and clinical or microbiological failure must be treated with a 2-staged excisional arthroplasty and 3 months of treatment with doxycycline and rifampicin.

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices. We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively. The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02. The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.

High-energy penetrating injuries are increasingly common in the civilian setting. During the years 2000 to 2003, more than 70 suicide bombing attacks occurred in Israel. These were characterized by high numbers of casualties, primarily caused by blast injuries. Injury caused by a blast can be either a primary blast effect of acceleration-deceleration of the blast wave or a secondary effect of metal fragments deliberately placed in explosives, causing severe penetrating injuries. The latter type of injury may result in severe open limb fractures.We identified and reviewed 91 patients with 117 long bone fractures caused by penetrating terror-related injuries treated in our institution during 2000 to 2003. The patients were divided according to the mechanism of injury, i.e., either gunshot injury or blast injuries; several parameters were compared.Patients in the blast injury group included more children and elderly patients than the gunshot injury group did. This group also had a significantly higher Injury Severity Score and a higher number of associated injuries, including multiple fractures and mortality. The treatment modalities for the fractures were similar for both groups, as was the fracture final outcome. Local soft tissue injury was more severe in the gunshot injury group, as demonstrated by a higher number of type IIIC fractures, as well as more nerve injuries.Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures. These should be aggressively treated by physicians remaining cognizant of other systemic and general implications of such a severe trauma.