Chronic Ankle Instability and Neuromuscular Performance in Prerecruitment Infantry Soldiers.

CONTEXT: Ankle instability can describe various impairments, including perceived instability (PI), mechanical instability (MI), and recurrent sprains (RSs), alone or combined. OBJECTIVE: To examine the prevalence of 8 ankle impairment subgroups and their effect on neuromuscular performance in prerecruitment combat soldiers. DESIGN: Cross-sectional study. SETTING: Military infantry basic training base. PATIENTS OR OTHER PARTICIPANTS: A total of 364 infantry male combat soldiers entering basic training (aged 18-21 years). MAIN OUTCOME MEASURE(S): Participants were assessed for PI (via the Cumberland Ankle Instability Tool), MI (using the Anterior Drawer Test and Medial Talar Tilt Test), and RSs (based on history) of their dominant and nondominant legs. Injuries were categorized in 8 subgroups: PI, RSs, PI + RSs, MI, PI + MI, MI + RSs, PI + MI + RSs, and none. Participants were screened for neuromuscular performance (dynamic postural balance, proprioceptive ability, hopping agility, and triceps surae muscle strength) during the first week of military basic training. RESULTS: For the dominant and nondominant legs, RSs were reported by 18.4% (n = 67) and 20.3% (n = 74) of the participants, respectively; PI was reported by 27.1% (n = 99) and 28.5% (n = 104) of the participants, respectively; and MI was seen in 9.9% (n = 36) and 8.5% (n = 31) of the participants, respectively. A 1-way analysis of variance showed differences in the mean proprioceptive ability scores (assessed using the Active Movement Extent Discrimination Apparatus) of all subgroups with impairments in both the dominant and nondominant legs (F = 6.943, η2 = 0.081, P < .001 and F = 7.871, η2 = 0.091, P < .001, respectively). Finally, differences were found in the mean muscle strength of subgroups with impairment in the nondominant leg (F = 4.884, η2 = 0.056, P = .001). CONCLUSIONS: A high prevalence of ankle impairments was identified among participants who exhibited reduced abilities in most neuromuscular assessments compared with those who did not have impairments. Moreover, participants with 1 impairment (PI, MI, or RSs) exhibited different neuromuscular performance deficits than those with >1 impairment.

Cross-cultural adaptation, validation and psychometric evaluation of the International Hip Outcome Tool 12 (iHOT12) to Hebrew.

BACKGROUND: The "International Hip Outcome Tool 12" (iHOT12) is a self-administered patient-reported outcome tool for measuring health-related quality of life and physical functioning in young and active patients with hip pathology. Since the iHOT12 has become widely used, we sought to translate and validate it for Hebrew-speaking populations. The aims of this study were: (1) To translate and culturally adapt the iHOT12 into Hebrew using established guidelines. (2) To test the new Hebrew version for validity, and (3) reliability. METHODS: The iHOT12 was translated and culturally adapted from English to Hebrew (iHOT12-H) according to the COSAMIN guidelines. For validity, the iHOT12-H and Western Ontario and McMaster universities osteoarthritis index (WOMAC) were completed by 200 patients with hip pathology. Exploratory factor analysis was used to assess structural validity. Subsequently, 51 patients repeated the iHOT12-H within a 2-week interval. Intraclass Correlation Coefficient (ICC), Cronbach alpha, and Standard Error of Measurement (SEM) were calculated to assess reliability. RESULTS: Construct validity: iHOT12-H correlated strongly to the WOMAC scores (r = -0.82, P < 0.001, Spearman). Factor analysis revealed a two-factor structure. Cronbach's alpha was 0.953 confirming internal consistency to be highly satisfactory. Test-retest correlation of the iHOT12-H was excellent with an ICC = 0.956 (95% CI 0.924-0.974). There was no floor or ceiling effect. CONCLUSION: The iHOT12 Hebrew version has excellent reliability, good construct validity and can be used as a measurement tool for physical functioning and quality of life in young, physically active patients with hip pathology. This study will serve Israeli researchers in evaluating treatment effectiveness for these patients. Moreover, it will also enable multinational cooperation in the study of hip pathology.

Lisfranc Injury Diagnosis: What Is the Diagnostic Reliability of New Radiographic Signs Using Three-dimensional CT?

BACKGROUND: Up to one-third of Lisfranc injuries (an injury affecting the normal stability, alignment, and congruency of the tarsometatarsal joints) are misdiagnosed. Delayed diagnosis and improper treatment may lead to long-term, irreversible sequela and functional disability. Recently, the employment of three-dimensional (3D) CT demonstrated higher diagnostic reliability, but there is limited evidence on this, and radiologic features of Lisfranc injuries when using this diagnostic modality are not well described. QUESTION/PURPOSE: What is the diagnostic performance of several novel radiographic signs on 3D CT when evaluating for Lisfranc injury, namely the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign, and what is the interobserver and intraobserver reliability of those diagnostic signs? METHODS: In this retrospective, diagnostic study, video clips of 3D CT reconstructions of 52 feet with intraoperatively confirmed Lisfranc injuries and 50 asymptomatic feet with a normal appearance of the tarsometatarsal joints, as ascertained by a subspecialty-trained foot and ankle surgeon and a musculoskeletal radiologist, were analyzed by two foot and ankle specialists and three orthopaedic residents twice each, with a washout period of 2 weeks. Among the 52 patients with intraoperative evidence of Lisfranc injury, there were 27 male patients and 25 female patients, with a median (IQR) age of 40 years (23 to 58); among the 50 controls, there were 36 male and 14 female patients, with a median age of 38 years (IQR 33 to 49). For each video clip, the presence of all three radiographic signs was documented (each sign was rated in a binary yes/no fashion). Before the evaluations, all observers underwent a short training session by the head of the foot and ankle department. Later, these reading were used to assess for the sensitivity, specificity, and area under the receiver operating characteristic curve in terms of Lisfranc diagnosis against the gold standard of intraoperative testing of tarsometatarsal joint stability. Intraoperatively, the congruency and stability of the second tarsometatarsal joint had been evaluated by direct visualization and by the insertion of a probe into the joint between the base of the second metatarsus and the medial cuneiform and twisting the probe to assess for stability. The individuals evaluating the video clips were unaware of the surgically obtained diagnosis at the time they performed their evaluations. RESULTS: All 3D radiographic signs that were examined had excellent diagnostic reliability in terms of sensitivity and specificity, ranging from 92% to 97% and from 92% to 93%, respectively. When assessing the association between the suggested 3D radiographic signs and Lisfranc injury diagnosis as a function of the area under the receiver operating characteristic curve, the Mercedes sign demonstrated a higher area under the curve than the other signs did (0.91 versus 0.87 versus 0.8; p < 0.001). The mean intraobserver and interobserver reliability (kappa) values were excellent for all 3D radiographic signs that were evaluated. CONCLUSION: The proposed radiographic findings demonstrated excellent diagnostic performance and were repeatable within and among observers. Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase because obtaining AP bilateral standing radiographs of the foot is often impractical in the acute setting. Further research and comparison with AP weightbearing radiographs of the bilateral feet may be warranted. LEVEL OF EVIDENCE: Level III, diagnostic study.

At long-term follow-up many first-time male traumatic shoulder dislocators remain symptomatic.

OBJECTIVES: To assess the status at 13 to 17 years follow-up of a cohort of young male traumatic shoulder dislocators. STUDY DESIGN: Prospective cohort study. METHODS: A prospective study of first-time young male traumatic shoulder dislocators, began in 2004. Subjects were evaluated by the apprehension test after completing rehabilitation 6 to 9 weeks post dislocation. Between March 2021 and July 2022, a telephone questionnaire was administered to ascertain their current shoulder status. Subjects were questioned about avoidance of activities of daily living and sport, participation in sports, current instability, and self-assessed shoulder function by the SANE score. RESULTS: 50/53 (94.3%) of the study subjects, mean age 20.4 years, completed a mean follow-up of 181.8 ±â€¯12 months. The non-redislocation survival was 13% for those with a positive apprehension test and 49% for those with a negative test (p = 0.007). SANE scores were 64.3 ±â€¯23.7 for those with a positive apprehension test and 83.7 ±â€¯19.7 for those with a negative test (p = 0.001). In the year before the follow-up, 33.3% of those treated conservatively and 42.9% treated surgically experienced subluxation (p = 0.5). Fifty-seven percent of those who were treated conservatively and 56% of those who underwent surgery avoided some ADL or sports because of their shoulder. CONCLUSIONS: For young male first time traumatic shoulder dislocators a positive apprehension test after rehabilitation is associated with a high risk for reoccurrence and poorer long-term results. Most subjects were still dealing with shoulder symptoms at long-term follow-up.

Impact of an Enhanced Transtheoretical Model Intervention (ETMI) Workshop on the Attitudes and Beliefs Regarding Low Back Pain of Primary Care Physicians in the Israeli Navy.

Low back pain (LBP) is a major cause of discomfort and disability. Physicians' attitudes and beliefs influence the way patients with LBP are diagnosed and treated. The objective of the study is the assessment of military primary care physicians' attitudes towards LBP and the effect of an enhanced transtheoretical model intervention (ETMI) workshop on them. We evaluated the impact of a 90-min ETMI workshop on the attitudes and beliefs of primary care physicians in the Israeli Navy on LBP. Outcomes were assessed using the Attitudes to Back Pain Scale in Musculoskeletal Practitioners questionnaire (ABS-mp). Participants responded before and after the workshop, and responses were compared to a control group of primary care physicians in the Air and Space Force. The intervention group included 22 participants and the control group included 18 participants. Both groups were heterogenic (gender, age, seniority). In both groups, primary care physicians reported the common use of non-steroidal anti-inflammatory drugs (NSAIDs) and over-the-counter (OTC) pain medications and often included physical activity and physiotherapy in the treatment plan. Physicians mentioned reassurance and suggestions of early return to physical activity as part of their appointment. There was a positive correlation between questionnaire items suggesting the physician tended to a biomedical approach and reporting the use of imaging modalities (r = 0.451, p = 0.005). After attending the workshop, physicians were significantly more likely to recommend an early return to physical activity (18 ± 0.48 vs. 16.4 ± 0.52, p = 0.04). An ETMI workshop had a minor impact on the attitudes and beliefs of primary care physicians regarding LBP, but a statistically significant impact was noted on return to physical activity recommendations. These findings may be important in the military setting.

A Novel Classification for Diabetic Foot Ulcers of the First Ray.

OBJECTIVE: Diabetic foot ulcers of the first ray result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed if surgical offloading is contemplated. The objective of this study was to create a classification of the anatomical deformities of first-ray ulcers that could lead to better standardization of treatment and reporting. METHODS: The authors performed a file review of patients with diabetic neuropathy diagnosed with first-ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was the metatarsophalangeal joint, the interphalangeal joint, and the distal phalanx. RESULTS: Records for 59 patients (mean age, 62 years) with University of Texas A1 and A2 ulcers were reviewed. Mean ulcer duration was 2 months. The more common deformities were hallux valgus (41%), hallux valgus interphalangeus (14%), and hallux malleus (20%), and these were primarily associated with metatarsophalangeal, interphalangeal joint, and tip-of-toe ulcers, respectively (P < .0001). CONCLUSIONS: By classifying ulcer locations, the relevant corrective surgery may be chosen. Although some prophylactic procedures may be safe and effective, prophylactic hallux valgus correction in the diabetic foot requires further study.

Radiographic Bone Healing in Minimally Invasive Floating Metatarsal Osteotomy for Neuropathic Plantar Metatarsal Head Ulcers - A Retrospective Cohort Study.

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.

The role of three dimension computed tomography in Lisfranc injury diagnosis.

PURPOSE: To evaluate the intra/inter observer and diagnostic reliability of 3-dimensional (3D) model reconstruction computed tomography (CT) compared to the traditional two-dimensional (2D) CT when evaluating Lisfranc (LF) injuries. METHODS: A retrospective study was performed on CT studies of patients with clinically suspected LF injuries examined in the emergency department at medium size medical center. Each CT study was evaluated for metatarsal fractures and subluxations employing both standard 2D and 3D CT model reconstruction. Four orthopaedists, 2 senior and 2 residents, were assigned to review and evaluate each CT. Each CT study was reviewed twice by each reader in a randomized order. Descriptive statistics were calculated for all measured variables. The intra-observer and inter-observer agreement Kappa coefficients were calculated to evaluate reliability and reproducibility between and within readers for each modality. RESULTS: The study included 44 patients. Median age was 41.4 years (interquartile range, 23-58). The intra-observer and inter-observer reliability was good (intra-observer; 3D Kappa; 0.76 and 2D Kappa 0.73 p<0.001, inter-observer; 3D Kappa 0.68, 2D Kappa 0.63 and combined 2D and 3D kappa 0.68, p<0.001). Three dimensional CT was found to be more sensitive than 2D CT, specifically when evaluating for second metatarsal dislocation (sensitivity: 70% vs 47%). Combined evaluation of 2D and 3D CT, greatly improved sensitivity rate to 85.7%. In terms of fracture diagnosis, combined evaluation of 2D and 3D CT showed higher sensitivity and specificity rates as compared to 2D or 3D alone. CONCLUSION: The employment of 3D CT in LF injury diagnosis, in isolation and in combination with 2D CT, seems to improve the diagnostic accuracy and reliability between and within observers compared to 2D CT alone.

Lower Extremity Amputee Outcomes with Reference to Co-morbidities.

BACKGROUND: Lower extremity amputation related to diabetes is a serious outcome, which can have devastating effects on the patient and family. The epidemiology of amputations has recently been used as a possible measure of the adequacy of medical prevention and treatment of diabetes and diabetic foot complications. OBJECTIVES: To report on patients undergoing amputations at one medical center in Israel, their co-morbidities, and the outcomes. METHODS: A retrospective chart study was conducted of amputees operated between 1 September 2017 and 30 September 2018. RESULTS: The study population comprised 72 patients who had major amputations for diabetes and/or ischemia, mean age 72 ± 10 years, 74% males, 93% with type 2 diabetes. Mean age corrected Charlson Comorbidity Index was 8.2 ± 2.1 with 90% (65 patients) presenting with a score of 6 or higher. Before the recent deterioration, fewer than 20% of the patients exited their home routinely and 24% had an official diagnosis of dementia. There were 31 below knee amputations (BKA) and 41 above knee amputations (AKA). The 30-day, 3-month, 1-year, and 2-year mortality rates were 15.3%, 27.8%, 43.1%, and 54.2% respectively. Median survival period was 20 months. Survival after AKA was 13.4 ± 20, which was significantly less than after BKA (25.4 ± 2.7, P = 0.097). CONCLUSIONS: Factors other than the quality of management of patients with diabetes and complications may contribute to amputation rates; thus, making speculations from international comparisons of raw amputation rates problematic. This population was less healthy than reported in most studies.

Short-term Results and Return to Duty Following Hip Arthroscopy in Soldiers.

BACKGROUND: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement. OBJECTIVES: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty. METHODS: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record. RESULTS: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18-42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity. CONCLUSIONS: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.

In vivo strains at the middle and distal thirds of the tibia during exertional activities.

There is a known variance in the incidence and anatomical site of tibial stress fractures among infantry recruits and athletes who train according to established uniform training programs. To better understand the biomechanical basis for this variance, we conducted in vivo axial strain measurements using instrumented bone staples affixed in the medial cortex, aligned along the long axis of the tibia at the level of the mid and distal third of the bone in four male subjects. Strain measurements were made during treadmill walking, treadmill running, drop jumps from a 45 cm height onto a force plate and serial vertical jumps on a force plate. Significance levels for the main effects of location, type of activity and their interaction were determined by quasi-parametric methodologies. Compared to walking, running and vertical jumping peak axial tensile strain (µÎµ) was 1.94 (p = 0.009) and 3.92 times (p < 0.001) higher, respectively. Peak axial compression strain (µÎµ) values were found to be greater at the distal third than at the mid tibia for walking, running and vertical jumping (PR = 1.95, p-value<0.001). Peak axial compression and tension strains varied significantly between the subjects (all with p < 0.001), after controlling for strain gauge location and activity type. The study findings help explain the variance in the anatomical location of tibial stress fractures among participants doing the same uniform training and offers evidence of individual biomechanical susceptibility to tibial stress fracture. The study data can provide guidance when developing a generalized finite element model for mechanical tibial loading. For subject specific decisions, individualized musculoskeletal finite element models may be necessary.

Mini Invasive Floating Metatarsal Osteotomy for Diabetic Foot Ulcers Under the First Metatarsal Head: A Case Series.

Diabetic foot ulcers under the first metatarsal head are difficult to treat and prevent recurrence. The aim of this study is to summarize the results of a distal first metatarsal minimally invasive floating osteotomy for ulcers under the first metatarsal head in patients with diabetic neuropathy. We reviewed files of patients with diabetic neuropathy undergoing a floating first metatarsal osteotomy. Demographic and clinical data were collected and analyzed to determine success and complications. We found records for 21 patients (mean age 64) with University of Texas 1A ulcers. The ulcer's mean age was 11.2 months. Following surgery, the ulcer completely resolved after a mean of 3.7 (2 to 11) weeks in 19 patients. During the first year, there were 4 complications related to the surgery (including 3 infections). At latest follow-up, 17/21 (81%) patients had healed with satisfactory results. Minimal invasive floating distal osteotomy of the first metatarsal can cure and prevent recurrence of diabetic foot ulcers under the first metatarsal head in 80% of the patients, but the ability to provide close follow-up and prompt response are prerequisites.

Does Acute Exercise Stress Affect Postural Stability and Cognitive Function in Subjects with Chronic Ankle Instability?

Altered postural control in people with chronic ankle instability (CAI) may be attributed to deficits that are associated with neurocognitive function. Acute training is another factor that may negatively affect postural control and increase the risk of ankle sprain. The purpose of this investigation was to determine the effect of acute exercise on postural stability and cognitive function among patients with CAI. Fifteen patients with CAI (aged 21.5 ± 2.0 years) and 15 healthy controls (aged 20.3 ± 1.7 years) completed a single-limb stance postural control test and a battery of computer-based cognitive tests before and after acute exercise. The overall stability index (OSI) was used as a measure of postural stability. The cognitive domains tested were global cognitive score, executive function, attention, visual-spatial perception, information processing, and fine motor control. Subjects in both groups had similar OSI scores, with a trend for reduced stability in the CAI after the exercise protocol (p = 0.053). There were no differences between the groups in all cognitive domains before or after exercise. Following exercise, the domains of overall cognitive score, visual-spatial perception, and information processing speed improved in both groups (p = 0.003, p = 0.033, p = 0.001; respectively). These findings should be considered with caution due to the heterogeneity of the CAI population.

Reliability of Trigger Point Evaluation in the Lower Leg Muscles.

BACKGROUND: Myofascial trigger point diagnosis is a clinical palpatory skill dependent on the patient's subjective response. The inter- and intra-rater reliability of trigger point physical evaluation in the lower leg muscles has rarely been reported. Previous reliability studies suffered from the Kappa paradox. OBJECTIVE: To evaluate the inter- and intra-rater reliability of trigger point recognition in the lower leg muscles implying a specific method to overcome the first Kappa paradox. DESIGN: A reliability study with pre-second examiner exclusion to correct prevalence index. SETTING: Physical therapy outpatient clinic, Beer-Sheva, Israel. SUBJECTS: In sum, 86 soldiers aged 18-30 referred for physical therapy with a diagnosis of musculoskeletal pain consented to take part in this study; 26 were excluded for lacking trigger points, leaving 60 subjects for analysis (31 women, 29 men). METHODS: Both legs were evaluated, and the results were analyzed separately for symptomatic (N = 87) and asymptomatic legs (N = 31). Each subject was evaluated three times, twice by one examiner, and once by a second examiner. Dichotomous findings including palpable taut-band, tenderness, referred pain, and relevance of referred pain were recorded. RESULTS: Inter-rater reliability for active trigger points ranged from 0.49 to 0.75 (median: 0.52) and intra-rater reliability ranged from 0.41 to 0.84 (median: 0.65) and. For total trigger points intra-rater reliability ranged from 0.52 to 0.79 (median: 0.67), and inter-rater reliability ranged from 0.44 to 0.77 (median: 0.66). CONCLUSIONS: Physical examination is a reliable method of trigger point evaluation in lower leg muscles, and it can be used as a diagnostic method for trigger point evaluation.

The correlation between the ACR questionnaire and fitness for work of fibromyalgia patients.

OBJECTIVES: Fibromyalgia (FM) is a central pain syndrome characterised by widespread pain, fatigue, unrefreshing sleep, memory impairment and cognitive changes, predominantly in women, and is a cause for disability and frequent sick leave. So far, no assessment has been made of the use of the American College of Rheumatology (ACR) 2010 questionnaire in the fitness for work (FFW) assessment of FM patients. To assess the correlation between the severity of FM as measured by the ACR questionnaire and other parameters and FFW. METHODS: We conducted a retrospective cross-sectional study involving women with FM who had their FFW assessed at an occupational health clinic between 2014-2018. The ACR questionnaire was completed during the medical assessment. RESULTS: We examined 60 files of women, mean age 48.8 years. Absolute loss of working capacity (ALWC) was calculated in relation to a standard 8-hour workday, while relative loss of working capacity (RLWC) was based on the patient's actual appointment percentage before the examination. The average ALWC determined by the occupational physicians was 59% ± 33%. Age group correlated significantly with ALWC (correlation coefficient = 0.03, p<0.05). The Part 2b symptoms (0-41) also correlated significantly with ALWC (mean ± SD 21.8±5.6, correlation coefficient = 0.23, p<0.05). Medical treatment correlated significantly with RLWC (correlation coefficient = 0.02, p<0.05). The rate of disability was high compared to what was reported in other studies. The correlation between different parts of the ACR questionnaire and disability demonstrated that symptom severity is a predictor of loss of working capacity. CONCLUSIONS: When performing a FFW assessment of FM patients, physicians may use the ACR questionnaire, since FFW correlates with its score. We assume that patients who experience more pain visit their physicians more often and consume more analgesics.

Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers.

BACKGROUND: Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study's purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers. METHODS: We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year. RESULTS: Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa (P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s (P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics. CONCLUSION: This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence. LEVEL OF EVIDENCE: Level III, retrospective case series of prospectively collected data.

Reliability and validity of the Hebrew version of the forgotten joint score for assessing the outcomes of total knee arthroplasty.

BACKGROUND: This prospective study aimed to assess the reliability and validity of the Hebrew version of the forgotten joint score-12 in patients undergoing total knee arthroplasty, because it is going to be used in the Hebrew-speaking populations in Israel. METHODS: The English version of forgotten joint score-12 was translated into Hebrew version by using the standard procedures and in collaboration with its authors. The consecutive patients who had undergone total knee arthroplasty in a single hospital were asked to fill out the Hebrew version of forgotten joint score-12, Oxford knee score, Short Form 12, and visual analog scale. A random subgroup of 60 patients were then asked to fill out a second Hebrew version of forgotten joint score-12 at a minimum of 2-week interval. The reliability was assessed in terms of internal consistency, test-retest reliability and split-half reliability. The validity was measured in terms of the outcomes as mentioned above. RESULTS: A total of 102 patients participated in the study. The Hebrew version of forgotten joint score-12 showed high reliability. The internal consistency was excellent (Cronbachs' α = 0.943) and test-retest reliability was high (Intraclass correlation = 0.97). The forgotten joint scores were correlated with the Oxford knee score, Short Form 12, and visual analog scale (r = 0.86, r = 0.72, and r=-0.8, respectively), indicating a high validity. CONCLUSIONS: The Hebrew version of forgotten joint score-12 has excellent reliability, excellent test-retest reliability and good validity. It can be safely used for assessing outcomes of TKA.

Medial tibial stress fracture diagnosis and treatment guidelines.

OBJECTIVES: To validate and make evidence based changes to the Israel Defense Forces medial tibial stress fracture diagnosis and treatment protocol. DESIGN: Prospective cohort study. METHODS: 429 Elite infantry recruits were reviewed for signs and symptoms of medial tibial stress fracture during 14 weeks of basic training. Suspicion of medial tibial stress fracture was based on the presence of pain, tenderness <1/3 the length of the tibia and a positive fulcrum and/or hop test. Recruits with suspected medial tibial stress fractures were initially treated with 10-14 days of rest. Bone scan was performed only when recruits failed to respond to the rest regimen or required immediate diagnosis. RESULTS: 31 Out of 49 recruits with a suspicion of medial tibial stress fracture underwent bone scan, including 8/26 recruits whose symptoms did not resolve after being treated clinically as stress fractures. There was a significantly greater incidence of medial tibial stress fractures when a positive hop test was present in addition to tibial pain and tenderness (p=0.0001), odds ratio 52.04 (95% CL, 2.80-967.74). Medial tibial stress fracture was found to occur when the band of tibial tenderness was ≤10cm in length. Tibial pain scores were not predictive of stress fracture. CONCLUSIONS: This validation study provides the clinician with evidence based guidelines for the clinical diagnosis and treatment of medial stress fractures and their differentiation from shin splints. An initial treatment protocol without the use of imaging was found to be effective in more than two-thirds of the cases.

Occupational influences on Spondylolysis and Spondylolisthesis in a cohort of 18-year-old male military conscripts.

BACKGROUND: The reported prevalence of spondylolysis (SL) in the adult population is 6-7%. Data concerning adolescent-onset spondylolisthesis (SLS) and the impact of certain activities on it is scarce. We examined the risk of clinical progression of SL and SLS as a function of primary severity and occupational strain among military recruits. METHODS: Based on the Israel defense Force (IDF) central human resources database, we identified 1521 18-year-old males inducted to the IDF with SL/SLS between the late nineteen nineties and early two-thousands. We followed changes in the SL/SLS status during the 3 years of obligatory military service. Disease severity was classified as Cat2: radiological findings of SL without clinical findings; Cat3: painful SL or asymptomatic grade 1 SLS; Cat4: grade 1 SLS with pain; Cat5: Grade 2 SLS. The soldiers were subdivided into the following occupational categories: administrative, combat, maintenance, and driving. The purpose was to compare the progression rates in different medical categories and job assignments. RESULTS: There were 162 recruits in Cat2, 961 in Cat3, and 398 recruits in Cat4. The overall progression rate to Cat5 (grade 2 SLS) was 1.02%. Significant progression rates were seen amongst administrative soldiers with a relatively higher risk of progression from Cat4 (painful-grade-1 SLS: 2.2%) vs. Cat3 (asymptomatic SLS: 0.5%, relative risk = 4.7, p < 0.02). Other occupational categories did not exhibit significant progression rates. CONCLUSION: Progression of SL/SLS was highest in Cat4, i.e. for recruits already diagnosed with painful SLS (i.e. with a more severe baseline disorder). Progression did not correlate with military occupation. We recommend further follow-up studies that include, aside from progression rates, incidence rates of newly diagnosed grade 2 SL during military service.