Introduction

Degenerative, inflammatory, and posttraumatic arthritis of the ankle are the primary indications for total ankle arthroplasty

Ankle arthrodesis has long been the “gold standard” for the surgical treatment

Total Ankle Arthroplasty. implant survivorship has been reported to range from 70% to 98% at three to six years

The combination of younger age and hindfoot arthrodesis or osteoarthritis may lead to a relative increase in failure rates after TAA

Intraoperative complication include malaligment, fracture and tendon Postoperative complications include syndesmotic nonunion, wound problems, infections and component instability and lysis

After TAA few difficulties mainly due to poor Talar and Tibial bone stock. It is difficult to stabilize the fusion and usually there is shortening after removal of the implant. Also there is a need for massive bone graft-allograft or autograft.

In cases when there is significant bone loss there is a need for stable reconstruction and stabilization of the hindfoot. Bone grafting with structural bone graft may collapse and it has to be stabilized with screws or nail.

Background

Hip fractures affect annually over 350,000 people in the USA and over 1.6 million worldwide. About 50% of these numbers are intertrochanteric fractures,

The surgeon should be able to minimize the morbidity associated with the fracture by: recognizing the fracture pattern, choosing the appropriate fixation device, performing accurate reductions with ideal implant placement and being conscious of implant costs. In this study we assessed the ability of the orthopaedic surgeons to recognize fractures pattern, and choosing the ideal implant for the recognized fracture.

Purpose: Describe our experience with our new approach for treating displaced subcapital femoral fractures in our active patients.

Materials and Methods: From August 2005 till January 2008, 79 active patients were treated for displaced Sub-capital Femoral fracture by close reduction and internal fixation with Short Trochanteric Antegrade Nail (T.A.N.) (Smith& Nephew).

Mean age 74.5 (range 38–93),

Partial weight bearing began 0–4 weeks post operation and Full Weight Bearing 4–8 weeks post operation.

Patients were evaluated at 1,2,6,12& 24 months after the operation.

Results: All patients returned to walk on their feet.

The patients were scored by modified lower extremity questionnaire with mean results 4.1 (scale of 1–5, 1-poor, 5-excellent).

There were no cases of implant failure. No cases of infections.

Two patients had a cut-out of the implant and two other patients had a nonunion of the fracture. Those 4 patients (5.06%) were converted to a THR.

There were no cases of avascular necrosis.

Conclusions: Our complications rate for displaced sub-capital fractures treated by C.R.I.F. were lower than that reported for the alternative treatment modality. Our findings show that these fractures can be treated with a high rate of success by closed reduction and internal fixation with an intramedullary biaxial fixation in all age groups. With this simple and minimally invasive operation and the nail’s biaxial angular stability, we can achieve stable fixation.

This procedure offers several advantages over hemiarthroplasty, by lowering the risk of immediate complications such as prolonged anesthesia, bleeding, infection, periprosthetic fractures and dislocations. Furthermore, the use of the short TAN preserves the femoral head and the normal anatomy in active patients in order to avoid the late complications of hemiarthroplasty.

Introduction: Stress fractures comprise a major problem in female police or army recruits. The incidence of stress fractures is reported ranging from 3 to 10 fold when compared to male recruits taking the same training program. This study consisted of an intervention program aiming at reducing combat gear weight and locating the gear as close as possible to the body center of gravity.

Material and Methods: In a prospective study we followed up two companies of female recruits of the Israel Border Police. Both companies were followed for the four months of basic training using a basic data questionnaire inclusive of previous physical activity habits, previous acute and overuse injuries, menstrual history and previous smoking habits. An injury questionnaire was filled on commencement of the course and every two weeks thereafter. The clinical records of medic and doctor visits, as well as the personal medical file, were revised. Roentgenological and scintigraphic imaging were performed during the course, when clinical suspicion of a stress fracture arose.

The first company of 71 fighters used the standard combat gear amounting to 12.5 kg. The second company of 64 fighters used combat equipment weighing 9.4 kg, held in a combat girdle close to the body center of gravity, inclusive of a shorter personal combat riffle and personal combat vest.

Results: There was no difference in the number of clinic visits between the two companies. Complaints suggesting stress fractures were recorded in the first company from the 3^rd to the 8^th week of training and in the second from the 1^st to 3^rd week. The percentage of fighters sent for Scintigraphy because of clinical suspicion of stress fractures was 22.5% in the first company and 6.25% in the second. The percentage of fighters in whom stress fractures were located by Scintigraphy was 15.5% in the first company and 4.7% in the second. The number of stress fractures in average per fighter was 0.45 fractures in the first company and 0.27 fractures in the second. When calculating only “dangerous” stress fractures (long bones and navicular) there were noted 0.34 fractures per fighter in the first company and 0.20 in the second. Total average training days lost for reason of stress fractures was 2.21 per fighter in the first company and 1.08 in the second.

Conclusions: Reducing the weight of the fighting gear and securing it closer to the body center of gravity may have a positive effect in reducing the incidence of stress fractures in female recruits of fighting units during the intense basic training program.

Purpose: To report our experience in diagnosis and treatment of Osteoid Osteoma in the foot and ankle.

Material and Methods: Six patients, 4 males and 2 females, mean age 24 (range 17–40), were diagnosed, suffering of osteoid osteoma of the foot and ankle in our outpatients clinic. All the patients had typical spontaneous pain and night pain improved by NSAIDs. In all patients, the diagnosis was delayed for one – two years. Treatment by Computed Tomography guided percutaneous radiofrequency ablation was performed in 4 patients, one patient underwent CT guided curettage and one underwent open excision and local bone graft of the lesion. In patients treated by RF, the lesions were heated three times to 90° for 2 minutes. All the procedures were done under ankle block and local anesthesia. Patients were evaluated in our outpatients foot and ankle clinic 1–2 years following the procedure.

Results: The Osteoid Osteoma was found in the talus of two patients and one in the cuboid, one in the base of third metatarsus, one in the calcaneus and one in the ankle. In all patients most of the pain was resolved within 3 days of the procedure. In 3 patients after a year there was still mild pain at tremendous physical efforts attributed to minimal damage to adjacent joint. Three patients completely recovered including pain free physical efforts. CT at follow-up in 2 patients revealed no pathology of the involved bones.

Conclusions: OO is an uncommon affection in the foot and ankle. The diagnosis is difficult and usually there is delayed. CT guided percutaneous radiofrequency of the foot is a safe and effective. The procedure can be performed under ankle block and local anesthesia.

The Purpose: To compare clinical results of proximal humerus fractures following internal fixation with proximal humeral locked plate versus conservative treatment.

Materials and Methods: 25 patients sustained 3-part fractures of the proximal humerus. 8 were internally fixed and 17 were treated conservatively in two different centers.

Mean age: 65.4±12.7 Gender: 22 females, 3 males. Age and gender were similar in both groups. Follow up was longer in the conservative group (23.8 m ±7.5) compared to the operated one (11.1 m ±8.3).

All the patients were evaluated clinically using Constant’s score.

Statistical analysis was performed using Fisher’s exact test (examination rates differences), Mann-Whitney test (examination means difference) and Spearman’s test (evaluation of the correlation coefficient between two continuous variables).

Results: Constant’s score in the operated group was 57.1±19.3 and 58±21.5 in the conservative group. Union was noticed in all the operated patients, and there was one case of nonunion in the conservative group. There were no cases of AVN in any group.

Statistical Analysis: No significant difference between the two groups was found for total Constant’s score. ROM was similar in both groups except for the rotations, which tended to be better in the operated group: IR 7.6±2.6 versus 5.4±3.3 (p=0.103) respectively, ER 7.7±3.1 versus 6±2.6 (p=0.169) respectively.

Conclusions: Clinical results are similar for operative and conservative treatments in 3 part fractures of the proximal humerus. There are better results for rotations in the operated group. Strength in abduction is superior in the conservative group.

The difference could be influenced by the shorter follow–up period in the operated group.

Purpose: The elderly population is increasing in the modern world. Societies in general and medical personnel are facing new ethical and medical dilemmas when treating extremely old patients. Elderly patients have osteoporotic bone and hence a high incidence of fractures. Evaluating this unique group of patients who have hip fractures is our goal.

Materials and Methods: A retrospective analysis of all patients who had hip fractures between January 1990 and December 2001 and were beyond 100 years old was handled.

Data was collected from the medical files (hospitalization and out-patient charts) for age, sex, type of fracture, type of treatment, background disease, rehabilitation and time until death. The latter was confirmed by data from ministry of home office.

Results: 23 patients (17 females and 6 males) were found. Ages ranged from 100 and 107 (mean: 101.78). They had 4 subcapital and 19 per-subtrochanteric fractures. The patients had between 1–5 major background diseases. 4 patients were treated conservatively (1 due to major pneumonia and 3 refused the operative procedure). All these patients died at the same month of admission. Among the 19 patients who underwent operation, 12 patients have died and lived between 0–34 months (mean: 7.43) post-operatively, and 7 are still alive for 4–75 months (mean: 34.43) post-operatively. No differences between the operative and conservative groups in terms of major background disease were found.

Conclusions: Most of hip fractures in the extreme old age are per-subtrochanteric. Operative treatment yielded better results and should be the treatment of choice.

Purpose: To evaluate the use of locked Compression Plate (L.C.P.) in metaphyseal long bones fractures, and report our preliminary results.

Materials and Methods: 23 patients 14–82 years old with long bones metaphyseal fractures underwent surgery with the use of L.C.P. between January 2004 and August 2004. Four patients were adolescents.

7 patients had Supracondylar femoral fracture. One of them had the fracture at the tip of IMN. 11 patients had distal Tibia, one had proximal+midshaft tibia and 4 had distal humerus fractures. All plates were prebended to fit the area of the fracture using a skeleton model. The plates were inserted percutaneously with reduction of the fracture.

Partial weight bearing started after 6 weeks and full weight bearing started after 12 weeks.

Results: Unuion was seen in x-ray after 6 to 12 week in 95% of patients. 20 patients regained full range of motion of the adjacent joints at 3 months follow-up.

Complications: One patient developed compartment Syndrome in a high energy tibial fracture. One patient developed deep infection at the site of fibular plate not affecting the L.C.P. at the tibia. One patient developed temporary weakness of extensor Hallucis longus.

Conclusions: L.C.P. proved to be effective in fixation of meta-epiphyseal zones which are difficult in IMN fixation. The use of this plate enables fixation of long bones in adolescents with open growth plate. The locking system enables good fixation of osteoporotic bones and in periprosthetic fracture. The high primary stability in combination with newly developed minimal-invasive techniques (MIPO = minimal invasive plate osteosynthesis) are the bases for a rapid bony consolidation, a low complication rate and good functional results.

Purpose: To describe the first 22 cases of Total Ankle Replacement (TAA) performed by the same team. The learning curve and the complications due to technical problems or medical problems are discussed

Patients : 22 patients underwent TAA during the last two and half years in our department. There were 6 males and 7 females. The average age was 63 ranging from 22 –79 years old. 11 patients developed osteoarthritis after trauma to the ankle, 9 had primary osteoarthritis and 2 patients suffered from rheumatoid arthritis.

Results: The average time of operation was 111 minutes (range 148–90) and 12 patients were operated under general anesthesia and the rest had spinal epidural anesthesia. During the operations the medial malleolus was fractured three times and one patient had fracture of the lateral malleolus fixated with KW. In two patients Achilles lengthening was performed as well. There was fracture of the posterior lip of the tibia during insertion of the tibial component in one patient. All the patients recovered with no primary wound healing problem. There was deep infection after 6 weeks in one patient who was treated by drainage debridment of synovium and recovered uneventfully. One patient had synovitis 6 months after the operation and underwent synovectomy proved to be non infected.

One patient still had pain after a year after the operation and x ray disclosed medial talar osteophyte which had to be resected and one patient progressed to subtalar arthritis and had to be fused. The same patient had superficial nerve neuralgia as well and the nerve was resected at the same procedure.

Altogether there were five fractures during the insertion, 2 late operations and one deep infection. The average follow up was two years (ranging from 7 months to 30 months). The patients had free painless ankle range of motion of 40 degrees and could walk few hundreds meters without pain. All the patients were satisfied from the procedure except for one patient with the medial talar osteophyte.

Clinical relevance: The outcome of TAA is good and leads to high satisfaction from the patients. However it is demanding procedure and has long learning curve with high rate of technical complications which can be overcome leading to complete recovery.

Purpose: Evaluating the rate of complications with the use of Proximal femoral nail (P.F.N.), and discuss the reasons for the complications and their solution.

Material and Methods: During last 4.5 years 308 patients underwent P.F.N. for unstable proximal femoral fracture. The average age of the patients was 75.6 (range 20–96).

A.O. classification. A1: 27. A2: 180. A3: 96. In 7 patients a failed dynamic hip screw (D.H.S.) was changed to P.F.N. All the patients were allowed to begin full weight bearing immediately. In 81% of patients short femoral nail was inserted and in the rest long one.

Results:

Complications:Malfixation(internal-rotation, varus, valgus, shorting, bad position of the screw in the neck) – 10%

Deep infection 0.7%, nonuonion 1%, cut out 2%,

Nail breakage 0.6%, Broken drills, bad position of locking screws.

Solutions:

Re-operation 1.6%, T.H.R. 1.3 %, removal of nail 1.6%, nail change 0.9%.

During the last year we began to use a new and improved insertion set with less complications.

Conclusions: P.F.N. is a valid solution for unstable proximal femoral fractures enabling immediate full weight bearing. P.F.N. may be used as a good salvage procedure for failed dynamic hip screw. The procedure demands accurate and meticulous operative technique in order to avoid technical complications. In cutout nails T.H.R. is a good salvage procedure in older patients.

Purpose: The purpose of the study is to assess the prevalence of osteoporosis diagnosis and treatment in hip fracture patients, prior to fracture.

Materials and Methods: We interviewed and reviewed medical files of 127 patients (39 men and 88 women), with an average age of 81.25. All were admitted with a hip fracture caused by minor trauma between February and June 2004. Data was collected regarding previous fractures, DEXA (dual energy X-ray absorptiometry) examination and previous drug therapy.

Results: 31 patients (24.4%) were previously diagnosed as osteoporotic. 19 patients (15%) had a DEXA examination in the past, and 17 of them were positive. 20 patients (15.7%) were treated with vitamin D and calcium supplements. 11 patients (8.7%) were treated with specific antiosteoporotic drugs. 36 patients (28.3%) had a previous fracture within 10 years, including 18 hip fractures. In 19 patients information about fractures could not be obtained due to dementia. Of this 36, only 7 (19.4%) had a DEXA examination, and 14 (38.9%) were diagnosed as osteoporotic. 5 patients in this group (13.9%) were treated with an antiosteoporotic drug.

Conclusions: Investigation and treatment of osteoporosis in elderly population is insufficient. Even after suffering a fracture, most elderly people are not investigated for bone density. In patients who are diagnosed as osteoporotic, only one third are treated with specific drugs.

Insertional Achilles tendonitis is an inflammatory disorder affecting mainly active young patients. The etiology is multifactorial and include the combination of anatomical and biomechanical characteristics. One fifth of the tendon injuries in athletes are insertional complaints which includes bursitis and insertion tendinitis.The complex of the insertion of the Achilles tendon includes three main components of fibrocartilage sesamoid, periosteum and enthesis. A conservative regime is recommended as the first line of treatment. In case of failure a surgical decompression of the posterior margin of the calcaneum is indicated.

Nine cadaveric legs were used for the experiment. The leg was mounted on an MTS machine and was axially loaded 360 N. The foot was attached to a plate which enabled dorsal and plantar flexion. The Achilles was sutured twice in an Ethibond No. 5 using the Krakow technique in order to anchor the tendon to an actuator. A thin pressure sensor plate (Teckscan) was inserted into the retrocalcaneal bursa to measure the force, pressure and contact area of the Achilles to the calcaneus in various positions of the foot. The conditions included 90 degrees of the foot, 15 and 30 degrees of dorsiflexion while the tension that was applied on the Achilles was 0, 200 N and 300 N. After resection of the posterior surface of the calcaneus in a 20 degrees inclination.

The mean peak force, pressure and area did not change in Achilles tensioning while the foot was in 90 degrees and were close to zero. In 15 degrees of dorsiflexion there was increase in the mean peak force, pressure and area when the Achilles was tensed to 200 and 300 Newton. Larger increase in these parameters was achieved by further dorsiflexion of the foot to 30 degrees.

After resection of the posterior margin of the calcaneus in an angle of 20 degrees the mean peak force, pressure and area dropped close to zero and remained almost unchanged during the various conditions of the experiment.

Dorsiflexion and tension of the Achilles tendon increases the mean peak force, pressure and area in the Achilles retrocalcaneal bursa. These data may explain the mechanism for insertional Achilles tendinosis. Resection of the posterior surface of the calcaneus in 20 degrees efficiently decompresses the retrocalcaneal bursa in various angles of the foot and in various tensions of the Achilles.

The treatment of OA of the ankle is similar to any other large joint and includes conservative and surgical treatment. The surgical treatment is fusion or replacement but conservative treatment is limited and include mainly ankle supports and physiotherapy. Hyaluronic acid was discovered by Meyer and Palmer in 1934 and recently is widely used in the treatment of knee osteoarthritis. We evaluated the efficacy of intra-articular preparation containing Sodium Hyaluronate, in the treatment of OA of the ankle.

A group of 16 patients suffering from ankle osteoarthritis were selected for the study. The mean age was 43 years (range 31–79 years) and the duration of pain from nine months to 27 years. Twelve patients had ankle fractures and four had no trauma history. The clinical presentation included at least one or more of the following conditions of the ankle joint: pain in motion or at rest, swelling and tenderness for over than nine months. The radiographic severity of the ankle osteoarthritis was grade II, III or IV according to Kellgren and Lawrence. Intra-articular injections of 25 mg Sodium-hyaluronate (Adant) were administered on five consecutive weeks. Follow-up visits were perfumed one, two, three, four and seven months post treatment and included clinical evaluation and score scale.

Global assessment showed, in 13 out of 16 patients, improvement in the range of motion by 20%. Significant reduction of the OA symptoms according to the score: two to three points improvement on each scale. According to the osteoarthrithis ankle score scale: up to 20 points. Improvement continued for seven months follow-up after the treatment; no decrease in the treatment efficacy has been shown. Global assessment of two patients did not show any significant improvement after the treatment. One patient dropped off the study due to other operation.

Symptomatic relief of OA of the ankle can be achieved by injection of intraarticular preparation containing Sodium Hyaluronate.

Background: Seven cases of osteochondritis dissecans (OCD) of the tarsal navicular bone have been described mainly radiologically.

Aims: We report our experience with additional 6 patients which represent the largest series described, and conclude about the treatment modalities in this unique type of OCD.

Methods: All patients who had OCD of the tarsal navicular bone during the years 1993 and 1998 were evaluated. The parameters which were examined were the age and sex of the patients, the location of pain, duration of symptoms, and any trigger mechanism if this was noted. The various treatments used for these patients as well as their outcome were recorded.

Results: Six patients were treated by us between 1993 and 1998 (follow up 3–7 years). There were 4 males and 2 females aged between 14 and 35 years (mean 21 years). All patients had pain in the dorsal aspect of the midfoot, and painful limitation in midfoot movements. Duration of symptoms varied between 4 months and 1 year. In 3 patients basic training in army service and in one running short distances triggered the pain. In 3 patients an accompanying stress fracture of the navicular bone was developed. Three patients were managed conservatively. Two patients underwent excision, curettage and drilling, and one patient underwent excision and fusion. All patients, whether treated conservatively or surgically, still suffer form pain in activities and painful limitation of midfoot motion.

Conclusions: OCD of tarsal navicular bone affects mainly young patients. Physical efforts are the trigger mechanism for the symptoms. The clinical presentation includes painful limitation in midfoot motion. The outcome is reserved both for conservative or operative treatment.

Background: Osteoarthritis (OA) may affect large and small joints and is common final pathway of large array of conditions. OA of the large joints includes mainly hip, knee, shoulder and ankle. The treatment of OA of the ankle is limited and the surgical treatment is usually salvage procedure as fusion. Therefore there is a need for an efficient conservative treatment of the ankle OA.

Aims: The objective of this clinical trial was to evaluate the symptomatic efficacy of intraarticular preparation containing Sodium Hyaluronate, in the treatment of OA of the ankle.

Methods: The study was conducted on patients who visited our out-patients clinic under the direct supervision of the principle investigator. The male or female patient aged between 30 and 80 suffering from osteoarthritis of the ankle joint of radiographic severity II or III or IV according to Kellgren and Lawrance, suffering from one or more of the following conditions of the ankle joint: swelling, tenderness or pressure, and/or pain on motion or at rest, who have clinical history of ankle pain for over 6 months.

Intraarticular injections of 25 mg Sodium-hyaluronate in 5 following weeks were administrated to 16 patients, 31–79 years old (average 43 years) suffering from pain in the ankle, 9 months to 27 years. 12 patients after operation, 4 with no trauma history.

Follow-up visits were performed 1,2,3,4,7 months post treatment and included clinical evaluation and score scale.

Results: Global assessment showed in 13 out of 16 patients improvement in the motion range (20%) and significantly reduction of the OA symptoms according to the score: 2–3 points improvement on each scale and according to the osteoarthritis ankle hindfoot score scale (100 points total): up to 20 points improvement. Seven months after the treatment, no decrease in the treatment efficacy has been shown.

Global assessment of 2 patients did not show any significant improvement after the treatment. One patient dropped off the study due to other operation.

Conclusions: Symptomatic relief of OA of the ankle can be achieved by admission of intraarticular preparation containing Sodium Hyaluronate.

Background: Osteoarthritis (OA) is a common phenomena in the population. About 80% of the patients more than 55 years of age have reontgenographic signs of OA, while 25% have clinical signs. Eventually OA leads to joint destruction, which may necessitate joint replacement.

Aims: Our goal was to evaluate the synovial reaction in 10 patients who suffered from arthritis and thus underwent total knee replacement operation.

Methods: Ten patients with arthritis of the knee joint (8 with OA and 2 with rheumatoid arthritis (RA) who underwent total knee replacement were evaluated.

Age ranged between 66 and 79 years (mean 71 years). A control group consisted of 6 cadaver knees (mean age 31 years) with no previous history of knee problems.

All the patients in the research group were graded functionally for their knee score by the system of Hospital for Special Surgery Functional Score.

Additional plain X-ray score on a three point scale was performed. During surgery macroscopic changes on the articular surface of all three compartments were recorded on a four point scale. Synovial specimens were taken from each compartment for microscopic examination.

Results: In the research group the average knee score was 54. The macroscopic changes were found predominantly in the medial compartment. No correlation was found between microscopic and histological changes in the synovia. However, a statistically significant correlation between radiological changes in the medial and lateral compartments and macroscopic changes was noted. In the OA patients the ratio of T to B cells was 60% in favor of the B cells, in contrast to RA which was 75% in favor of T cells. In the control group the common find-ing was a thickened sub-synovial fat layer in the patello-femoral (PF) compartment.

Conclusions: Inflammatory reaction in the synovia is graded by the lymphocytic infiltration into the synovia. In OA this is usually mild. However, the predominant reaction is fibrosis. There is no correlation between this fibrotic reaction and overt radiological or macroscopic findings. The thick subsynovial fat layer found in the PF compartment in the control group has not been described previously in the literature and should be the focus of further investigations.

Background: The surgical treatment of extensive diffuse Pigmented Villonodular Synovitis (PVNS) of large joints alone, is unsatisfactory, with high rates of local recurrence. Postsynovectomy adjuvant treatment with external beam radiation therapy or intraarticular injection of Yttrium90 (Y90) yielded better results.

Aims: Experience with 10 cases treated with debulking surgery followed by intraarticular injection of Y90 is reported.

Methods: Between January 1989 and June 1998, 10 patients (8 males and 2 females aged 15049 years) with extensive diffuse PVNS were treated. In 6 patients the knee joint, in 3 patients the ankle joint, and in 1 patient the hip joint were involved. The 10 patients underwent 15 operations, 1 patient had 3 surgical procedures, and 3 patients underwent 2 surgeries (interval between re-operations for local recurrence were 2–4 years). All patients had an intraarticular injection of 15–25 mCi of Y90, 6–8 weeks after the last surgery.

Results: Follow up time was 2.5–12 years (mean 6 years). All patients were followed by repeated computerized tomography (CT) scans, magnetic resonance imaging (MRI), plain X-ray films and bone scans semi-annually. In 9 patients no evidence of disease and no progression of bone or articular destruction have been noted. In 1 patient stabilization of disease was achieved with no further evidence of bony or articular damage. No complications were noticed after surgery, nor after the intraarticular Y90 injection.

Conclusions: A combination of debulking surgery with intraarticular injection of Y90 for extensive diffuse PVNS of major joints is a reliable way of treatment with good results.

Background: Female recruits are known to have a relatively high incidence of stress fractures (SF). This has been apparent also when female recruits entered the Israel Border Police training program.

Aims: To examine the influence of various interventions including shoe modification, nutrition, controlled training program and pre-recruit course on the incidence of SF.

Methods: Between February 1996 and February 1998, five courses of female recruits were held with a total of 229 participants. The four later courses were controlled and strictly documented. These included 203 recruits. The total number of SF was recorded using bone scintigraphy. “Dangerous SFX” was described as those SF including the long bones of the lower limb and the navicular bone. Due to high number of SF the organic medical team introduced various interventions: 1. Shoes were replaced with lither and flexible shoes with soft absorbing soles (course I onward). 2. Nutrition was modified (course II onward). 3. A training scale was programmed and introduced (course III onward). 4. Selecting candidates six months before recruitment and running a three-month preparation course (course IV onward).

Results: 1) 55 recruits (of 203) or 27.1% suffered SF grade I or more (2.9 SF for injured recruit or 0.78 SF for each recruit in the course. 2) 36 recruits (of 203) or 17.7% suffered SF grade II or more (2.1 SF for injured recruit or 0.37 SF for each recruit in the course. 3) The data concerning 229 recruits along the 5 courses was recorded and found that the incidence of number of recruits suffering dangerous SF in all grades, or grade II or higher, and the number of dangerous SF per recruit was reduced gradually from course to course.

Conclusions: The incidence of stress fractures in female recruits during basic training is high, ranging in the series for the various courses from 23% to 35% for all grades and from 8.3% to 19% for “dangerous” SF (basically of the long bones) graded II onward. Various interventions including shoe modification, nutrition, controlled training program and pre-recruit course seems to have a possible combined effect in reducing the incidence and severity of stress fractures, especially those termed “dangerous stress fractures”.