Israel Medical Association Journal

Background: Surgery for hip fractures within 48 hours of admission is considered standard. During the lockdown period due to the coronavirus disease-2019 (COVID-19) epidemic, our medical staff was reduced.

Objectives: To compare the demographics, treatment pathways, and outcomes of patients with hip fractures during the COVID-19 epidemic and lockdown with the standard at routine times.

Methods: A retrospective study was conducted of all patients who were treated surgically for hip fracture in a tertiary center during the COVID-19 lockdown period between 01 March and 01 June 2020 and the equivalent period in 2019. Demographic characteristics, time to surgery, surgery type, hospitalization time, discharge destination, postoperative complications, and 30- and 90-day mortality rates were collected for all patients.

Results: During the COVID-19 period, 105 patients were operated due to hip fractures compared to 136 in the equivalent period with no statistical difference in demographics. The rate of surgeries within 48 hours of admission was significantly higher in the COVID-19 period (92% vs. 76%, respectively; P = 0.0006). Mean hospitalization time was significantly shorter (10 vs. 12 days, P = 0.037) with diversion of patient discharge destinations from institutional to home rehabilitation (P < 0.001). There was a significant correlation between the COVID-19 period and lower 90-day mortality rates (P = 0.034). No statistically significant differences in postoperative complications or 30-day mortality rates were noted.

Conclusions: During the COVID-19 epidemic, despite the limited staff and the lack of therapeutic sequence, there was no impairment in the quality of treatment and a decrease in 90-day mortality was noted.

Background: Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world.

Objectives: To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture

Methods: We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6–12 weeks following the fracture to ensure treatment initiation.

Results: From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate.

Conclusions: FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center

Background: Proximal femoral fractures (PFF) are among the most common injuries in the elderly population treated by orthopedic surgeons. Postoperative complications, especially infections, are of great importance due to their effect on patient mortality and morbidity and healthcare costs.

Objectives: To assess the main causes for postoperative infection among PFF patients.

Methods: We conducted a retrospective analysis of PFF patients in our medical center between 2015 and 2017. Patients were divided into two groups based on whether there was postoperative infection during immediate hospitalization and 30 days after surgery. Factors such as time from admission to surgery, duration of surgery, and length of stay were analyzed. Groups were analyzed and compared using a t-test, chi-squared and Fisher’s exact tests.

Results: Of 1276 patients, 859 (67%) underwent closed reduction internal fixation, 67 (5%) underwent total hip arthroplasty, and 350 (28%) underwent hemiarthroplasty. Of the total, 38 patients (3%) were diagnosed with postoperative infection. The demographics and co-morbidities were similar between the two study groups. The incident of infection was the highest among patients undergoing hemiarthroplasty (6%, P < 0.0001). Length of hospitalization (15 vs. 8 days, P = 0.0001) and operative time (117 vs. 77 minutes, P = 0.0001) were found to be the most significant risk factors for postoperative infection.

Conclusions: Predisposition to postoperative infections in PPF patients was associated with prolonged length of surgery and longer hospitalization. We recommend optimizing fast discharge, selecting the appropriate type of surgery, and improving surgical planning to reduce intraoperative delays and length of surgery.

Background: The incidence of fragility hip fractures, intracapsular and extracapsular, has been increasing worldwide. Fracture stability is important for treatment decision-making and is related to the expected rate of complications. It is unclear whether metabolic therapy explains the increased incidence of unstable fractures.

Objectives: To investigate the possible association between treatment with bisphosphonates and the various patterns encountered with intertrochanteric hip fractures.

Methods: Patients with fragility hip fractures who were treated in our department between 2013 and 2014 were included in this study. They were classified into three groups: group 1 had a stable extracapsular fracture, group 2 had an unstable extracapsular fracture, and group 3 had an intracapsular fracture. Collated data included: osteoporosis preventive therapy and duration, fracture-type, history of previous fractures, and vitamin D levels.

Results: Of 370 patients, 87 were previously treated with bisphosphonates (18.3% prior to fracture in group 1, 38.3% in group 2, and 13.8% in group 3). Of those treated with bisphosphonates, 56.3% had an unstable fracture, 21.8% had a stable fracture, and the rest an intracapsular fracture. In contrast, only 27.9% of patients who were not treated with bisphosphonates had an unstable fracture and 30.0% had stable fractures.

Conclusions: Our findings show a higher proportion of complex and unstable fractures among patients with fragility hip-fractures who were treated with bisphosphonates than among those who did not receive this treatment. The risk for complex and unstable fracture may affect the preferred surgical treatment, its complexity, length of surgery, and rehabilitation.

Background: In recent years, treatment for Achilles tendon rupture (ATR) went through radical changes: from the conservative non-weight bearing approach to a functional protocol. This functional protocol allows complete weight bearing after only 2 weeks by placing the foot in a plastic boot in tapered down equines and using interchangeable wedges under the heel. This change of approach has dramatically lowered the rate of re-rupture.

Objectives: To describe our preliminary results with this functional protocol and to assess outcome measures in the functional conservative treatment.

Methods: The study comprised 15 people who were evaluated clinically and by sonograph. We measured calf circumference, ankle joint range of motion (ROM), and single-leg heel-rise test (SLHRT). In addition, standard scoring methods (Achilles Tendon Rupture Score and Physical Activity Scale) were examined.

Results: In our cohort 14 people successfully gained SLHRT. The mean Achilles Tendon Rupture Score functional questionnaire and Physical Activity Scale physical activity questionnaire score was 85.6 of 100, and 4.7 of 6, respectively. There were no significant differences in ankle ROM compared to the uninjured limb. There was statistically significant reduction in the calf circumference and soleus muscle thickness sonographically.

Conclusions: It seems that the conservative functional treatment of ATR demonstrates good functional outcomes, with the patients returning to close to normal activity, although noted muscle wasting and weakness. This protocol presents a true alternative to surgery and should be considered for most non-insertional Achilles tendon tears

Background: Acute extremity compartment syndrome is a surgical emergency for which timely diagnosis is essential.

Objectives: To assess whether the time from the initial insult to the fasciotomy of compartment syndrome of the upper extremity affects outcomes and to examine the differences between compartment syndrome secondary to fractures and that resulting from a non-fracture etiology with regard to the time from insult to fasciotomy and the long-term patient outcomes.

Methods: Patients presented with documented fasciotomy treatment following acute upper extremity compartment syndrome and a minimum of 6 months follow-up. Patient information included demographics, cause of compartment syndrome, method of diagnosis, and outcome on follow-up.

Results: Our study was comprised of 25 patients. Fasciotomies were performed for compartment syndrome caused by fracture in 11 patients (44%), and due to insults other than fractures in 14 patients (56%). The average time to fasciotomy in patients without a fracture was 10.21 hours and 16.55 hours with a fracture. Fasciotomy performed more than 24 hours from the initial insult was not found to significantly affect long-term sequelae compared to fasciotomy performed earlier than 24 hours from the initial insult. The non-fracture group had more long-term sequelae than the fracture group (13/15 patients and 5/11 patients, respectively).

Conclusions: Most injuries treated for fasciotomy of compartment syndrome were non-fracture related, with more complications found in patients with non-fracture related injuries. Time interval from insult to fasciotomy did not affect outcome and was longer in the fracture group, suggesting longer monitoring in this group and supporting fasciotomy even with late presentation.

Background: Cervical spinal surgery is considered safe and effective. One of the few specific complications of this procedure is C5 nerve root palsy. Expressed primarily by deltoid muscle and biceps brachii weakness, it is rare and has been related to nerve root traction or to ischemic spinal cord damage.

Objectives: To determine the clinical and epidemiological traits of C5 palsy. To determine whether C5 palsy occurs predominantly in one specific surgical approach compared to others.

Methods: A retrospective study of patients who underwent cervical spine surgery at our medical center during a consecutive 8-year period was conducted. The patient data were analyzed for demographics, diagnosis, and surgery type and approach, as well as for complications, with emphasis on the C5 nerve root palsy.

Results: The study group was comprised of 124 patients. Seven (5.6%) developed a C5 palsy following surgery. Interventions were either by anterior, by posterior or by a combined approach. Seven patients developed this complication. All of whom had myelopathy and were older males. A combined anteroposterior (5 patients) and posterior access (2 patients) were the only approaches that were associated with the C5 palsy. None of the patients who were operated via an anterior approach did develop this sequel.

Conclusions: The incidence of the C5 root palsy in our cohort reached 5.6%. Interventions performed through a combined anterior-posterior access in older myelopathic males, may carry the highest risk for this complication

Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment

Background: The coronavirus disease-2019 (COVID-19) pandemic forced drastic changes in all layers of life. Social distancing and lockdown drove the educational system to uncharted territories at an accelerated pace, leaving educators little time to adjust.

Objectives: To describe changes in teaching during the first phase of the COVID-19 pandemic.

Methods: We described the steps implemented at the Technion–Israel Institute of Technology Faculty of Medicine during the initial 4 months of the COVID-19 pandemic to preserve teaching and the academic ecosystem. 

Results: Several established methodologies, such as the flipped classroom and active learning, demonstrated effectiveness. In addition, we used creative methods to teach clinical medicine during the ban on bedside teaching and modified community engagement activities to meet COVID-19 induced community needs. 

Conclusions: The challenges and the lessons learned from teaching during the COVID-19 pandemic prompted us to adjust our teaching methods and curriculum using multiple online teaching methods and promoting self-learning. It also provided invaluable insights on our pedagogy and the teaching of medicine in the future with emphasis on students and faculty being part of the changes and adjustments in curriculum and teaching methods. However, personal interactions are essential to medical school education, as are laboratories, group simulations, and bedside teaching

Background: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries.

Objectives: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic.

Methods: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications.

Results: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001).

Conclusions: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition

Background: Psoriatic arthritis (PsA) is an inflammatory rheumatic disease characterized by different phenotypes in terms of joint involvement. The so-called oligoarticular pattern involves fewer than five active joints at a different time points. The evaluation of disease activity in this subset of patients is an unmet need due to the lack of specific indices able to capture modifications over time.

Objectives: To evaluate the ability of musculoskeletal ultrasound to monitor the response to apremilast treatment in oligoarticular PsA patients.

Methods: We evaluated 24 oligoarticular patients (19 women, 5 men; median age 56 years, interquartile range (IQR) 19; median disease duration 5 years, IQR 5.75). All patients were assessed at baseline (T0), and after 6 (T1), 12 (T2), and 24 (T3) weeks. Clinical assessment included evaluation of 66 swollen joints and patient global health assessment. All the patients underwent ultrasound assessment of the clinically involved joints. Synovial effusion/hypertrophy and power Doppler were scored with a semi-quantitative scale (0–3). The total inflammatory score was the sum of the scores.

Results: We found a reduction in the ultrasound inflammatory score at all time points, with a significant improvement at 6 and 12 weeks of treatment compared with baseline: T0 median 8.5 (IQR 5.0); T1 3.5 (3.0); T2 2.0 (3.5); P  = 0.01. We observed a significant reduction of patient global health assessment after 24 weeks (T0 median 50 (32.5); T3 40 (57.5); P = 0.01).

Conclusions: Musculoskeletal ultrasound could be useful in the assessment of treatment response in PsA patients with oligoarticular subset

Background: Adenovirus infections are prevalent in children. They usually cause a mild self-limited disease. However, this infection can be associated with considerable morbidity and mortality in specific populations, especially among immunocompromised children. Children with Down syndrome are susceptible to a higher frequency and increased severity of viral infections. Little is known about the severity and clinical course of adenovirus infections in children with Down syndrome.

Objectives: To characterize hospitalized children diagnosed with Down syndrome and presenting with adenovirus infection.

Methods: We performed a retrospective review of children admitted with adenovirus from January 2005 to August 2014 from a single tertiary pediatric medical center in Israel. Data were compared between patients with and without Down syndrome.

Results: Among the 486 hospitalized children with adenoviral infection, 11 (2.28%) were diagnosed with Down syndrome. We found that children with Down syndrome were more likely to experience a higher incidence of complications (18.2% vs. 2.4%, P = 0.008), a higher rate of admissions to the intensive care unit (36.4% vs. 2.4%, P < 0.001), and more prolonged hospitalizations (17 ± 15.9 days compared to 4.46 ± 3.16, P = 0.025).

Conclusions: Children with Down syndrome who were hospitalized with adenovirus infection represent a high-risk group and warrant close monitoring. If a vaccine for adenovirus becomes available, children with Down syndrome should be considered as candidates

Background: Screening for asymptomatic urinary retention (AUR) in older adult men at hospital admission to the internal medicine department has never been studied.

Objectives: To assess the incidence of AUR in older adult men at hospital admission, its risk factors, and its outcome.

Methods: The study comprised 111 older adult men aged ≥ 75 years who were admitted to three internal medicine departments. All men underwent post-void residual (PVR) urine volume measurement on the morning following admission by using a portable ultrasound bladder scan. AUR was defined as a PVR urine volume of ≥ 200 ml without symptoms. Men with AUR had a follow-up phone call concerning symptoms and urinary catheter status30 days following hospitalization.

Results: Seven (6.3%) men had AUR. Relative to the 104 men without AUR, they had significantly higher prevalence of severe dependency (6/7 vs. 33/104, 85.7% vs. 31.7%, (P = 0.007), cognitive impairment (5/7 vs. 19/104, 71.4% vs. 18.3%, P = 0.005), and use of anticholinergic agents (4/7 vs. 19/104, 57.1% vs. 18.3%, P = 0.033). A urinary catheter was inserted in one man (14.3%), but it was removed later during hospitalization. No symptoms were reported and no urinary catheter was inserted following hospitalization in men with AUR.

Conclusions: AUR in older adult men at hospital admission is uncommon and has a favorable outcome. Hence, screening for AUR in all older adult men at admission is not recommended, but it may be considered in severely dependent older adult men with cognitive impairment who use anticholinergic agents

Background: Pregnant women with Marfan syndrome (MS) have a high risk of aortic dissection around delivery and their optimal management requires a multi-disciplinary approach, including proper cardio-obstetric care and adequate pain management during labor, which may be difficult due to the high prevalence of dural ectasia (DE) in these patients.

Objectives: To evaluate the multidisciplinary management of MS patients during labor.

Methods: Nineteen pregnant women (31 pregnancies) with MS were followed by a multi-disciplinary team (cardiologist, obstetrician, anesthesiologist) prior to delivery.

Results:^. Two patients had kyphoscoliosis; none had previous spine surgery nor complaints compatible with DE. In eight pregnancies (7 patients), aortic root diameter (ARd) before pregnancy was 40 to 46 mm. In this high-risk group, one patient underwent elective termination, two underwent an urgent cesarean section (CS) under general anesthesia, and five had elective CS; two under general anesthesia (GA), and three under spinal anesthesia. In 23 pregnancies (12 patients), ARd was < 40 mm. In this non-high-risk group three pregnancies (1 patient) were electively terminated. Of the remaining 20 deliveries (11 patients), 14 were vaginal deliveries, 9 with epidural analgesia and 5 without. Six patients had a CS; four under GA and two2 under spinal anesthesia. There were no epidural placement failures and no failed responses. There were 2 cases of aortic dissection, unrelated to the anesthetic management.

Conclusions: The optimal anesthetic strategy during labor in MS patients should be decided by a multi-disciplinary team. Anesthetic complications due to DE were not encountered during neuraxial block

Background: Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.

Objectives: To investigate the possible implication of TR among STEMI patients.

Methods: We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR as well as the relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.

Results: The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%, P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (2.44, 95% confidence interval 1.06–5.6, P = .036) for patients with moderate to severe TR.

Conclusions: Among STEMI patients after primary PCI, the presence of moderate to severe TR was independently associated with adverse outcomes and significantly lower survival rate