Estimation of Dog-Bite Risk and Related Morbidity Among Personnel Working With Military Dogs.

BACKGROUND: Soldiers serving in the Israel Defense Force Military Working Dogs (MWD) Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard. METHODS: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers. Bite locations were presented graphically. RESULTS: Seventy-eight soldiers participated and reported on 139 bites. Mean time of working with dogs was 16 months (standard deviation, ±9.4 months). Overall bite incidence was 11 bites per 100 person-months; the mean time to first bite event was 6.3 months. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard. About 90% of bites occurred during routine activities, and 3.3% occurred on combat missions. Only in 9% of bite events did soldiers observed the safety precautions code. Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Most bites (57%) were located on hands and arms. CONCLUSION: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Surgical site infection in elderly patients with hip fractures, silver-coated versus regular dressings: a randomised prospective trial.

OBJECTIVE: Surgical site infection (SSI) after hip fracture surgery is a well-known complication with serious consequences for both the patient and the medical system. Silver ion treatment is considered an effective antibacterial agent, however, the use of silver dressing (SD) in the primary prevention of SSIs is controversial. The aims of this study were to compare SD with regular dressing (RD) in the prevention of SSI in elderly patients undergoing surgery for hip fractures, and to compare costs. METHOD: A matched group of 55 patients with hip fractures undergoing surgery with dynamic hip screw, cephalomedullary nail or hemiarthroplasty were randomised to either SD or RD groups. The dressings were applied in the operating theatre, and the patients were followed for one week for clinical signs of infection (discharge, erythema and fever). The RDs were replaced daily. The SDs were not removed for 5-7 days and kept moist. Skin swabs were taken from the wound surface on postoperative day 5-7 for bacterial skin colonisation. RESULTS: The SD (n=31) and RD (n=24) groups were similar in age, sex and comorbidities. Infection signs were seen in two (2/31, 6.4%) of the SD patients compared with 2 (2/24, 8.3%) RD patients (p=1.0). Skin colonisation by bacteria at postoperative day 5-7 was tested in 27 patients: it was higher in the SD group (positive skin swab, 12/19, 63.2%) compared to the RD group (4/8, 50%, p=0.67). The use of SD added ~US$5 (UK ~£3.19) per patient. CONCLUSION: The use of SD was associated with higher costs than RD, but not superior in preventing SSIs in elderly patients undergoing hemiarthroplasty or fixation of hip fractures. SD was also not effective in reducing bacterial skin colonisation following hip fracture and surgery.

Norton scale scores and 1-year mortality in elderly patients following lower limb amputations.

BACKGROUND: The Norton scale is used for assessing the risk of pressure ulcers. The association between low admission Norton scale scores (ANSS), complications and mortality in elderly patients following lower limb amputations has never been studied until now. OBJECTIVES: The aim of this study was to investigate if low ANSSs are associated with complications the 30-day and 1-year mortality in elderly patients following lower limb amputations. MATERIALS AND METHODS: The medical charts of 104 elderly (≥ 65 years) patients following lower limb amputations were studied for the following measurements: ANSS, demographics, comorbidities, complications during hospitalization, 30-day mortality and 1-year mortality. Complications included acute coronary syndrome, major bleeding, stroke, systemic infections, organ failure and thromboembolism. An ANSS ≤ 14 was considered as being low. RESULTS: Overall 54 (51.9%) patients underwent below-knee amputations and 50 (48.1%) patients underwent above-knee amputations. Most (n = 78; 75.0 %) patients were men and the mean age was 78.5 ± 7.9 years. Following the amputation 46 (44.2%) patients had complications other than pressure ulcers, 24 (23.1%) patients died within 30 days and 63 (60.6%) patients died within 1 year. A total of 61 (58.7%) patients had a low ANSS. The incidence of complications other than pressure ulcers, 30-day and 1-year mortality rates were higher in patients with a low ANSS relative to patients with a high ANSS. A regression analysis showed that 1-year mortality was independently negatively associated with ANSS (t = 2.629; p = 0.010). CONCLUSION: The Norton scale can be used for predicting 1-year mortality in elderly patients following lower limb amputations.

Effects of commonly used medications on bone tissue mineralisation in SaOS-2 human bone cell line: an in vitro study.

We analysed the effects of commonly used medications on human osteoblastic cell activity in vitro, specifically proliferation and tissue mineralisation. A list of medications was retrieved from the records of patients aged > 65 years filed in the database of the largest health maintenance organisation in our country (> two million members). Proliferation and mineralisation assays were performed on the following drugs: rosuvastatin (statin), metformin (antidiabetic), metoprolol (ß-blocker), citalopram (selective serotonin reuptake inhibitor [SSRI]), and omeprazole (proton pump inhibitor (PPI)). All tested drugs significantly stimulated DNA synthesis to varying degrees, with rosuvastatin 5 µg/ml being the most effective among them (mean 225% (SD 20)), compared with metformin 10 µg/ml (185% (SD 10)), metoprolol 0.25 µg/ml (190% (SD 20)), citalopram 0.05 µg/ml (150% (sd 10)) and omeprazole 0.001 µg/ml (145% (SD 5)). Metformin and metoprolol (to a small extent) and rosuvastatin (to a much higher extent) inhibited cell mineralisation (85% (SD 5)). Our results indicate the need to evaluate the medications prescribed to patients in terms of their potential action on osteoblasts. Appropriate evaluation and prophylactic treatment (when necessary) might lower the incidence and costs associated with potential medication-induced osteoporosis.

Effects of a customized biomechanical therapy on patients with medial compartment knee osteoarthritis.

OBJECTIVE: Previous studies have shown that a customized biomechanical therapy can improve symptoms of knee osteoarthritis. These studies were small and did not compare the improvements across gender, age, BMI or initial severity of knee osteoarthritis. The purpose of this study was to evaluate the effect of new biomechanical therapy on the pain, function and quality of life of patients with medial compartment knee osteoarthritis. METHODS: Six hundred and fifty-four patients with medial compartment knee osteoarthritis were examined before and after 12 weeks of a personalized biomechanical therapy (AposTherapy). Patients were evaluated using the Western Ontario and McMaster Osteoarthritis (WOMAC) Index and SF-36 Health Survey. RESULTS: After 12 weeks of treatment, the WOMAC-pain and WOMAC-function subscales were significantly lower compared to baseline (both P≤0.001). All eight categories of the SF-36 health survey significantly improved after treatment (all P≤0.001). Females and younger patients showed greater improvements with therapy. CONCLUSIONS: Twelve weeks of a customized biomechanical therapy (AposTherapy) improved symptoms of patients with medial compartment knee osteoarthritis. We recommend that this therapy will be integrated in the management of knee osteoarthritis.

Composite grafts in the treatment of osteosarcoma of the proximal humerus.

Treatment of osteosarcoma (OSA) of the proximal humerus poses many difficulties and challenges to the treating team. Between 1993 and 2000, we treated 11 patients (three women, eight men; age range, 17-74 years) suffering from OSA of the proximal humerus by 'composite': massive allografts and long humeral prosthesis. At presentation, 10 patients were at stage 2-B and one at stage 3-B of OSA. One patient presented with a pathologic fracture. All patients except patient No. 6, received preoperative chemotherapy followed by limb salvage surgery and postoperative chemotherapy.Surgical margins were graded as wide in all patients. Postoperative complications included non-union at the allograft/host junction (which united after auto grafting) and superficial wound infections that resolved after antibiotic therapy. All surgical procedures were performed by a team headed by an orthopedic oncologist and shoulder surgeon. At latest follow-up (December 2001) all patients, with the exception of one (who was at stage 3-B at presentation) were alive, and had good function of the upper limb. It is our opinion that the team approach comprising an orthopedic oncologist and shoulder surgeon greatly contributed to the good surgical outcome, and hence the good survival and functional results of the patients. Bone allograft offers a modular malleable durable solution to the resected bone segment.

Total hip arthroplasty in patients younger than 30 years of age following developmental dysplasia of hip (DDH) in infancy.

Total hip arthroplasty (THA) in young patients is a controversial subject, due to the high failure rates reported in the literature, and even more so in patients with a history of developmental dysplasia of the hip (DDH). A group of 11 patients, all under the age of 30 years at the time of surgery, underwent THA due to congenital dislocation of the hip. Mean age at the time of operation was 23.3 years (range 16-30 years). The mean follow-up period was 9 years (range 3-14 years). The mean preoperative Harris' hip score (HHS) was 56.9 compared with the postoperative HHS of 90.6. Due to aseptic loosening of the cup, 4 patients underwent successful revision arthroplasty. These encouraging medium-term results in our patients suggest that THA may be a good solution for young patients suffering from coxarthrosis due to DDH, at least temporarily, especially when other alternatives, such as arthrodesis or resection arthroplasty, are considered.

Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature.

Sonographic examination of the knee has been proposed by several authors in the past as a simple and reliable method to diagnose Osgood-Schlatter disease (OSD). Ultrasound was used to compare the knees of 25 boys and 10 girls with typical OSD with 35 symptom-free knees of an aged-matched group of children. Based on recorded data, patients were categorized (one affected knee in each individual) according to the classification system proposed by De Flaviis et al. in 1989. The results included the following pathological findings: pretibial swelling, fragmentation of the ossification center, insertional thickening of the patellar tendon, and excessive fluid collection in the infrapatellar bursa. Of our patients, 26% fell into the type 1 category, 43% were type 2, 20% type 3, and 11% type 4. This distribution of cases was found to be statistically similar to the initial findings reported by De Flaviis and colleagues. This study therefore supports the validity and reproducibility of their classification method for the ultrasonographic evaluation of children with OSD. This is only the first step, and further assessment of this classification is still required to elucidate its clinical as well as its prognostic value.

The inhibitory effects of colchicine on cell proliferation and mineralisation in culture.

Colchicine is often used in the treatment of diseases such as familial Mediterranean fever (FMF) and gout. We have previously reported that patients with FMF who had colchicine on a daily basis and who had a total hip arthroplasty showed no heterotopic ossification after surgery. The mechanism by which colchicine causes this clinical phenomenon has never been elucidated. We therefore evaluated the effect of various concentrations of colchicine on cell proliferation and mineralisation in tissue culture, using rat and human cells with and without osteogenic potential. Cell proliferation was assessed by direct cell counts and uptake of (3H)thymidine, and mineralisation by measuring the amount of staining by Alizarin Red. Our findings indicate that concentrations of colchicine of up to 3 ng/ml did not affect cell proliferation but inhibition was observed at 10 to 30 ng/ml. Mineralisation decreased to almost 50%, which was the maximum inhibition observed, at concentrations of colchicine of 2.5 ng/ml. These results indicate that colchicine at low concentrations, of up to 3 ng/ml, has the capacity to inhibit selectively bone-like cell mineralisation in culture, without affecting cell proliferation. Further clinical and laboratory studies are necessary to evaluate the effects of colchicine on biological processes involving the proliferation of osteoblasts and tissue mineralisation in vivo, such as the healing of fractures, the formation of heterotopic bone and neoplastic bone growth.

Ultrasonography: an imaging modality enabling the diagnosis of bipartite patella.

Ultrasound was used to diagnose bipartite patella in seven adolescents with anterior knee pain, and the findings were compared to those from plain radiography and to those of a group of asymptomatic subjects. In all affected individuals the quadriceps and patellar tendons appeared normal on ultrasound. Sonographic examination of the patella demonstrated an irregularity of the bony contour with occurrence of a cleft between the main part of the patellar body and the large superolateral accessory ossicle. The signal detected in the interface between bones was less echogenic than bone reflecting its fibrocartilaginous nature. The correlation with conventional radiography was absolute, as was the inter- and intraobserver reliability. Ultrasound is thus proposed as a simple and reliable imaging modality in bipartite patella. We do not believe that it should replace the initial radiographic, but it can be used to evaluate the contralateral knee for bilaterality and as an adjunct to therapeutic procedures such as local injections to increase the accuracy of treatment.

Inhibition of the second phase of amyloidogenesis in a mouse model by a single-dose colchicine regimen.

Amyloidogenesis consists of two stages. In the first, amyloid enhancing factor (AEF) is generated, and in the second, deposition of amyloid fibrils occurs. Colchicine is a known inhibitor of amyloidosis of familial Mediterranean fever (FMF) and of mouse experimental amyloidosis, but the timing and mechanism of its effect are still unclear. The aim of this study is to determine whether colchicine inhibits the second phase of amyloidogenesis and to study the time correlate of such an effect. To that end, amyloid was induced in Swiss male mice with AEF and AgNO(3) (an inflammatory stimulus), a method that skips the first phase of amyloidogenesis. Two amyloid induction protocols were used: a standard protocol, in which AEF and AgNO(3) were administered concurrently, and a prolonged protocol, in which the administration of AgNO(3) was delayed by 24 hours or 7 days. To study the inhibitory effect of colchicine on the second phase of amyloidogenesis, a single dose of colchicine (30 microg) was injected intravenously before, during, or after administration of AgNO(3) in both the standard and prolonged amyloid induction protocols. The amount of amyloid deposition in the spleens was determined with the crush-and-smear technique and a 5-grade scale. Colchicine was found to inhibit the second phase of amyloidogenesis. Its best effect was achieved when administered 48 hours after initiation of AgNO(3) injections. The pattern of colchicine-inhibition-in-time in the standard and the prolonged amyloid induction protocols was similar, indicating that colchicine exerts inhibition through its effect on the inflammatory stimulus (AgNO(3)). These findings suggest that (1) colchicine suppresses amyloidogenesis in the late (second) stage and that (2) this suppression is possibly related to the anti-inflammatory effect of colchicine.

Ultrasonography as a diagnostic modality and therapeutic adjuvant in the management of soft tissue foreign bodies in the lower extremities.

BACKGROUND: Foreign bodies are sometimes overlooked in the initial evaluation of soft tissue wounds in the emergency room setting. The physical examination identifies foreign bodies that are superficial enough to be seen or palpated, while radiographs reveal those that are radio-opaque. If these two criteria are not met, however, the foreign body may remain undetected. These patients present later with long-standing pain in the area of penetration sometimes associated with localized tenderness. OBJECTIVES: To assess the role of ultrasonography in the diagnosis and management of patients with a suspected retained foreign body. METHODS: Ultrasound was used in 21 patients with suspected retained foreign bodies and the diagnosis was positive in 19. Fifteen underwent a surgical exploration in which the ultrasound was used as an adjunctive modality either pre- or intraoperatively to assist in the localization of the foreign body. RESULTS: All procedures were successful. No postoperative complications were recorded at an average follow-up of 2 years. Three patients gradually became asymptomatic and were left untreated. One patient was lost to follow-up. CONCLUSION: Sonography is an extremely effective tool for the late diagnosis of retained foreign bodies in the soft tissues. We suggest that its availability in the emergency room may decrease the rate of misdiagnosis and avoid these unfortunate cases, although this remains to be proven.

Subtalar arthritis as a presenting symptom of Familial Mediterranean fever: case report and literature review.

Familial Mediterranean fever (FMF) is an autosomal, recessive disease affecting mainly people of Mediterranean origin. The primary pattern of FMF is acute, self-resolving periodic attacks of high-grade fever, accompanied by either peritonitis, pleuritis, or arthritis and sometimes typical ankle rash that simulates erysipelas. Rare manifestations, such as pericarditis or massive knee effusion, have been reported in the literature as a presenting symptom of FMF. The final diagnosis has recently become more accurate by identification of the gene for FMF. We describe a unique presenting symptom of subtalar arthritis with no former personal or family history of FMF. A genetic evaluation revealed a 694/726 genetic variant that confirmed the diagnosis of FMF. Treatment with daily colchicine, 1 mg/day, resulted in complete resolution of all complaints.

A young athlete with myositis ossificans of the neck presenting as a soft-tissue tumour.

Myositis ossificans is usually the result of direct injury to a muscle and is a self-limiting disease. It may present as a soft-tissue mass with a broad differential diagnosis, including highly malignant tumours, such as soft-tissue sarcomas. Many theories can be found concerning the aetiology of myositis ossificans, but minor or major traumas are considered to be the most common cause. A unique case of myositis ossificans of the neck in a 17-year-old professional, female, ground gymnast, who presented initially with a soft-tissue tumour, was treated successfully. The main differential diagnosis is presented along with typical radiographic features on conventional radiography, computerised tomography and magnetic resonance imaging, and typical pathological appearance, such as the pathognomonic "zoning phenomenon". Myositis ossificans should be added to the differential diagnosis of every young patient who engages in sport presents with a soft-tissue mass. Careful padding of the area and teaching the rolling technique to avoid repeated injuries to the neck can prevent recurrence.

Fishing penetration injuries.

BACKGROUND: Fishing involves millions of people throughout the world and is considered a pleasant and harmless sport. However, many kinds of injury can occur. Penetrating injuries to the extremities by fishing equipment such as hooks and harpoons, and even by scales, or infection from penetration of scales etc are relatively common although hardly ever reported in the literature. METHODS: Illustrative cases of penetrating fishing injuries are presented and discussed, with suggestions for the recommended management of these types of injury. RESULTS: Most of these objects are designed to catch and hold resisting fish, so are usually sharp and narrow in the front and wider in the rear with or without spurs. Because of their very irregular shape, simple extraction by pulling is not recommended, because further damage may occur. CONCLUSIONS: The use of the appropriate imaging modalities, a full knowledge of the contours of the object, and careful preplanning of the method of treatment are very important.

Total hip arthroplasty in patients with below-knee amputations.

We present a unique small group of 5 patients with below-knee amputation who underwent total hip arthroplasty after a displaced subcapital fracture of the femur. Three patients were operated on after failed fixation of the fracture, and 2 were operated on as a primary procedure. All 5 patients resumed their prefracture level of activity and mobilization with no deterioration during follow-up (average, 69 months [range, 22-98]). These encouraging results call for use of total hip arthroplasty or hemiarthroplasty as the primary treatment modalities of patients with displaced subcapital femoral head fracture in an extremity with below-knee amputation.

Total hip arthroplasty after childhood septic hip in patients younger than 25 years of age.

Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of total hip arthroplasty in young patients, and the reports are on patients older than 32 years of age. We present here a unique group of very young patients with early coxarthrosis caused by septic hip in childhood, with an average age of 19.14 years (range, 14-25) at the time of the arthroplasty. The Harris hip score improved from a preoperative mean of 58.43 to a postoperative mean of 94.14. The follow-up period ranged between 2 and 24 years, with an average of 8.14 years. We conclude that total hip arthroplasty in young people with early coxarthrosis caused by septic hip in childhood provides good functional results.

The epidemic of ankle fractures in the elderly--is surgical treatment warranted?

Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%-30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 +/- 8.96 in the non-operated group compared with 75.2 +/- 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

Localization, detection and guided removal of soft tissue in the hands using sonography.

Penetrating wounds and lacerations are frequent pathologies treated in the emergency room. The management of hand trauma represents a large part of the work in any surgical practice. Although X-rays are routinely taken, numerous foreign bodies remain undetected, and the wounds are just locally debrided and the lacerations sutured. Unfortunately, as not all foreign bodies are radio-opaque, the radiography results may appear normal, but the patient fails to recover. Patients complaining of persistent wound tenderness were sent for ultrasound investigations, and foreign bodies were detected. Had ultrasonography been carried out initially in the emergency room, the correct diagnosis would have been made, and the sonographic equipment could have helped to guide the physician in his attempt to remove the foreign body. Usually, in response to continued pain, an ultrasound investigation is ordered, and the pathology becomes apparent. A number of examples are briefly described in order to highlight the present inadequacies. It is suggested that hospital administrators consider the need to provide ultrasonographic services as an integral facility of the emergency room.