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Imhauser G (1977) Late results of Imhauser’s osteotomy for slipped capital femoral epiphysis generic pariet 20 mg online. Z Orthop 115:716–725 Follow-up Study After Corrective Imhäuser Intertrochanteric Osteotomy for Slipped Capital Femoral Epiphysis Shigeru Mitani discount 20 mg pariet with mastercard, Hirosuke Endo buy pariet 20mg line, Takayuki Kuroda buy pariet 20mg online, and Koji Asaumi Summary purchase pariet 20mg without a prescription. We investigated 28 hips in 26 patients with slipped capital femoral epiphy- sis who were treated by the Imhäuser intertrochanteric osteotomy, with subsequent removal of implants. The mean age at operation was 13 years, and the mean age at the time of the final follow-up was 19 years. PTA became restored to within the allowable range of up to 30° in all patients. The limitation of range of motion completely resolved in all patients, and none had necrosis of the femoral head postoperatively. Four patients had a fracture due to bone fragility from long- term traction and bed rest. Chondrolysis developed in only 1 male classified as an unstable case with an unstable classified as unstable. The Imhäuser treatment system for mild to severe cases may be said to be reasonable in that the physeal stability is rendered stable by traction and then the PTA is reduced to 30° or less by osteotomy to lessen the severity to mild. So, satisfactory results were obtained both clinically and roentgenographically in short- or midterm outcome. Slipped capital femoral epiphysis, Intertrochanteric osteotomy, In situ pinning, Posterior tilting angle, Physeal stability Introduction Since 1977, we have been treating slipped capital femoral epiphysis at our hospital using the Imhäuser treatment system. In patients incapable of walking or suffering from hip joint pain on exertion, traction is undertaken until irritant pain in the hip joint disappears. This treatment is not intended for reduction of slipped epiphysis but is aimed at attaining fibrous or osseous stabilization of the slippage site. Therefore, the Imhäuser treatment system may be characterized by these two surgical procedures used according to disease Department of Orthopaedic Surgery, Okayama University Hospital,2-5-1Shikata-cho, Okayama 700-8558, Japan 39 40 S. Imhäuser’s treatment system for slipped capital femoral epiphysis (SCFE). PTA, poste- rior tilt angle severity and preoperative attainment of stabilization of the slippage site. Imhäuser has documented that gratifying treatment results were obtained from a follow-up investigation in patients with slipped capital femoral epiphysis conducted over 11 to 22 years, showing that arthrotic changes had been seen in as few as 2 of 68 hip joints treated. To date, we also have had favorable results using this treatment system, as previously reported. However, because several complications have been noted and because some other investigators demonstrated, even in severe cases, that better treatment results were obtained with the in situ pinning technique than with osteot- omy, we considered it necessary to reexamine this treatment system. The present study was performed to evaluate the treatment system for its usefulness and for any problems involved by reviewing retrospectively patients with slipped capital femoral epiphysis showing a PTA of 30° or greater that was treated by intertrochanteric osteotomy. Patients We investigated 28 hips in 26 patients, which were treated by the Imhäuser intertro- chanteric osteotomy, with subsequent removal of implants. Of the 28 affected hip joints studied, 22 were unilateral in unilater- ally affected cases, 2 were unilateral in bilaterally affected cases, and 4 were in 2 Corrective Imhäuser Intertrochanteric Osteotomy for SCFE 41 bilaterally affected cases. The age at onset of the disorder, estimated from the medical history taken at clinic interview, ranged from 8 years and 6 months to 22 years and 9 months (mean, 12 years and 4 months), and the age at which surgical treatment was performed was between 8 years and 10 months and 23 years and 2 months (mean, 13 years and 2 months). Age at the time of the final follow-up was between 13 years and 8 months and 28 years and 3 months (mean, 18 years and 9 months). The postopera- tive follow-up duration ranged from 2 to 11 years (mean, 5 years and 7 months). According to the classification defined by Campbell Operative Orthopaedics, the type of onset was chronic for 11 hips, acute on chronic for 15, and acute for 2. In situ pinning on unaffected hips for epiphyseodesis was performed on 20 hips. Methods Pertinent data were reviewed as to duration of preoperative traction and intraopera- tive correction angle by osteotomy and such clinical parameters as range of motion of the hip joint, any pain, and, in unilaterally affected cases, difference in leg length. Roentgenographically, the apparent neck–shaft angle was measured in the anteropos- terior (AP) view and the pre- and postoperative PTA in the lateral view. Results Duration of Traction The duration of preoperative traction ranged from 2 to 114 days (mean, 45 days). According to the classification based on physeal stability, the range of this duration was 2 to 53 days (mean, 21 days) for stable cases and 36 to 114 days (mean, 58 days) for unstable cases. Correction Angle The intraoperative correction angle was 15° to 40° (mean, 31°) on flexion, 10° to 30° (mean, 24°) on valgus, and 25° to 50° (mean, 37°) on anterotation.

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The fact that the inferior branch of the superior gluteal artery cheap pariet 20 mg amex, which runs in a rather mobile periosteal tissue along the distal border of the gluteus minimus and provides the perfusion of the supraacetabular bone together with arcades of the anastomosing supraacetabular artery and branches of the iliolumbar artery proven 20 mg pariet, can be mobilized and lifted from the bone to be osteotomised offers the possibility of a lateral acetabular reorientation together with a substantial capsulotomy with pre- served perfusion of the acetabular fragment safe pariet 20mg. This osteotomy is in its supraacetabular course slightly more proximal to preserve the vessel arcade (Fig generic pariet 20mg overnight delivery. We have successfully performed seven cases so far buy 20mg pariet fast delivery, all with conditions necessitating a lateral approach (Fig. Anatomical dissec- tion of the lateral iliac wing with the superior gluteal artery (A. The ramus supraacetabularis follows the course of the piriformis muscle (MPi) and crosses the line of the osteotomy Periacetabular Osteotomy in Treatment of Hip Dysplasia 159 Fig. In conclusion, in our armamentarium of surgical techniques to preserve the natural hip joint, periacetabular osteotomy is the operation that leads to the most predictable results. The technical execution is demanding, and even more so is orientation of the acetabulum, which must be individualized. The correction must be exact in all param- eters, including a normal version of the acetabulum. In addition, one has to consider that the proximal femur may be dysplastic as well, which has to be corrected if pos- sible at the same time. Cooperman DR, Wallensten R, Stulberg SD (1983) Acetabular dysplasia in the adult. Kummer B (1991) The clinical relevance of biomechanical analysis of the hip area. Millis MB, Murphy SB, Poss R (1955) Osteotomies about the hip for prevention treat- ment of osteoarthrosis. Leunig M, Siebenrock KA, Ganz R (2001) Rationale of periacetabular osteotomy and background work. Ganz R, Klaue K, Vinh TS, et al (1988) A new periacetabular osteotomy for the treat- ment of hip dysplasias. Hempfing A, Leunig M, Notzli HP, et al (2003) Acetabular blood flow during Bernese periacetabular osteotomy: an intraoperative study using laser Doppler flowmetry. Beck M, Leunig M, Ellis T, et al (2003) The acetabular blood supply: implications for periacetabular osteotomies. Leunig M, Rothenfluh D, Beck M, et al (2004) Surgical dislocation and periacetabular osteotomy through a posterolateral approach: a cadaveric feasibility study and initial clinical experience. Siebenrock KA, Scholl E, Lottenbach M, et al (1999) Bernese periacetabular osteotomy. Siebenrock KA, Leunig M, Ganz R (2001) Periacetabular osteotomy: the Bernese expe- rience. Clohisy JC, Barrett SE, Gordon JE, et al (2005) Periacetabular osteotomy for the treat- ment of severe acetabular dysplasia. Katz DA, Kim YJ, Millis MB (2005) Periacetabular osteotomy in patients with Down’s syndrome. Matta JM, Stover MD, Siebenrock K (1999) Periacetabular osteotomy through the Smith-Petersen approach. Mayo KA, Trumble SJ, Mast JW (1999) Results of periacetabular osteotomy in patients with previous surgery for hip dysplasia. Murphy S, Deshmukh R (2002) Periacetabular osteotomy: preoperative radiographic predictors of outcome. Trousdale RT, Cabanela ME (2003) Lessons learned after more than 250 periacetabular osteotomies. Valenzuela RG, Cabanela ME, Trousdale RT (2003) Sexual activity, pregnancy, and childbirth after periacetabular osteotomy. Leunig M, Podeszwa D, Beck M, et al (2004) Magnetic resonance arthrography of labral disorders in hips with dysplasia and impingement. Li PL, Ganz R (2003) Morphologic features of congenital acetabular dysplasia: one in six is retroverted. Mast JW, Brunner RL, Zebrack J (2004) Recognizing acetabular version in the radio- graphic presentation of hip dysplasia. Dora C, Buhler M, Stover MD, et al (2004) Morphologic characteristics of acetabular dysplasia in proximal femoral focal deficiency. Dora C, Zurbach J, Hersche O, et al (2000) Pathomorphologic characteristics of post- traumatic acetabular dysplasia. Dora C, Mascard E, Mladenov K, et al (2002) Retroversion of the acetabular dome after Salter and triple pelvic osteotomy for congenital dislocation of the hip. Siebenrock KA, Schöll E, Lottenbach M, et al (1999) Periacetabular osteotomy.

This causes hypoxaemia (low blood oxygen tension and reduced oxyhaemoglobin saturation) discount pariet 20mg on-line. The resulting clinical cyanosis may pass unrecognised in poor ambient light conditions and in black patients trusted pariet 20 mg. The use of pulse oximetry (SpO2) monitoring during resuscitation is recommended but requires pulsatile blood flow to function order 20 mg pariet visa. A combination of arterial hypoxaemia and impaired arterial oxygen delivery (causing myocardial damage order 20 mg pariet amex, acute blood loss generic pariet 20mg line, or severe anaemia) may render vital organs reversibly or irreversibly hypoxic. The brain will respond with loss of Pulse oximeter consciousness, risking (further) obstructed ventilation or unprotected pulmonary aspiration (or both). Impaired oxygen supply to the heart may affect contractility and induce rhythm disturbances if not already present. Renal and gut hypoxaemia do not usually present immediate problems but may contribute to “multiple organ dysfunction” at a later stage. The principles of airway management during cardiac arrest or after major trauma are the same as those during anaesthesia. Airway patency may be impaired by the loss of normal muscle tone or by obstruction. In the unconscious patient relaxation of the tongue, neck, and pharyngeal muscles causes soft tissue obstruction of the supraglottic airway. This may be The ABC philosophy in both cardiac and corrected by the techniques of head tilt with jaw lift or jaw trauma life support relies on a combination thrust. The use of head tilt will relieve obstruction in 80% of of actions to achieve airway patency, optimal patients but should not be used if a cervical spine injury is ventilation, and cardiac output, and to restore suspected. Chin lift or jaw thrust will further improve airway and maintain circulatory blood volume patency but will tend to oppose the lips. With practice, chin lift 25 ABC of Resuscitation and jaw thrust can be performed without causing cervical spine movement. In some patients, airway obstruction may be particularly noticeable during expiration, due to the flap-valve effect of the soft palate against the nasopharyngeal tissues, which occurs in snoring. Obstruction may also occur by contamination from material in the mouth, nasopharynx, oesophagus, or stomach—for example, food, vomit, blood, chewing gum, foreign bodies, broken teeth or dentures, blood, or weed during near-drowning. Laryngospasm (adductor spasm of the vocal cords) is one of the most primitive and potent animal reflexes. It results from stimuli to, or the presence of foreign material in, the oro- and laryngopharynx and may ironically occur after cardiac resuscitation as the brain stem reflexes are re-established. Recovery posture Patients with adequate spontaneous ventilation and circulation who cannot safeguard their own airway will be at risk of developing airway obstruction in the supine position. Turning Airway patency maintained by the head tilt/chin lift the patient into the recovery position allows the tongue to fall forward, with less risk of pharyngeal obstruction, and fluid in the mouth can then drain outwards instead of soiling the trachea and lungs. Spinal injury The casualty with suspected spinal injuries requires careful handling and should be managed supine, with the head and cervical spine maintained in the neutral anatomical position; constant attention is needed to ensure that the airway remains patent. The head and neck should be maintained in a neutral position using a combination of manual inline immobilisation, a semi-rigid collar, sandbags, spinal board, and securing straps. The usual semi-prone recovery position should not be used because considerable rotation of the neck is required to prevent the casualty lying on his or her face. If a casualty must be turned, he or she should be “log rolled” into a true lateral Airway patency maintained by jaw thrust position by several rescuers in unison, taking care to avoid rotation or flexion of the spine, especially the cervical spine. If the head or upper chest is injured, bony neck injury should be assumed to be present until excluded by lateral cervical spine radiography and examination by a specialist. Further management of the airway in patients in whom trauma to the cervical spine is suspected is provided in Chapter 14. Casualties with spinal injury often develop significant gastric atony and dilation, and may require nasogastric aspiration or cricoid pressure to prevent gastric aspiration and tracheobronchial soiling. Vomiting and regurgitation Rescuers should always be alert to the risk of contamination of the unprotected airway by regurgitation or vomiting of fluid or solid debris. Impaired consciousness from anaesthesia, head injury, hypoxia, centrally depressant drugs (opioids and recreational drugs), and circulatory depression or arrest will rapidly impair the cough and gag reflexes that normally Medical conditions affecting the cough prevent tracheal soiling. It occurs more G Bulbar and cranial nerve palsies commonly during lighter levels of unconsciousness or when G Guillain-Barré syndrome cerebral perfusion improves after resuscitation from cardiac G Demyelinating disorders arrest. Prodromal retching may allow time to place the patient G Motor neurone disease in the lateral recovery position or head down (Trendelenburg) G Myasthenia gravis tilt, and prepare for suction or manual removal of debris from the mouth and pharynx.

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Hence doctors who take on a wider social role find themselves implementing policies which generic pariet 20mg on-line, far from offering greater liberty and democracy 20 mg pariet overnight delivery, have an inherently coercive character buy pariet 20mg low price. What a bitter irony that Virchow 20 mg pariet otc, the great libertarian generic pariet 20 mg without a prescription, now provides an aura of radical legitimacy for an authoritarian government health policy. The pre-eminent role of health in Western society since the early 1990s is linked to a significant shift in the boundaries between the spheres of public and personal life, and to changes in the relationship between the state and the medical profession. Challenging the tyranny of health in the context of the wider social changes we have discussed, involves redefining these boundaries. This means, on the one hand, defending the autonomy of the medical profession and, on the other, upholding the autonomy of the patient. He further argued that professional autonomy was ‘the critical outcome of the interaction between political and economic power and occupational representation, interaction sometimes facilitated by educational institutions and other devices which successfully persuade the state that the occupation’s work is reliable and valuable’ (Freidson 1970:82–3). The licensing system introduced in Britain by the 1858 Medical Act sought to guarantee the public that a registered doctor was a ‘safe general practitioner’ and the GMC policed both the conduct of doctors with their patients and in their relations with other practitioners. It also allowed a unified profession to project an ethical orientation which put public service before self interest. As Freidson put it, ‘the profession’s service orientation is a public imputation it has successfully won in a process by which its leaders have persuaded society to grant and support its autonomy’ (Freidson 1970:82). In the course of its development from the foundations established in the 1850s, the medical profession had to negotiate two key sets of relationships— with the state and with the market. Doctors were always ambivalent about the state, an ambivalence that persisted despite the advance of state intervention in health from the late nineteenth century onwards. On the one hand, doctors recognised that state patronage was crucial to the establishment and maintenance of their professional hegemony. On the other, they regarded state incursions as a threat to cherished traditions of individual freedom and professional autonomy. While doctors recognised the necessity for state sponsorship, they remained jealous of their professional independence, particularly emphasising the threat of external interference to the integrity of the confidential doctor-patient relationship. Hence, while generally welcoming a state licensing system, the medical profession ensured that this system was administered by a General Medical Council dominated by representatives of the profession itself. Thus was inaugurated the principle of self-regulation, albeit within a state- imposed framework, a principle vigorously upheld by the profession and respected by the state. In 1975, for example, an independent commission set up to review the GMC, unequivocally endorsed self- 164 CONCLUSION regulation: ‘It is the essence of a professional skill that it deals with matters unfamiliar to the layman, and it follows that only those in the profession are in a position to judge many of the matters of standards of professional conduct which will be involved’ (Merrison 1975:133). Though in their posture of resistance to the state, doctors have often claimed an ideological affinity for the principles of the free market, in reality their relations with the world of commerce are also characterised by a high degree of ambivalence. In his survey of the medical profession in the USA, where entrepreneurial principles are most fervently cherished—not least among doctors—Paul Starr noted that ‘the contradiction between professionalism and the rule of the market is long-standing and unavoidable’ (Starr 1982:23). Traditional physicians regarded the market as a threat to both income and status, as they were forced to compete with diverse unscrupulous practitioners and also deal with attempts to turn them into mere employees. In response, doctors—in common with other aspiring professionals—tried to distinguish themselves from tradesmen and businessmen by claiming a commitment to a higher cause than vulgar commercial interests: ‘In justifying the public’s trust, professionals have set higher standards of conduct for themselves than the minimal rules governing the marketplace and maintained that they can be judged under those standards only by each other, not by laymen’ (Starr 1982:23). Whereas the market ideal is that the consumer rules, the ideal of a profession ‘calls for the sovereignty of its members’ independent, authoritative judgement’. From this perspective, a quack is a practitioner who tries to please his customers rather than his colleagues. Professional organisation is a form of resistance to the market, which seeks to restrict competition by regulating the supply of medical services, though, paradoxically, a degree of independence from the market was only achieved through increasing dependence on the state. The conception of the ‘competent general practitioner’ is very important in the traditions of the medical profession. Once registered as such with the GMC, doctors were independent professionals who could put up their own plate and practise medicine according to their own judgements and aspirations. The notion that professional excellence could be guaranteed by some external agency, such as the state, was alien to the medical profession in its ascendant phase. Professional autonomy has long been recognised as vital to the integrity of the doctor-patient relationship. This is, ideally, an intimate relationship, developed in the course of repeated 165 CONCLUSION interaction, often in the context of critical life events—birth, serious illness, death. It is a personal relationship between two idiosyncratic individuals, significant to both and, when successful, mutually rewarding as well as being beneficial to the patient. Inevitably, as in all relationships, reality sometimes lags some distance behind the ideal, yet there has always been enough of a glimpse of the ideal for both doctor and patient to aspire to achieve it. Like all intimate relationships, this one is inscrutable to the outsider—and also often, to some degree, to the participants.

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