By H. Kalan. Rhode Island School of Design.
Certainly a recon- must be located isometrically to avoid over- struction of the MPFL with a stronger structure stretching it to failure during joint motion or to will have greater chances to succeed generic amantadine 100mg with amex symptoms of hiv infection after 5 years. A trans- The technique we postulate follows the same verse hole is placed through the patella at about principles as the one described for reconstruc- the mid-one-third height. In addition to the use of isometer to determine the isometric point that is quadriceps tendon or bone-tendon or other close to the lateral epicondyle. Once the isometric allografts, the adductor magnus tendon or ham- location is found, the graft must be fixed to the string tendons have been used as grafts. The bone block is coun- adductor magnus with its insertion just proxi- tersunk into the femur and fixed with a 4. The tendon is pulled into used to reconstruct the MPFL (Figure 21. We set the tension alta, proximal displacement of the tubercle for with the knee flexed 60° to 90° to avoid the risk of patella baja, lateral tubercle transfer for inade- pulling too far lateral. The range of motion must quate Q-angle, and medial tubercle transfer for be tested to ensure there is no restriction of patel- grossly excessive Q-angle. If impingement on the wall of Patella alta has been long recognized as asso- the lateral femoral condyle is detected, the graft ciated with patellar instability. This is likely can be placed on the anterior surface of the because the patella is not engaged in the trochlea Failure of Patellofemoral Surgery: Analysis of Clinical Cases 341 previously normal TT-TG. Excessive medializa- tion may contribute to medial subluxation or dislocation of the patella and to the develop- ment of medial patellofemoral osteoarthritis as well as medial compartment osteoarthritis due to overload of the medial compartment. Additionally, the tibia is externally rotated and the patients may walk with increased outward foot progression angle. This external rotation of the tibia on the femur stresses the tibiofemoral capsule and pain at the posteriomedial corner of the joint may be present. A symptomatic medially transferred tibial tubercle should be repositioned laterally so the TT-TG distance is between 10 and 20 mm. Skeletal alignment in all three planes has a great influence on patellar tracking and loading. The source of patellofemoral loading is extra-articu- and thus receives neither the trochlear buttress lar; this is the reason that operations limited to support nor the necessary fulcrum for the the knee joint frequently fail when skeletal medial patellofemoral ligament to operate effi- malalignment is not recognized. The treatment ciently during the twisting activity that usually of skeletal malalignment requires the correct causes patellar subluxation. If there is genu valgum because The transfer is planned on the lateral preoper- of a short lateral femoral condyle, a femoral ative x-rays; the tubercle should be moved dis- varus osteotomy is indicated. If the genu valgum tally enough to create an Insall-Salvati ratio of 1. Genu varum with medial trochlear tibial tubercle is exposed and the patellar tendon degeneration should be treated with tibial valgus insertion is identified. Inward pointing knees with second- is placed just distal to the patellar tendon; then an ary lateral subluxation should be treated by with anteroposterior hole (2. The distance between the K-wire internal rotation tibial osteotomy if it is caused and the hole will determine the amount distaliza- by increased external tibial torsion. Combined tion and is calculated from the preoperative plan- deformities are not uncommon and the type of ning. A series of drill holes are placed from lateral osteotomy and location depends on the defor- to medial and connected with a chisel. A detailed description of the types and level ment should be at least 7 cm long and 15 mm of the osteotomies is presented in Chapter 11. The fragment is If the articular cartilage has been lost and pulled distally so the proximal hole is aligned osteoarthritis develops, two alternatives are avail- with the distal drill hole, and then a K-wire is used able: (1) restoration of the normal extra-articular to maintain alignment while the fragment is fixed anatomy and stability and (2) replacement of the with 2 lag screws. Options for articular cartilage The same technique is used to lateralize the replacement are biological or prosthetic. In the medial tubercle to restore the normal tibial past 18 years, 11 patients have undergone 14 fresh tubercle–trochlear (TT-TG) groove distance in patellar and trochlear allografts. The most fre- patients who have had an excessive medial quently performed pre-replacement procedure in transfer.
Stenosing lesions of the renal circulation cause hypertension through ischemia-mediated activation of the renin-angiotensin-aldosterone system 10 BOARD REVIEW ❏ C cheap 100mg amantadine visa hiv infected babies symptoms. Fibromuscular disease is an uncommon cause of renovascular hyper- tension in patients of this age ❏ D. Atheromatous disease and fibromuscular disease are equally frequent causes of renovascular hypertension Key Concept/Objective: To know the characteristics of renovascular hypertension that is mediat- ed by atheromatous lesions and fibromuscular disease Renovascular hypertension is the most common form of potentially curable secondary hypertension. It probably occurs in 1% to 2% of the overall hypertensive population. The prevalence may be as high as 10% in patients with resistant hypertension, and it may be even higher in patients with accelerated or malignant hypertension. Stenosing lesions of the renal circulation cause hypertension through ischemia-mediated stimulation of the renin-angiotensin-aldosterone axis. Fibromuscular disease is the most common cause of renovascular hypertension in younger patients, especially women between 15 and 50 years of age; it accounts for approximately 10% of cases of renovascular hypertension. Athero- matous disease is the most common cause of renovascular hypertension in middle-aged and older patients and accounts for approximately 90% of cases of renovascular hyper- tension. The prevalence of atheromatous renal artery disease increases with age and is common in older hypertensive patients, especially in those with diabetes or with athero- sclerosis in other vascular beds. Most patients with atheromatous renal vascular disease and hypertension have essential hypertension. A 55-year-old man presents to establish primary care. His medical history is significant only for 40 pack- years of smoking. On physical examina- tion, the patient’s blood pressure is 158/98 mm Hg, and he is moderately obese (body mass index, 27); the rest of his examination is normal. His laboratory examination, including a chem 7, CBC, TSH, and urinalysis, is normal, as is his electrocardiogram. Repeated blood pressure measurements over the next month are similar to the values first obtained. With respect to this patient’s blood pressure, what therapeutic option should be offered to this patient now? Lifestyle modifications, including decreased alcohol consumption, weight loss, smoking cessation, and moderate exercise for 6 months ❏ D. Given his smoking history, he has greater than or equal to 1 risk factor for CV disease, which puts him in risk group 2. On the basis of the JNC VI (Joint National Committee on Prevention, Detection, and Treatment of High Blood Presssure) recommen- dations, it is appropriate to try lifestyle modifications (weight loss, dietary modification such as adherence to the DASH [Dietary Approaches to Stop Hypertension] diet, and mod- erate exercise) for 6 months before starting medications. The patient in Question 18 adhered to your recommendations, but his blood pressure remains elevated to the same degree. He is interested in controlling his blood pressure but is worried about the cost of medications. What should be the first-line pharmacologic therapy for this patient? Hydrochlorothiazide, 25 mg/day Key Concept/Objective: To know the recommended first-line medications for treatment of hyper- tension Thiazide diuretics for the treatment of high blood pressure have been shown most consis- tently to have the best outcomes with respect to stroke and CV disease, mortality, and patient compliance. Given that the benefits of treating high blood pressure accrue only over the long term, the last of these attributes is especially important. Also, hydrochloro- thiazide is by far the least expensive of all of the medications listed. Three months after starting therapy, the patient in Question 18 returns for follow-up. His blood pressure is 145/92 mm Hg, and blood pressure values that he has obtained outside the clinic are similar. He says that he has been taking hydrochlorothiazide as directed and has noted no unpleasant side effects. He is doing his best to adhere to the lifestyle modifications that you recommended. What is the best step to take next in the management of this patient? Double the dose of hydrochlorothiazide to 50 mg/day ❏ D. Add amlodipine, 5 mg/day Key Concept/Objective: To understand the goals of antihypertensive therapy and to be able to select an appropriate second medication to achieve those goals The goal for the treatment of hypertension is a blood pressure lower than 140/90 for most people (although this number is arbitrary, and some experts recommend still lower tar- gets).
Success of therapy likely depends on patient susceptibility and attitude toward hypnosis generic 100mg amantadine otc hiv infection via urethra. Biofeedback involves self-regulation of the physiologic response to stress through relaxation techniques. Instrumentation (electroencephalography, elec- tromyography, skin temperature/sweat monitors) is used to assess and guide therapy. Thus, biofeedback is one of the least subjective of the mind-body interventions. Aroma- therapy involves the use of essential oils (e. The proposed mechanism of action of mind-body interventions involves hor- monal changes (e. Counteracting the physiologic effects of stress can presumably help combat the manifestations of various disease states. A 54-year-old woman whom you have followed for years in clinic for benign hypertension, osteoporo- sis, and chronic low back pain returns for her annual examination. She has no new complaints, but she is interested in alternative forms of treatment for her low back pain. Which of the following statements concerning chiropractic treatment is true? Spinal manipulation is considered a first-line treatment for low back pain because there are no known side effects ❏ B. Studies have suggested that spinal manipulation is an effective treat- ment option for patients with chronic back pain ❏ C. Health care insurance plans do not cover chiropractic treatments ❏ D. Osteoporosis does not preclude this patient’s use of chiropractic treat- ment for low back pain CLINICAL ESSENTIALS 23 Key Concept/Objective: To understand the uses and limitations of chiropractic treatments Health care insurance plans, including Medicare, cover many of the services performed dur- ing chiropractic visits. Most chiropractic visits are for musculoskeletal problems, including low back pain, neck pain, and extremity pain. Much of the current use of chiropractic care stems from its utility in cases of low back pain. A number of controlled trials on chiro- practic treatment for low back pain have been done, with conflicting results. A recent sys- tematic review suggested that spinal manipulation is effective and is a viable treatment option for patients with acute or chronic low back pain. Patient satisfaction also seems to be high with such therapy. Serious complications from lumbar spinal manipulation seem to be uncommon, although there are reports of cauda equina syndrome. Many patients, however, experience mild to moderate side effects, including localized discomfort, headache, or tiredness. Brain stem or cerebellar infarction, vertebral fracture, tracheal rupture, internal carotid artery dissection, and diaphragmatic paralysis are rare but have all been reported with cervical manipulation. Given the lack of efficacy data and the risk (although small) of catastrophic adverse events, it is difficult to advocate routine use of this technique for treatment of neck or headache disorders. Physicians should also recognize potential contraindications to chiropractic ther- apy. Patients with coagulopathy, osteoporosis, rheumatoid arthritis, spinal neoplasms, or spinal infections should be advised against such treatments. A 63-year-old man presents to your clinic for an initial evaluation. He has a history of coronary artery disease, congestive heart failure, atrial fibrillation, benign prostatic hyperplasia, and erectile dysfunction. His current medical regimen includes hydrochlorothiazide, metoprolol, enalapril, digoxin, coumarin, and terazosin. During the visit, the patient pulls out a bag of vitamins and herbal supplements that he recently began taking. He hands you several Internet printouts regarding the supplements and asks your advice.
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