By A. Phil. Western Maryland College. 2018.
All the cases in which the preoperative stage was advanced were included in those with advanced OA at the last follow-up buy levitra soft 20mg without prescription. In contrast buy cheap levitra soft 20 mg on line, collapse progression was not observed in the cases without advanced OA at the last follow-up. According to these data, we reconﬁrmed that collapse progression is the main cause for poor outcome after osteotomy, and that cases operated on at an early stage are apt to experience a good prognosis. When the indication and the operation are appropriate, osteotomy could prevent disease deterioration even more than 25 years after the operation. Osteonecrosis of the femoral head, Osteotomy, Transtrochanteric anterior rotational osteotomy, Collapse, Clinical outcome Introduction Once collapse occurs at the necrosis area of the femoral head, it usually progresses. Collapse causes incongruity and instability of the hip joint, and the progression of collapse causes incongruity and instability to increase and ﬁnally results in secondary osteoarthritis (Fig. The purpose of osteotomy for osteonecrosis of the femoral head (ONFH) is to prevent the progression of collapse and secondary osteoarthritis. A principle of osteotomy is to support weight-bearing with intact or live bone instead Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan 79 80 S. The dashed line shows the osteonecrosis area of the femoral head from the anterior view of the necrotic bone and to restore the subluxated femoral head (Fig. In other words, osteotomy is on-site vascularized bone grafting with articular cartilage and with good congruency. Options of osteotomy for ONFH are transtrochanteric anterior or posterior rotational osteotomy (ARO or PRO) developed by Sugioka et al. The treatment option is chosen depending on the lesion of osteonecrosis or on where and how wide is the osteonecrosis area in the femoral head. Especially for young patients, oste- otomy is an important treatment option to be considered, and they are expected to survive for a long time after their hip osteotomy. Sugioka developed transtrochanteric rotational osteotomy Long-Term Experience of Osteotomy for Femoral Head Osteonecrosis 81 Fig. Sequential photographs of anterior rotation of the femoral head show a model of ante- rior rotational osteotomy (ARO) with 20° varus position and indicate how ARO results in weight-bearing with the living posterior surface of the femoral head (a–f). According to anterior rotation, the osteotomy line is 10° inclination away from the perpendicular to the neck (a) and 10° ret- roversion. The result is 20° varus position after anterior rotation of the femoral head (f) of the femoral head, so-called “rotational osteotomy” or “Sugioka’s osteotomy”. Anterior rotation of the femoral head with vascularity results in weight-bearing with the live posterior surface of the femoral head (Fig. Experience of Osteotomy in Kyushu University Between 1972 and 1979 The cases that survived more than 25 years after the operation were investigated to reconﬁrm the principles or the indication based upon our previous experience with osteotomy treatment for ONFH [1,2,4]. Patients and Methods Between 1972 and 1979, 128 patients with idiopathic ONFH underwent osteotomy in our department. Fifteen hips of 9 patients, who had been visiting our outpatient ofﬁce and had their living hip joints more than 25 years after operation, were examined. One group includes the hips that had advanced or terminal osteoarthritis (OA) at the last follow-up. Age at operation and period after opera- tion were similar in both the groups.
The initial experience was usually satisfac- tory buy levitra soft 20 mg with visa, but the results gradually deteriorated with longer follow-up purchase 20 mg levitra soft with visa. Allograft was another choice that avoided the problem of harvest site morbidity. The initial allograft that was sterilized with ethylene oxide had very poor results. Today the freeze-dried, fresh-frozen, and cryo- preserved are the most popular methods of preservation of allografts. The allograft has become a popular alternative to the autograft because it reduces the harvest site morbidity and operative time. However, Noyes has reported a 33% failure with the use of allografts for revision ACL reconstruction. The aggressive postoperative rehabilitation program advocated by Shelbourne in the 1990s greatly diminished the problems associated with the patellar tendon graft. Before that, the patient had to be an athlete just to survive the operation and rehabilitation program. Graft Selection aggressive program emphasized no immobilization, early weight bearing, and extension exercises. Biomechanical testing on the multiple-bundle semitendinosus and gracilis grafts demonstrated them to be stronger and stiffer than other options. This knowledge combined with improved ﬁxation devices such as the Endo-button gave surgeons more conﬁdence with no-bone, soft tissue grafts. The Endo-button made the procedure endoscopic, thereby eliminating the need for the second incision. Fulkerson, Staubli, and others popularized the use of the quadriceps tendon graft. This again reduced the harvest morbidity, especially when only the tendon portion was harvested. Shelbourne has described the use of the patellar tendon autograft from the opposite knee. He claims that this divides the rehabilitation between two knees and reduces the recovery time. With the contralat- eral harvest technique, the average return to sports for his patients was four months. With both the patellar tendon and the semitendinosus added to the list of graft choices, the need for the use of an allograft is minimized. The latest evolution is to use an interference ﬁt screw to ﬁxate the graft at the tunnel entrance. It means that the surgeon now has to learn just one technique for drilling the tunnels and can chose whatever graft he or she wishes: hamstring, patellar tendon, quadriceps tendon, or allograft. Successful ACL reconstruction depends on a number of factors, including patient selection, surgical technique, postoperative rehabilita- tion, and associated secondary restraint ligamentous instability. Errors in graft selection, tunnel placement, tensioning, or ﬁxation methods may also lead to graft failure. Comparative studies in the literature show that the outcome is almost the same regardless of the graft choice. The only signiﬁcant fact from the metaanalysis, as conﬁrmed by Yunes, is that the patellar tendon group had an 18% higher rate of return to sports at the same level. The most important aspect of the operation is to place the tunnels in the correct position.
Most emergency departments rely on the use of mobile radiographic equipment for investigating seriously ill patients cheap 20 mg levitra soft mastercard, but the quality of films obtained in this way is usually inferior purchase levitra soft 20mg with amex. Once the patient’s condition is stable, radiographs can be taken in the radiology department. In the presence of neurological symptoms, a doctor should be in attendance to ensure that any spinal movement is minimised. Sandbags and collars are not always radiolucent, and clearer radiographs may be obtained if these are removed after preliminary films have been taken. Plain x ray pictures in the lateral and anteroposterior projections are fundamental in the diagnosis Figure 3. Spinal cord injury without radiological abnormality (SCIWORA) may occur due to central disc prolapse, ligamentous damage, or cervical spondylosis which narrows the spinal canal, makes it more rigid, and therefore renders the spinal cord more vulnerable to trauma (particularly in cervical hyperextension injuries). SCIWORA is also relatively common in injured children because greater mobility of the developing spine affords less protection to the spinal cord. Cervical injuries The first and most important spinal radiograph to be taken of a patient with a suspected cervical cord injury is the lateral view obtained with the x ray beam horizontal. This is much more likely than the anteroposterior view to show spinal damage and it can be taken in the emergency department without moving the supine patient. The lateral view should be repeated if the original radiograph does not show the whole of the cervical spine and the upper part of the first thoracic vertebra. Failure to insist on this often results in injuries of the lower cervical spine being missed. The lower cervical vertebrae are normally obscured by the shoulders unless these are depressed by traction on both arms. The traction must be stopped if it produces pain in the neck or exacerbates any neurological symptoms. If the lower cervical spine is still not seen, a supine “swimmer’s” view should be taken. With the near shoulder depressed and the arm next to the cassette abducted, abnormalities as far down as the first or second thoracic vertebra will usually be shown. This view is not easy to interpret, and does not produce clear bony detail (Figure 3. The interpretation of cervical spine radiographs may pose problems for the inexperienced. First, remember that the spine consists of bones (visible) and soft tissues (invisible) Figure 3. These are functionally arranged into three columns, anterior, middle, and posterior, which together support the stability of the spine (Figure 3. The bases of the spinous processes (ligamentum flavum)— spinolaminar line. The anterior arch of C1 lies in front of the odontoid process and is therefore anterior to the first line described (unless the odontoid is fractured and displaced posteriorly). Extended upwards, the spinolaminar line should cross the posterior Figure 3. A line drawn downwards from the dorsum sellae along the surface of the clivus across the anterior margin of the foramen magnum should bisect the tip of the odontoid process. The disc space may be widened if the annulus fibrosus is ruptured or narrowed in degenerative disc disease. Note the less-than-half vertebral body slip in the lateral view, and the lack of alignment of spinous processes, owing to rotation, If the anterior or posterior displacement of one vertebra on in the anteroposterior view. Anterior displacement of less than half the diameter of the vertebral body suggests unilateral facet dislocation; displacement greater than this indicates a Ligamentum flavum bilateral facet dislocation.