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Therefore medicine runny nose eldepryl 5 mg buy otc, it does not take a genius to work out that you will need to get the dietician to see half of your patients and improve their nutritional status medicine 770 buy 5 mg eldepryl overnight delivery. The bottom line is do not underestimate the importance of all the other health professionals around you symptoms constipation eldepryl 5 mg order visa. If you do not know what they do medicine bow 5 mg eldepryl for sale, then it is better to ask them than to ignore them medications like abilify eldepryl 5 mg buy on line. Secondly, if you are clever and have read between the lines then you will realise that, as a busy pre-registration house officer/senior house officer, you can ask the expertise of others, which will take less time than trying to work all these things out on your own. Your consultant will be most impressed if the post- operative infection rates suddenly decrease because you have been improving the nutritional status of your patients or getting them mobile early. Unfortunately, the way of the world is that the most junior on the team is always given the job of referring, as it can be awkward, difficult and time-consuming. The practical joke of the matter is that you will always be asked to refer to a more senior doctor,but it is the junior on the team with the least experience who has to make the referral! A large proportion of doctors,but not all,do not like to receive referrals as it involves more work for already overworked people. For this reason, doctors such as this to whom you are referring will usually find some way of refusing a referral or delaying when they need to come and see the patient. This attitude, while not necessarily in the correct ethos of medicine,is entirely understandable and should not be scoffed at without thought. For this reason referring is perhaps one of the most difficult tasks for the junior doctor and this section has the following objectives: G to make it easier and less stressful to refer G to make you sound more knowledgeable G to make you more professional G to reduce the likelihood of your referral being refused or delayed Why Refer? Throughout all stages of a clinical career it is necessary to refer patients to other spe- cialists for their opinion. This is because our breadth of medical/surgical knowledge decreases with seniority and,conversely,depth increases. Thus,one would not expect a chest physician to know the intricacies of biliary surgery and likewise one would not expect a cardiac surgeon to know all about oncology,etc. However,when a ward patient is unwell it would be professionally and ethically inappropriate for a junior to manage the patient alone and therefore‘senior’ special- ist opinion is sought. Some juniors may disagree with this statement thinking they are able to deal with most problems. However,imagine if a close relative or parent was unwell post-operatively with a lobar pneumonia. You would want a chest physician to see them to give advice on local sensitivities or up to date British Thoracic Society guidelines rather than let the surgical SHO treat the patient using their knowledge alone, however competent they may be. It should be noted though that,even if a referral is made,it is not always necessary for that patient to be seen by the specialist. You or your firm may be more than happy to manage the patient after seeking telephone advice,but this advice can only be given if the appropriate referral is made. Types of Referral Effective and appropriate communication is the mainstay of referring. One needs to imagine the information we would require if we were listening to a referral. This information differs, depending on the type of referral, which should always be stated at the beginning (Figure 10. The first rule of referring is to make sure you are referring to the correct speciality and then the correct firm. Let me explain: in different hospital trusts the same clin- ical diagnosis may not be treated/accepted by the same firm. For example, both med- ical and surgical firms may treat pancreatitis, while accident and emergency (A&E) consultants, general surgeons, orthopods or neurologists/neurosurgeons may man- age head injuries. Most often your seniors or senior nursing staff will be able to inform you of the customs in your hospital. Sometimes your consultant will wish you to refer a patient to a particular consult- ant rather than a speciality, which may consist of several consultants. This information is listed in A&E majors and in the switchboard each day. The referral ‘for’ a consultant will usually be ‘taken’ by his/her specialist registrar (SpR) or SHO and again your seniors or senior nursing staff will be able to inform you. If you are in doubt it is better to bleep the SHO and ask their advice: they will either take the referral or ask you to bleep their registrar. Referring and Requesting 61 Types of referral Urgent Routine A&E In-patient Out-patient In-patient Out-patient patient seen patient seen patient seen patient seen patient seen within minutes within 1–24 within days within days, within weeks to to hours hours to weeks usually after months according investigation to waiting list Figure 10. The ‘Art’ The information required is no different in bulk from that which a medical student can easily obtain from questioning and observation using common sense. Once you have bleeped and you are telephoned back,introduce yourself and make sure you are talking to the correct person as often a nurse or medical student may answer a bleep if the doctor is busy. It would be a waste of time for both of you to start refer- ring to the wrong person. Name, age, ward or clinic location and referring consultant are all obvious points but next is the presentation: what, how and when, with salient, related, past medical and surgical, drug and social history. In addition, include previous admissions with the same complaint and, if a particular consultant already knows the patient. What the relevant examination findings were at presentation, what treatment you have given and what the examination findings are now. Penultimately,include what would you like the doctor to whom you are referring the patient to do (Figure 10. Lastly, how soon do you want the patient seen, expressed in minutes, hours or days. It is perfectly reasonable for a PRHO to ask an SpR to be on the ward within five minutes if your patient is‘going off’,but what a registrar does not want,is to be asked to rush up to a ward to see an‘urgent’referral when in reality it could have waited six or even 24 hours. All the information required seems commonsense and indeed it is, but when you are anxious about speaking to a more senior doctor whom you may not know, it is easy to forget to give or ask the most important details. This is particularly the case in the adrenaline rush of speaking to a senior whom you have woken up or who seems annoyed that you have bothered them. Examination findings at presentation and provisional diagnosis What treatment have you given? Examination findings now Finally: What would you like them to do – see the patient now, later or just give advice? Specialist Specialist opinion Take over care Provide joint care investigation or management of the patient of the patient Figure 10. Referring and Requesting 63 Often,if you have woken someone up,they will be half asleep too and forget to ask you important information you have forgotten to volunteer. The patient had presented with an acute‘asthma attack’in the early hours of the morning. The medical SHO was dealing with an unwell patient on the ward and was tired. He accepted the referral without protest and left the unwell patient on the ward for the A&E department, thinking that the patient with the asthma attack would be more unwell and therefore take priority. On arrival in the A&E department he dis- covered the patient sitting up talking in full sentences, having been managed through the acute phase by the A&E staff. He rapidly returned to the ward without consequence to the other patient, but cursed himself for having left the ward without asking the vital question of‘how the patient was now’, not‘how were they on arrival’. The lesson here is that the A&E SHO did not refer the patient properly and the med- ical SHO did not‘take’the referral well. When these basic day-to-day tasks become second nature the job gets much easier, but hopefully if you have read this you will be well ahead of the game. These referrals may be urgent (patient seen within two weeks) or routine (patient not usually seen within at least six to eight weeks of referral). Out-patient clinics are run by a clinic manager (usually a senior sister or nurse who has taken on a part managerial, part clinical role). The team is expected to attend in full unless stated otherwise by your seniors. The clinic nurse(s) will pro- vide a computer-generated list of patients that are expected to attend, identifying new patients and follow-up attendees. The consultant will usually highlight those patients to be seen by the senior and junior members of the team. Junior doctors should present their patients to the specialist registrar (SpR) or the consultant (as per the instructions of the consultant) before instigating out-patient management (obviously). If patients are to be admitted from the clinic then they should be clerked and examined there and then. A drug and fluid chart should be completed and any blood or radiographic investigations performed in the out-patients department before the patient goes to the ward. Fracture Clinics The casualty senior house officer (SHO) or occasionally SpR refers patients directly from the accident and emergency (A&E) department. These patients have presented to the A&E department within the last few days with an acute injury. They will have a suspected or confirmed fracture that has been treated in a‘back slab’(half plaster of Paris cast which allows soft tissue swelling in the few days after a bony injury). The patient and their fracture is either treated conservatively in plaster and followed up or admitted from the clinic for fracture fixation (that is sur- gery). These clinics are excellent learning opportunities in orthopaedic management. Being in theatre can be the most incredible experience or your worst nightmare. Aspiring surgeons can hate being on a surgical firm (as I did as an undergraduate) and, equally, career physicians or general practitioners can love their theatre time. With a little knowledge regarding the staff and general running of theatres you will find your time much more enjoyable. The golden rule is if in doubt ask, but there are other secrets to being in theatre. Getting to Know the Staff The following people, who can seem unnerving at first, staff theatres. Any procedure done under local anaesthetic does not require an anaesthetist. All of these individuals are senior and have invariably worked together for many years so know each other well. As with any circle of friends,the newcomer finds it dif- ficult to break into the ring and should not be put off if the first few attempts fail. The first and most important thing to do when you walk into the operating theatre is to 67 68 What They Didn’t Teach You at Medical School introduce yourself to all present. Make sure that the nursing staff know your name and grade,particularly the scrub nurse. You will find that the scrub nurse can be your best ally during a difficult operation and the trust and friendship that develops between you will be invaluable when you are operating alone or when on-call. I have been saved on more than one occasion by the scrub nurse, who has told me which suture type my consultant prefers for wound closure. This has allowed my consultant to gain confidence in me and prevents embarrassing ticking off sessions on the post- operative ward round. When talking to your registrar or consultant in the first few weeks of your post, before you know them well, keep small talk to appropriate breaks in the surgeon’s concentration and the subject professional at first. Learning Anatomy Theatres are the place to improve your knowledge of anatomy, but not to ‘learn’ it. This may sound strange,but I guarantee that you will find it more productive to learn your anatomy at home before entering the operating theatre. When you are assisting you can then see the anatomy you have learnt come to life and appreciate it in three dimensions as well as see variations between individuals. All theatre operation lists must be submitted a day in advance (except emergency lists), so that it is always possible to find out which operations are to be performed the following day. Your seniors will always question you in theatre on your anatomy and it pays to read up the night before. Do this every time and not only will you impress your boss,but you will accel- erate your anatomical and surgical knowledge. If you feel the timing is not appropriate then wait until after the operation and then ask (I often do this – it shows maturity and an under- standing that the surgeon is concentrating). The Operating Theatre 69 Don’ts 1 Engage in conversation during emergencies. Your seniors are not out to get you and there will be a good reason that you may not understand. You are within your rights to ask for an explanation after the operation. This is actually a good way to improve your surgical understanding as long as you take the correct approach. This contaminates theatre floors and means that the nursing staff will have to clean them again. 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.

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The term “public access defibrillation” is used to describe the process by which Defibrillation by first aiders defibrillation is performed by lay people trained in the use of an AED treatment for depression order eldepryl cheap. These individuals (who are often staff working at places where the public congregate) operate within a system that is under medical control treatment 5th finger fracture buy eldepryl line, but respond independently medications qhs generic 5 mg eldepryl fast delivery, usually on their own initiative medicinebg generic eldepryl 5 mg buy line, when someone collapses medications similar to vyvanse purchase 5 mg eldepryl amex. Early schemes to provide defibrillators in public places reported dramatic results. In the first year after their introduction at O’Hare airport, Chicago, several airline passengers who sustained a cardiac arrest were successfully resuscitated after defibrillation by staff at the airport. In Las Vegas, security staff at casinos have been trained to use AEDs with dramatic result; 56 out of 105 patients (53%) with VF survived to be discharged from hospital. The closed circuit TV surveillance in use at the casinos enabled rapid identification of potential patients, and 74% of those defibrillated within three minutes of collapsing survived. Other locations where trained lay people undertake defibrillation are in aircraft and ships when a conventional response from the emergency services is impossible. In one report the cabin crew of American Airlines successfully AED on a railway station 13 ABC of Resuscitation defibrillated all patients with VF, and 40% survived to leave hospital. In the United Kingdom the remoteness of rural communities often prevents the ambulance service from responding quickly enough to a cardiac arrest or to the early Assess victim according to basic life support guidelines stages of acute myocardial infarction. Increasingly, trained lay people (termed “first responders”) living locally and equipped Basic life support, if AED not immediately available with an AED are dispatched by ambulance control at the same time as the ambulance itself. They are able to reach the patient Switch defibrillator on and provide initial treatment, including defibrillation if Attach electrodes necessary, before the ambulance arrives. Other strategies used Follow spoken or visual directions to decrease response times include equipping the police and fire services with AEDs. Analyse The provision of AEDs in large shopping complexes, airports, railway stations, and leisure facilities was introduced as government policy in England in 1999 as the “Defibrillators Shock indicated No shock indicated in Public Places” initiative. The British Heart Foundation has supported the concept of public access defibrillation After every 3 shocks If no circulation enthusiastically and provided many defibrillators for use by CPR 1 minute CPR 1 minute trained lay responders working in organised schemes under the supervision of the ambulance service. As well as being used Algorithm for the use of AEDs to treat patients who have collapsed, it is equally valid to apply an AED as a precautionary measure in people thought to be at risk of cardiac arrest—for example, in patients with chest pain. If cardiac arrest should subsequently occur, the rhythm will be analysed at the earliest opportunity, enabling defibrillation with the minimum delay. Sequence of actions with an AED Once cardiac arrest has been confirmed it may be necessary for an assistant to perform basic life support while the Safety factors equipment is prepared and the adhesive electrodes are ● All removable metal objects, such as chains and medallions, attached to the patient’s chest. The area of contact may need should be removed from the shock pathway—that is, from the front of the chest. Body jewellery that cannot be removed will to be shaved if it is particularly hairy, and a small safety razor need to be left in place. Although this may cause some minor should be carried with the machine for this purpose. Most machines have motion sensors that can ● The patient’s chest should be checked for the presence of detect any interference by a rescuer and will advise no contact self-medication patches on the front of the chest (these may deflect energy away from the heart) between shocks. If two rescuers are present one metal surfaces that connect the patient to the operator. It is should go for help and to collect the AED while the other important to recognise that volatile atmospheres, such as petrol or aviation fumes, can ignite with a spark assesses the patient. One electrode should be placed at the upper right sternal border directly below the right clavicle. The other should be placed lateral to the left nipple with the top margin of the pad approximately 7cm below the axilla. The correct position is usually indicated on the electrode packet or shown in a diagram on the AED itself. It may be necessary to dry the chest if the patient has been sweating noticeably or shave hair from the chest in the area where the pads are applied. ECG analysis Other factors is usually performed automatically, but some machines ● Use screens to provide some dignity for the require activation by pressing an “analyse” button. Do not check for a pulse or other signs of a circulation between the three shocks. This will be timed by the machine, after clinical experience with automated external defibrillators. Alternatively, this procedure may start automatically, ● Davies CS, Colquhoun MC, Graham S, Evans, T, Chamberlain D. Defibrillators in public places: the introduction of a national Shocks should be repeated as indicated by the AED. Check the patient every minute to ensure that signs ● International guidelines 2000 for cardiopulmonary of a circulation are still present. Use of automated external defibrillators by the AED scheme so that data may be extracted from the a US airline. Ensure all supplies are replenished ready for the ● Resuscitation Council (UK). The diagram of the algorithm for the use of AEDs is adapted from ● Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman Resuscitation Guidelines 2000, London: Resuscitation Council (UK), RG. PEA was formerly known as electromechanical dissociation but, by international agreement, PEA is now the preferred term. In the community, VF is the commonest mode of cardiac arrest, particularly in patients with coronary disease, as Asystole: baseline drift is present. The ECG is rarely a completely straight line in asystole described in Chapter 2. Asystole is the initial rhythm in about 10% of patients and PEA accounts for an even smaller proportion, probably less than 5%. The situation is different in hospital, where the primary mechanism of cardiac arrest is more often asystole or PEA. These rhythms are much more difficult to treat than VF and carry a much worse prognosis. Asystolic cardiac arrest Suppression of all natural or artificial cardiac pacemakers in asystolic cardiac arrest leads to ventricular standstill. Under normal circumstances an idioventricular rhythm will maintain The onset of ventricular asystole complicating complete heart block cardiac output when either the supraventricular pacemakers fail or atrioventricular conduction is interrupted. Myocardial disease, electrolyte disturbance, anoxia, or drugs may suppress this idioventricular rhythm and cause asystole. Excessive vagal activity may suddenly depress sinus or atrioventicular node function and cause asystole, especially when sympathetic tone is reduced—for example, by blockers. Asystole will also occur as a terminal rhythm when VF is not successfully treated; the amplitude of the fibrillatory waveform declines progressively as myocardial energy and oxygen supplies are exhausted and asystole supervenes. When asystole occurs under these circumstances virtually no one survives. Onset of asystole due to sinoatrial block The chances of successful resuscitation are greater when asystole occurs at the onset of the arrest as the primary rhythm rather than as a secondary phenomenon. Diagnosis and electrocardiographic appearances Asystole is diagnosed when no activity can be seen on the electrocardiogram (ECG). Atrial and ventricular asystole usually coexist so that the ECG is a straight line with no recognisable deflections representing myocardial electrical activity. This straight line may, however, be distorted by baseline drift, electrical interference, respiratory movements, and artefacts arising from cardiopulmonary resuscitation (CPR). A completely straight line on the monitor screen often means If the ECG appears as a straight line the leads, gain, and electrical that a monitoring lead has become disconnected. As VF is so readily treatable and resuscitation is more likely to be successful, it is vital that great care is taken before diagnosing asystole to the exclusion of VF. The electrocardiographic leads and their connections must all be checked, as must the gain and brilliance of the monitor. All contact with the patient should cease briefly to reduce the possibility of interference. Persistent P waves due to atrial depolarisation are seen 16 Asystole and pulseless electrical activity recorded when the monitor has the facility to do this, or the defibrillator monitor electrodes should be moved to different positions. BP 0 On occasions, atrial activity may continue for a short time after the onset of ventricular asystole. In this case, the ECG will ECG show a straight line interrupted by P waves but with no evidence of ventricular depolarisation. Pulseless electrical activity in a patient with acute myocardial infarction. PEA Despite an apparently near normal cardiac rhythm there was no blood pressure (BP) Diagnosis PEA is the term used to describe the features of cardiac arrest despite normal (or near normal) electrical excitation. The diagnosis is made from a combination of the clinical features of cardiac arrest in the presence of an ECG rhythm that would PEA can be a primary cardiac normally be accompanied by cardiac output. In “primary” PEA, excitation-contraction coupling fails, which results in a profound loss of cardiac output. Causes include massive myocardial infarction (particularly of the inferior wall), poisoning with drugs (for example, blockers, calcium antagonists), or toxins, and electrolyte disturbance (hypocalcaemia, hyperkalaemia). In “secondary” PEA, a mechanical barrier to ventricular filling or cardiac output exists. Causes include tension pneumothorax, pericardial tamponade, cardiac rupture, pulmonary embolism, occlusion of a prosthetic heart valve, and Cardiac arrest hypovolaemia. Treatment in all cases is Precordial thump, if appropriate directed towards the underlying cause. Basic life support algorithm, if appropriate Management of asystole and PEA Attach defibrillator/monitor Guidelines for the treatment of cardiopulmonary arrest caused by asystole or PEA are contained in the universal advanced life Assess rhythm support algorithm. Treatment for all cases of cardiac arrest is determined by the presence or absence of a rhythm likely to respond ± Check pulse to a countershock. Both are treated in the same way, by following the right-hand side of the algorithm. CPR 3 minutes (1 minute if immediately after defibrillation) When using a manual defibrillator and ECG monitor, non-VF/VT will be recognised by the clinical appearance of the patient and the rhythm on the monitor screen. When using an During CPR, correct reversible causes If not done already: automated defibrillator, non-VF/VT rhythms are diagnosed • Check electrode/paddle positions and contact when the machine dictates that no shock is indicated and the • Attempt/verify: Airway and O2, intravenous access • Give adrenaline (epinephrine) every 3 minutes patient has no signs of a circulation. When the rhythm is • Consider: Amiodarone, atropine/pacing, buffers checked on a monitor screen, the ECG trace should be examined carefully for the presence of P waves or other Potentially reversible causes electrical activity that may respond to cardiac pacing. Pacing is • Hypoxia often effective when applied to patients with asystole due to • Hypovolaemia • Hyper- or hypokalaemia and metabolic disorders atrioventricular block or failure of sinus node discharge. The role • Tamponade • Toxic/therapeutic disturbances of cardiac pacing in the management of patients with • Thromboembolic or mechanical obstruction cardiopulmonary arrest is considered further in Chapter 17. As soon as a non-VF/VT rhythm is diagnosed, basic life The advanced life support algorithm for the management of non-VF cardiac support should be performed for three minutes, after which arrest in adults. Adapted from Resuscitation Guidelines 2000, London: the rhythm should be reassessed. During this first loop of the Resuscitation Council (UK), 2000 17 ABC of Resuscitation algorithm, the airway may be secured, intravenous access 4Hs obtained, and the first dose of adrenaline (epinephrine) given. If asystole is present atropine, in a single dose of 3mg ● Hypoxia ● Hypovolaemia intravenously (6mg by tracheal tube), should be given to block ● Hyper- or hypokalaemia and metabolic the vagus nerve completely. The most common treatable causes are ● Tension pneumothorax ● Tamponade listed as the 4Hs and 4Ts at the foot of the universal algorithm. If, during the treatment of asystole or PEA, the rhythm changes to VF (which will be evident on a monitor screen or by an automated external defibrillator advising that a shock is indicated) then the left-hand side of the universal algorithm should be followed with attempts at defibrillation. After the delivery of a shock, it takes a few moments before the monitor display recovers; during this time the rhythm may be Asystole after defibrillation interpreted erroneously as asystole. With modern defibrillators this period is relatively If asystole or PEA occurs immediately after the delivery of a short but it is important to be aware of the shock, CPR should be administered but the rhythm and potential problem, particularly with older circulation should be checked after only one minute before any equipment further drugs are given. This procedure is recommended because a temporarily poor cardiac output due to myocardial stunning after defibrillation may result in an impalpable pulse and a spurious diagnosis. After one minute of CPR the cardiac output might improve and the presence of a circulation becomes apparent. In this situation further adrenaline (epinephrine) could be detrimental, and this recommended procedure is designed to avoid this. If asystole or PEA is confirmed, the appropriate drugs should be administered and a further two minutes of CPR are Gel defibrillator pads may cause spurious given to complete the loop. This becomes increasingly likely when a number of shocks have been delivered through the same gel pads. Monitoring with the defibrillator electrodes is unreliable in this situation and a diagnosis of asystole should be confirmed independently by conventional electrocardiograph monitoring leads. Asystole after defibrillation 18 Asystole and pulseless electrical activity Drug treatments Further reading Atropine is recommended in the treatment of cardiac arrest ● European Resuscitation Council. European Resuscitation Council guidelines 2000 for adult advanced life support. In the past, calcium, alkalising agents, high dose and emergency cardiovascular care—an international consensus adrenaline (epinephrine), and other pressor drugs have been on science. Interest has recently been focused on a possible role of ● Viskin S, Belhassen B, Berne R. Aminophylline for bradysystolic adenosine antagonists in the treatment of asystolic cardiac cardiac arrest refractory to atropine and epinephrine. Myocardial ischaemia is a potent stimulus for the release Med 1993;118:279-81. Adenosine attenuates adrenergic mediated increases in myocardial contractility and may increase coronary blood flow. Although these effects may be cardioprotective, it has been suggested that under some circumstances they may produce or maintain cardiac asystole. Aminophylline and other methylxanthines act as adenosine receptor blocking agents, and anecdotal accounts of successful resuscitation from asystole after their use have led to more detailed investigation.

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Many of these cases required arthroscopic debridement (10–18% medicine 752 eldepryl 5 mg buy low price, in the first year) 8h9 treatment purchase eldepryl 5 mg. The loss of extension was almost completely eliminated by changing to an exten- sion splint medications management cheap eldepryl uk. The acceptance of aggressive physiotherapy to regain exten- sion eliminated the problem treatment 7th march buy eldepryl canada. This problem of postoperative stiffness made the use of a synthetic ligament treatment 4 sore throat eldepryl 5 mg buy amex, with no immobilization, very attractive. Contraindications to Harvest of the Patellar Tendon Preexisting Patellofemoral Pain Is preexisting patellofemoral pain a contraindication to harvesting the patellar tendon? The conventional wisdom is yes; it would not be a wise procedure in this situation. In the past, when chondromalacia was seen at the time of arthroscopy, the graft choice would be changed to hamstrings. The Small Patellar Tendon The harvesting of the central third of the patellar tendon in a small tendon is more theoretical than practical. The advice in a small patient with a tendon width of only 25mm would be to take a narrower graft of 8 to 9mm or use another graft source. Preexisting Osgoode-Schlatters Disease Shelbourne has reported that a bony ossicle from Osgoode-Schlatters disease is not a contraindication to harvest of the patellar tendon. Because the fragment usually lies within the bony tunnel, this bone may be incorporated into the tendon graft. Hamstring Grafts Advantages of Hamstring Grafts The main advantage of the hamstring graft is the low incidence of harvest site morbidity. The 4-bundle graft is usually 8mm in diameter, which is a larger cross-sectional area than the patellar tendon. Graft Selection Disadvantages of Hamstring Grafts The disadvantage of any autograft is the removal of a normal tissue to reconstruct the ACL. The harvest of the semitendinosus seems to leave the patient with minimal flexion weakness. One study did show some weakness of internal rotation of the tibia after hamstring harvest. Injury to the saphenous nerve is rare and can be avoided with careful technique. Issues in Hamstring Grafts The major issues with the use of hamstring grafts are: Graft strength. In one of the earlier studies, Noyes reported that one strand of the semi-t was only 70% the strength of the ACL (Fig. The composite hamstring graft is twice the strength and stiffness of the native ACL. This was widely quoted as a reason to use the patellar tendon graft rather than the hamstring. With the advent of the multiple bundles of hamstrings, this graft now has twice the strength of the native ACL (Fig. Sepaga later reported that the semitendi- nosus and gracilis composite graft is equal to an 11-mm patellar tendon graft. Marder and Larson felt that if all the bundles are equally ten- sioned, the double-looped semi-t and gracilis is 250% the strength of the normal ACL. Hamner, however, emphasized that the strength is only additive if the bundles are equally tensioned. Soft Tissue Fixation Techniques There are various techniques for securing the soft tissue to the bony tunnel in ACL reconstruction. Pinczewski pioneered the use of the RCI interference fit metal screw for soft tissue fixation. The use of a similar type of bioabsorbable screw that was used in bone tendon bone fixation was a natural evolution. To overcome the weak fixation in poor quality bone, the use of a round pearl, made of PLLA or bone, was developed. The Endo-button, popularized by Tom Rosenberg, was improved with the use of a continuous polyester tape. This made the fixation stronger and avoided the problems of tying a secure knot in 56 5. The cross-pin fixation has proven to be the strongest, but has a significant fiddle factor to loop the tendons around the post. Weiler, Caborn, and colleagues have summarized the current concepts of soft tissue fixation. The estimates of the force on the normal ACL during activities of daily living are as follows: Level walking: 169N Ascending stairs: 67N Descending stairs: 445N Ascending ramp: 27N Descending ramp: 93N It is commonly quoted that a person needs more than 445N pullout strength of the device just to handle the activities of daily living. However, Shelbourne has reported good results with the patellar tendon graft fixed by tying the leader sutures over periosteal buttons (Ethicon, J&J, Boston, MA). This form of fixation has a low failure strength, but is clinically successful. The gold standard of the interference fit screw fixation of the bone tendon bone, 350 to 750N, has been used to compare the soft tissue fixation. The femoral pullout is higher because the tunnel is angled to the graft and the pull is against the screw that is placed endoscopically. In the tibial tunnel, the graft pulls away from the screw in the direct line of the tunnel. The initial fixation points were at a distance from the normal anatomi- cal fixation of the ACL. The trend has been to move the fixation closer to the internal aperture of the tunnel. This shortening of the intra- articular length has improved the stiffness of the graft. The pullout strength of bioabsorbable screw can vary widely depending on its composition. These considerations should be taken into account when choosing a femoral fixation device for soft tissue grafts. Disadvantages The disadvantages of the hamstring graft are the various methods used to fix the graft to bone, including staples, Endo-button, and interference fit screws. Furthermore, the graft harvest can be difficult, the tendons can be cut off short, and there is a longer time for graft healing to bone, approximately 10 to 12 weeks. Mitek 600N BioScrew 400N Endo-button: tape 500N BioScrew: Endo-pearl 700N Bone mulch screw 900N Cross pin 900N Endo-button with closed loop tape 1300N Pullout Strengths of Soft Tissue Devices The fixation of the graft depends on both the tibial and femoral fixa- tion. Advantages The advantages are as follows: Quick, familiar, and easy to use. Direct bone to tendon healing, with Sharpey’s fibers at the tunnel aperture. Disadvantages The disadvantages are as follows: Longer graft preparation time. The interference screw fixation of the soft tissue graft in a cadaver model. Several refinements have been made to the interference screw tech- nique to increase the pullout strength and cyclic load performance. The end of the graft may be backed up with a round ball of PLLA, the Endo- Pearl (Linvatec, Largo, FL) or bone to abut against the screw and prevent the slippage of the graft under the screw. A longer screw with a heavy whipstitch in the graft improves pullout strength. The leader sutures from the graft may be tied over a button or post on the tibial side to back up the screw fixation. Disadvantages The disadvantages are as follows: Pin may tilt in soft bone and lose fixation. Advantages The advantages are as follows: The Endo-button with closed loop tape is strong, if expensive. The Endo-button periosteal cortical femoral fixation of hamstring grafts. Considerations 61 Disadvantages The disadvantages are as follows: Fixation site is distant with increase in laxity, with the bungee cord effect. Tibial Fixation The tibial fixation remains a problem with soft tissue graft fixation. Patients generally do not tolerate metal devices in the subcutaneous area on the front of the tibia. The interference screw gets away from that problem, but has poor performance in cyclic load. The Intrafix (Mitek) device uses the interference screw fixation principle, but increases both the ultimate load to failure and the cyclic load performance (Table 5. Considerations The most important consideration in ACL reconstruction is that the tunnels are put in the correct position. After this, the fixation of the graft is the next most important factor in a satisfactory clinical outcome. Single staple 100N Double staple 500N Screw post 600N Button 400N RCI 300N BioScrew 400N BioScrew and button 600N Intrafix 700N Screw and washer 800N Washer Loc 900N 62 5. Graft Selection sions, physicians may need to have available another type of fixation to deal with hardware and tunnel expansion. Tendon-to-Bone Healing Studies have shown that it takes at least 8 to 12 weeks for soft tissue to heal to bone, as compared to 6 weeks for bone-to-bone healing with the patellar tendon graft. Recent studies have shown that the compression of the tendon in the tunnel with a screw speeds the time of healing, similar to internal compression in bone healing. Donor Site Morbidity In 1982, Lipscomb found that after harvest of the semitendinosus only the strength of the hamstrings was 102% and after harvest of both the strength was 98%. Recently, it has been shown that the internal rota- tion strength is decreased after the harvest of the semitendinosus. The patellofemoral pain incidence has been reported by Aligetti to be 3 to 21% after semitendinosus reconstruction. Early Rehabilitation Prospective randomized studies by Aligetti and Marder have shown that with early and aggressive rehabilitation, there was no difference between the semitendinosus and patellar tendon grafts in stability or final knee rating. This puts to rest the argument as to whether the hamstring graft can withstand early aggressive rehabilita- tion protocols. Central Quadriceps Tendon This graft has been largely ignored in North America over the past decade. An assistant can harvest the graft while the surgeon is doing the notchplasty. The tendon graft is fixed with interference screws for the bone plug and sutures tied over buttons for the tendon end. A bioabsorbable interference screw may be used at the internal aperture of the tunnel to reduce the tendon motion in the tunnel. The quadriceps tendon graft should reduce the need for the allograft or synthetic in revision cases. With no harvest required, the time of the operative procedure is reduced. Disadvantages The main objection to the use of the allograft is the risk of disease transmission. Jackson has shown that it takes longer for the graft to incorporate and mature, meaning a longer time until the patient can return to sports. In the 1997 survey of the ACL study group by Campell, none of the members used allografts for primary reconstructions. Synthetic Grafts The best scenario for the use of the LARS synthetic graft is when the graft can be buried in soft tissue, such as in extra-articular reconstruc- tion. This allows for collagen ingrowth and ensures the long-term via- bility of the synthetic graft. It will be sure to fail early if it is laid into a joint bare, especially going around tunnel edges, and is unprotected by soft tissue. Advantages There is no harvest site morbidity with the use of the synthetic graft. Disadvantages The main disadvantage is that all the long-term studies have shown high failure rate. There is the potential for reaction to the graft material with synovitis, as seen with the use of the Gore-Tex graft. With the Gore-Tex graft, there was also the increased risk of late hematogenous joint infec- tion. The results that have been reported with the use of the Gore-Tex graft suggest that it should not be used for ACL reconstruction. Unac- ceptable failure rates have also been reported with the use of the Stryker Dacron ligament and the Leeds-Keio ligament. The criteria for reconstruction is a positive pivot-shift test and a measure- ment of more than 5mm in the KT-1000 manual maximum side-to-side comparison. KT-1000 Measurements, Joint Injection, and Femoral Nerve Block First confirm which is the correct side. The low profile leg holder is high on the thigh to allow the graft passing wire to penetrate the anterolat- eral thigh. The KT-1000 arthrometer measurement of the anterior-to-poste- rior motion of the knee. The setup for ACL reconstruction showing the tourniquet, the leg holder and the marking to determine the correct site for surgery. Preemptive Pain Management In a recently published paper, we documented the benefit of the preemptive use of the femoral nerve block, intravenous injections, and local knee injections. The anesthetist uses a peripheral nerve stimulator before the arthroscopy to block the femoral nerve (Fig. The knee joint and the incisions are injected with 20cc of bupivacaine 0. The anesthetist gives 30mg of Toradol intra- venously and 1gm of Ancef intravenously.

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People with arthritis often describe immobilizing and painful stiffness treatment chlamydia purchase generic eldepryl online, especially on awaking in the morning or after prolonged sitting medicine go down cheap eldepryl. Like the tin woodsman from The Wizard of Oz after a rainfall symptoms at 4 weeks pregnant eldepryl 5 mg purchase otc, they feel rusted in place 6 medications that deplete your nutrients buy 5 mg eldepryl overnight delivery, painfully unable to flex medicine hat generic eldepryl 5 mg online, bend, or move. Jimmy Howard, in his late forties, feels “like somebody’s in there with a hammer and a chisel, just chiseling away. Then one day I was walking, and, whoa, it really started—excruciat- ing pain. I’d be in the supermarket, and I’d have to grab onto peo- ple I don’t know. If I tell them to help me, and my knee’s still locked, I can’t go no place. Cynthia Walker, in her mid thirties, has two children under five years old. Her rheumatoid arthritis primarily affects her ankles, knees, and wrists. With rheumatoid arthritis, when you’re immobile, when you lie on the couch, on a bed, your joints are very relaxed. You really have to put pressure on the floor for quite a while for your joints to hold your weight, to put one foot in front of the other, and sometimes you just can’t stand up anymore. If a child yells for you or you need to be somewhere fast, it’s a problem.... And the child is screaming, and the crutches are upstairs because you left them upstairs that morning. You want to get just two rooms over, but that two rooms might as well be two miles. My knees don’t work, and if I get down on the floor, how the hell am I going to get back up? They also attempt steroid injections, acupuncture, heating pads or cold compresses, pool therapy, massage, and prayer. Some- times physicians explicitly say they can do nothing more for the pain, leav- ing people angry, frustrated, and disheartened (chapter 8). Nevertheless, most people say they are stoic, refusing to “give in” to pain. Despite her older children’s protests, Mattie Harris sweeps her kitchen floor when it’s dirty; she can’t “sit there and see something that needs to be done. Even those with self-described high pain thresholds may eventually try surgery Sensations of Walking / 29 in an attempt—sometimes successful, sometimes not—to eliminate pain and restore function. Mike Campbell Mike Campbell, a retired maintenance man in his mid sixties, had os- teoarthritis of both knees. He and his wife, Betty, occupied an in-law apart- ment upstairs in their daughter’s home outside a New England picture postcard town. We met on a perfect autumn day, crimson and golden leaves swirling in the wind, pumpkins on every stoop. The air smelled wonderful and woodsy when I and Ron, my administrative assistant and driver, emerged from the car onto a bed of needles from towering pine trees. From the driveway, we saw only the side of the house, with steep, wooden stairs leading to a second floor door. Ron reported that we were meeting in the daughter’s living room downstairs. Campbell, a big man, ruddy in a hale and hearty way, sat in a wing- back chair at one end of an immaculate living room dotted with china fig- urines. Having had his second knee replaced several weeks previously, he had crutches propped against the wall, and his left knee appeared thickly padded. Campbell had not planned on retiring from building maintenance two years previously. But my legs got so bad that I figured I’d take early retirement and get done with it. The pain got so bad at the end that I could only walk 35, 40 yards, and then I’d stop and rest. Sitting in a straight- backed chair, I had to get halfway across the room before I could get straightened up and my legs working. Her father had it before her, and my brother just had his second knee replaced. For the last thirty years of her life, maybe forty, she rarely ever went out. One day, she weighed over 300 pounds, and she never really tried to do anything. But then the doctor said they couldn’t guarantee me more than fifteen years, and fifty-five is kind of young to get something like that done. Then when I couldn’t get around anymore, it just seemed like the practical thing to do. Campbell patted his right knee; that replacement had worked like a charm. He and Betty planned to return to long walks at the local shopping mall. I got a little bit in the left one, but that’s going to be here until the swelling goes down. The only thing I would advise other people is, when they start having troubles and their leg starts acting up, get it checked out. The left knee replacement had alleviated his pain and restored his ability to walk, but Mike had died a few weeks before my call from an unusually ag- gressive pneumonia. Landau sounded shaken that he could not save this man he had known for fifteen years. People describe weakness, over- Sensations of Walking / 31 whelming fatigue, imbalance, tripping or careening into objects, stubbing toes on tiny bumps and cracks, and having trouble initiating, maintaining, or controlling movement. They have difficulty describing their sensations to loved ones, friends, and physicians. Walter Masterson, in his late fifties, was a business executive flying frequently abroad for ex- hausting negotiations. He disregarded the initial symptoms of amyo- trophic lateral sclerosis (ALS), Lou Gehrig’s disease. I started being bothered by the limp in the summer but didn’t go to the doctor until that fall. I would go overseas for two, three, sometimes even four weeks at a time, which meant I was carrying damned near everything I own and running through airports with this massive bag banging against my knee. So I never really thought much about it except that this one didn’t go away. I came in for a variety of torture tests, which were essentially measuring the nerves’ response to being stabbed and jolted. Progres- sively, I had to have braces on one leg and then both legs to help me stand up. Shortly thereafter I got a wheelchair for outside and a tricycle walker for home. Increasing weakness in my legs that has taken me from limping to not being able to walk at all. Lester Goodall, in his mid fifties, had long-standing diabetes requiring insulin. A manager in a Fortune 500 company, Lester’s recreational passion was throwing darts in leagues organized at local pubs. I would pick up my darts and try to get into the right position holding the darts, but I couldn’t. Then I’d stand on the line like you normally do, and the 32 / Sensations of Walking next step lose my balance. I attributed this to my dia- betes acting up, my blood sugar being high because I wasn’t control- ling it like I’m supposed to . It was like someone had taken the contrast on a TV and turned it up as bright as they could, and I couldn’t see the contrasts. So they put me through all of these tests, a vestibular test for the balance, this test, that test. Goodall’s MS started with two characteristic symptoms of the dis- ease—imbalance and difficulties with vision. This combination is especially troubling since vision problems compound the risk of falls. Goodall’s im- balance often leads people to think he is drunk:“It always appeared that I was inebriated and losing my balance. I didn’t know myself what was wrong back in those days, so I just figured, hey! I know there’s times when I’m walking and people look at me and think this man had too much to drink. Instead of planting their feet firmly where they used to , striding purpose- fully forward, their legs splay outward and their steps veer erratically. Often these changes reflect the nervous system’s attempt to restore or maintain balance in the face of neurologic deficits. The characteristic gait of a person with MS is described as “broad based”—feet planted far apart, trying to keep the walker erect. In contrast, diabetes mellitus can lead to “peripheral neuropathy,” a nerve problem that diminishes sensations in the lower extremities (toes, feet, and legs). That is one reason why periodic foot examinations are recommended for persons with diabetes, who may not feel injuries or sore spots, leaving wounds inadequately treated. Arnis Balodis had peripheral neuropathy from decades with diabetes and had had both legs amputated because of encroach- ing gangrene. Using mirrors, he carefully checked the stumps of his legs where they fit into his prostheses. Especially with illnesses that com- promise cognitive function or the ability to communicate, walking prob- Sensations of Walking / 33 lems may appear relatively manageable, particularly if they can be compen- sated for with mobility aids. An example is Parkinson’s disease, first de- scribed by James Parkinson over 180 years ago. Affecting more than one million people in North America, its cause is unknown, although genetics and aging play a role (Lang and Lozano 1998a, 1998b). Parkinson’s disease not only produces progressive debility, often including dementia, but it also shortens longevity. No current treatment reliably slows the progression of Parkinson’s disease. He offered to talk at my office, observing, “I feel like I’m at the hospital every other day. Fink has a shock of white hair, ruddy face, and Puckish grin, although his features frequently freeze in a sad, suspended expression. His voice is soft, breathy, and blurred, some- times trailing away entirely. He walked independently, without using a cane or holding onto his wife, Rachel, although he shuffled and lurched slightly to one side. Starting about five years ago, a two-year period began during which Bar- ney experienced vague problems—difficulty writing, trouble walking, a feeling that “something is not going right. Barney finally consulted a neurologist, who noticed that his face had a “fixed, glazed look,” a common appearance with Parkinson’s disease. After an extensive evaluation, the neu- rologist confirmed the diagnosis and started levodopa treatment. As is typical in Parkinson’s disease, Barney’s biggest walking problem is “Getting started, getting over the inertia. Even before the merchants get there, the employees get there, we usually get there one day a week. As I fell, I put this arm out to break my fall, and that’s when I ripped this. The last time I went to the neurologist, he says, ‘You’re doing great, you’re doing great. Walking is certainly problematic, but other things go to the core of his identity. Al- though the fixed income from disability insurance is tight, he feels relieved to no longer practice. I’ve had patients for four or five months, and I become very attached to them. Two years later, I asked his primary care physician how Barney was doing. Medical conditions that com- promise global physical endurance therefore affect walking. Heart and lung conditions are the fourth and sixth most common causes of mobility problems among adults (see Table 2). These conditions and circulatory dif- ficulties of almost any type limit the capacity for physical exertion and ac- tivities demanding energy and oxygen, such as walking. During exertion, heart and lung problems often produce difficulty breathing or shortness of breath. As Nan Darnelle, a former nurse in her early forties, observed, arthritis hurts but being short of breath really stops her. Sensations of Walking / 35 I had an operation on my knees for arthritis. I have to go shopping for myself, and I have to walk to the store because I don’t drive. But now it takes me an hour just to walk to the store, and I only carry maybe two things at a time.

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A flap tear of the meniscus will cause pain treatment 9mm kidney stones eldepryl 5 mg buy without a prescription, swelling treatment quincke edema purchase 5 mg eldepryl visa, catching and giving way (Fig treatment under eye bags buy generic eldepryl 5 mg on-line. The flap is easily resected with a basket forceps and a motorized shaver treatment action campaign buy eldepryl in united states online. In young patients medicine 75 yellow eldepryl 5 mg sale, the surgeon should make every attempt to repair the meniscus rather than resect it. The long-term results of reconstruction are more related to the state of the meniscus than to the stability. The debate is whether to repair the meniscus and do the ACL reconstruc- tion at the same sitting. If the limita- tion of extension is mild, the patient is weight bearing and the graft choice is hamstrings, the meniscus repair and ACL reconstruction can be done in one sitting. If the patient is on crutches with a significant lack of extension, for example 40°, the procedure should be staged to avoid postoperative stiffness. The meniscus repair is carried out, and when the patient has regained full range of motion, an ACL reconstruction is done. For the management of the associated meniscus pathology, see the hamstring graft, described in Chapter 6. Graft Harvest and Preparation The longitudinal incision should be 8 to 10cm long and 1cm medial to the tendon. The surgeon should plan for the lower end to incorporate the tibial tunnel. The incision can be as short as 5cm if cosmetic appearance is important. The author has used two separate transverse Graft Harvest and Preparation 125 incisions in the past, but prefers, in a teaching situation, to use the lon- gitudinal incision. Studies have shown that the two transverse incisions do not injure the infrapatellar branch of the nerve, and the patients are able to kneel after the patellar tendon harvest. A double-bladed knife cuts a 10-mm wide graft from the central third of the tendon (Fig. A Hall (Linvatec, Largo, FL) microoscillating saw is used to cut the bone plugs (Fig. A deep V-cut should be avoided, as it can lead to a stress riser and late fracture. If the bone plug is cut too thin, or fractured, then the fixation will have to be augmented by tying the sutures over a screw post or a button. The video on the CD demonstrates the technique of patellar tendon harvest. The transfer of the graft from the harvest site to the back table is where it can be dropped (Fig. The cleansing should consist of mechani- cally irrigating the graft by multiple separate rinsing. And use a small rongeur or bone cutter to size the bone plugs: the patella plug to 9mm and the tibia bone plug to 10mm. The cylindrical sizing tubes from Linvatec should be used to determine the size. The patella end should be made round to pass easily into the femoral tunnel. Leader sutures should be put through the holes in the bone plugs; in the patella use 2 number 0 Vicryl and in the tibia bone plug use 2 number 2 Ti-Cron. The Vicryl sutures (Ethicon, J&J, Boston, MA) are tied together in a knot that rests on the tip of the bone block. A blue mark with a marking pen is placed at the patella bone tendon junction. Notchplasty The lateral wall and roof have to be opened up to accommodate a 10-mm graft. In cases with a very narrow A-frame notch, this will be more exten- sive (Fig. Patellar Tendon Graft Technique as a pituitary rongeur that opens to 10mm. It is important to remove the soft tissue to visu- alize the back of the notch. The residents ridge does not have this fringe, so the physician should easily identify the correct area. Put the pump pressure at this stage to distend the fat behind the PCL so the drop-off of the femoral condyle can be clearly seen. The back of the lateral femoral condyle has been cleared to see the fringe of tissue that marks the over-the-top position (Fig. Linvatec makes a southpaw for left knees that also eliminates the jumping. The author makes a small divot with the burr at the position that the tunnel should be, that is, 7mm in from the drop-off, at 11 or 1 o’clock. The major mistake would be not to clear enough soft tissue to expose the poste- rior aspect of the notch. The tip of the Linvatec guide is placed 2-mm medial to the crest of the tibia and 5cm distal to the joint line. The tip of the guide should be adjacent to the medial collateral ligament. The oblique position will allow the positioning of the femoral guide in an oblique position (Fig. The guide is inserted through the anteromedial portal, by turning it upside down. The surgeon should make sure to aim to bring the long graft passing wire out the antero- lateral thigh. The target zone is a 10-cm oval region just above the lateral suprapatellar pouch. If necessary, chamfer the posterior rim with the chamfering device on the drill. There should be a 3- to 4-mm posterior wall between the tunnel and the PCL Tibial Tunnel 129 Figure 7. The oblique position of the tibial tunnel allows the drilling of the femoral tunnel at the 11 or 1 o’clock position. Femoral Tunnel Patellar Tendon The Bullseye femoral aiming guide is inserted through the tibial tunnel and hooked over the top of the femur (Fig. The over-the-top Bullseye guide, from the Linvatec GrafFix (Linvatec, Largo, FL) system, is used to position the K-wire for the drill (Fig. The Bullseye guide is removed and the 10-mm C-reamer is manually advanced to drill the femur (Fig. A footprint is drilled deep enough to be sure the posterior cortex is not drilled out. When Femoral Tunnel Patellar Tendon 131 you have determined that the posterior cortex is intact, advance the bit to a depth of 30mm (Fig. The knee is flexed to 120°,the notcher inserted into the anteromedial portal,and the supero- lateral aspect of the tunnel is notched (Fig. The notching should only be at the entrance of the tunnel rather than run the whole length. The tunnel is notched to start the BioScrew; avoid breaking the screw in young patients with hard bone. The eccentric guide is put into the tibial tunnel, through the joint, and again into the tibial tunnel. Once the pin has penetrated the far cortex, a kocher should be placed against the lateral thigh to stop the pin from skiving up the thigh. The guide wire for the screw insertion is put through the anteromedial portal and placed into the channel in the two-pin passer. The second BioScrew guide wire is placed anterior to the graft in the tibia tunnel. Patellar Tendon Graft Passage The two-pin passer is used to pull the leader sutures out the lateral thigh. The patella bone plug passes through the intercondylar notch and is pulled into the femoral tunnel. Tension is maintained on both ends of the leader sutures, and the knee is put through a range of motion to look for adequate clear- ance in the notch. If there is difficulty in passing the graft, the bone plug may be pulled off. The surgeon will then have to place sutures into the tendon and tie them over a button. The leading edge of the patellar bone plug is tapered like a boat when it is cut. Remember that the patellar bone plug has also been trimmed to a size of 9 mm, thereby allowing it to pass easily through the 10-mm tunnel. Graft Fixation Femoral Fixation The two-pin passer allows the BioScrew guide wire to be passed directly up the anterior aspect of the femoral tunnel (Fig. The insertion of the BioScrew should be done with the knee flexed to 120° to avoid injury to the graft and to follow the direction of the 134 7. The BioScrew guide wire and the screw should be directed into the notch. Tension is maintained on both sets of leader sutures, and the screw is slowly advanced (Fig. Once into the tunnel, the screw will start to squeak, and the surgeon will feel a good purchase in the bone tunnel. The video on the CD shows how the screw is inserted flush with the tunnel exit and the bone plug. The screw should be against the cancel- lous side of the bone plug, parallel with the tunnel. This configuration places the tendon in the most posterior aspect of the tunnel. With the BioScrew, the surgeon has one chance to get it right, so do not remove and replace it unless it is necessary to go up a size. The screw should not be forced, as it might break or deform the threads. The main advantage of the BioScrew is that it will eventually disappear. Tibial Fixation The knee is placed at 20° to 30° of flexion, pulling with 12 to 15lbs on the distal sutures. An 8 ¥ 25-mm BioScrew is introduced along the K-wire and into the tunnel (Fig. Two sutures should be used in the tibial bone plug at slightly different angles. Guard against letting the screw push the bone plug up the tibial tunnel by pulling firmly on the distal sutures. The screw should remain at the external tibial cortex to have the best purchase on the bone plug. If the bone plug protrudes from the tibial tunnel, an interference fit screw cannot be used to fix it (Fig. If there is a graft mismatch, that is, if the bone plug protrudes out the tibial tunnel, the fixation may have to be changed. The options are to groove the anterior tibia and fix the graft with a staple or small frag- Figure 7. The graft is inspected as the knee is moved through a range of motion, looking for anterior impingement and lateral wall abrasion. KT-S Measurements Before the sutures are cut, the KT-S is used to pull a manual maximum a-p translation (Fig. Patellar Tendon Graft Technique 10% of the time, the difference is greater than 3mm, and revision of the tensioning of the graft at the tibial end is done. One common problem is letting the screw push the bone plug up the tibial tunnel. The sutures are cut off when the surgeon is satisfied that the knee is stable and the fixation is secure. Postoperative Regimen: Extension Splint, Cryo-Cuff, and Continuous Passive Motion Machine After the wounds are closed, the author applies a Tegaderm dressing, a compressive stocking, and the Cryo-Cuff (Fig. When the patients get up, they use the extension splint and crutches (Fig. The patient stays several hours in the hospital and goes home with the continuous passive motion (CPM) machine, the Cryo-Cuff, the extension splint, and crutches. Oral pain medication is one or two Tylenol # 3 every 4 hours as necessary. The patient is discharged the same day after several hours in the recovery room. The Jones and Tegaderm dressing is removed, and the Cryo-Cuff is applied directly to the skin. The wounds are cleansed for the next few days with 3% hydro- gen peroxide. The author has a protocol that can be mailed to remote physiotherapy locations, as well as posted on our Web site, to ensure that the early extension routine is started. Note that the only difference in the rehabilitation protocol between the semitendinosus and the patellar tendon grafts is that with the semi-t, active knee flexion exercises are avoided for six weeks. Before the operative pro- cedure, there should be no effusion, a full range of motion, and good quadriceps and hamstring strength. Postoperative Goals Physiotherapy should begin the day of surgery if the final result is to be full range of motion, no effusion, and strength equal to the opposite side. The surgeon or physiotherapist should make any necessary alterations in this program.

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