By O. Iomar. Luther Seminary.

We con- clude that VIBG for ION should be indicated for (1) joints without or with little col- lapse of the femoral head and (2) joints with a wide lesion for which transtrochanteric rotational osteotomies are never indicated buy clomiphene 25mg low price. VIBG is a time-saving surgery for young patients to postpone total hip arthroplasty or hemiarthroplasty generic clomiphene 100mg without prescription. VIBG cannot always prevent stage progression of the femoral head after ION. Preoperative collapse, sex, total curettage of the necrotic lesion for bone grafts, and bilateral ION reduce JOA score after VIBG. Total curettage of the necrotic lesion, operative age over 30 years, precollapse, and abuse of alcohol reduce survival rate of ION when the endpoint is set at progress of femoral head collapse. VIBG is a “time-saving surgery” for young patients with ION to postpone perfor- mance of total hip arthroplasty or hemiarthroplasty. Solonen KA, Rindell K, Paavilainen T (1990) Vascularized pedicled bone graft into the femoral head: treatment of aseptic necrosis of the femoral head. Cheung HS, Stewart IE, Ho KC, Leung PC, Metreweli C (1993) Vascularized iliac crest grafts: evaluation of viability status with marrow scintigraphy. Sugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K (2003) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Hasegawa Y, Iwata H, Mizuno M, Genda E, Sato S, Miura T (1992) The natural course of osteoarthritis of the hip due to subluxation or acetabular dysplasia. Pavlovcic V, Dolinar D, Arnez Z (1999) Femoral head necrosis treated with vascular- ized iliac crest graft. Eisenschenk A, Lautenbach M, Schwetlick G, Weber U (2001) Treatment of femoral head necrosis with vascularized iliac crest transplants. Feng CK, Yu JK, Chang MC, Chen TH, Lo WH (1998) Vascularized iliac bone graft for treating avascular necrosis of the femoral head. Nagoya S, Nagao M, Takada J, Kuwabara H, Wada T, Kukita Y, Yamashita T (2004) Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head. Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K, Iwasada S (1997) Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. Norman D, Reis D, Zinman C, Misselevich I, Boss JH (1998) Vascular deprivation- induced necrosis of the femoral head of the rat. An experimental model of avascular osteonecrosis in the skeletally immature individual or Legg–Perthes disease. Noguchi M, Kawakami T, Yamamoto H (2001) Use of vascularized pedicle iliac bone graft in the treatment of avascular necrosis of the femoral head. Sugioka Y (1978) Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Sugioka Y, Hotokebuchi T, Tsutsui H (1992) Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Nakamura H, Watanabe Y, Hasegawa K, Tanabe H, Yoshino K, Fukuda T, Katsuro T (2002) Analysis of vascularized iliac bone graft using superficial circumflex iliac artery and vein. Relationship between bone strut and collapse of the femoral head (in Japanese). Endo N, Kitahara H, Ohkawa Y, Ogawa T, Matsuba A, Tokunaga K, Dohmae Y, Sofue M, Minato I (2000) Analysis of patients underwent vascularized iliac bone graft with poor clinical results and required additional surgeries (in Japanese). Hip Joint 26: 373–375 Part III Osteoarthritis of the Hip: Joint Preservation or Joint Replacement? The decision-making process in context with the treatment of hip joint diseases and posttraumatic conditions more than ever has to be respected. Multifold experiences—especially long-term results after hip joint replacement—during the past 46 years since Charnley justify and require detailed discussion and evaluation in respect to the borderline between a joint-preserving and a joint-replacing procedure. We must remember and respect the progress made in connection with bone and joint preservation techniques and the importance of the factor of gaining time for our patients—preferably the younger patient cohort—with a longer age expectancy. Introduction The Joint-Preserving Procedure Charnley’s idea, almost 46 years ago, about the use of cement to anchor prosthetic components, together with his low-friction principle, profoundly influenced arthro- plasty of the hip joint and promoted its clinical application. Despite all the blessings that joint replacement has brought to many people throughout the world in the past few decades, we must remember and admit that neither the implants nor the techniques available to us today, particularly with respect to long-term results—and also and especially in younger and active people—can yet fulfill all our wishes and requirements. Facing an increasing number of problems in context with aseptic loosening after primary or secondary joint replacement (that is, revision), it is necessary to improve and make use of all possible joint-preserving measures to prevent or at least delay joint replacement. In many cases it might be easier, faster, spectacular, and also “economically more advantageous” for the surgeon to select a prosthesis as a primary intervention rather than to perform a more or less demanding joint reconstruction or correction with all its long and detailed postoperative procedures. We, however, should not focus on short- or medium-term results, but must look much more these days for good long-term solutions, especially when dealing with a Engelfriedshalde 47, D-72076 Tuebingen, Germany 137 138 S. Weller rising number of younger age patients from a continuously growing community of people active in sports. It is this group of patients, who have a constant desire and demand—for whatever reason—after an injury or any joint disease to return to their athletic as well as social activities as soon as possible. More and more, the demands and expectations of our so-called modern treatment results (as repeatedly advertised in the media (e. It seems that in our technically orientated and fast-changing world people think everything is possible and sometimes we forget that there are still “unsolved prob- lems,” especially biological barriers, which we cannot overcome. Joint replacement, therefore, still deserves critical observation and evaluation in respect to indication and technique (Fig. We can make the following statement: “Sometimes it is good to remember where we have come from to recognize where we must go!

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Notchplasty and ACL Stump Debridement The ACL stump is removed with a combination of the shaver and the electrocautery cheap 25 mg clomiphene visa. In most cases no bone is removed buy discount clomiphene 25mg line, only the soft tissue from the wall of the notch. There is still considerable controversy over the extent of the notchplasty. Each physician should do what needs to be done to accommodate an 8 to 10mm graft. In cases with a very narrow A-frame notch, this will mean more extensive use of the burr to remove enough bone to visualize the back of the notch (Fig. Measure the size of the notch with an instrument, such as a pituitary rongeur that opens to 10mm. It is important to remove the soft tissue to visualize the back of the notch. The residents ridge does not have this fringe, so the physician should easily identify the correct area. Linvatec makes a southpaw for left knees that also eliminates the jumping. The author makes a small divot with the burr at the position that the tunnel should be, that is, 7mm in from the drop- off at 11 or 1 o’clock. The major mistake would be not to clear enough soft tissue to expose the posterior aspect of the notch. Tibial Tunnel Choosing the correct position for the tibial tunnel is crucial to the rest of the operation. The landmarks are external surface of the tibia, 4cm from joint line, 2cm medial to tibial tubercle; inside, 7mm anterior to the leading edge of the PCL, in the midline. The guide is inserted through the anteromedial portal, by turning it upside down. The distal point of the guide is positioned 2cm medial to the tubercle and 4cm from the joint line. If necessary, chamfer the posterior rim with the chamfering device on the drill. The wire is in the middle of the ACL stump, approximately 7mm in front of the PCL, in the midline and just touching the edge of the PCL. Femoral Tunnel To drill the femoral tunnel, the Bullseye (Linvatec, Largo, FL) femoral aiming guide is placed through the tibial tunnel. This means that the tibial tunnel must be in the correct position and at the correct angle or it will be impossible to place the femoral tunnel correctly. Femoral Tunnel 107 are drilled according to the graft measurement, that is, 7 or 8mm. The physician should not leave the graft soaking in saline, as it may swell and make passing difficult. The femoral tunnel is drilled through the tibial tunnel with the use of the femoral aiming guide (Fig. The Bullseye guide is inserted through the tibial tunnel, the flare of the guide placed over the top of the femoral condyle, and the guide aimed at the 11 or 1 o’clock posi- tion (Fig. A long, guide-passing wire is drilled into the femur and retrieved through the anterolateral thigh. The surgeon should avoid placing the femoral tunnel in a vertical position. Howell has shown that the vertical graft provides a-p stability, but not rotational stability at 30° of knee flexion. The oblique position of the graft is preferable to the vertical graft position. The guide wire (Linvatec, Largo, FL) is overdrilled with the same size C-reamer as used in the tibial tunnel. It is important to make a foot- print on the condyle by drilling only half of the head of the drill bit into the bone. The drill bit is retracted and the footprint examined to deter- mine if it is in the correct position (Fig. Tunnel Dilation Tunnel dilation is a method to compact the tunnel wall to improve the pullout strength of the interference screw. In the middle-aged patient, the tunnels should be dilated 2 sizes to improve the fixation strength. For example, if the graft is 8mm, drill a 6-mm tunnel and dilate 2 sizes. Drilling a small tunnel in both the tibia and femur and inserting the graft passing wire through both tunnels facilitates the dilation procedure. With the graft passing wire inserted, both tunnels can be quickly dilated with a single pass of the dilators (Fig. Tunnel Notching The edge of the tunnel must be notched to start the BioScrew (Linvatec, Largo, FL) (Fig. The Notcher (Linvatec, Largo, FL) is inserted through the tibial tunnel to notch the femoral tunnel. This demonstrates the notch in the edge of the tunnel to start the screw. Graft Passage 111 Graft Passage The four-bundle semi-t and gracilis graft is attached to the looped end of the graft passing guide wire and the number 5 Ti-Cron is drawn into the femoral tunnel.

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In 1978 Ausubel and colleagues suggested that the attachment secret of education is to find out what the learner already knows Efficiency* High Medium Low Low Very low and teach accordingly cheap 100mg clomiphene with visa. In a lecture order 25mg clomiphene mastercard, tutorial, or seminar you Active Low Variable High Medium Very high cannot hope to diagnose and respond to every individual’s learning (usually) to high learning needs, but a one to one relationship provides an Mutual Low Medium High Medium Very high opportunity to match the learning experience to the learner. Stott and Davis in 1979 promoted the idea that one to one PBL=problem based learning. The principles used in primary care consultations can be applied to one to one teaching, and the secret is forethought and planning. Plan ahead—ask yourself some important questions x What is the main purpose of the one to one attachment? Exceptional potential of one to one teaching x How would you like this learner to describe the experience to a peer? Find out and remember the learner’s name—a simple but important courtesy. Outline the special opportunities and benefits that the attachment can provide. Ask the learner to prepare a learning plan and then compare the learner’s plan to your own expectations. Once the plan has been agreed, don’t shelve it—refer to it during the attachment and modify as necessary. Agree on the ground rules Ground rules are both practical (punctuality, dress, access to patient records) and philosophical (respect for patients and colleagues, confidentiality, consent, openness to different points of view). Make sure that the learner knows how much Find out and remember the learner’s name—a simple but important courtesy time you will be able to spend in observing, teaching, and giving feedback and what you expect in return. Ask helpful questions Open ended questions are generally better than closed questions at the beginning of the exchange. A small number of Skilful teaching is not unlike skilful closed questions later in the conversation help you to history taking “diagnose” just how much the learner knows and understands. Try to formulate questions that assume an appropriate amount of knowledge, but build in higher order thinking and/or higher order skills. You might ask the learner, for example, to explain to you (as if you were the patient) the mechanisms behind a condition such as asthma or hypertension. This simulates “If musicians learned to play their instruments as clinical interface with a patient—testing recall, understanding, physicians learn to interview patients, the procedure and communications skills all at once. The instructor of course, would not be present to observe or listen to the Learners value feedback highly, and valid feedback is based on student’s efforts, but would be satisfied with the observation. Deal with observable behaviours and be practical, student’s subsequent verbal report of what came out of timely, and concrete. Begin by asking the George Engel, after visiting 70 medical schools in learner to tell you what he or she feels confident of having done North America wellandwhatheorshewouldliketoimprove. Followupwith your own observations of what was done well (be specific), and then outline one or two points that could help the student to improve. Encourage reflection Monitor progress Just as many learning opportunities are wasted if they are not x Identify deficiencies accompanied by feedback from an observer, so too are they x Ask the learner, half way through the attachment, to do a self wasted if the learner cannot reflect honestly on his or her assessment of how things are going. One to one teaching is ideally suited to identify deficiencies within a safe learning environment, you can encouraging reflective practice, because you can model the way work together to tackle them well before the attachment ends a reflective practitioner behaves. Two key skills are (a) x If you have serious concerns, you have an obligation to make them known to the learner and to the medical school or training “unpacking” your clinical reasoning and decision making authority processes and (b) describing and discussing the ethical values x It is not appropriate to diagnose serious problems and hand the and beliefs that guide you in patient care. When 23 ABC of Learning and Teaching in Medicine junior colleagues interact with a learner, you can encourage them with positive feedback on their teaching. Every patient interview and every physical examination places the learner in a privileged relationship with a patient. We all have patients whom we especially admire—particularly people who have coped bravely with a chronic illness or a major disability, a disaster such as war, or other misfortunes. Such patients activate an emotional response in the learner, imprinting an enriched memory of the patient and the patient’s illness. Promote active learning x Time is limited in most clinical settings, and it can be tempting to revert to a passive observational teaching model “Cultivate the society of the young, remain interested and never stop learning” (Cicero) x Think about strategies to promote active learning x Brief students to observe specific features of a consultation or procedure x Ask patients for permission for the learner to carry out all or part Points to remember of the physical examination or a procedure while you observe Do x If space is available, allow students to interview patients in a x Welcome separate room or cubicle before presenting them to you x Set shared achievable goals x If possible videotape consultations for a debriefing session at a x Put yourself in the learner’s shoes more convenient time x Ask interesting questions x Arrange for the learner to see the same patient over time, or in x Monitor progress and give feedback another context, such as a home visit x Encourage Don’t x Appear unprepared Reap the rewards x Be vague about your expectations x Confine the learner to passive roles The role of the teacher is frequently undervalued, and yet x Be “nit-picking” teaching is potentially rewarding and enjoyable. It is also one of x Leave feedback to the final assessment the defining features of a profession. Without teaching to x Humiliate ensure the transmission of knowledge, medicine becomes just another “job. If the learner trusts you, he or she will be able to tell you what has worked well, and what could be improved. Med Educ Respond to feedback by reflecting rather than by explaining, 2001;35:409-14. Precepting medical excusing, or offering counter arguments to defend your students in the office. Collaborative clinical education:the foundation of attribute that is best modelled one to one. Learners for whom you have been a role model and mentor x Whitehouse C, Roland M, Campion P, eds. New York: Oxford the opportunity to observe their personal and professional University Press, 1997. The exceptional potential in each primary care development long after the one to one attachment has finished.

Whatever contradictory statements came under my notice in the course of this comparision Human Osteology order clomiphene 100 mg overnight delivery. His mental and physical were noted down proven clomiphene 25 mg, and made the subject of careful powers deteriorated to such an extent that he research in several extensive anatomical collections entered St. Ward’s experiments to show the nature and The book is of small dimensions. The pages composition of bone provide interesting conclu- of the first edition measure only two and three- sions. On quarters by four and a half inches, the volume page 370 of Human Osteology, Ward illustrated being one and three-quarters inches thick. Though the triangle in the neck of the femur with which it cannot be said to present the attractions of the his name is still associated. A similar area is to be modern textbook, its text and illustrations achieve found in the calcaneum. He made this observation: qualifying medical examination, but we know that for some years he practiced as a surgeon. His The arrangement of the cancellous tissue in the ends of interests extended far beyond the confines of the femur is very remarkable; and, as it illustrates the medicine. In the lower who introduced him to Edwin Chadwick, both extremity of the bone, it consists of numerous slender of whom were pioneers of the new medicolegal columns, which spring on all sides from the interior group of sanitary reformers. Fired with their surface of the compact cylinder, and descend, con- enthusiasm, Ward wrote at this time a number verging towards each other, so as to form a series of of popular articles in which he criticized water inverted arches, adapted by their pointed form to supply and hygiene and proposed control under sustain concussion or pressure transmitted from below. These converging columns not only meet but decussate 346 Who’s Who in Orthopedics each other; and they are further strengthened by innu- succeeded in performing the first arthroscopic merable connecting filaments and laminae, which cross meniscectomy. Many of the world’s finest sur- them in all directions, so that no single arch could break geons, including Dr. Richard O’Connor, visited Tokyo Teishin Hospi- Hence, notwithstanding the tenuity and brittleness of tal to learn arthroscopy. These surgeons faithfully each several fibre, the reticular structure possesses passed on the teaching of Professor Watanabe to great strength as a whole. In 1974, Watanabe founded the International Ward’s account of the triangle in the neck of Arthroscopy Association (IAA), and was elected the femur attracted little attention for many years, its first president. It is strange to recall that one of but the introduction of roentgen rays showed the purposes of the IAA was to prevent the tech- clearly that the translucent triangular area was a nique slipping into obscurity as it had done pre- normal feature of the femoral neck. In 1975, he was elected the first president of the Japanese Arthroscopy Association. He devoted his whole life to the development of the arthroscope, not only in Japan but also in the world. He received many prizes; in 1983, he was awarded the Asahi Prize, one of the largest scientific awards in Japan, for his unique contri- butions to the development and improvement of arthroscopy. At that time he was already trying to develop a small arthroscope, video systems, and arthroscopic surgery. Even in the midst of busy research work, he handled the arthroscope very gently as if treating his beloved grandchild. Professor Watanabe stated in the preface of the Atlas of Arthroscopy, 2nd edition, in 1969, that it would give him great pleasure if arthroscopy were to bring about some progress in orthopedics and rheumatology. Arthroscopes are Masaki WATANABE indispensable in orthopedics and rheumatology. Professor Watanabe’s dedication to training in the Department of Orthopedic Surgery arthroscopy placed orthopedic surgery at the fore- at Tokyo Imperial University. He then began his front of the revolution in minimal access surgery research into arthroscopy under Professor Kenji that is now sweeping the world of surgery. This work was interrupted by the Second He died on October 15, 1995, of complications World War, but in 1949 Dr. Watanabe became after the apparently successful treatment of a director of the Department of Orthopedic Surgery femoral neck fracture at Tokyo University and at Tokyo Teishin Hospital, where he put his heart Teikyo University Hospitals. His delightful face, and soul into the development of arthroscopy and when he talked about arthroscopy in his hospital came to be respected as the world’s leading expo- bed before he died, is an unforgettable memory. In 1960, he developed the Watanabe Type 21 arthroscope, which became the standard instru- ment around the world for almost two decades, and in 1962, after great effort and research, he 347 Who’s Who in Orthopedics was the only means of survival in those days when all hospital work was unpaid. In 1928, he was appointed to the Country Orthopedic Hospital at Gobowen, later to become the Robert Jones and Agnes Hunt Orthopedic Hospital, and also held an honorary appointment at the North Wales Sanatorium, where there were at that time many cases of ortho- pedic tuberculosis. It was oversubscribed and many of those who attended were his equals or elders, which was a great tribute to a young man in his early thirties. However, it must be remembered that he had by Sir Reginald WATSON-JONES then become well known nationally and interna- tionally for his contributions to the literature. The 1902–1972 success of the fracture course prompted his admirers to urge him to write a textbook on the Reginald Watson-Jones was born on March 4, treatment of fractures, and this led him to the first 1902. He died in London after a short illness on of his three great achievements. With his passing, the surgical My first encounter with Watson-Jones was as a world has lost one of its great leaders. My father was medical officer of The First World War was a tragic illustration of health for the County of Denbigh. Orthopedic the fact that injuries can eclipse other causes of clinics were held within the ambit of Gobowen at deformity.

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