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By F. Moff. Saginaw Valley State University.

The cannula is readjusted to enable placement of a vertical mattress suture and the second stitch is passed buy cheap super p-force oral jelly 160mg on-line. The stitches are made from 2–0 nonabsorbable material buy 160 mg super p-force oral jelly visa, such as Ethi- bond, and is attached to a 0. Tears are routinely repaired with the scope in the ipsilateral portal and the cannula coming in from the contralateral portal (Fig. Although accessory portals are not routinely needed, they may be used to assist with positioning of the cannulae. Sutures may be placed in either a horizontal fashion or a vertical orientation. The sutures may be placed at 4- to 5-mm inter- vals alternating between the upper and the lower meniscal surfaces Figure 6. The loop vertical suture placed under the meniscus with the hor- izontal loop placed above the meniscus. If ACL reconstruction is done, the sutures are tightened so that the repair can be verified. The sutures are usually tied after the completion of the meniscal repair and are then tied sequentially over the knee capsule. Cannon believes that the risk-benefit ratio should discourage the placement of sutures posterior to 1cm from the posterocentral insertion of the posterior horn of the menisci. He believes that the suturing ante- rior to this point should provide enough strength to reduce and hold the meniscus. Working posterior to this places undue difficulty on the pro- cedure and unnecessary risk to the neurovascular bundle. This has become the major benefit of the hybrid repair, using the sutures for the easy to access mid-portion and the bioabsorbable fixators for the diffi- cult to access posterior region. Results of Zone-Specific Repair Rosenberg and his colleagues have evaluated the type of suture used for repair. This group found that the use of nonabsorbable sutures did not abrade or damage the articular cartilage on second look arthroscopy. Hamstring Graft Reconstruction Techniques sutures broke several months after repair. Because of these findings, Rosenberg does not recommend the use of absorbable sutures for routine meniscal tears. Capsular tears that heal quickly may be amenable to the use of absorbable sutures. Several other studies have also reported good success with this technique. The gold standard for results can be identified by a series that uses second-look arthroscopy as an outcome measure. The cannula is placed in the contralateral portal, while viewing from the ipsilateral portal. In the latter group 4 out of 5 of the knees were ACL deficient at the time of repair and second-look arthroscopy. The Technique of the BioStinger Insertion The appropriate length of BioStinger (Linvatec, Largo, FL) selected, is usually 13mm, and loaded on the cannulated wire of the delivery unit (Fig. The cannula is placed against the meniscus and 2mm of cannulated wire is delivered into the torn fragment (Fig. When the torn fragment is reduced, the cannulated wire is advanced into the rim using the slider bar on the side of the device (Fig. The BioStinger is inserted into the meniscus by depressing the handle on the end. To prevent the cannulated wire from bending, firm pressure must be exerted on the cannula to keep this against the meniscus. The cannula is backed up 5mm, and the head of the BioStinger inspected to be sure 84 6. The BioStinger is driven across the tear by depressing the handle of the delivery device. The appearance of the completed meniscal repair using sutures in the middle segment and BioStinger posterior is shown in Figure 6. The use of the fibrin clot was shown by Henning and later Jackson to improve the results of isolated meniscal repairs. Most repairs are done in association with ACL reconstruction and do not require the use of a fibrin clot. If the physician needs to repair an isolated tear, the addition of a fibrin clot will improve the results. To prepare the clot, the physi- cian will need a glass syringe and a glass rod to stir the blood to form a firm clot. The clot is then inserted under the meniscus at the meniscus synovial border. The fibrin clot may also be produced by curetting a portion of the notch to produce bleeding. If the ACL reconstruction is done, then bleeding will be produced by the notchplasty. Clinical Results Peter Kurzweil reported the following results at the Arthroscopy Asso- ciation of North America (AANA) fall course in San Diego: The Technique of the BioStinger Insertion 87 Figure 6.

Local governments are even being encouraged to harness computers for the task of identifying and tracking disease outbreaks (as reported in the The Diagnosis Dilemma 15 June 2003 issue of Governing generic super p-force oral jelly 160 mg without prescription, a magazine designed for states and localities) super p-force oral jelly 160 mg overnight delivery. Clearly, though, we are still only in the infancy stages of gathering and exchanging data. It is easy to see how many diseases simply have not yet been identified and can be diagnostic mysteries. The Immeasurable Effects of the Environment The increase in mystery ailments may be related to factors we encounter in the environment, ranging from chemicals to microorganisms whose growth may be stimulated by changing climatic conditions. For instance, toxic mold can cause serious illnesses that not all doctors know how to recognize. They might expect to find such diseases in those who live in substandard hous- ing but fail to ask pertinent questions of their well-heeled patients. There are many unanswered questions about environment-related dis- eases and many aspects that must be researched, and without clear cause- and-effect statistics, physicians may be reluctant to link mysterious symptoms to such exposures. Even so, it is now estimated that forty million people have some form of environmental illness due to allergic or toxic reac- tions to hundreds of thousands of chemicals contained in our air, food, water, homes, workplaces, and schools. But until more studies are con- ducted, it is diagnostic guesswork at best. Kathy, a hard-working executive secretary, had a complex of symptoms that started insidiously with flulike signs—chills, joint pain, and breathing difficulties—which ultimately landed her in the hospital emergency room gasping for breath. But no one could diagnose her condition until she found one smart doctor who was willing to look beyond the usual. He found that Kathy was suffering from a malady known as hypersensitivity pneumoni- tis—also known as farmer’s lung or cheese lung—and more recently iden- tified as a form of “sick building syndrome. It is also found in hay stored in barns and in the fermentation process at cheese factories. For those who are sensitive to this type of mold, prolonged exposure to it can cause fibrosis of (a buildup of tissue in) the lungs. Closely associated with sick building syndrome and other syndromes resulting from exposure to toxic mold is a controversial illness known as 16 Becoming Your Own Medical Detective “multiple chemical sensitivity. For an esti- mated 20–30 percent of the population (some thirty-seven million Ameri- cans), the symptoms of multiple chemical sensitivity can range from mild headaches, dizziness, short-term memory loss, nosebleeds, irritability, itchy eyes, and scratchy throats to possible damage to the nervous and respiratory systems. In its most extreme form, sufferers are confined to a plastic bubble world or one made up of only natural materials. A different set of illnesses of an environmental nature appear to be a by-product of disturbance of ecosystems. This would include, for example, occurrences of Lyme disease in suburbia. Given that Borrelia burgdorferi, the bacteria that causes Lyme disease, has been around a long time, why are peo- ple suddenly being diagnosed with it? In open woodlands, foxes and bob- cats keep a lid on the bacteria by hunting the mice that carry it, but when these predators vanish with our woodlands as developers clear lots for new subdivisions, the mice and their ticks proliferate unnaturally. Richard Oster- field, an animal ecologist at the Institute of Ecosystem Studies in Millbrook, New York, found in a recent survey that infected ticks were seven times as prevalent on one- and two-acre lots as they were on the fifteen-acre lots of yesteryear. The intriguing case study of a little boy who contracted Lyme disease while on a Boy Scout outing is described in Chapter 13. In Malaysia, where pig farmers started pushing back the forest to expand operations, displaced fruit bats began spreading a pathogen now known as the Nipah virus. The pigs developed a cough so loud it became known as the “one-mile cough. A full discussion of the medical consequences of disturbing the ecosys- tem is beyond the scope of this book. The point we are trying to make is how easy it is to have an undiagnosed disease that is quite real but remains a mystery until the root cause is found. Potential Dangers from Genetically Modified Foods Many scientists argue that we are creating a new kind of biological pollu- tion by altering the genetics in food. Genetic manipulation of everything The Diagnosis Dilemma 17 from corn to papayas may have unintended consequences, causing new drug-resistant diseases to emerge. While biotechnology is likely to change the world for the better in ways we can only imagine, it’s still in its infancy. Fears that genetically modified (GM) foods might promote drug-resistant “superbugs” have been fueled by some research findings. Dutch scientists recently discovered it might be pos- sible for genes to jump from GM food into bacteria in the gut of farm ani- mals. If the transferred genes are the antibiotic-resistant ones used in some of the GM crops fed to livestock, then there is a danger that antibiotic- resistant bacteria could spread from animals to humans. But many people, includ- ing some scientists, are concerned that ingesting them may lead to changes in human cells and subsequent disease. Jane Rissler of the Union of Con- cerned Scientists says, “We know very little about the long-term impacts of genetically engineered food, so as a general matter, they should be subject to more scrutiny. Ravi Durvasula, an infectious disease scientist at Yale University, calls the possibility of laboratories unleashing potentially deadly disease the “Jurassic Park syndrome”—an assessment that he says “may be rooted in real concern. But they are not quite there, even though genetic links have been found to some diseases such as dyslexia and certain types of high blood pressure. Likewise, physicians and their patients who suffer from little-understood conditions such as fibro- myalgia, irritable bowel syndrome, and certain other inflammatory disor- ders have long suspected a genetic link to such conditions.

The initial radiograph shows a large lesion with mild dome depression (A) super p-force oral jelly 160 mg sale, and the 6-year follow-up radiographs show good incorporation of the vascular fibula with partial regeneration of bone in the subchondral area (B) Large Osteonecrotic Femoral Head Lesions 111 confidence interval cheap super p-force oral jelly 160mg online, 69. Gross and histological examinations of the cross-sectional femoral head when the hip had been converted to THR showed partially regenerated bone with a good incorporation of the fibula graft to the host bone in the VFG and absence of this effect in the NVFG. Complica- tions occurred predominantly in the vascularized group, with clawing of the toes in 3 patients and sensory peroneal neuropathy in another 3. Only 1 complication (a sensory peroneal neuropathy) was reported in the NVFG group. We strongly suggest that VFG is associated with better results than NVFG, particu- larly in young patients with precollapsed large osteonecrotic lesions. The study has obvious advantages over the previous report of Plakseychuk and Kim; it is a closely matched prospective study in which both VFG and NVFG were done in parallel by the same surgeons at the same institution. Evaluation of patient outcomes did not indicate differences in ethnicity or in social and economic factors. The patency of the artery, which is critical in free vascular bone graft, was evaluated with a buoy flap, color Doppler ultrasonography, magnetic resonance angiography, and bone scintigraphy, rather than by invasive direct angiography [46,48]. We believe that the VFG had better clinical and radiographic results compared with the NVFG, particularly in Steinberg stage IIc hips of young patients, because the VFG-treated hips seemed to have less dome depression of the femoral head, retention of head sphericity associated with a more rapid osteoinduction of the primary callus forma- tion in the subchondral bone, and more robust revascularization. Free vascularized fibular grafting is a technically difficult procedure that requires specialized training and expertise. It is costly and time consuming, and it requires a long period of re- covery. In addition, it comes with a relatively high prevalence of complications [57–59]. Conclusions Core decompression showed better clinical results than nonoperative management. We demonstrated that VFG had significantly better results than NVFG, particularly in large osteonecrotic lesions of ONFH. VFG had less dome depression of the femoral head and retained sphericity of the femoral head. In addition, we think VFG can change large lesions into small ones and lateral lesions into medial or central ones, which will be less likely to progress, even though it cannot cure large necrotic lesions. Recently, surgeons have tried core decompression with autogenous bone marrow cells [60,61] and osteoinductive bone morphogenetic protein to enhance bone repair in the femoral head. In an animal osteonecrosis model, osteogenic protein 1 or vascular endothelial growth factor were successful in regenerat- ing bone defects. In the future, it is believed that nonsurgical techniques or minimally invasive procedures using tissue engineering will be tried. We cannot directly compare the results of the VFG with those of other techniques for treating large osteonecrotic lesion of the femoral head. Large randomized and prospective controlled trials, which can compare the efficacy of several treatment modalities regarding the specific stages, sizes, and locations of osteonecrosis, however, are needed in future. Merle d’Aubigne R, Postel M, Mazabraud A, et al (1965) Idiopathic necrosis of the femoral head in adults. Assouline-Dayan Y, Chang C, Greenspan A, et al (2002) Pathogenesis and natural history of osteonecrosis. Marcus ND, Enneking WF, Massam RA (1973) The silent hip in idiopathic aseptic necrosis. Steinberg ME, Hayken GD, Steinberg DR (1995) A quantitative system for staging avascular necrosis. Kerboul M, Thomine J, Postel M, et al (1974) The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. Koo KH, Kim R (1995) Quantifying the extent of osteonecrosis of the femoral head. Ohzono K, Saito M, Sugano N, et al (1992) The fate of nontraumatic avascular necrosis of the femoral head. Sugano N, Atsumi T, Ohzono K, et al (2002) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Gardeniers JWM (1993) The ARCO perspective for reaching one uniform staging system of osteonecrosis. In: Schoutens A, Arlet J, Gardeniers JWM, et al (eds) Bone circulation and vascularization in normal and pathological conditions. Jergesen HE, Kahn AS (1997) The natural history of untreated asymptomatic hips in patients who have non-traumatic osteonecrosis. Kopecky KK, Braunstein EM, Brandt KD, et al (1991) Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft patients. Nishii T, Sugano N, Ohzono K, et al (2002) Progression and cessation of collapse in osteonecrosis of the femoral head. Cheng EY, Thongtrangan I, Laorr A, et al (2003) Spontaneous resolution of osteone- crosis of the femoral head. Koo KH, Kim R, Ko GH, et al (1995) Preventing collapse in early osteonecrosis of the femoral head. Sakamoto M, Shimizu K, Iida S, et al (1997) Osteonecrosis of the femoral head: a pro- spective study with MRI. Mont MA, Carbone JJ, Fairbank AC (1996) Core decompression versus nonoperative management for osteonecrosis of the hip. Stulberg BN, Davis AW, Bauer TW, et al (1991) Osteonecrosis of the femoral head. Hernigou P, Poignard A, Nogier A, et al (2004) Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip. J Bone Joint Surg 86A:2589–2593 Large Osteonecrotic Femoral Head Lesions 113 22. Beltran J, Knight CT, Zuelzer WA, et al (1990) Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging.

Representative intertrochanteric osteotomies for SCFE are Southwick’s and Imhaeuser’s osteotomy [8 cheap super p-force oral jelly 160 mg with visa,9] generic super p-force oral jelly 160mg with mastercard. We think these are good methods theoretically; however, the technique is complicated and not always easy to carry out. There is discrepancy between planning before the operation and radiograms after the operation in their procedures. So, we have done the simpler and more certain CO using an original plate. We think it is a useful method for moderate SCFE because the radiographic and clini- cal results at maturity are good, with a low incidence of complications. There is, of course, limitation of correction angle normally because we correct the deformity by accommodating to the plate; however, we believe perfect correction is not necessary. Fifteen of the 20 patients in this study had remodeling after the operation. We also emphasize the needlessness of the physeal fixation at CO as natural physeal closure occurs without further slippage. Physeal fusion is promoted by reorienting the plane of the capital physis into a more horizontal position. There is still expansion of the indications for in situ pinning for SCFE [1–5], and also the indications for pinning or osteotomy for SCFE have not yet been made clear. Also, in our hospital, we expanded its indication in 1995, although it was PTA less than 30° until 1994. So, we presently select in situ pinning for SCFE with PTA 45° or less and CO for SCFE with PTA more than 45°. O’Brien ET, Fahey JJ (1977) Remodeling of the femoral neck after in situ pinning for slipped capital femoral epiphysis. Jones JR, Paterson DC, Hillier TM, et al (1990) Remodeling after pinning for slipped capital femoral epiphysis. Rostoucher P, Bensahel H, Pennecot GF, et al (1996) Slipped capital femoral epiphysis: evaluation of different modes of treatment. Bellemans J, Fabry G, Molenaers G, et al (1996) Slipped capital femoral epiphysis: a long-term follow-up, with special emphasis on the capacities for remodeling. Boero S, Brunenghi GM, Carbone M, et al (2003) Pinning in slipped capital femoral epiphysis: long-term follow-up study. Boyer DW, Mickelson MR, Ponseti IV (1981) Slipped capital femoral epiphysis: long- term follow-up study of one hundred and twenty-one patients. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. Imhauser G (1977) Late results of Imhauser’s osteotomy for slipped capital femoral epiphysis. Z Orthop 115:716–725 Follow-up Study After Corrective Imhäuser Intertrochanteric Osteotomy for Slipped Capital Femoral Epiphysis Shigeru Mitani, Hirosuke Endo, Takayuki Kuroda, and Koji Asaumi Summary. We investigated 28 hips in 26 patients with slipped capital femoral epiphy- sis who were treated by the Imhäuser intertrochanteric osteotomy, with subsequent removal of implants. The mean age at operation was 13 years, and the mean age at the time of the final follow-up was 19 years. PTA became restored to within the allowable range of up to 30° in all patients. The limitation of range of motion completely resolved in all patients, and none had necrosis of the femoral head postoperatively. Four patients had a fracture due to bone fragility from long- term traction and bed rest. Chondrolysis developed in only 1 male classified as an unstable case with an unstable classified as unstable. The Imhäuser treatment system for mild to severe cases may be said to be reasonable in that the physeal stability is rendered stable by traction and then the PTA is reduced to 30° or less by osteotomy to lessen the severity to mild. So, satisfactory results were obtained both clinically and roentgenographically in short- or midterm outcome. Slipped capital femoral epiphysis, Intertrochanteric osteotomy, In situ pinning, Posterior tilting angle, Physeal stability Introduction Since 1977, we have been treating slipped capital femoral epiphysis at our hospital using the Imhäuser treatment system. In patients incapable of walking or suffering from hip joint pain on exertion, traction is undertaken until irritant pain in the hip joint disappears. This treatment is not intended for reduction of slipped epiphysis but is aimed at attaining fibrous or osseous stabilization of the slippage site. Therefore, the Imhäuser treatment system may be characterized by these two surgical procedures used according to disease Department of Orthopaedic Surgery, Okayama University Hospital,2-5-1Shikata-cho, Okayama 700-8558, Japan 39 40 S. Imhäuser’s treatment system for slipped capital femoral epiphysis (SCFE). PTA, poste- rior tilt angle severity and preoperative attainment of stabilization of the slippage site. Imhäuser has documented that gratifying treatment results were obtained from a follow-up investigation in patients with slipped capital femoral epiphysis conducted over 11 to 22 years, showing that arthrotic changes had been seen in as few as 2 of 68 hip joints treated. To date, we also have had favorable results using this treatment system, as previously reported. However, because several complications have been noted and because some other investigators demonstrated, even in severe cases, that better treatment results were obtained with the in situ pinning technique than with osteot- omy, we considered it necessary to reexamine this treatment system. The present study was performed to evaluate the treatment system for its usefulness and for any problems involved by reviewing retrospectively patients with slipped capital femoral epiphysis showing a PTA of 30° or greater that was treated by intertrochanteric osteotomy. Patients We investigated 28 hips in 26 patients, which were treated by the Imhäuser intertro- chanteric osteotomy, with subsequent removal of implants.

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