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Apley's System of Orthopaedics and Fractures

TL;DR: Diagnosis in Orthopaedics Infection Rheumatic Disorders Crystal deposition Disorders Osteoarthritis and related disorders Osteonecrosis and osteochondritis Metabolic and endocrine disorders Genetic disorders Dysplasias and malfunctions Tumours Neuromuscular disorders Peripheral nerve injuries orthopaedic operations.
Abstract: Diagnosis in Orthopaedics Infection Rheumatic Disorders Crystal deposition disorders Osteoarthritis and related disorders Osteonecrosis and osteochondritis Metabolic and endocrine disorders Genetic disorders Dysplasias and malfunctions Tumours Neuromuscular disorders Peripheral nerve injuries Orthopaedic operations The shoulder The elbow The wrist The hand The neck The back The hip The knee The ankle and foot The management of acute injuries Principles of fractures Injuries of the upper limb Injuries of the spine Injuries of the pelvis Injuries of the lower limb Overuse injuries
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Journal ArticleDOI
TL;DR: Two years after surgical repair of a large rotator cuff defect supplemented with a xenograft, patients had several persisting deficits and no recognizable benefit as compared with the results in a control group, and the Restore Orthobiologic Implant is not recommended in its present form.
Abstract: Background: Following repairs of large-to-massive tears of the rotator cuff, the rates of tendon retears are high and often involve tissue deficiency. Animal studies of the Restore Orthobiologic Implant, a collagen-based material derived from the small intestine mucosa of pigs, have indicated that it might be used to help overcome such problems. We carried out a study to determine whether patients who received this xenograft to augment a rotator cuff repair exhibited greater shoulder strength, shoulder function, and/or resistance to retearing. Methods: We compared data from a group of patients who had undergone conventional rotator cuff repair with xenograft augmentation (the xenograft group) with data from a group in whom a repair had been done by the same surgeon without augmentation (the controls). The groups were matched for gender, mean age, and mean size of the rotator cuff tear. All subjects completed a pain and function questionnaire and were given a systematic clinical shoulder examination preoperatively and at three, six, and twenty-four months postoperatively. The twenty-four-month visit included magnetic resonance imaging to determine whether a retear had occurred. Results: Four patients who had received a xenograft had a severe postoperative reaction requiring surgical treatment. At two years after the surgery, six of the ten tendons repaired with a xenograft and seven of the twelve control tendons had retorn, as documented by magnetic resonance imaging. The patients with a xenograft had significantly less lift-off strength, as measured with a dynamometer, and significantly less strength in internal rotation and adduction than the controls at two years after the surgery (all p < 0.05). Also, the xenograft group had significantly more impingement in external rotation, a slower rate of resolution of pain during activities, more difficulty with hand-behind-the-back activities, and less sports participation (all p < 0.05). Conclusions: Two years after surgical repair of a large rotator cuff defect supplemented with a xenograft, patients had several persisting deficits and no recognizable benefit as compared with the results in a control group. In view of these findings, together with the unsatisfactorily high proportion of patients with a severe inflammatory reaction to the xenograft, we do not recommend use of the Restore Orthobiologic Implant in its present form. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

240 citations

Journal ArticleDOI
TL;DR: In this article, the authors reviewed the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the distal tibiofibular syndesmosis, and proposed a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weightbearing.
Abstract: The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.

171 citations

Journal ArticleDOI
TL;DR: Recent advances in stem cell‐based composite tissue constructs are focused on and attempts to outline challenges for the manipulation of stem cells in tailored biomaterials in alignment with approaches potentially utilizable in regenerative medicine of human tissues and organs are outlined.
Abstract: A major task of contemporary medicine and dentistry is restoration of human tissues and organs lost to diseases and trauma. A decade-long intense effort in tissue engineering has provided the proof of concept for cell-based replacement of a number of individual tissues such as the skin, cartilage, and bone. Recent work in stem cell-based in vivo restoration of multiple tissue phenotypes by composite tissue constructs such as osteochondral and fibro-osseous grafts has demonstrated probable clues for bioengineered replacement of complex anatomical structures consisting of multiple cell lineages such as the synovial joint condyle, tendon-bone complex, bone-ligament junction, and the periodontium. Of greater significance is a tangible contribution by current attempts to restore the structure and function of multitissue structures using cell-based composite tissue constructs to the understanding of ultimate biological restoration of complex organs such as the kidney or liver. The present review focuses on recent advances in stem cell-based composite tissue constructs and attempts to outline challenges for the manipulation of stem cells in tailored biomaterials in alignment with approaches potentially utilizable in regenerative medicine of human tissues and organs.

166 citations

Journal ArticleDOI
TL;DR: The combination of a positive Paxinos test and a positive bone scan predicted damage to the acromioclavicular joint as the cause of shoulder pain with a high degree of confidence.
Abstract: Methods: Of 1037 patients with shoulder pain, 113 who mapped pain within an area bounded by the midpart of the clavicle and the deltoid insertion were eligible for inclusion in the study. Forty-two subjects agreed to participate, and four of them were lost to follow-up. Twenty clinical tests, radiography, bone-scanning, magnetic resonance imaging, and an acromioclavicular joint injection test were performed on all patients. The patients were divided into two groups according to whether they had a ≥50% decrease in pain following the acromioclavicular joint injection. Statistical anal- ysis, including multivariate regression analysis, was performed in order to evaluate the diagnostic effectiveness of the various tests. Results: Acromioclavicular joint pain was confirmed in twenty-eight of the thirty-eight patients. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic reso- nance imaging (85%), and bone-scanning (82%), but these studies had low specificity. In the stepwise regression model, with the response to the injection used as the dependent variable, bone-scanning and the Paxinos test were the only independent variables retained. Patients with a positive Paxinos test as well as a positive bone scan had high post-test odds (55:1) and a 99% post-test probability of having pain due to pathological changes in the acromio- clavicular joint. The likelihood ratio for patients with one negative test and one positive test was indeterminate (0.4:1). Patients with both a negative Paxinos test and a negative bone scan had a likelihood ratio of 0.03:1 for hav- ing acromioclavicular joint pain, which basically rules out the disorder. Conclusions: The highly sensitive tests had low specificity, and the highly specific tests had low sensitivity. However, the combination of a positive Paxinos test and a positive bone scan predicted damage to the acromioclavicular joint as the cause of shoulder pain with a high degree of confidence. Level of Evidence: Diagnostic study, Level I-1 (testing of previously developed diagnostic criteria in series of consec- utive patients (with universally applied reference "gold" standard)). See Instructions to Authors for a complete de- scription of levels of evidence.

158 citations


Cites background from "Apley's System of Orthopaedics and ..."

  • ...Exclusion criteria included (1) previous distal clavicular or acromioclavicular joint surgery, (2) clavicular fracture (acute or nonunion), (3) previous or known allergies to lidocaine or the radiopaque contrast medium, (4) pregnancy, (5) any other contraindication to magnetic resonance imaging or nuclear scanning, (6) objections to participating in the study, or (7) markings on the pain diagram that extended beyond the area defined in Figure 1....

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Journal ArticleDOI
TL;DR: There is little convincing evidence that an abnormal range of ankle plantar flexion, genu varum or valgum or undue muscle tightness may be potential risk factors for injury, and all of these biomechanical abnormalities need further evaluation.
Abstract: There is a significant risk of injury when undertaking physical activities. Abnormal biomechanics of the lower limb has been implicated as a causative factor for injury. Although there have been a large number of studies in this field, many lack consistency of definitions and methodology. A large number of these studies have been retrospective, and it is often impossible to identify the baseline population. The evidence suggests that limitation of range of ankle dorsiflexion, limitation of range of hip eversion, excessive joint laxity, leg length discrepancy, an excessively supinated or pronated foot, excessively high or low arches of the foot and a large Q-angle are risk factors for injury. On the other hand, there is little convincing evidence that an abnormal range of ankle plantar flexion, genu varum or valgum or undue muscle tightness may be potential risk factors. All of these biomechanical abnormalities need further evaluation as potential risk factors for injury. Any trials undertaken must endeavour to define and describe their methods fully, and ensure that their results are reproducible.

147 citations


Cites background from "Apley's System of Orthopaedics and ..."

  • ...[25,34,35] A patient with excessive femoral neck anteversion will usually demonstrate an apparent excess of hip internal rotation and an apparent limitation of hip external rotation....

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