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A double dissociation of sensory modalities on opposite sides of the trunk is seen in the Brown-Séquard syndrome discount adalat generic arrhythmia education inc. Small fibre peripheral neuropathies may selective affect the fibers which transmit pain and temperature sensation purchase adalat without prescription blood pressure monitors at walmart, leading to a glove- and-stocking impairment to these modalities buy adalat 30 mg hypertension 160100. Neuropathic (Charcot) joints and skin ulceration may occur in this situation; tendon reflexes may be preserved cheap 20mg adalat visa heart attack feat mike mccready money mark. Cross References Analgesia; Ataxia; Brown-séquard syndrome; Charcot joint; Main suc- culente; Myelopathy; Proprioception; Pseudoathetosis; Sacral sparing - 96 - Dorsal Guttering D Divisional Palsy The oculomotor (III) nerve divides into superior and inferior divi- sions, usually at the superior orbital fissure. The superior division or ramus supplies the superior rectus and levator palpebrae superioris muscles; the inferior division or ramus supplies medial rectus, infe- rior rectus and inferior oblique muscles. Isolated dysfunction of these muscular groups allows diagnosis of a divisional palsy and sug- gests pathology at the superior orbital fissure or anterior cavernous sinus. However, occasionally this division may occur more proxi- mally, at the fascicular level (i. This may reflect the topographic arrangement of axons within the oculomotor nerve. Proximal superior division oculomotor nerve palsy from metastatic subarachnoid infiltration Journal of Neurology 2002; 249: 343-344 Cross References “False-localizing signs”; Oculomotor (iii) nerve palsy Dix-Hallpike Positioning Test - see HALLPIKE MANEUVER, HALLPIKE TEST Doll’s Eye Maneuver, Doll’s Head Maneuver This test of the vestibulo-ocular reflex (VOR) is demonstrated by rotating the patient’s head and looking for a conjugate eye movement in the opposite direction. Although this can be done in a conscious patient focusing on a visual target, smooth pursuit eye movements may compensate for head turning; hence the head impulse test (q. The maneuver is easier to do in the unconscious patient, when testing for the integrity of brainstem reflexes. While directly observing the eyes, “catch up” saccades may be seen in the absence of VOR. Measuring visual acuity (dynamic visual acuity, or illegible E test) two to three lines may be dropped on visual acuity with head movement compared to visual acuity with the head still if VOR is impaired. Cross References Bell’s phenomenon, Bell’s sign; Caloric testing; Coma; Head impulse Test; Oculocephalic response; Supranuclear gaze palsy; Vestibulo- ocular reflexes “Dorsal Guttering” Dorsal guttering refers to the marked prominence of the extensor tendons on the dorsal surface of the hand when intrinsic hand mus- cles (especially interossei) are wasted, as may occur in an ulnar nerve lesion, a lower brachial plexus lesion, or a T1 root lesion. Benign - 97 - D Double Elevator Palsy extramedullary tumors at the foramen magnum may also produce this picture (remote atrophy, a “false-localizing sign”). In many elderly people the extensor tendons are prominent in the absence of significant muscle wasting. Cross References Wasting “Double Elevator Palsy” This name has been given to monocular elevation paresis. It may occur in association with pretectal supranuclear lesions either contralateral or ipsilateral to the paretic eye interrupting efferents from the rostral interstitial nucleus of the medial longitudinal fasciculus to the superior rectus and inferior oblique subnuclei. Brain 1992; 115: 1901-1910 Cross References Bell’s phenomenon, Bell’s sign Downbeat Nystagmus - see NYSTAGMUS Dressing Apraxia - see APRAXIA Drooling - see SIALORRHEA Dropped Head Syndrome Dropped head syndrome (head droop or head drop) refers to forward flexion of the head on the neck, such that the chin falls on to the chest (cf. This syn- drome has a broad differential diagnosis, encompassing disorders which may cause axial truncal muscle weakness, especially of upper thoracic and paraspinous muscles. Of these, probably MND and myasthenia gravis are the most common causes. Treatment of the underlying condition may be possible, hence investigation is mandatory. References Katz JS, Wolfe GI, Burns DK, Bryan WW, Fleckenstein JL, Barohn RJ. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 218 (abstract 26) Rose MR, Levin KH, Griggs RC. The dropped head plus syndrome: quantitation of response to corticosteroids. Lancet 1998; 352: 758 Cross References Antecollis; Camptocormia; Myopathy Dynamic Aphasia Dynamic aphasia refers to an aphasia characterized by difficulty initi- ating speech output, ascribed to executive dysfunction. There is a reduction in spontaneous speech, but on formal testing no para- phasias, minimal anomia, preserved repetition and automatic speech. Dynamic aphasia may be conceptualized as a variant of transcortical motor aphasia, and may be seen with lesions of dorsolateral prefrontal cortex (“frontal aphasia”). Cambridge: MIT Press, 2003: 165-174 Esmonde T, Giles E, Xuereb J, Hodges J. Journal of Neurology, Neurosurgery and Psychiatry 1996; 60: 403-410 Robinson G, Blair J, Cipolotti L. Dynamic aphasia: an inability to select between competing verbal responses. Brain 1998; 121: 77-89 Cross References Echolalia; Transcortical aphasias - 99 - D Dysarthria Dysarthria Dysarthria is a motor speech disorder of neurological origin (cf. There are various syndromes of dysarthria, which have been clas- sified as follows: ● Flaccid or nasal dysarthria: hypernasal, breathy, whining output, as in bulbar palsy, myasthenia gravis. Philadelphia: Lippincott Williams & Wilkins, 2002: 236-243 Murdoch BE (ed. Cheltenham: Stanley Thornes, 1998 Cross References Anarthria; Aphasia; Asynergia; Broca’s aphasia; Bulbar palsy; Coprolalia; Dysphonia; Fatigue; Lower motor neurone (LMN) Syndrome; Parkinsonism; Pseudobulbar palsy; Scanning speech; Upper motor neurone (UMN) syndrome Dyscalculia - see ACALCULIA - 100 - Dysexecutive Syndrome D Dyschromatopsia - see ACHROMATOPSIA Dysdiadochokinesia Dysdiadochokinesia or adiadochokinesia is a difficulty in performing rapid alternating movements, for example pronation/supination of the arms, tapping alternately with the palm and dorsum of the hand, tap- ping the foot on the floor. Dysdiadochokinesia is a sign of cerebellar dysfunction, especially hemisphere disease, and may be seen in association with asynergia, ataxia, dysmetria, and excessive rebound phenomenon. It may reflect the impaired checking response seen in cerebellar disease. Dysdiadochokinesia may also be seen with disease of the frontal lobes or basal ganglia. Cross References Asynergia; Ataxia; Cerebellar syndromes; Dysmetria; Rebound phenomenon Dysesthesia Dysesthesia is an unpleasant, abnormal or unfamiliar, sensation, often with a burning and/or “electrical” quality. Some authorities reserve the term for provoked positive sensory phenomena, as opposed to sponta- neous sensations (paresthesia). Dysesthesia differs from paresthesia in its unpleasant quality, but may overlap in some respects with allody- nia, hyperalgesia and hyperpathia (the latter phenomena are provoked by stimuli, either nonnoxious or noxious). There are many causes of dysesthesia, both peripheral (including small fibre neuropathies, neuroma, nerve trauma) and central (e. Dysesthetic sensations may be helped by agents, such as carbamazepine, amitriptyline, gabapentin and prega- balin. Cross References Allodynia; Hyperalgesia; Hyperpathia; Paresthesia Dysexecutive Syndrome The term executive function encompasses a range of cognitive processes including sustained attention, fluency and flexibility of thought, problem solving skills, planning and regulation of adaptive and goal-directed behavior. Some authors prefer to use these individ- ual terms, rather than “lump” them together as executive function. Deficits in these various functions, the dysexecutive syndrome, are typ- ically seen with lateral prefrontal cortex lesions. Cambridge: MIT Press, 2003: 259-279 Cross References Attention; Frontal lobe syndromes - 101 - D Dysgeusia Dysgeusia Dysgeusia is a complaint of distorted taste perception. It may occur along with anosmia as a feature of upper respiratory tract infections, and has also been described with various drug therapies, in psychiatric diseases, and as a feature of zinc deficiency. Cerebellar dysfunction, mental changes, anorexia and taste and smell dysfunction. Archives of Neurology 1975; 32: 745-751 Cross References Ageusia; Anosmia Dysgraphesthesia - see AGRAPHOGNOSIA; GRAPHESTHESIA Dysgraphia - see AGRAPHIA Dyskinesia Dyskinesia may be used as a general term for excessive involuntary movements, encompassing tremor, myoclonus, chorea, athetosis, tics, stereotypies, and hyperekplexia. The term may be qualified to describe a number of other syndromes of excessive movement, e. In MPTP-induced parkinsonism, dyskinesias tend to occur early, hence it may be the depth of dopamine deficiency rather than chronicity of treatment which is the key determinant; reduction in over- all levodopa use (increased frequency of smaller doses, con- trolled-release preparations, addition of dopamine agonists) may reduce these effects; amantadine is sometimes helpful.

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There he worked under the biochemist sequence will adopt the similar folded structures purchase adalat on line pulse pressure of 50. This protein is similar in amino where Sanger suggested that he work with antibodies adalat 30 mg fast delivery heart attack 18. In mice adalat 30mg with amex arteria frontalis-, an immune reac- received his doctorate from the University of Freiburg for tion to Chlamydia triggers a condition known as inflammatory work performed at the Institute for Immunology in Basel order adalat 30mg on line heart attack signs, heart disease. To produce the needed antibodies, Milstein and the heart, leading to cardiac malfunction. After shown that a significant number of patients with heart disease extracting the resulting lymphocytes from the mouse’s blood, have antibodies to Chlamydia in their blood, indicative of a they fused one of them with a myeloma cell. As Milstein soon realized, their tech- that is the consequence of an autoimmune reaction. Other bacteria, viruses, fungi and In the example of the injection, alcohol swabbing of the injec- protozoa share the antigenic similarity with the mouse anti- tion site will kill the bacteria on the skin, so that living bacte- genic region. The bacteria include Borrelia burgdorferi (the ria are not carried into the body upon insertion of the needle. Pure alcohol rapidly Antigenic mimicry may also be the basis of the ulcers coagulates surface proteins, producing a coagulated crust formed upon infection of humans with Helicobacter pylori. The acidic environment of the stomach would exacerbate host Another antiseptic is carbolic acid. Antigenic mimicry supports a hypothesis known as the Originally phenol was poured down sewers to kill microor- “infection hypothesis,” which proposes that common human ganisms. If so, then treatment for geon Joseph Lister began using a spray of phenol to disinfect heart disease and stomach ulcers would involve strategies to open wounds during surgery. It is added to household disinfectants more because of its pleas- ant smell than its aseptic power nowadays. In fact, it inclu- ANTISEPTICS sion actually weakens the bacteria-killing power of the Antiseptics household disinfectant. Antiseptics are compounds that act to counteract sepsis, which Lister’s method was supplanted by the adoption of is an illness caused by a bacterial infection of the blood. This approach is known as anti- antiseptic may kill a microorganism, but it does not necessar- septic surgery. The Lister’s era often did not change or clean their operating garb weaker, slower growing microbes may then be more suscepti- between operations. A surgeon would often commence an ble to the defense mechanisms of the host. Yet they do have different mean- sepsis in the operating room, the rate of death following sur- ings. An antiseptic is a chemical or technique that is used on gery was almost 60%. A disinfectant is a chemical that is applied to an inan- recorded death rate in England dropped to four per cent. An anti- Hand washing has also become standard practice in the septic generally does not have the same potency as a hospital and the home. Otherwise, the chemical would harm the tissues Another antiseptic technique is sterilization. For this reason, an antiseptic should not steam at higher than atmospheric pressure is an effective be used to treat inanimate objects. Likewise, the generally means of killing many types of bacteria, including those that more toxic disinfectant should not be used to treat skin or form spores. In the home, antiseptics are often evident as lotions or While more is known of the molecular basis of antisep- solutions that are applied to a cut or scrape to prevent infec- tic actions, the use of antimicrobial compounds is ancient. For these uses, it is necessary to clean the affected area example, the black eye make-up known as kohl, which was of skin first to dislodge any dirt or other material that could used by the ancient Arabs and Egyptians, is a mixture of cop- reduce the effectiveness of the antiseptic. Indeed, ularly those used in the home, are designed for a short-term the modern cure for trachoma (blindness caused by infection use to temporarily rid the skin of microbes. The skin, being of the eyes by the bacterium Chlamydia trachomatis) is in primary contact with the environment, will quickly remarkably similar in composition to kohl. Long-term use of There are a number of antiseptics and antiseptic pro- antiseptics encourages the development of populations of cedures. In a health care setting, powerful antiseptics are used to Additionally, the skin can become irritated by the long expo- ensure that the skin is essentially sterile prior to an operation. Some people can even develop Examples of such antiseptics include chlorhexidine and allergies to the antiseptic. Alcohol is an anti- Another hazard of antiseptics that has only become septic, which is routinely used to swab the skin prior to an apparent since the 1990s is the contamination of the environ- injection. Antiseptic solutions that are disposed of in sinks and toi- 31 Antiserum and antitoxin WORLD OF MICROBIOLOGY AND IMMUNOLOGY lets can make their way to rivers and lakes. Contamination of Antiserum and antitoxin are obtained from the blood of the aquifer (the surface or underground reserve of water from the test animal. The blood is obtained at a pre-determined time which drinking water is obtained) has become a real possibility. The antiserum constitutes part of the plasma, the clear See also Antibiotics; Infection control component of the blood that is obtained when the heavier blood cells are separated by spinning the blood in a machine called a centrifuge. AAntiserum and antitoxinNTISERUM AND ANTITOXIN Examples of antisera are those against tetanus and rabies. Typically, these antisera are administered if someone Both antisera and antitoxins are means of proactively combat- has been exposed to an environment or, in the case of rabies, ing infections. The introduction of compounds to which the an animal, which makes the threat of acquiring the disease immune system responds is an attempt to build up protection real. The antisera can boost the chances of successfully com- against microorganisms or their toxins before the microbes actually invade the body. After the threat of disease is The use of antiserum and antitoxin preparations is now gone, the protective effect is no longer required. The beginnings of the The advent of antibiotics has largely replaced some strategies dates to the time of Edward Jenner in the late eigh- types of antiserum. Then, Jenner used an inoculum of cowpox antiserum can cause allergic reactions that in some people are material to elicit protection against the smallpox virus. The allergic nature of antiserum, which is also known as Jenner’s strategy of using a live organism to elicit an serum shock, arises from the nature of its origin. Because it is antibody response led to a “third-party” strategy, whereby derived from an animal, there may be components of the ani- serum is obtained from an animal that has been exposed to an mal present in the antiserum. When introduced into a human, antigen or to the microorganism that contains the antigen. This the animal proteins are themselves foreign, and so will pro- so-called antiserum is injected into the human to introduce the duce an immune response. For this reason antiserum is used protective antibodies directly, rather than having them manu- cautiously today, as in the above examples. In this case, the risk of acquiring a life-threatening malady if treatment is not material injected into the animal would consist of active toxin, undertaken.

Immersed though he was in serious work generic adalat 20 mg with mastercard blood pressure and age, his The integrity of his publications purchase adalat visa blood pressure printable chart, as of all his love and zest for sports always managed to shine work 20mg adalat with visa hypertension nutrition, is and will remain beyond question cheap adalat 30 mg visa zithromax arrhythmia. I shall never forget the fishing trips fessionally and socially, Albert believed in and we took together in California, Idaho, Oregon, lived the truth. There was never a dull 1928, he made an English translation of Normal moment, due to his unfailing good humor, his and Pathological Physiology of Bone, from the ready wit, and his joy in seeing others catch more original French by Leriche and Policard. His ability to start a conversation mount the difficulties of a foreign language. He had as broad a his flair for absolute truth, Albert replied, “Avec knowledge of orthopedic surgery and of general le dictionnaire. He was extremely He became associated with the Washington kind and modest to the point where, when asked University School of Medicine in 1926 as associ- to give a paper or make some other presentation, ate in clinical orthopedics; in 1927, he was he willingly shared his honor with one of his col- appointed assistant professor of clinical orthope- leagues; in fact, he often turned the whole matter dics and, in 1931, head of the division of to the other man’s credit. He had a prodigious memory, arduous, often when they were finished, some- especially for the minutiae in orthopedic litera- times as late as five in the afternoon, his terrific ture. His presence at any function, social or drive compelled him to begin work on some medical, was practically a guarantee of its project of his own. He was an active member of Theta Nu cal and analytical mind had full scope. He was Epsilon, Gamma Alpha, Alpha Omega Alpha fra- full of intellectual curiosity. His original ideas were never-ending, Clinical Orthopedics at Washington University in and he pursued not one, but many simultaneously. Louis and head of the Division of Orthopedics, Once he stated that he had decided long before a position he held until his death. Among them was the excellent book one, a person might be slowed down and thus The Management of Fractures, Dislocations, and spend years to finish it. In Cowdry’s Special His own drive was a great stimulus to those Cytology he described synovial membranes, with whom he worked. He found time to contribute to advance his younger men and associates into to The Practitioners Library of Medicine and positions at the school and toward membership in Surgery, Military Surgical Manual of the orthopedic societies. Several times he said that he National Research Council, Clinics, Instructional hoped some day his younger men would be Course Lectures of The American Academy of among the leaders in orthopedic surgery. He was Orthopedic Surgeons, Lewis’Practice of Surgery, totally unselfish, both with his time and his A Textbook of Surgery by American Authors, money. He made private loans to those who Bancroft and Murray’s Surgical Treatment of the needed them, and it is known that he paid the Motor-Skeletal System, Ghormlley’s Orthopedic 173 Who’s Who in Orthopedics Surgery, Cirzrrgia de L’rgezzcia, Cole’s Opera- These meetings were held at the time of those tive Technic and Clinical Orthopedics. Among his of the Congress of the American College of many articles that have appeared in scientific Surgeons. This article contains and clinical observation of the effects of com- what I would consider fair and just criticism of pression in arthrodesis, lesions of the interverte- the National Board of Orthopedic Surgery. He voiced his objection Committee for Investigation of the Kenny Treat- to the regimentation of orthopedic surgeons and ment of Poliomyelitis appointed by the American to a self-perpetuating board, which existed at that Orthopedic Association, the American Academy time. In his analysis of the group comprising the of Orthopedic Surgeons, and the Section on American Orthopedic Association, he found that Orthopedic Surgery of the American Medical their qualifications for this specialty varied and Association. His constructive criticism of the that their success had been obtained by a variety Kenny method of treatment in infantile paralysis of routes. He objected to a uniform, prescribed and his evaluation and report on this method of method of training and, as he stated in the final treatment remain a masterpiece. At the meetings of the American of demanding that a candidate follow a rigidly outlined Academy of Orthopedic Surgeons, his contribu- course of orthopedic training and that they recognize tions to discussion were eagerly sought. His the incontrovertible fact that satisfactory orthopedic knowledge of orthopedic surgery was so profound surgeons have been and can be developed in many dif- ferent ways. Their standards of excellence should not that, in discussing papers, he could seize on the be lowered and they can demand more time devoted salient points and illuminate them as nobody else to practice, but they should not close the door of our could. He was a member of the American Medical specialty in the face of men who are well qualified, but Association, American Surgical Association, whose education has not been along the lines which American College of Surgeons, American they have laid down. They are not omniscient but with Radium Society, Missouri Medical Association, the best of intentions they are becoming omnipotent Orthopedic Research Society (of which he was and this is not to the best interests of orthopedic surgery president at the time of his death), Clinical Ortho- of the future. Finally it is to be reiterated that the func- pedic Society, Southern Medical Association, tion of the Board is to establish minimum standards; Southern Surgical Association, and the Robert for the practice of and not to dictate the future devel- opment of orthopedic surgery. Key, and he had the This presidential address should be read and fullest cooperation from his confreres; although re-read by all aspirants to the field of orthopedic he was most grateful, he suffered from “an embar- surgery, as well as by those who have already rassment of riches”—everyone wanted to speak arrived, for stripped of all unnecessary verbiage on his program. Needless to say, the meeting was as it is, it contains the outline of basic training, a great success. Adding to that success, he invited educational requirements, and necessary qualifi- all the members of the Club for dinner at his home cations for a true orthopedic surgeon. John Albert Key died at his country home Some of us were fortunate enough to spend a near Steelville in the Ozarks on August 6, 1955. Key presided at the first Orthopedic Section of the Forum on Fundamental Surgical Problems, of the American College of Surgeons in 1951. He organized this section of the forum and all suc- ceeding meetings of this section until his death. Kidner contributed extensively to orthope- dic literature throughout his active life. His pub- lications covered a wide range of subjects and added greatly to orthopedic knowledge and tech- niques. Probably the outstanding characteristics of his writings were their conservatism and soundness; he was not one to be carried away by new ideas just because they were new, but was always ready to accept new proposals that had been thoroughly tested by time and experience. He was a member of the American Orthopedic Association, serving as its president in 1937–1938, and a member of the Clinical Ortho- pedic Society. He was a fellow of the American Academy of Orthopedic Surgeons and the Frederick Clinton KIDNER American College of Surgeons. He was associate professor of orthopedic surgery, emeritus, Wayne 1879–1950 University School of Medicine; surgeon-in-chief, emeritus, of Orthopedics at the Children’s Hospi- Dr. Frederick Clinton Kidner was born on April tal of Michigan; retired chief surgeon of the 13, 1879, at Ipswich, Massachusetts. He received Department of Orthopedics at Harper Hospital; his preliminary education in Boston and at St. He was graduated from Harvard pital and Wyandotte General Hospital; consultant University, receiving his AB degree in 1900 and in orthopedic surgery at the Woman’s and Receiv- his degree of MD in 1904. Kidner early manifested an interest in his friends and the love that came to him from orthopedic surgery and after his internship those, especially the crippled children of his state, pursued special courses in this branch of medi- who through his skill and devotion were restored cine in Boston. Kidner was invited to become a Kidner died in Detroit on October 20, 1950. Kidner, in addition to his active medical career in Detroit, played a large part in the development of a state-wide Crippled Children’s Service in Michigan, one of the first in this country. While on their honeymoon, he was called to active service in the army as a captain and was immediately sent to England with the first group of orthopedic surgeons assigned to help Sir Robert Jones in his work with British casualties. He was stationed at the Military Ortho- pedic Hospital at Shepherd’s Bush until 1918, when he was promoted to the rank of major and made consultant in orthopedic surgery for the 175 Who’s Who in Orthopedics Robert KIENBÖCK Donald E. KING 1871–1953 1903–1987 Robert Kienböck was born in Vienna and was Donald E.

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Patients selected for this surgical approach all receive accelerated physical therapy with imme- diate weight-bearing and physiotherapy within the first 24h purchase adalat pills in toronto blood pressure chart kpa. Berger buy adalat without a prescription blood pressure 8060, one of the early enthusiastic proponents of the two-incision technique discount adalat uk blood pressure chart mayo, reported on his adalat 30mg on line arrhythmia 3 year old, single-surgeon, results of the first 100 total hip arthroplasties performed using this approach. After the first 12 cases performed, he initiated an outpatient protocol in which 85% of patients were discharged home (not to other care facilities) on the day of surgery and the remaining 15% the day following surgery. One intraoperative proximal femoral fracture was reported for the first 100 cases. Radiographic analysis of component positioning for the first 30 cases showed 91% of femoral stems in neutral alignment (a range of neutral to 3° valgus). The average abduction angle for the ace- tabular component was 45° (range, 36°–54°). Berger concluded that the two-incision technique was safe and facilitated a rapid patient recovery. Mears’ results were similar in a highly selected patient population, with 90% of patients discharged home within 24h of surgery. Concerns regarding the two-incision technique are based on several factors. Furthermore, it has been claimed that this technique avoids muscle or tendon damage; however, a cadaveric study conducted and reported by Mardones et al. In addition, even those surgeons who Minimally Invasive Hip Replacement Surgery 187 advocate the benefits of this technique admit that there is a learning curve and that appropriate training is required. The early experi- ence of a group of 159 surgeons who had completed a designated training programme was followed. A learning curve over the first ten cases for the surgeons showed a sig- nificant decrease in mean operative and fluoroscopic screening time; however, key complications (fractures, dislocations, and nerve deficits) were not reduced over the first ten cases. Berger admits that the technique is technically challenging, and states that surgery via this approach should only be attempted after proper hands-on training, which should include cadaveric workshops as an essential component of that training process. The hope is that this training will lead to a decreased complication rate and assure success when the two-incision approach is performed on patients. The many surgeons who oppose the two-incision technique remain sceptical and claim that promotion of this form of minimally invasive hip arthroplasty is being commercially driven and has been marketed without appropriate evidence-based evaluation. Although there are reports from those who have developed the technique on the early clinical results, it will be several years before the mid- or long-term results are available on these patients [1,11]. In conclusion, two-incision minimally invasive total hip arthroplasty surgery is technically challenging and requires specialized training before use on patients. It is interesting to note that of those surgeons who train for the procedure, 90% gravitate to using another approach for total hip surgery. Anterolateral Approach Technique The anterolateral or direct lateral approach is well known to surgeons. A shorter skin incision is made and similar muscle dissection down to the joint is performed. They wanted to assess the accuracy and reproducibility of implantation, determine if obesity influenced the outcome and technique, and compare operative and post- operative outcomes. They found that the advantages of MIS were that the patients had a decreased transfusion requirement, had a better functional recovery, ambulated significantly earlier, required significantly less transfer assistance, and required sig- nificantly less skilled nursing care after discharge. There was no difference in the accuracy of implant positioning, and obesity did not adversely alter patients’ opera- tive approach or outcome. Posterior Approach Technique This “mini-incision” posterior approach is the most commonly used less-invasive surgical technique for total hip replacement. The less-invasive posterior approach involves a 10-cm oblique incision which, unlike the two-incision approach, is non- proprietary (Figs. Cemented or cementless prostheses can be implanted through this approach implant malpositioning hip. Acetabular socket retroversion (or varus posi- tioning of the femoral stem) are more common with this approach (Figs. Mean hospital stay was 3 days with 87% of patients discharged to their own home, the remaining 13% to a rehabili- tation facility. Results of computer navigation in association with a mini-incision posterior approach technique were reported by DiGioia et al. He found that the mini-incision group had less limp and better stair-climbing at 3 months, and less limp and improved stair-climbing and distance walked at 6 months. This report included a randomized trial in which 22 patients with a mean inci- sion length of 8cm were compared to 24 patients with a standard 15-cm incision. Complications encountered were 4 dislocations, 1 femoral fracture, 2 neuropraxias, and 2 wound haematomas. Conclusion The evidence to date in support of minimally invasive total hip arthroplasty is not convincing. Current practice of this technique requires careful patient selection, a body mass index less than 30, and a routine uncomplicated total hip arthroplasty. Intraoperative soft tissue balancing is important to prevent dislocation, as is the use of larger femoral heads (32 or 36mm), lipped acetabular liners, and cross-linked polyethylene. The interest in minimally invasive total hip replacement is growing and will con- tinue to grow. It has sparked a reevaluation of all aspects of hip replacement surgery: reduction and management of postoperative pain, minimization of blood loss, reduc- tion in length of hospital stay, promotion of earlier rehabilitation, and improved cosmesis. Most surgeons recognize that the potential for complications increases with the limited exposure that is afforded by MIS techniques [16,17]. Advocates of less-inva- sive procedures suggest that the marriage of the technologies of MIS and computer- assisted surgery may be the future. This is a reasonable hypothesis, but computer navigation adds an additional complexity and cost to the operative procedure. Careful review of component positioning following minimally/less-invasive tech- niques shows greater acetabular cup retroversion and femoral stem placement in 190 C. Clinical photograph of right hip scar following MIS posterior approach varus (Figs. Several authors have reported increased implant malposition when a minimally invasive technique was undertaken. The National Institute of Clinical Excellence (NICE) is an independent British organization responsible for providing national guidance on promotion of good health and prevention and treatment of ill health. It has published guidance on mini- mally invasive hip arthroplasty, which recommends that “there is insufficient evi- dence on the safety and efficacy of the two-incision technique for it to be performed without special arrangement for consent, audit or research”. Guidance on single mini-incision hip replacement recommends that “there may be benefits to this pro- cedure but it should only be used in appropriately selected patients by clinicians with adequate training in the technique”. Bourne Despite its purported popularity among surgeons, a minimally invasive approach for total hip arthroplasty surgery is performed by less than 10% of surgeons in Canada. The initial enthusiasm for minimally invasive total hip arthroplasty seems to be waning due to less-precise component positioning and the greater risk of complica- tions associated with this technique. Berry DJ, Berger RA, Callaghan JJ, et al (2003) Minimally invasive total hip arthro- plasty.

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In the early years he contributed erudite papers on the pathology of carpal tunnel syn- drome and of Morton’s metatarsalgia discount adalat 30mg online arrhythmia caffeine, but soon developed his special interest in osteoarthritis of the hip—or “primary coxarthrosis purchase 20 mg adalat with mastercard blood pressure guidelines 2013,” as he pre- ferred to call it adalat 20 mg cheap heart attack young square. Early on generic adalat 20 mg visa arrhythmia detection, he was quick to embrace the novel technique of replacement of the femoral head pioneered by the Judet brothers of Paris in 1950, and he wrote a book on the subject. The operation, however, failed to pass the test of time and was abandoned. From then on, Nissen championed the cause of minimal displacement intertrochanteric Karl Iversen NISSEN osteotomy of the femur, a development of the original McMurray osteotomy. He saw in this a 1906–1995 means of promoting natural healing through the medium of “tufts” of cartilage that sprouted from Karl Nissen began his career in England only 2 the articular surfaces. In many cases he was years after that great pioneer, Sir Robert Jones, indeed able to show the reappearance of a sub- had died. He was almost contemporary with such stantial cartilage space after the operation, which surgeons as Watson-Jones, Osmond-Clarke and could persist for 20 years or more. He added luster to the orthope- for this “conservative” operation with character- dic scene. Nissen and Charnley each fying in 1932 from the University of Otago, he performed his chosen operation before the first went into general practice before deciding to cameras for a notable television program some 30 specialize. A research project followed, in which years ago: Nissen was always keen to show later he studied in great detail several generations radiographs of his patient, who had gained lasting of a family affected with brachydactyly. In another project he Royal National Orthopedic Hospital he organized studied that ancient reptile, the tuatara—almost and convened annual postgraduate courses for unchanged in 130 million years and unique to young surgeons from European countries. He brought him many lasting friendships among never returned to New Zealand. After a period in European colleagues and led to his being elected general surgery, he trained in orthopedics at the as corresponding member of most of the ortho- newly established Princess Elizabeth Orthopedic pedic societies of Western Europe—honors that Hospital in Exeter, under the tutelage of Norman he greatly cherished. Capener, and later at the Royal National Ortho- He had a natural aptitude for the English lan- pedic Hospital. During the Second World War he guage and a rare capacity for critical assessment served in the Royal Naval Volunteer Reserve, of scientific papers, which led to his being drawn mainly in South Africa and St. He years—mostly in an honorary capacity—and 244 Who’s Who in Orthopedics even today there are many who are grateful to him for honing their papers to his own high standards. After his retirement he maintained a keen inter- est, especially in hip surgery. He studied French to enliven his contacts with friends in France and Belgium, and to give lectures in the native tongue. At the same time he devoted himself to the care of his ailing wife Honor, often taking her in her wheelchair for holidays abroad. In later life Nissen himself was severely hand- icapped by peripheral neuropathy, but in spite of increasing difficulty in walking he remained active, through sheer determination. His enquir- ing mind and the wide scope of his interests led him to a deep study of the genetic basis of osteoarthritis and the early history of Man. NOULIS tions of tribes carrying genes that marked specific skeletal disorders are reflected today in the world 1849–1919 distribution of such disorders as congenital dislo- cation of the hip and osteoarthritis of the hip and George C. His hobby was received his elementary and high school educa- conversing with colleagues, juniors, or even total tion at the famous Zosimea School in Ioannina, strangers. He was always kind and notably gen- from which he graduated with honors in 1866. For many was admitted to the University of Athens School years after retirement he made a practice of enter- of Medicine as an exceptional student, where he taining two or three sixth-formers from Sherborne earned his medical degree with honors in 1871. School to tea on Sundays, and doubtless added He was granted a scholarship to pursue postgrad- significantly to their education from his enormous uate study at the University of Paris Faculty of store of general knowledge and anecdotes. Noulis studied in Paris for 5 years, months before his death he gained particular receiving further training in internal medicine and pleasure from being able to travel to Aberdeen for general surgery. University of Paris School of Medicine, which included many prominent professors. In his doc- toral thesis, Noulis described precisely the role of the cruciate ligaments of the knee and how to test their functional integrity. The method Noulis described in his thesis is identical to that used in the Lachman test. Noulis returned to Greece in 1876, where he practiced medicine in Ioannina, which at that time was still a part of the Ottoman Empire. Because of his ability, Noulis was elected to be one of five physicians designated as physicians of the poor. In this position he had a large practice, 245 Who’s Who in Orthopedics which included prominent individuals in the standing orthopedic programs in the city into one region. In 1895, Noulis moved with his family to Beginning in 1950, O’Donoghue began aggres- Athens, and 2 years later moved on to Constan- sively to address the problems of ligament tinople (Istanbul), where he spent the rest of his injuries in college athletes. He became a member, and later president, conservative style of treatment consisting of pro- of the Committee on Biological Sciences, and longed immobilization in plaster dressings, which actively participated in and contributed to the was the standard of the day, he advocated early medical life of the city. He numbered the Sultan operative repair followed by a focused rehabilita- Hamit’s son and one of the sultan’s wives among tion program. Pawssler HH, Michel D (1982) How New is the O’Donoghue’s work has affected the treatment Lachman Test? The results obtained by the aggressive approach to open exposure and repair of ligamentous injuries are far superior to those of the conservative approach. Don O’Donoghue truly was one of the founders and pioneers of the field of sports medicine. O’Donoghue was born in Storm Lake, IA, where he attended the local schools, including Buena Vista College, from which he obtained a BS degree in 1920. He studied medicine at the University of Iowa and received his medical degree in 1926. He studied orthopedics at the Uni- versity of Iowa Hospital under the aegis of Arthur Steindler. O’Donoghue spent time in the general practice of orthopedic surgery in Oklahoma City before joining the university faculty as chief of orthopedics. In this role, he united the free- 246 Who’s Who in Orthopedics grounding in the fundamentals of wound healing, and his observation of man under stress enriched his understanding of human behavior. Returning to Boston in 1919 with the rank of Lieutenant Colonel, Army of the United States, Ober plunged into his civilian professional career as the associate and protégé of Robert W. Lovett, who was chief at the Children’s Hospital and pro- fessor at Harvard Medical School. Graduate education of physicians was one of his major interests; he was assistant dean in charge of Harvard Medical School’s courses for graduates for a number of years. Harvard’s present position in graduate medical education owes much to his vision and leadership. Most of his teaching was done at the Children’s Hospital, where he rose from junior member of the visiting staff to chief orthopedic surgeon in Frank Roberts OBER 1931. He was for 10 years John Ball and 1881–1960 Buckminster Brown Clinical Professor of Ortho- pedic Surgery. Desert, Maine, June sors, he taught by the case method at grand rounds 1, 1881, and died in Boston on December 26, and by demonstration of his technical ability, 1960. Of Down-East Yankee stock, his 80-year which was characterized by a deceptive simplic- life was a kind of Horatio Alger success story, ity and the dispatch that came from a thorough compounded of native ability, ingenuity, hard knowledge of anatomy and from having thought work, and devotion to duty.

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