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All the cases with advanced osteoarthritis (OA) had collapse progression 250 mg eulexin otc. All the cases in which the preoperative stage was advanced were included in those with advanced OA at the last follow-up purchase 250 mg eulexin with visa. In contrast cheap eulexin 250mg on-line, collapse progression was not observed in the cases without advanced OA at the last follow-up purchase eulexin 250 mg otc. According to these data buy discount eulexin 250 mg line, 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. Clinical scores were assessed according to the hip scoring system by the Japanese Orthopaedic Association. Characterization of the hips in two groups With advanced OA Without advanced OA Number of examined hips Age at operation (years) 31 (19–52) 31 (24–38) Involved in the contralateral side 6 (67%) 3 (50%) Period after operation (years) 28 (25–30) 27 (26–29) Stage 3A: 5 (56%); 3B: 4 (44%) 3A: 6 (100%) Collapse progression 9 (100%) 0 (0%) JOA scorea at the last follow-up 55 (34–82) 86 (54–100) OA, osteoarthritis aIn the clinical scoring system for hip joints developed by the Japanese Orthopaedic Association, the maximum score is 100 points Results All hips that had no or early OA at the last follow-up were at stage 3A at operation and had no collapse progression after osteotomy (see Table 1). In contrast, approximately half of the hips that had advanced or terminal OA at the last follow-up were at stage 3B at operation. Further- more, all of them had collapse progression and had poor clinical scores at the last follow-up. Representative Cases Case 1 The patient was male and had bilateral ARO at 38 years old (Fig. Preoperative stage of the right and left hip was 3A or 3B, respectively. Twenty-eight years after operation, collapse had progressed in the left hip, and that hip showed terminal OA at the last follow-up (Fig.

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After accounting for various personal factors buy eulexin 250 mg low cost,4 we find that cane users live alone 50 percent more frequently than other people buy discount eulexin 250mg line, and walker users 30 percent more often generic eulexin 250mg fast delivery. The survey has no information on whether mobility aids allow people to live alone more independently and safely than without the equipment generic 250 mg eulexin otc. Mobility aids have their own hierarchy 250 mg eulexin fast delivery, from low-tech wooden canes with crook handles, to multifooted canes, to crutches, to walkers, to manual wheelchairs and scooters, to sophisticated power wheelchairs. People gen- erally start with the lowest practical option, then, if impairments progress, they move up the hierarchy, as did Walter Masterson (chapter 3). Over the last two decades the sophistication, design, and diversity of mobility aids have grown dramatically, offering consumers wide-ranging options for most tastes and requirements. Yet little systematic evidence is available about the technical pros and cons of different mobility aids and their safety and biomechanics in routine use. Research including persons with ac- 184 mbulation Aids tual mobility problems is generally conducted in laboratories, with few studies examining how people use mobility aids in daily life or whether these aids save societal costs (e. Choice of mobility aids must consider many factors beyond lower- extremity functioning, including people’s cognitive status and judgment, vision, vestibular function (which affects balance), upper-body strength, and global physical endurance, as well as home and community environ- ments. Ambulation aids fall at the low-tech, higher-functioning end of the mobility device continuum. Stuart Hartman, an orthopedic surgeon, encourages patients to use ambulation aids by emphasizing that they will still walk independently, albeit now with mechanical assistance: People don’t normally want these things—they just don’t want to be seen that way. They feel like everybody is looking at them, like they’re getting old and that’s the final chapter. But I say to people, “Look, you would walk much better, much farther, more comfort- ably, and you’d walk more places because you’d feel supported and steadier on your feet. They go farther because they’re not as exhausted, they’re not huffing and puffing. Canes augment muscle action and provide stability, especially for people with neurologic conditions. For balance, a sin- gle finger lightly touching fixed objects, like walls, actually improves stabil- ity better than canes (Maeda et al. People often “furniture surf” at home, placing objects strategically to balance themselves, but in open spaces have nothing fixed to grab. Canes can convey tactile information and en- hance balance, as fingers touching walls do (Jeka 1997; Maeda et al. Unfortunately, most people get little instruction in proper use of canes (Kuan, Tsou, and Su 1999), although, as Dr. Hartman notes, “somebody with a balance disturbance should use a cane differently from someone with a bad hip or knee who uses it for weight-bearing. Up to 70 percent of canes are the wrong length, faulty, or damaged (Joyce and Kirby 1991; Kumar, Roe, and Scremin 1995; Alexander 1996). Ambulation Aids / 185 Although canes are the least sophisticated ambulation aid, several vari- ants are available, differing at their handles and bases. Canes come with crook tops, spade tops, and straight tops; they can have a single rubber-capped tip or three or four short legs attached to little platforms at their base. Func- tional differences among these variants are unclear, and studies are limited and contradictory. Depend- ing on users’ upper-body strength, underarm crutches can bear up to 100 percent of their weight, while forearm crutches (i. Cuffs free the hands of forearm crutch users for ac- tions like opening doors. Various styles of crutches offer different benefits for people with weakness in specific arm muscles (Ragnarsson 1998). Again, choosing the most suitable crutch depends on individual circumstances. Walkers provide additional stability for people with poor balance and lower-extremity weakness and come in many styles, from standard rigid models without wheels to collapsible wheeled walkers, with handbrakes, seats, and baskets. As with canes, walkers must be the proper height, and training is essential. Wheeled walkers are dangerous if they roll forward un- expectedly, but they are easy to propel on smooth surfaces (Joyce and Kirby 1991), demand less energy (Foley et al. Rigid walkers appear institutional, symbolizing serious debility—anathema to many people. Colorful rolling walkers with baskets and seats, in contrast, are practical (e.

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The Operating Theatre 69 Don’ts 1 Engage in conversation during emergencies quality eulexin 250 mg. Your seniors are not out to get you and there will be a good reason that you may not understand generic 250mg eulexin fast delivery. You are within your rights to ask for an explanation after the operation buy 250mg eulexin mastercard. This is actually a good way to improve your surgical understanding as long as you take the correct approach order 250 mg eulexin mastercard. This contaminates theatre floors and means that the nursing staff will have to clean them again purchase 250mg eulexin with visa. The purpose of a mask is to prevent droplets from your mouth from being projected forward. If you turn your head to sneeze you will fire your germs straight into the wound. The following are the departments commonly dealt with by all house officers: G haematology G biochemistry G microbiology G transfusion G virology G histopathology All junior doctors should have a list of the daytime and on-call telephone numbers of each of these departments which will save hours on the telephone to the switchboard in the middle of the night. Just like any other department there is a hierarchy of seni- ority in these departments and a consultant who works in conjunction with the chief technician usually heads each one. You can imagine that each patient in hospital has on average one blood test a day and perhaps one body fluid examination every three or four days (for example a mid-stream urine or wound swab). If the hospital has 1000 beds you can imagine how busy these departments are. For run of the mill non-urgent investigations there is no need to discuss requests, unless you are contacted by the laboratory. However, if you need to request an unusual or urgent investigation then telephoning the department is not only courteous, but it will ensure that the test is actually performed. This is particularly important outside normal working hours when samples are often only picked up from the drop box (where the porters or vac- uum chutes leave them) if the technician is telephoned in advance. When speaking to departments always ensure that you are talking to the relevant person at the start of the conversation and then explain your request. There is rarely any problem with requests being accepted unless it is the middle of the night where you will be asked 71 72 What They Didn’t Teach You at Medical School for clinical justification. This is rarely a taxing matter however, and a simple reply usually suffices. One small note that will win you favour is to inform the on-call technician in advance if you know that you will be taking a sample in the middle of the night. This information is invaluable as they will keep the machines running and stick around in the hospital until the sample arrives. In small hospitals the technicians often go home, as there is little work at night and only return to the hospital if bleeped by you. Saving them a journey home and back again will make their life easier and also means that you will get your result faster. Usually you will be waiting up to get the result, so you can see how a one-minute telephone call at 9 p. You will be introduced to them in the first week of your post (supposedly), but quite often the time you start a job is when they are away on holiday. During your‘interview’, which is more like an informal chat, you will be asked what your expectations of the post are and what your career plans are (if you have any). If you have any professional or personal problems that may interfere or are interfering with your job you should discuss them with your tutor. Your tutor will be surprisingly understanding and is there to help you rather than to intimidate or hinder you. The purpose of this meeting is not only for you to find out what is expected of you, but also for the department to find out what you expect of them. It may sound unusual that you can have expectations, but if you are in a training post then the trust and department has an obligation to provide ward- and lecture- based‘bleep-free’teaching,as well as practical on-the-job training. Often departments and trusts do not provide the required teaching and it is not unreasonable to make a complaint about this early on in your post to your clinical tutor.

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