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  • Arthroscopic Treatment of Mild/Borderline Hip Dysplasia with Concomitant Femoroacetabular Impingement-Literature Review. Current reviews in musculoskeletal medicine Atzmon, R., Safran, M. R. 2022


    PURPOSE OF REVIEW: This literature review aims to survey the current knowledge about the management FAI in the setting of borderline hip dysplasia.RECENT FINDINGS: With better understanding, hip arthroscopy has recently been advocated for treating mild or borderline hip dysplasia (BDH) with concomitant femoroacetabular impingement (FAI) despite early studies that condemned its use. Recent outcome data have demonstrated that hip arthroscopy is a viable option in BDH, with and without FAI, and has been gaining wider acceptance. Hip arthroscopy can address the concomitant soft tissue and bony intra-articular pathologies and obviate the necessity for other surgeries. Moreover, hip arthroscopy may be used as an adjuvant treatment to other procedures such as a periacetabular osteotomy (PAO). Hip arthroscopy for BDH is an evolving procedure with promising short- and mid-term outcomes. The combination of BDH and FAI is becoming recognized as a problem in its own right, requiring dedicated treatment.

    View details for DOI 10.1007/s12178-022-09765-4

    View details for PubMedID 35708882

  • Bipolar hemiarthroplasty may reduce cerebrovascular accidents and improve early weight-bearing in the elderly after femoral neck fracture MEDICINE Dubin, J., Atzmon, R., Feldman, V., Farkash, U., Nyska, M., Rath, E., Palmanovich, E. 2022; 101 (4): e28635


    Cerebrovascular accidents (CVA) in the elderly population after femoral neck fracture remain great concern for physicians. Specifically, surgical fixation techniques, such as bipolar hemiarthroplasty (HA) and internal fixation play a significant role in influencing the occurrence of postoperative CVA in the elderly population.In order to identify 2 cohorts, we used a rigid selection process based on our institution's database. The cohorts were comprised of a HA cohort and a cannulated screw cohort, of which underwent femoral neck surgery, performed by 3 fellowship trained surgeons from 2003 to 2014. Risk factors were documented and measured, including Coumadin use and hypertension, and postoperative complications such as CVA and death rate were also recorded. A P-value of <.05 was determined to be statistically significant.A power analysis was performed and achieved a power of 0.95. We found a non-significant reduction in CVA for bipolar HA (3.6% CVA vs 0.0% in the non-CVA group, P = .48) and a non-significant increase in CVA for cannulated screw use (7.6% CVA vs 14.4% in the non-CVA group, P = .11). In addition, we found a significant difference in terms of weight-bearing status at 6-weeks postoperatively (0.95 vs 2.0, P < .0001), favoring the bipolar HA group.Among the advantages of bipolar HA surgery, surgeons should consider its value in reducing the occurrence of postoperative CVA. Furthermore, patients who underwent bipolar HA had improved weight-bearing status postoperatively compared with cannulated screw fixation.

    View details for DOI 10.1097/MD.0000000000028635

    View details for Web of Science ID 000748355900007

    View details for PubMedID 35089201

    View details for PubMedCentralID PMC8797593

  • Amputation versus Primary Nonoperative Management of Chronic Osteomyelitis Involving a Pedal Digit in Diabetic Patients. Journal of the American Podiatric Medical Association Feldman, V., Segal, D., Atzmon, R., Ron, I., Nyska, M., Ohana, N., Palmanovich, E. 2021; 111 (4)


    The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis.We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated.The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69).Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.

    View details for DOI 10.7547/19-155

    View details for PubMedID 34478533

  • The Efficacy of Labral Reconstruction: A Systematic Review ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Safran, N., Rath, E., Haviv, B., Atzmon, R., Amar, E. 2021; 9 (2): 2325967120977088


    With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.Systematic review; Level of evidence, 3.PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.

    View details for DOI 10.1177/2325967120977088

    View details for Web of Science ID 000620771300001

    View details for PubMedID 33644246

    View details for PubMedCentralID PMC7894601

  • Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY Warschawski, Y., Ankori, R., Rutenberg, T., Steinberg, E. L., Atzmon, R., Drexler, M. 2022; 142 (5): 777-785


    Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN.A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life.The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively).According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures.Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.

    View details for DOI 10.1007/s00402-020-03726-7

    View details for Web of Science ID 000607342200006

    View details for PubMedID 33417024

  • The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery ARCHIVES OF ORTHOPAEDIC AND TRAUMA SURGERY Atzmon, R., Drexler, M., Ohana, N., Nyska, M., Palmanovich, E., Dubin, J. 2022; 142 (6): 947-953


    Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold.There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively).We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

    View details for DOI 10.1007/s00402-020-03721-y

    View details for Web of Science ID 000607342200014

    View details for PubMedID 33417019

  • Midterm Outcomes and Satisfaction After Hip Arthroscopy Are Associated With Postoperative Rehabilitation Factors ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Amar, E., Martin, R. L., Tudor, A., Factor, S., Atzmon, R., Rath, E. 2021; 9 (1): 2325967120981888


    Arthroscopic hip-preservation surgery is commonly performed to address nonarthritic sources of hip pain in young, active individuals. However, there is little evidence to support postoperative rehabilitation protocols, including the most appropriate frequency and length of individual formal physical therapy sessions. There is also a lack of information to look at patients' perceived value of their home program/self-practice in relation to outcomes.To investigate postoperative rehabilitation factors after hip arthroscopy related to formal physical therapy and home program/self-practice and their correlation with patient outcomes and satisfaction.Cohort study; Level of evidence, 3.A total of 125 patients who underwent hip arthroscopy for femoroacetabular impingement syndrome and a labral tear (75 men) were included. The mean age was 34.6 ± 14.4 years, and the mean follow-up time was 4.9 ± 1.6 years. Hip Outcome Score-Activities of Daily Living subscale (HOS-ADL) scores, overall satisfaction scores, and factors related to supervised physical therapy and home program/self-practice were collected. Correlations between continuous variables and differences in the length of individual formal physical therapy and patients' rating of the importance of their home program/self-practice between those who would and those who would not undergo surgery again were assessed.The frequency and length of individual formal physical therapy sessions were significantly correlated with postoperative HOS-ADL scores (r = 0.22, P = .014; and r = 0.24, P = .007, respectively) and level of satisfaction (r = 0.24, P = .007; and r = 0.21, P = .02, respectively). The length of individual formal physical therapy sessions was significantly greater in those who noted they would undergo surgery again (35.3 vs 26.3; P = .033). A significant correlation was identified between the rating of the importance of their home program/self-practice and postoperative HOS-ADL scores (r = 0.29; P = .001) and their level of satisfaction (r = 0.23; P = .009). There was a significant difference in the rating of the importance of their home program/self-practice between those who would undergo surgery again and those who would not (8.9 vs 7.8; P = .007).Surgeons and physical therapists should emphasize the value of home program/self-practice when it comes to outcomes and may want to encourage their patients to participate in more frequent, longer, formal physical therapy sessions.

    View details for DOI 10.1177/2325967120981888

    View details for Web of Science ID 000617155100001

    View details for PubMedID 33614802

    View details for PubMedCentralID PMC7869163

  • Subspinal impingement: clinical outcomes of arthroscopic decompression with one year minimum follow up. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Michal, F., Amar, E., Atzmon, R., Sharfman, Z., Haviv, B., Eisenberg, G., Rath, E. 2020; 28 (9): 2756-2762


    This study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively.Retrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine.Thirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25 months (13-37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11-90), 48 (20-91) and 20 (0-80) to 95 (27-100), 94 (30-100) and 91 (5-100), respectively (p < 0.0001, p = 0.001, p < 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients.Arthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure.IV.

    View details for DOI 10.1007/s00167-018-4923-5

    View details for PubMedID 29610973

  • Distal Chevron Osteotomy vs The Simple, Effective, Rapid, Inexpensive Technique (SERI) for Mild to Moderate Isolated Hallux Valgus: A Randomized Controlled Study INDIAN JOURNAL OF ORTHOPAEDICS Palmanovich, E., Ohana, N., David, S., Small, Hetsroni, Amar, E., Sharfman, Z. T., Segal, D., Atzmon, R. 2021; 55 (SUPPL 1): 110-118


    Hallux valgus is a common foot deformity that leads to functional disability with serious sequelae. Minimally invasive surgery is often used to treat hallux valgus in order to reduce wound complications and improve recovery time. The objective of this study was to compare a Simple, Effective, Rapid, Inexpensive (SERI) technique with a simple Chevron technique in patients with minimum of 1-year follow-up.Between the years 2014-2015, we performed a prospective study comparing the SERI minimally invasive technique to treat symptomatic hallux valgus with a standard chevron osteotomy technique. All procedures were performed by a single fellowship trained foot and ankle surgeon. Twenty-one patients were randomized to the SERI cohort and 15 to the standard Chevron technique.The mean preoperative intermetatarsal angle (IMA) of the SERI group was 14.8 ± 1.9 (11.9-22.9). The mean preoperative IMA of the Chevron control group was 13.3 ± 2.3 (10.4-18.2) (p = 0.038). The mean IMA two weeks after the surgery was 6.0 ± 2.3 (2.4-12) in the SERI group, and 6.1 ± 3 (2.6-13.1) in the control group. At the two-week and 1-year follow-up, there was no significant difference found in the IMA between the two groups (p = 0.871). The mean hallux valgus angle reduction was 11.85 ± 4.88 (3-20.8) and 11.09 ± 6.51 (- 1.1 to 22.5) in the SERI and Chevron groups, respectively (p = 0.69). Neither groups reported symptomatic transfer metatarsalgia throughout the follow-up period. The SERI group had increased metatarsophalangeal joint (MTPJ) motion (p < 0.001); however, all other parameters with similar.The SERI technique provided comparable outcomes at up to 1-year follow-up when compared with a standard Chevron osteotomy for moderate hallux valgus. This study demonstrated good reproducible results using the SERI technique for moderate hallux valgus.Level II Prospective Study.Approved by local IRB at MMC.

    View details for DOI 10.1007/s43465-020-00209-0

    View details for Web of Science ID 000557335100001

    View details for PubMedID 34122763

    View details for PubMedCentralID PMC8149498

  • Proximal Derotation Phalangeal Osteotomy for Medial First Toe Diabetic Ulcer INDIAN JOURNAL OF ORTHOPAEDICS Palmanovich, E., Ohana, N., Slevin, O., Tamir, E., Ilan, S., Segal, D., Atzmon, R. 2021; 55 (SUPPL 1): 97-102


    Foot ulcers are a common complication in diabetic patients. Mild callus formation due to a plantar pressure can lead to an ulcer formation with potentially hazardous sequelae. Eliminating the pressure from the ulcer is essential for a proper healing process. Proximal derotation phalangeal osteotomy is a relatively simple procedure that can redistribute the planter pressure points over the hallux.Thirteen patients underwent proximal derotation phalangeal osteotomy to relieve the bony pressure causing an ulcer in the first toe, which was refractory to non-operative treatment. Twelve patients had diabetes type 2 and one had Charcot-Marie-Tooth disease.Ulcers were completely resolved in all 13 patients in an average time of 4.3 (range 2-8) weeks. Four patients (31%) had mild complications that resolved well. No further surgery was required at 1-year follow-up.Proximal derotation phalangeal osteotomy enabled ulcer healing in refractory cases.Level III retrospective study.

    View details for DOI 10.1007/s43465-020-00193-5

    View details for Web of Science ID 000548490800001

    View details for PubMedID 34122761

    View details for PubMedCentralID PMC8149505

  • MICA: A Learning Curve. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Palmanovich, E., Ohana, N., Atzmon, R., Slevin, O., Brin, Y., Feldman, V., Segal, D. 2020; 59 (4): 781-783


    Techniques of minimally invasive bunion surgery have become increasingly popular in recent years. However, the learning curve involved in mastering these innovative techniques has not been described. To address this issue, a trained foot and ankle surgeon in a university hospital operated on 50 patients using the minimally invasive Chevron and Akin procedure over the course of 3 years, from January 2016 through December 2018. Surgery duration and x-ray exposure were documented. Results showed that surgery duration decreased from >2 hours in the first cases to a mean of ∼45 minutes in the third year. This learning curve plateaued by the 21st patient. The number of intraoperative fluoroscopy studies used decreased substantially over the first 27 surgeries, at which point the learning curve plateaued. In summary, it took about 27 procedures for an inexperienced surgeon to acquire the skill of performing minimally invasive Chevron and Akin osteotomy.

    View details for DOI 10.1053/j.jfas.2019.07.027

    View details for PubMedID 32340840

  • Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs JOURNAL OF ORTHOPAEDIC SURGERY AND RESEARCH Palmanovich, E., Ohana, N., Yaacobi, E., Segal, D., Iftach, H., Sharfman, Z. T., Vidra, M., Atzmon, R. 2020; 15 (1): 119


    A proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification.A retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely "postero-lateral," "postero-medial," or "postero-central," according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system.The mean trajectory angle was 21° lateral for "postero-lateral" fragments, 7° lateral for "postero-central" fragments, and 28° medial for "postero-medial" fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20° within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons).There are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.

    View details for DOI 10.1186/s13018-020-01637-2

    View details for Web of Science ID 000522351300001

    View details for PubMedID 32216805

    View details for PubMedCentralID PMC7099790

  • Postoperative Weightbearing Protocols After Arthroscopic Surgery for Femoroacetabular Impingement Does Not Affect Patient Outcome: A Comparative Study With Minimum 2-Year Follow-up (vol 36, pg 159, 2020) ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Avnieli, I., Vidra, M., Factor, S., Atzmon, R., Persitz, J., Safran, N., Rath, E., Amar, E. 2020; 36 (3): 923
  • The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery. Archives of orthopaedic and trauma surgery Atzmon, R., Sharfman, Z. T., Atoun, E., Sampson, T. G., Amar, E., Rath, E. 2020; 140 (1): 85-92


    Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated.Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery.Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated.The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment.The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

    View details for DOI 10.1007/s00402-019-03293-6

    View details for PubMedID 31734733

  • Postoperative Weightbearing Protocols After Arthroscopic Surgery for Femoroacetabular Impingement Does Not Affect Patient Outcome: A Comparative Study With Minimum 2-Year Follow-up Avnieli, I., Vidra, M., Factor, S., Atzmon, R., Persitz, J., Safran, N., Rath, E., Amar, E. W B SAUNDERS CO-ELSEVIER INC. 2020: 159-164


    To evaluate the effects of immediate postoperative weightbearing protocols after hip arthroscopy for femoroacetabular impingement (FAI) with minimum 2-year follow-up, as measured by patient-reported outcome measures and satisfaction rates.Between January 2011 and June 2016, patients undergoing hip arthroscopy for FAI and labral tears were reviewed. Exclusion criteria was previous hip pathology or arthroscopy, active Workers' Compensation claims, and concomitant pathologies impeding weightbearing. Patients who were operated on before September 2013 were treated with 3 weeks of postoperative non-weightbearing (NWB), with weightbearing as tolerated (WBAT) thereafter. From October 2013, patients were allowed immediate postoperative WBAT.A total of 351 hip arthroscopic surgeries were performed; 133 of these patients met the inclusion criteria. Of the 133 included patients, 69 were in the NWB group and 64 were in the WBAT group. No differences were found in terms of sex (P = .603) or age (P = .241). No differences were found in postoperative scores (the Modified Harris Hip Score was 84.5 [range 79-89] for NWB vs 86.7 [78-89] for WBAT [P = .0.523], and the Hip Outcome Score was 83.1 [78-88] vs 88.4 [80-90], respectively; P = .130). Subjective rates of improvement, satisfaction score and the will to undergo surgery again did not differ between the groups (P = .674, P = .882, P = .730). The rate of subjects who met or exceeded the MCID in the NWB and WBAT groups was 82.6% and 81.2% for the Modified Harris Hip Score (P = .838) and 79.7% and 82.8% for the Hip Outcome Score (P = .647). There were no reported complications. Limitations include the possibility of the study being underpowered.After a 2-year minimum follow-up, patient-reported outcome measures and satisfactory rates with immediate weightbearing after hip arthroscopy for isolated FAI syndrome and labral tears do not differ significantly from results after strict NWB rehabilitation protocols. Revising weightbearing restrictions may allow for a more comfortable rehabilitation process after arthroscopic hip surgery for FAI and labral repair.Level 3 - case-control study.

    View details for DOI 10.1016/j.arthro.2019.08.012

    View details for Web of Science ID 000503200600033

    View details for PubMedID 31864571

  • Does capsular closure influence patient-reported outcomes in hip arthroscopy for femoroacetabular impingement and labral tear? Journal of hip preservation surgery Atzmon, R., Sharfman, Z. T., Haviv, B., Frankl, M., Rotem, G., Amar, E., Drexler, M., Rath, E. 2019; 6 (3): 199-206


    Capsulotomy is necessary to facilitate instrument manoeuvrability within the joint capsule in many arthroscopic hip surgical procedures. In cases where a clear indication for capsular closure does not exist, surgeon's preference and experience often determines capsular management. The purpose of this study was to assess the influence of capsular closure on clinical outcome scores and satisfaction in patients who underwent hip arthroscopy surgery for femoroacetabular impingement (FAI) and labral tear. Data were prospectively collected and retrospectively analysed for hip arthroscopy surgeries with a minimum 2 years follow-up. Patients with developmental dysplasia of the hip, previous back or hip surgeries, and degenerative changes to this hip and secondary gains were excluded. Demographic data, intraoperative findings and patient-reported outcome scores were recorded, including the Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). A total of 29 and 35 patients were included in the non-closure and closure groups, respectively. The mean follow-up time was over 3 years for both groups. The mean pre-operative and post-operative HOS scores and MHHS scores did not significantly differ between groups (pre-operative HOS: 65.6 and 66.3, P = 0.898; post-operative HOS: 85.4 and 87.2, P = 0.718; pre-operative MHHS: 63.2 and 58.4, P = 0.223; post-operative MHHS: 85.7 and 88.7, P = 0.510). Overall patient satisfaction did not differ significantly between groups (non-closure 86.3%, closure group 88.6%; P = 0.672). Capsular closure did not significantly influence satisfaction or clinical outcome scores in patients who underwent arthroscopic hip surgery for FAI or labral tear.

    View details for DOI 10.1093/jhps/hnz025

    View details for PubMedID 31798927

    View details for PubMedCentralID PMC6874774

  • A combined endoscopic and open surgical approach for chronic retracted proximal hamstring avulsion. Journal of hip preservation surgery Atzmon, R., Amar, E., Maor, D., Rath, E. 2019; 6 (3): 284-288


    Proximal hamstring avulsion is an uncommon injury which usually requires surgical intervention. When possible, primary surgical fixation is recommended. In chronic hamstring avulsion with significant retraction of the tendon, hamstring reconstructions using an autograft or allograft are required in order to bridge the gap. This is mainly performed using an open surgical technique. We describe a combined endoscopic and open surgical approach to hamstring reconstruction surgery.

    View details for DOI 10.1093/jhps/hnz037

    View details for PubMedID 31798931

    View details for PubMedCentralID PMC6874769

  • Merkel Cell Carcinoma of the Digit. Annals of plastic surgery Persitz, J., Atzmon, R., Keren, T., Avisar, E. 2019; 83 (2): 169-171


    Merkel cell carcinoma (MCC) is a biologically aggressive neuroendocrine tumor of the skin. There are roughly 1500 new cases of MCC diagnosed every year in the United States, with an increased incidence over the past 15 years reaching up to 8%. Epidemiological studies show that the highest MCC incidence is seen in men older than 65 years, with a ratio of 0.23 per 10,000 among whites. Merkel cell carcinoma of the skin most commonly presents as a single, rapidly growing, flesh-colored, painless mass. Because MCC is uncommon, histopathological examination is usually delayed. Because of the high mortality rate associated with this aggressive tumor, a multidisciplinary panel is recommended to ensure high-quality coordinated care. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities, and performance status of the patient. We report a case of MCC to alert medical professionals of this potentially fatal tumor, as early diagnosis and treatment may improve morbidity and mortality rates.

    View details for DOI 10.1097/SAP.0000000000001897

    View details for PubMedID 31008795

  • Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities. Journal of hip preservation surgery Dallich, A. A., Rath, E., Atzmon, R., Radparvar, J. R., Fontana, A., Sharfman, Z., Amar, E. 2019; 6 (1): 3-15


    The diagnosis and treatment of chondral lesions in the hip is an ongoing challenge in orthopedics. Chondral lesions are common and several classification systems exist to classify them based on severity, location, radiographic parameters, and potential treatment options. When working up a patient with a potential hip chondral lesion, a complete history, thorough physical exam, and ancillary imaging are necessary. The physical exam is performed with the patient in standing, supine, prone, and lateral positions. Plain film radiographs are indicated as the first line of imaging; however, magnetic resonance arthrogram is currently the gold standard modality for the diagnosis of chondral lesions outside of diagnostic arthroscopy. Multiple treatment modalities to address chondral lesions in the hip exist and new treatment modalities continue to be developed. Currently, chondroplasty, microfracture, cartilage transplants (osteochondral autograft transfer, mosaicplasty, Osteochondral allograft transplantation) and incorporation of orthobiologics (Autologous chondrocyte implantation, Autologous matrix-induced chondrogenesis, Mononuclear concentrate in platelet-rich plasma) are some techniques that have been successfully applied to address chondral pathology in the hip. Further refinement of these modalities and research in novel techniques continues to advance a surgeon's ability to address chondral lesions in the hip joint.

    View details for DOI 10.1093/jhps/hnz002

    View details for PubMedID 31069090

    View details for PubMedCentralID PMC6501440

  • Graft choices for acetabular labral reconstruction. Journal of hip preservation surgery Atzmon, R., Radparvar, J. R., Sharfman, Z. T., Dallich, A. A., Amar, E., Rath, E. 2018; 5 (4): 329-338


    The acetabular labrum plays a key role in maintaining hip function and minimizing hip degeneration. Once thought to be a rare pathology, advances in imaging have led to an increase in the number of diagnosed labral tears. While still a relatively new field, labral reconstruction surgery is an option for tears that are irreparable or require revision after primary repair. Various autograft and allograft options exist when considering labral reconstruction. The first labral reconstruction surgery was described using the ligamentum teres capitis, and has since evolved, incorporating more graft sources and reconstructive techniques. The purpose of this review is to assess and describe the different graft sources and technique currently implemented by hip surgeons. Moreover, this review attempts to determine whether a single labral reconstructive graft type is superior to the others. Techniques using the Ligamentum teres capitis autograft, ITB autograft, gracilis autograft, quadriceps tendon autograft, capsular autograft, semitendinosus allograft, indirect head of the rectus femoris autograft, peroneus brevis tendon allograft and Tensor fascia lata allograft were found. Scoring was available on 5 out of the 9 graft types. The advantages and disadvantages of each graft source is described as a comparative tool. No single graft type has shown increased benefit in acetabular labral reconstruction. The lack of uniform outcome measurements hinders comparison of reported outcomes. Surgeons should make an informed decision based on their experience as well as the patient's history and needs when choosing which graft type would be best suited for their patients.

    View details for DOI 10.1093/jhps/hny033

    View details for PubMedID 30647922

    View details for PubMedCentralID PMC6328747

  • Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Amar, E., Sampson, T. G., Sharfman, Z. T., Caplan, A., Rippel, N., Atzmon, R., Drexler, M., Rath, E. 2018; 26 (8): 2512-2518


    The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair.Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS).Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001).Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission.IV.

    View details for DOI 10.1007/s00167-017-4641-4

    View details for PubMedID 28717888

  • Cerebrovascular accidents associated with hip fractures: morbidity and mortality-5-year survival. Journal of orthopaedic surgery and research Atzmon, R., Sharfman, Z. T., Efrati, N., Shohat, N., Brin, Y., Hetsroni, I., Nyska, M., Palmanovich, E. 2018; 13 (1): 161


    Hip fractures are associated with increased cerebrovascular accidents (CVAs) in the first postoperative year. Long-term follow-up for CVA and mortality after hip fracture is lacking. The purpose of this study was to identify risk factors for CVA and follow mortality in hip fractures in a cohort with greater than 2 years follow-up.We compared past medical history of patients with hip fractures to long-term survival and the occurrence of CVA. Past medical history, surgical intervention, CVA occurrence, and death were queried from the electronic medical recorder system. Level of significance was set at p < 0.05 with 95% confidence interval.Two thousand one hundred ninety-five patients met inclusion criteria. Mean follow-up was 5 years. One hundred ten (5.01%) patients were diagnosed with post-fracture CVA. Forty-one patients had CVA in the first year and 55 patients had CVA between 1 to 5 years after surgery. Among the potential risk factors, hypertension (HTN), atrial fibrillation (AF), and diabetes mellitus (DM) had the highest odds ratio for CVA (OR = 1.885, p value = 0.005; OR = 1.79, p value = 0.012; OR = 1.66, p value = 0.012). The median survival time in patients with CVA was 51.12 ± 3.76 months compared to 59.60 ± 0.93 months in patients without CVA (p = 0.033).HTN, AF, and DM are significant risk factors for the occurrence of CVA after hip fracture. The majority of CVAs occur between the first and fifth year postoperatively, and CVA is a negative prognostic factor for postoperative survival.

    View details for DOI 10.1186/s13018-018-0867-1

    View details for PubMedID 29954421

    View details for PubMedCentralID PMC6027793

  • A novel non-invasive hip traction technique for hip arthroscopy in the below-knee amputation (BKA) patient. Journal of hip preservation surgery Atzmon, R., Sharfman, Z. T., Valk, J. E., Persitz, J., Amar, E., Rath, E. 2017; 4 (3): 258-259


    Prolonged sitting and mobilizing from a seated position are known to exacerbate the symptoms in patients with hip pathology. For patients who lack mobility and require extended periods of time in seated positions, such as amputees, the symptoms of femeroacetabular impingement can be debilitating and limit their ability to operate a wheelchair, use a prosthetic limb or complete activities of daily living. Hip arthroscopy surgery offers a minimally invasive technique to treat hip pathology but requires hip distraction to facilitate instrument maneuverability. Invasive methods of hip distraction have been previously described for use in amputees for hip arthroscopy. We herein describe a non-invasive surgical technique for hip distraction in the below-knee amputation patient.

    View details for DOI 10.1093/jhps/hnx019

    View details for PubMedID 28948038

    View details for PubMedCentralID PMC5604086

  • Hip arthroscopy for intra-capsular benign tumors: a case series. Journal of hip preservation surgery Sharfman, Z. T., Atzmon, R., Gortzak, Y., Rotem, G., Drexler, M., Haviv, B., Amar, E., Rath, E. 2016; 3 (4): 312-317


    The purpose of this study is to demonstrate the assessment of intra-capsular femoral head and neck tumors, and to describe the arthroscopic surgical technique used to resect and fill the bone defects. Three cases of benign femoral head and neck lesions are presented. Two benign enchondromas and one benign osteochondroma were resected arthroscopically. Traction was used in one case. Modified Harris Hip Score improved in all three cases to scores of 95 or greater with an average improvement of 16 points with a minimum follow up of 15 months. Arthroscopic surgical resection of intra-capsular femoral hip lesions offers an effective alternative to open resection. This technique offered good outcomes in the limited cohort. We suggest that arthroscopic resection of intra-capsular femoral hip lesions be considered in relevant cases as an alternative to open resection.

    View details for DOI 10.1093/jhps/hnw025

    View details for PubMedID 29632691

    View details for PubMedCentralID PMC5883178

  • The Long-Term Outcome After Varus Derotational Osteotomy for Legg-Calvé-Perthes Disease: A Mean Follow-up of 42 Years. The Journal of bone and joint surgery. American volume Shohat, N., Copeliovitch, L., Smorgick, Y., Atzmon, R., Mirovsky, Y., Shabshin, N., Beer, Y., Agar, G. 2016; 98 (15): 1277-85


    Varus derotational osteotomy (VDRO) is one of the most common surgical treatments for Legg-Calvé-Perthes disease, yet its long-term results have not been fully assessed. We aimed to determine the long-term clinical and radiographic outcomes following VDRO.Forty patients (43 hips) who underwent VDRO for Legg-Calvé-Perthes disease at our institution from 1959 to 1983, and participated in a follow-up study completed 10 years earlier, were approached for the present study. Clinical examination and radiographs were evaluated. Hip status and well-being were assessed with the Harris hip score and the Short Form-36 (SF-36).Thirty-five patients (37 hips) participated in the study. Information regarding the need for an arthroplasty was gathered on 4 additional hips from the previous study. The mean follow-up was 42.5 years (range, 32.4 to 56.5 years), with a mean patient age of 50.2 years (range, 35.9 to 67.8 years). In total, 7 patients (7 hips; 17% of 41 hips for which information was available, including 1 hip from the original cohort of 40 patients [43 hips]), underwent a total hip arthroplasty for hip pain. Excluding patients who had undergone an arthroplasty, the mean Harris hip and SF-36 scores were 79.8 points (range, 23.1 to 100 points) and 74.8 (range, 15.1 to 100), respectively. Twenty (64.5%) of the 31 hips that had not been replaced achieved a good or excellent Harris hip score (≥80 points). Sixteen (57.1%) of 28 hips with follow-up radiographs had no, or minimal, signs of osteoarthritis. The Stulberg classification was associated with the Harris hip score, the SF-36 score, hip pain, a Trendelenburg sign, coxa magna, and the Tönnis grade. In a multivariate analysis, the Stulberg classification was the only factor associated with fair or poor outcomes (a Harris hip score of <80 points). Patients with a Stulberg class-III or IV hip had significant deterioration with respect to the Harris hip score and Tönnis grade during the 10-year period since the last follow-up.A long-term follow-up of patients who were operatively treated for Legg-Calvé-Perthes disease revealed that a low proportion underwent total hip arthroplasty and a relatively high proportion maintained good clinical and radiographic outcomes.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.15.01349

    View details for PubMedID 27489318

  • Tibial Plateau in Combination with Diaphyseal Fracture: A Case Study Atzmon, R. ClinMed International Library - Trauma Cases and Reviews. Trauma Cases and Reviews, 2016, 2:032, Volume 2 | Issue 1. 2016 ; ISSN: 2469-5777 4


    Simultaneous tibial plateau and diaphyseal tibial fractures are a rare occurrence and have seldom been reported in the literature. Each fracture requires a different surgical approach, which creates challenges for the operating physician. Tibial plateau fractures require anatomical reduction and restoration of the joint line in order to achieve rigid fixation and immediate mobilization of the joint. Conversely, diaphysis tibial fractures can be treated with relative stability and do not require anatomical reduction and fixation. The unique combination of tibial plateau and diaphysis tibial fractures is challenging, as the two pathologies require vastly different interventions performed in the same location. This case presents a single operation composed of two stages, starting with fixation of the diaphyseal fracture using an intra-medullary nail (IMN), and arthroscopic assisted closed reduction and internal fixation using cannulated screws for co-contaminant tibial plateau and diapheseal tibial fracture.

  • [Carpal tunnel syndrome in pregnancy]. Harefuah Atzmon, R., Eger, G., Lindner, D., Assaraf, E., Lin, E., Avissar, E. 2014; 153 (11): 663-6, 686


    Pregnancy related carpal tunnel syndrome (PRCTS) is the most frequent mononeuropathy during pregnancy. The reported incidence of PRCTS varies widely and ranges from 0.8% to 70% depending on the diagnostic method and the physician. The etiology for PRCTS is related to hormonal fluctuations, fluid accumulation, glucose level fluctuations, median nerve hypersensitivity etc. The diagnosis of PRCS is the same as carpal tunnel syndrome (CTS) in the gereral population and includes a thorough history, typical symptoms and physical examination. Electrodiagnostic studies such as EMG are valuable tools for the ratification of the diagnosis of CTS in the general population. But in light of the fact that the EMG examination is painful and can cause discomfort to the patient, its routine use during pregnancy is controversial and is not required for determining the diagnosis. Generally, the syndrome tends to pass after birth, on the other hand, according to the literature, it might not pass in lactating women until they stop breastfeeding and even afterwards. Treatment of PRCS is mostly conservative, and if there is lack of improvement local intracarpal injection of a steroid is indicated. Intracarpal injections have demonstrated a significant decrease in symptoms and low recurrence in comparison to the general population, and do not put the fetus or his mother at risk. A surgical intervention is rarely indicated during pregnancy.

    View details for PubMedID 25563028