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The operation was performed according to Sugioka’s femoral osteotomy with anterior rotation of 60°–70° and varus angulation of 40° (Fig levothroid 100 mcg cheap thyroid gland video. After 2 days bed rest order levothroid 50 mcg on-line thyroid cancer remission, wheelchair transfer was prescribed discount levothroid uk thyroid gland overactive treatment, and partial weight-bearing was allowed 8 weeks after operation; full-weight bearing was then permitted after 4 months. Bone scintigraphy was planned 1 week after the operation to confirm that the blood supply was preserved in the rotated femoral head. The Japanese Orthopedic Association (JOA) score was used to evaluate the clinical results. Complications such as infection, deep venous thrombosis, pulmonary embo- lism, massive bleeding, and nerve palsy were investigated. Radiograph shows the posterior tilt angle (PTA), an angle between a line perpen- dicular to the epiphyseal line and the femoral taeLral view shaft axis Transtrochanteric Rotational Osteotomy for Severe SCFE 29 p A Before osteotomy After anterior rotation A P P B Before osteotomy After anterior rotation Fig. Solid line indicates osteotomy line, which declined 20° varus to the line perpendicular to the femoral neck axis. Solid line indicates osteotomy line, which declined 20° to the baseline perpendicular to the femoral neck axis. Results The JOA score of 37 points preoperatively improved to an average of 90 points post- operatively. The PTA of 82° preoperatively improved to an average of 24° postopera- tively (Table 1). One patient had decreased blood supply of the femoral head detected in bone blood scintigraphy 1 week after operation, which resulted in partial osteonecrosis of the femoral head with segmental collapse (Fig. There was no infection, deep venous thrombosis, pulmonary embo- lism, massive bleeding, or nerve palsy after the operations. Comparision of preoperative and postoperative posterior tiltangle (PTA) Case Preoperative (°) Postoperative (°) 1 2 3 4 Average 82 24 Table 2. Restoration of range of motion (ROM) of the hip joint by the transtrachanteric rotational osteotomy (TRO) Case number Preoperative (°) Postoperative (°) 1 2 3 4 45 100 Average 25 83 Bone scintigraphy Segmental collapse of left femoral head Fig. Bone blood flow scintigraphy showing decreased blood supply in left femoral head of case 4 after TRO Transtrochanteric Rotational Osteotomy for Severe SCFE 31 Case 3 12y male A Preop Postop Case 3 a b B Fig. B Radiograph shows severe slipped capital femoral epiphysis (SCFE) in case 3 with 80° of PTA (a). The configuration of the hip joint was successfully restored with 15° of PTA after the operation (b) 32 S. Discussion In the natural history of untreated SCFE, more than one-third of severe cases develop end-stage degenerative arthritis of the hip joint. An adequate surgical intervention might be required to prevent further joint destruction. The in situ pinning method is expected to prevent further slipping and restore the spherical shape of the femoral head in patients with PTA less than 30°. Three-dimensional corrective osteotomy can be indicated for moderate cases with PTA less than 70°. However, because patients with severe slipping of femoral epiphysis have severe deformity of the femoral head and neck, sufficient correction is difficult to achieve. Several proximal osteotomies have been reported to be effective to correct slipped capital epiphysis [4,5]. TRO with varus angulation of the femoral head conferred restoration of configuration of the proximal femur and improvement of the range of flexion. There are only a limited number of reports in which TRO was employed for the treatment of severe SCFE. Sugioka experienced one osteonecrosis of the femoral head, and Masuda et al. We had one patient who developed osteonecrosis of the femoral head; bone scintigraphy indicated decreased blood supply to the bone 1 week after the operation. Because of the com- plicated technique of TRO, there may be a risk of some vascular problems of the femoral head. We, however, had confirmed that vascularity was preserved in the rotated femoral head during the operation. The other three patients without a necrotic event had the chronic type of SCFE. Because this patient with osteonecrosis had an acute on chronic type of SCFE, this may have led to osteonecrosis of the femoral head. Although the treatment strategy for severe SCEF remains controversial, our results suggest that TRO is a valuable option for treating severe SCFE with little risk of osteonecrosis of the femoral head. Southwick WO (1967) Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. Sugioka Y (1984) Transtrochanteric rotational osteotomy in the treatment of idiopathic and steroid-induced femoral head necrosis, Perthes’ disease, slipped capital femoral epiphysis, and osteoarthritis of the hip. Carney BT, Weinstein SL (1996) Natural history of untreated chronic slipped capital femoral epiphysis. Dunn DM (1978) Replacement of the femoral head by open operation in severe ado- lescent slipping of the upper femoral epiphysis. Kramer WG, Craig WA, Noel S (1976) Compensating osteotomy at the base of the femoral neck for slipped capital femoral epiphysis. Masuda T, Matsuno T, Hasegawa I, et al (1986) Trochanteric anterior rotational oste- otomy for slipped capital femoral epiphysis: a report of five cases. J Pediatr Orthop 6:18–23 Corrective Osteotomy with an Original Plate for Moderate Slipped Capital Femoral Epiphysis 1 2 2 Takahiko Kitakoji , Hiroshi Kitoh , Mitsuyasu Katoh , 1 2 Tadashi Hattori , and Naoki Ishiguro Summary. We investigated, at skeletal maturity, the radiographic and clinical results of 20 patients with slipped capital femoral epiphysis (SCFE) who were treated by cor- rective osteotomy (CO). CO was performed by the intertrochanteric open- wedge method using an original plate without physeal fixation. The mean posterior tilt angle (PTA) was 47° before CO, 12° after CO, and 9° at the final examination, which indicated that 35° correction was obtained by CO and that this was maintained to skeletal maturity. Fifteen of the 20 patients had remodeling of the proximal femur according to the cri- teria of Jones et al. Six patients had very mild osteoarthritis (OA) changes according to the criteria of Boyer et al. We think that CO using the original plate is a useful method for moderate SCFE because its radiographic and clinical results are good with a simple technique. We emphasize the needlessness of physeal fixation at CO because natural physeal closure occurs without further slippage. Slipped capital femoral epiphysis (SCFE), Corrective osteotomy (CO), Remodeling, Osteoarthritis (OA) Introduction There is still controversy about corrective osteotomy (CO) for slipped capital femoral epiphysis (SCFE). Also, there is contro- versy about the necessity of physeal fixation for stabilization at the time of osteotomy.

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It is as an editor that but pleasant accent best purchase levothroid thyroid vertigo, produces a very agreeable impres- Malgaigne exerted his greatest influence upon his sion on those to whom it is addressed buy levothroid 100 mcg overnight delivery thyroid symptoms normal results, and encourages contemporaries buy levothroid 100mcg low price thyroid gland and parathyroid gland. He was a staunch advocate of the them to bear with greater patience the suffering to statistical approach to the study of medical prob- which they are necessarily subjected. Young men and new ideas always gained a Malgaigne’s reputation today rests chiefly upon hearing on the pages of his journals. Con- Paré revues et collationnées sur toutes les édi- troversy and invective, “yellow journalism,” was tions aver les variantes. Such an exchange, between the his great work on fractures and dislocations, a former associates, Guérin and Malgaigne, led to brief comment on the other is in order. The basic point at issue Ambroise Paré was an attempt to produce, as was an important one. Can the results of clinical Littré had done for the works of Hippocrates, a 218 Who’s Who in Orthopedics definitive edition. It was a task of great complexity, for Paré had had a long life as a writer (1545–1590) and during this time had not only discussed a tremendous variety of subjects, but had modified and changed his opinions and doctrines continually. The entire body of Paré’s writing is arranged and ordered with great skill. It is possible to follow the devel- opment of Paré’s ideas on any subject to their final form. A considerable portion of the first volume is devoted to an introduction, which consists of a history of surgery in western Europe from the sixth to the sixteenth century, ending with a bio- graphy of Paré and a discussion of his work. This introduction is one of the finest short accounts of the history of surgery extant. It is unfortunate that it was not published separately, as it stands in the John L. MARSHALL shadow of the immensity of Paré’s achievement, and for this reason has not received the attention 1936–1980 that is its due. Marshall died in a light-plane crash on John Shaw Billings, American surgeon and his- February 19, 1980. He had just left the Atlanta, torian, epitomizes the career of Malgaigne: Georgia, meeting of the American Academy of Orthopedic Surgeons and was en route to Lake Malgaigne was the greatest surgical historian and critic Placid, New York, for the Winter Olympics the world has yet seen, a brilliant speaker and writer, as consultant to the US ski team. Although an whose native genius, joined to incessant labour, accomplished pilot, he was a passenger in the brought about a new mode of judging of the merits of plane. He was 43 years old and at the height of a surgical procedures—the mode of statistical compari- remarkably distinguished and productive career. Marshall was Director of Sports Medicine and although he made some improvement in the art, at the Hospital for Special Surgery in New York such as his hooks for the treatment of fractures of the patella, his suggestion of suprathyroid, laryngotomy, City, having founded the Sports Medicine Clinic etc. At the time of his death he had his work of exploding errors, exposing fallacies in rea- become a world-renowned figure in orthopedics soning, and bringing to bear upon the work of the and sports medicine. His patients included many present day the light of the experience of the past, of famous professional athletes as well as innumer- which his treatise on fractures and dislocations affords able New York City public-school athletes who many excellent examples. At the Hospital for Special Surgery he was an attending surgeon in References the Department of Orthopedics and Director of the Laboratory of Comparative Orthopedics and 1. As such, he lated from the French with Notes and Additions by was intimately involved in undergraduate and John H. Pettier LF (1958) Joseph François Malgaigne and Orthopedic Surgeons and the American College Malgaigne’s Fracture. Stewart FC (1843) The Hospitals and Surgeons of of Surgeons and was a member of numerous Paris. New York, Langley, and Philadelphia,Carey other professional organizations, including the and Hart, p 360 American Orthopedic Society for Sports Medi- cine, the American College of Sports Medicine, 219 Who’s Who in Orthopedics and the Orthopedic Research Society. He was As a teacher, he was exceedingly generous with widely known as team physician for the New his time and private operative cases. As an author, York Giants professional football club and a con- he was particular that homework be done and sultant for the New Jersey Nets basketball team, credit be given to other workers in the field. Many the New York City Public School Athletic of his more than 65 scientific papers appeared in League, and the Cornell University Athletic The Journal of Bone and Joint Surgery. Marshall’s incredible Marshall had his usual several papers on the success seemed to follow from his keen intellect, Academy program, but he also participated in limitless energy, and infectious enthusiasm. He panel discussions as a recognized expert on the was born in Schenectady, New York, on June 16, anterior cruciate ligament. He graduated from Cornell University in were yet to be published, but already his work 1956, excelling academically and athletically in was cited prominently in major textbooks. In 1960, he many years his concepts regarding cruciate graduated from the Cornell College of Veterinary ligament injuries were hardly fashionable or Medicine and entered private practice, specializ- accepted. His interest in high- completing his residency, yet saw his work rec- performance athletics never waned. It seemed ognized, is a testimony to his courage, scholar- natural that orthopedics would be his field. In ship, and persistent self-criticism in the laboratory 1961 he entered Albany Medical College, receiv- and operating room. John’s enthusiasm and energy extended outside Crawford Campbell, he developed an interest in the hospital. He was a fine athlete himself, an avid orthopedic research, to which he devoted a major skier, and an accomplished tennis player and portion of his future career. He trained regularly with many of his Research Award in 1963 for a paper on osteocar- patient athletes, and could run circles around most tilaginous loose bodies. After a surgical internship of his residents and fellows on the tennis court. Marshall came to the Hospital and was survived by his lovely wife Jan and their for Special Surgery as a Research Fellow in ortho- two children. In 1971 he completed the residency program and was named an American Orthopedic Association North American Traveling Fellow. He remained on the staff of the Hospital for Antonius MATHIJSEN Special Surgery until his death. Marshall’s major area of professional inter- 1805–1878 est was the knee. His earliest papers in the vet- erinary and human medical literature dealt with Antonius Mathijsen was born on September 4, articular cartilage and the unstable joint. He saw 1805, at Budel, a small village in North Brabant, the anterior cruciate deficient knee as a model for Holland, the son of Dr. Ludovicus Hermanus instability and arthritis in the experimental animal Mathijsen and Petronella Bogaers. He had person- Antonius should become a military surgeon; the ally dissected hundreds of cadaver knees and con- young man was first placed in the military hospi- stantly challenged his residents and fellows to test tal at Brussels, later in Maastricht, and finally at new and old concepts of anatomy and surgery in the large government hospital at Utrecht.

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Sometimes levothroid 100 mcg without prescription thyroid cancer ucsf, however order levothroid 100 mcg with mastercard thyroid cancer johns hopkins, pressures in excess of 30cmH20 will be necessary to inflate the surfactant-deficient lungs cheap 200mcg levothroid mastercard thyroid gland ultrasound images. In infants the commonest cause of ● An infant is a child under one year of age ● A child is aged between one and eight years death is sudden infant death syndrome, and in children aged ● Children over the age of eight years should between 1 and 14 years trauma is the major cause of death. In be treated as adults these age groups a primary problem is found with the airway. The resulting difficulties in breathing and the associated hypoxia rapidly cause severe bradycardia or asystole. The poor long-term outcome from many cardiac arrests in childhood is related to the severity of cellular anoxia that has to occur before the child’s previously healthy heart succumbs. Organs sensitive to anoxia, such as the brain and kidney, may be severely damaged before the heart stops. In such cases cardiopulmonary resuscitation (CPR) may restore cardiac output but the child will still die from multisystem failure in the ensuing days, or the child may survive with serious neurological Stimulate and check responsiveness or systemic organ damage. Therefore, the early recognition of the potential for cardiac arrest, the prevention and limitation Open airway. Head tilt, chin lift (jaw thrust) of serious injury, and earlier recognition of severe illness is clearly a more effective approach in children. Two effective breathes If no chest rise Paediatric basic life support - reposition airway - re-attempt up to five times Early diagnosis and aggressive treatment of respiratory or Assess for signs of a circulation If no success cardiac insufficiency, aimed at avoiding cardiac arrest, are the Yes Check pulse (10 seconds maximum) - treat as for airway obstruction keys to improving survival without neurological deficit in No seriously ill children. Five compressions: oxygenation are the most important actions in paediatric One ventilation, 100 compressions/minute resuscitation. Continue resuscitation Resuscitation should begin immediately without waiting for the arrival of equipment. This is essential in infants and Algorithm for paediatric basic life support children because clearing the airway may be all that is required. Assessment and treatment should proceed simultaneously to avoid losing vital time. As in any resuscitation event, the Airway-Breathing-Circulation sequence is the most appropriate. If aspiration of a foreign body is strongly suspected, because of sudden onset of severe obstruction of the upper airway, the steps outlined in the section on choking should be taken immediately. Assess responsiveness Determine responsiveness by carefully stimulating the child. Care must be taken not to overextend the neck (as this may cause the soft trachea to kink and obstruct) and not to press on the soft tissues in the floor of the mouth. Pressure in this area will force the tongue into the airway and cause obstruction. The small infant is an obligatory nose breather so the patency of the nasal passages must be checked and maintained. Alternatively, the jaw thrust manoeuvre can be used when a Opening infant airway 43 ABC of Resuscitation history of trauma or damage to the cervical spine is suspected. Maintaining the paediatric airway is a matter of trying various positions until the most satisfactory one is found. Breathing Assess breathing for 10 seconds while keeping the airway open by: ● Looking for chest and abdominal movement ● Listening at the mouth and nose for breath sounds ● Feeling for expired air movement with your cheek. If the child’s chest and abdomen are moving but no air can be heard or felt, the airway is obstructed. If the child is not breathing, expired air resuscitation must be started immediately. With the airway held open, the rescuer covers the child’s mouth (or mouth and nose for an infant) with their mouth and breathes out gently into the child until the chest is seen to rise. Minimise gastric distension by optimising the Mouth-to-mouth and nose ventilation alignment of the airway and giving slow and steady inflations. Up to five attempts may be made to achieve two effective breaths when the chest is seen to rise and fall. Circulation Recent evidence has questioned the reliability of using a pulse check to determine whether effective circulation is present. Therefore, the rescuer should observe the child for 10 seconds for “signs of a circulation. In addition, healthcare providers are expected to check for the presence, rate, and volume of the pulse. The brachial pulse is easiest to feel in infants, whereas for children use the carotid pulse. If none of the signs of a circulation have been detected, then start chest compressions without further delay and combine with ventilation. Immediate chest compressions, combined with ventilation, will also be indicated when a healthcare provider detects a pulse rate lower than 60beats/min. In infants and children the heart lies under the lower third of the sternum. In infants, compress the lower third of the sternum with two fingers of one hand; the upper finger should be one finger’s breadth below an imaginary line joining the nipples. When more than one healthcare provider is present, the two-thumbed (chest encirclement) method of chest compression can be used for infants. The thumbs are aligned one finger’s breadth below an imaginary line joining the nipples, the fingers encircle the chest, and the hands and fingers support the infant’s rib cage and back. In children, the heel of one hand is positioned over a compression point two fingers’ breadth above the xiphoid process. In both infants and children the sternum is compressed to about one third of the resting chest diameter; the rate is 100 compressions/min. The ratio of compressions to ventilations should be 5:1, irrespective of the number of rescuers. The compression phase should occupy half of the cycle and should be smooth, not jerky. In larger, older children (over the age of eight years) the adult two-handed method of chest compression is normally used (see Chapter 1). The compression rate is 100/min and Chest compression in infants and children the compression to ventilation ratio is 15:2, but the compression depth changes to 4-5cm. Activation of the emergency medical services When basic life support is being provided by a lone rescuer the emergency medical services must be activated after one minute 44 Resuscitation of infants and children because the provision of advanced life support procedures is vital to the child’s survival. The single rescuer may be able to carry an infant or small child to the telephone, but older children will have to be left. Basic life support must be restarted as soon as possible after telephoning and continued without further interruption until advanced life support arrives. In circumstances in which additional help is available or the child has known heart disease, then the emergency medical services should be activated without delay.

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A well-structured article will be organised and logical buy levothroid us thyroid gland virus, and will only include information that is necessary to meet your aims buy cheapest levothroid and levothroid thyroid symptoms vertigo. Researching your article Your next step is to carry out a thorough literature review of your intended subject area discount levothroid 50mcg line thyroid nodules ear pain. See Chapter 7 ‘Writing As an Aid to Learning’ for information on searches. Writing your draft Your approach and style will very much depend on your readership. When you are writing an article for colleagues within your own discipline you 284 WRITING SKILLS IN PRACTICE will be able to assume a certain knowledge base. It will be appropriate to use well-known terminology without the need for extensive explanations. However, other groups of readers, despite being a professional audience, will not always have a specialist knowledge of your subject area. You will need to take this into account when introducing information and in your use of terminology. Be careful not to make your subject area too wide, as you must comply with the word limit set by the journal. Set yourself limits so that you are able to deal effectively with the information within the constraints of a short article. Constantly refer back to your objective to keep you on track with your task. Double-check the accuracy of facts and figures, particular the dosage for drugs. Continually monitor events so that your information remains as up-to-date as possible. References Some journals place a limit on the number of references per article and this is often an indication of the academic level they are seeking. There are two commonly used styles of referencing – the Harvard and the Vancouver. Al­ ways check the journal’s guidelines for contributors on exactly how to present your references. Formalities Follow your organisation’s protocol on publication and seek permission for an article that relates in any way to your employment, for example if you have developed a procedure through work or your organisation is identified in the article. Presentation and submission of your journal article Journals usually require articles to be submitted on disk with one or two printed copies. Send these to the appropriate editor with a covering letter that includes your name and contact details. JOURNAL ARTICLES 285 It is important that you conform to the journal’s guidelines for contri­ butors. Journals usually require graphics to be presented on a separate disk and may limit the type and number of illustrations. These are print-outs that show how the article will actually look on the journal page. This is not the time to rewrite your article; only amend technical or copyright errors. Return the proofs by the agreed deadline, otherwise you may find the article goes to print contain­ ing the unamended errors. Setting up a peer review group is a useful way for potential authors to offer a critique on each other’s work. JOURNAL ARTICLES 287 Summary Points ° Health journals offer a forum for disseminating information, sharing ideas and initiating debate. It is not uncommon for revisions to be requested before an article is accepted. It also provides the opportunity: ° to complete a large scale piece of writing ° to write about your subject at length and in detail ° to reach a wider audience than that offered through other writing forums ° to satisfy a creative urge. Developing an idea Before approaching a publisher you will need to have formulated some preliminary ideas about: ° the topic or specific subject area ° the aims of your book ° the scope of your book ° the intended readership ° your style or approach (is it an academic text, practical guide, directory, handbook or one that combines text with a CD-ROM? Chapter 14 ‘Developing an Idea’ offers more suggestions about how to develop an idea for writing. At this stage you may also want to think about whether you want to write the book yourself or share the task with one or more other authors. There are advantages and disadvantages to both these methods of working. As a single author you: ° receive sole credit ° have control over the decision making ° are able to work at your own pace ° need to make fewer compromises. The downside is: ° it is more work ° you have sole responsibility ° you miss out on the enthusiasm and support you gain from having a writing partner(s). In collaborative writing you are able: ° to generate new ideas between you ° to share the workload ° to give and receive support and encouragement ° to benefit from different perspectives. The downside is you will need: ° to negotiate with your partner(s), which may mean having to make compromises ° to combine different writing styles and ways of working ° to make time for meetings and joint planning ° to organise the sharing of a working manuscript. If you do choose to work with someone else you will need to make a deci­ sion about who will be the lead author. This is necessary, as the publisher will prefer to deal with one person who is able to represent everyone’s views. You need to think very carefully about whether there is a market for your idea. Your topic may be your lifetime passion, but is it of interest to other people? Discussions with colleagues, particularly those involved in education, will help to highlight the current trends in reading material. You can do a literature search or ask advice from a librarian who is a specialist in your area. Most publishers also provide information on books that they are planning to publish in the coming year. Study complementary or competitive texts to check that your idea is new or different in some way from other publications. Think about how your book will differ from these texts: ° Do you have a new or different concept, for example an innovative clinical approach? Approaching a publisher Unless you have been lucky enough to have been asked to write something by a commissioning editor, you will have to make the first approach. Once you have a firm idea about the book you would like to write, start looking for a suitable publisher. You need one that deals with your subject area and has access to the appropriate markets for your book. Find out the names of publishers and the types of books they publish by checking what is currently on the market. You can access this informa­ tion through a variety of sources including: ° libraries ° bookshops ° catalogues BOOKS 291 ° journals ° book exhibitions at various conferences ° World Wide Web. Information about publishers can also be found in the following guides: ° The Writer’s Handbook ° Willings Press Guide ° Writers’ & Artists’ Yearbook. Some publishers have pre-prepared sheets offering advice and information to prospective writers.