However cheap antabuse 250 mg with visa, the evolving pattern of change in the society with upward economic mobility and increasing number of middle classes would mean that a significant number of life-style related diseases such as Ischemic Heart Disease are increasing antabuse 250 mg line. There is very little information about this and it would be useful to undertake long-term cohort studies in different population groups antabuse 500mg. Observational and Experimental Designs of these studies are based on cross-sectional buy antabuse 500 mg overnight delivery, case-control or cohort approaches. Scope of ethical guidelines for epidemiological studies is concerned with epidemiological research. Ethics in epidemiological studies is multidimensional covering clinical medicine, public health and the social milieu. Perhaps the code of ethics is much better understood for clinical research, where the interaction between a patient and a clinical researcher is of supreme importance. In epidemiological research the researcher is dealing with a group of individuals and the questions faced by an epidemiologist are more of a professional nature. These questions would pertain to interactions with individual subjects, sources of funding or employer, fellow epidemiologist and the society at large. Need for a code of ethics for epidemiologists is being recognized globally and the issues for such a code in the context of epidemiological research in India deserve attention. Epidemiological research differs from clinical research in the context of the large number of study subjects and generally a long time frame. If some mistakes or aberrations get detected during the course of conduct of such studies, repeating the whole exercise will be expensive, time consuming and may not even be feasible. Hence utmost care needs to be taken for various aspects—technical, practical and ethical. Cross-sectional studies (Surveys): This is primarily population based and involves selecting random samples of the population to be representative based on census data and then applying questionnaires to understand the prevalence of various diseases. Its aim is to assess aspects of the health of a population or to test hypotheses about possible cause of disease or suspected risk factors. Case-control studies: This usually compares the past history of exposure to risks among patients who have a specified condition/disease (cases) with the past history of exposure to this among persons who resemble the cases in such respects as age, sex socioeconomic status, geographic location, but who do not have the disease. Case control studies can be done by following up available records, usually records in a hospital, but in the context of a country like ours, it may require direct contact between research workers and study subjects and informed consent to participation in the study is necessary. However, if it entails only a review of medical records, informed consent may not be required and indeed may not be feasible. Cohort studies: These are longitudinal or prospective studies of a group of individuals with differing exposure levels to suspected risk factors. The rate of occurrence of the condition of interest is measured and compared in relation to identified risk factors. It requires a study of large number of subjects for a long time and involves asking questions, usually routine medical examination and sometimes laboratory investigations. Individuals are being followed up as the cohort and it is essential to identify precisely every individual to be studied. Experimental Epidemiology: In experimental epidemiology the investi- gators alter one or more parameters under controlled conditions to study the effects of the intervention. These are usually randomized controlled trials done to test a preventive or therapeutic regimen or the efficacy of a diagnostic procedure. Although these are strictly speaking epidemiological studies they come under the purview of clinical evaluation of drugs/devices/ products/vaccines, etc. The possibility of use of placebo as one of the arms of the trial should be explained and informed consent taken in such studies. At the same time it is essential that all individuals in an epidemiological research are treated alike keeping in mind the rules Ethical Issues in Health Research 241 of distributive justice. The welfare of the individual has to be balanced against the welfare of the community and society at large. With large segments of our population, given their level of education, the full understanding in the sense of industrialized countries may not be achievable. How the principle of “do no harm” is ensured under such circumstances without being paternalistic is a major issue that has to be taken into consideration in ethical guidelines. In cohort or survey techniques for incidence and prevalence of various diseases, a major issue that has to be considered is how much of intervention is justified and whether one is justified in withholding interventions. For example, if you are looking at longitudinal morbidity in a population group, should you give them health education that is well established with regard to preventive aspects, or should you leave them alone so that the natural evolution of the disease can be studied? Health education or other interventions including non-health interventions can be quite expensive. An alternate strategy that may be followed is to make curative therapy available to the population at their own request. This usually involves running a clinic, which is readily accessible to the population without any other intervention. However, it is generally considered unethical to withhold intervention or services. Informed consent: When individuals are to be the subject of any epidemiological studies, the purpose and general objectives of the study has to be explained to them keeping in mind their level of understanding. In the context of developing countries, obtaining informed consent has been considered many times as difficult/impractical/not meeting the purpose on various grounds such as incompetence to comprehend the meaning or relevance of the consent and culturally being dependent on the decision of the head of the family or village/community head. However, there is no alternative to obtaining individual’s informed consent but what should be the content of the informed consent is also a crucial issue. In spite of obtaining informed individual consent, it is quite likely that the subjects/patients may not be fully aware of their rights. In this context, the role of investigator is crucial and he/she should remain vigilant and conscious of his/her obligations towards the subjects/ patients, all through the course of the studies. In most epidemiological research it would be necessary to have the consent of the community which can be done through the village leaders, the panchayat head, the tribal leaders, etc. In obtaining the consent of individuals or communities it is important to keep in mind that working through peer groups or through panchayat etc. Particularly in a country like India, with the level of poverty that is prevalent it is easy to use inducements, especially financial inducements, to get individuals and communities to consent. However, it is necessary to provide for adequate compensation for loss of wages and travel/other expenses incurred for participating in the study. All risks involved including the risk of loss of privacy must be explained to the participants in an epidemiological study. The design of the study should ensure that the benefits of the study are maximised for the individuals and communities taking part in the study. This means that at the onset itself the investigators should design the way in which the results of the study are going to be communicated and also decide whether individuals identified at particular risk during the course of the studies would be informed. It may also be necessary in some instances to inform the concerned family members about the results. It may not always be possible to communicate study results to individuals but research findings and advice should be publicized by appropriate available means. It is also important that the beneficial results of epidemiological studies are fed into the health system and necessary training modules should be developed as part of the epidemiological project. All attempts should be made to minimize harm to the individuals and society at large. Special consideration for the cultural characteristics of the communities that are being studied is essential to prevent any disturbance to cultural sensitivities because of the investigation. A particular concern is the fact that some population based data may also have implications to issues like national security and these need to be carefully evaluated at the beginning. In all situations where there is likely to be conflicts of interest it must be ensured that the interest of the individuals involved in the study are protected at all cost. Scientific objectivity should be maintained with honesty and impartiality, both in the design and conduct of the study and in presenting and interpreting findings. Ethical Review Procedures: In all Ethical Committees at least one or two individuals with an understanding of the principles of epidemiological ethics should review the proposal. Informed Consent of Subject For all biomedical research involving human subjects, the investigator must obtain the informed consent of the prospective subject or in the case of an individual who is not capable of giving informed consent, the consent of a legal guardian. Informed consent is based on the principle that competent individuals are entitled to choose freely whether to participate in research or not. Informed consent protects the individual’s freedom of choice and respect for individual’s autonomy. When research design involves not more than minimal risk (for example, where the research involves only collecting data from subject’s records) the Institutional Ethics Committee may waive off some of the elements of informed consent. Waiver of informed consent could also be considered during conditions of emergency. However, this would be permissible only if Ethical Committee has already approved the study or use of drug. However, the patient or the legal guardian should be informed after she/he regains consciousness or is able to understand the study. Obligations of Investigators Regarding Informed Consent The investigator has the duty to– i. Communicate to prospective subjects all the information necessary for informed consent. There should not be any restriction on subject’s right to ask any questions related to the study as any restriction on this undermines the validity of informed consent. Exclude the possibility of unjustified deception, undue influence and intimidation. However, sometimes information can be withheld till the completion of study, if such information would jeopardize the validity of research. Investigator should not give any unjustifiable assurances to prospective subject, which may influence the subject’s decision to participate in the study. As a general rule, obtain from each prospective subject a signed form as an evidence of informed consent (written informed consent) preferably witnessed by a person not related to the trial, and in case of incompetence to do so, a legal guardian or other duly authorized representative. Renew the informed consent of each subject, if there are material changes in the conditions or procedures of the research or new information becomes available during the ongoing trial. The investigator must assure prospective subjects that their decision to participate or not will not affect the patient-clinician relationship or any other benefits to which they are entitled. Essential Information for Prospective Research Subjects Before requesting an individual’s consent to participate in research, the investigator must provide the individual with the following information in the language he or she is able to understand which should not only be scientifically accurate but should also be sensitive to their social and cultural context: i. The quality of the consent of certain social groups requires careful consideration as their agreement to volunteer may be unduly influenced by the Investigator. Writing the protocol helps the investigator to organize, clarify and refine all the elements of the study. A proposal is a written document for the purpose of obtaining fund from granting/funding agencies. It includes the study protocol, the budget and other administrative and supporting information that is required by the specific funding agency. A good proposal is direct, straightforward with high scientific quality and communicates well. It is also well-organized having various sections with headings and paragraphing and able to anticipate potential flaws and address them. It should make the central objectives and variables of the study clear to the reader (reviewer). The title provides the “keywords” for the classification and indexing of the project. If it is possible without undue length, the title can give a preview of the protocol.

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Mitral valve prolapse commonly occurs in patients with Marfan syndrome and is more common in women purchase 250 mg antabuse amex. The incidence is as high as 60% to 80% discount antabuse 250mg mastercard, and progressive mitral regurgitation occurs in about 25% of patients cheap 250mg antabuse free shipping. The valve leaflets are usually thickened and redundant discount 500 mg antabuse otc, and occasionally ruptured chordae or prolapse may be present. Standard management for chronic severe mitral regurgitation is indicated in symptomatic patients, with repair of the mitral apparatus if possible, but replacement may be necessary when the leaflets are very redundant or there is severe annular calcification or chordal damage. Dilated cardiomyopathy independent of, or out of proportion to, valvular abnormalities can occur in patients with Marfan syndrome. This has been hypothesized to be secondary to a potential role of fibrillin mutations in the reduction of myocardial function. Arrhythmias, both supraventricular and ventricular, can occur in patients with Marfan syndrome. Patients are predisposed to more aggressive and widespread vascular disease, including aneurysm formation and dissection, compared with Marfan syndrome, with a mean age of death of 26 years. Arterial rupture or dissections are the major causes of mortality in these patients and can occur in the thoracic or abdominal vessels, including aortic rupture or dissection. The median age of survival was about 48 years in a study of 220 patients with this disorder. In the same study, 25% of patients had a medical or surgical complication by the age of 25 years and >80% had such complications by the age of 40 years. Pregnant women have a 50% chance of transmitting the disorder to the child and about 11. Pregnancy should be considered high risk, and women should be counseled against it. Sarcoidosis is an idiopathic systemic granulomatous inflammatory disease affecting mainly the lungs, but can involve the lymph nodes, skin, eyes, heart, kidneys, musculoskeletal system, nervous system, and endocrine system. Cardiac involvement is found in 25% of patients with sarcoidosis on autopsy, but only 5% of patients have clinically apparent cardiac involvement. Arrhythmias can vary from conduction disturbances, including heart block to fatal ventricular arrhythmias. Complete heart block is the most common abnormality in patients with clinically evident sarcoidosis and is found in 20% to 30% of patients. Granulomatous infiltration of the ventricular myocardium can set up foci of automaticity, leading to ventricular arrhythmias. Sudden cardiac death caused by an arrhythmia is one of the leading causes of death (>60%) in patients with sarcoidosis. Congestive heart failure may occur secondary to widespread infiltration of the myocardium. Progressive congestive heart failure is the second most common cause of death in patients with sarcoidosis. Pericardial involvement can manifest as pericarditis, pericardial effusion, and constrictive pericarditis. Endomyocardial biopsy with finding of noncaseating granulomas has high specificity, but poor sensitivity owing to the patchy nature of myocardial involvement particularly in the basal septum, whereas the location of biopsy is often the apical septum. Electrocardiogram often reveals conduction abnormalities but has poor sensitivity. Echocardiographic findings include increased ventricular septal thickness (secondary to granulomatous expansion) or wall thinning (because of fibrosis), aneurysms, regional wall motion abnormalities, and eventually ventricular dilatation. Corticosteroid therapy can halt cardiac disease progression and improve survival; however, it does not prevent sudden cardiac death. Pacemaker implantation is often necessary in cases of symptomatic heart block or asymptomatic high-grade conduction disease. Cardiac transplantation for cardiac sarcoidosis is rarely used, because the disease can recur in the transplanted heart. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Coexistence of ischemic heart disease and rheumatoid arthritis patients: a case control study. Pericardial involvement in systemic lupus erythematosus: current diagnosis and therapy. An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus. Progression of aortic dilatation and the benefit of long- term beta-adrenergic blockade in Marfan’s syndrome. Early surgical experience with Loeys–Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease. The pericardium is a double-layered, flask-shaped sac containing the heart and the initial part of the great vessels. The outer fibrous layer adjoins adjacent intrathoracic structures, whereas the inner mesothelial portion forms a parietal and a visceral layer, between which lies the pericardial cavity. Normally, this contains <50 mL of serous pericardial fluid but this may expand substantially in pathologic states. It also permits the unimpeded expansion, within a protective range, of the ventricle during diastole. Normally, the pericardium readily transmits changes in intrathoracic pressure to the heart with important hemodynamic consequences. Finally, the pericardium can modulate cardiac reflexes and coronary tone via secretion of prostaglandins. The most common pericardial diseases identified in clinical practice include acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Despite relatively generally good prognosis, pericarditis usually recurs in one-third of patients without proper treatment with risks for deleterious complications along with a decrease in quality of life. Chest pain (>85% of cases) is usually affected by respiration and is retrosternal improved by sitting up and leaning forward. Pericardial rub (<33% of cases) is described as a scratchy and high- pitched sound—often evanescent with changes in quality and intensity on serial exam. Commonly, there is a biphasic rub consisting of atrial and ventricular systolic components. It is best heard during inspiration with the patient leaning forward while placing the diaphragm of the stethoscope at the left lower sternal border. A pericarditis illness that persists beyond 4 to 6 weeks is called incessant pericarditis, whereas chronic pericarditis is reserved for cases lasting longer than 3 months. Patients with acute pericarditis must be managed in the hospital if there exists a poor prognostic factor and/or concerns of underlying condition driving the illness. Failure to respond to medical therapy Other minor prognostic factors include myopericarditis, immunosuppression, trauma, and oral anticoagulant therapy. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. Chest x-ray—enlarged bottle-like cardiac silhouette occurs with large pericardial effusion (usually >300 mL). Transthoracic echocardiogram within a day of presentation to assess for effusion (only in 40% of cases), tamponade/constrictive physiology, increased pericardial brightness, and wall motion abnormality (if myocardium involved) e. Testing should be conducted only if the clinical scenario suggests an underlying etiology. Such testing includes bacterial culture, tuberculin test, viral serologies, fungal tests, thyroid function tests, autoimmune panel, cardiac biomarkers, and/or cytology. Echocardiography is the first-line imaging modality and is routinely indicated in acute pericarditis. Investigation of secondary cause of pericarditis—concomitant ischemia, neoplasm, lung infections, and so on D. Chest pain from acute pericarditis can mimic aortic dissection, pulmonary embolism, pneumothorax, or acute coronary syndrome. Echocardiography may help in making the distinction by assessing for wall motion abnormalities, which are usually absent in acute pericarditis. The addition of colchicine speeds resolution of symptoms and decreases risk of incessant or recurrent episode by half. Steroid use during the first episode increases the odds of recurrence by fourfold. Therefore, this is not recommended as first-line treatment for acute pericarditis. Most patients with idiopathic or viral pericarditis should have a 1-month follow-up to ensure resolution of symptoms and assess for constrictive changes. Patients with pericardial effusion should have serial echocardiograms to follow the size and resolution of the effusion. Complications usually relate to the underlying cause and not the number of recurrences. For instance, the overall rate or constrictive pericarditis is lower than reported after a first episode of pericarditis. Recurrent pericarditis: This is defined as a recurrent episode of pericarditis after a symptom-free period of at least 4 to 6 weeks(following taper of medication) from the initial episode. The proposed pathophysiology for recurrence is autoimmune or auto-inflammatory, whereas a viral cause is identified in up to 20%. Other risk factors proposed include fever, subacute presentation, immunosuppressed host, myopericarditis, large effusion, tamponade physiology, prior chest trauma, incomplete treatment course, and delayed response to therapy. Intrapericardial steroids have occasionally been used to minimize systemic effect of corticosteroids. Steroid-sparing alternative therapies currently under investigation include disease-modifying antirheumatic drugs (e. If either new focal or diffuse myocardial impairment is identified, then the event is defined as perimyocarditis. Coronary angiogram should be pursued in those cases with convincing angina and/or increased risk of coronary events. Activity restriction for at least 6 months is recommended in those patients with myopericarditis given increased risk of ventricular arrhythmias. In general, myopericarditis seems to have good prognosis with no increased risk of death or heart failure. Cardiac tamponade: occurs in up to 11% of cases, mostly in neoplastic and postsurgical cases. It should be suspected in any patient with acute pericarditis presenting with dyspnea, tachycardia, and hemodynamic instability. Acute pericarditis evolves into constrictive pericarditis only in 1% to 2% of cases, but rarely follows recurrent pericarditis. It is more commonly seen in purulent and tuberculous pericarditis (20% to 30% of cases).

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The condition can be acquired through infection discount 250mg antabuse with visa, arthritis generic antabuse 500 mg otc, trauma buy antabuse 500mg on-line, or iatrogenic buy antabuse 500mg otc. Lateral, Harris–Beath, and Isherwood views are the best radiographic views for visualization. Surgical treatment involves resection of the coalition and interposing soft tissue between bones. Triple arthrodesis may be warranted if previous surgery has failed or joint destruction is severe. There is often joint space narrowing with diminished clarity of the posterior facet even if only the middle facet contains the coalition. Talar beak sign: Flaring of the superior margin of the talar head Rounding of the lateral talar process: The lateral process of the talus becomes blunted or flattened. Shortening of talar neck: Dysmorphic sustentaculum tali: The 680 sustentaculum tali may be ovoid shaped as opposed to its normal brick shape. Ball-in-socket: Configuration of talus in the ankle mortise takes on a more rounded shape versus its normal squared off shape. Medial oblique radiographs may show where the calcaneus and navicular are in close proximity or connected (calcaneonavicular bar). Lateral views show the classic elongated anterior process of the calcaneus, anteater sign. They are mostly asymptomatic; when painful, pain begins around 3 to 5 years of age. Chief complaint is usually bump pain from shoe gear rubbing on the medial prominence. It affects 1 in 1,000 live births, male to female ratio is equal, and 55% of cases are bilateral. Ten percent of cases are associated with dislocated hip, and 86% of cases resolve satisfactorily without treatment. Clinical symptoms include an intoed gait with frequent tripping and a prominent styloid process. Metatarsus adductus is usually idiopathic and rarely associated with neuromuscular disease. Measuring the Metatarsus Adductus Angle Classic Method A line is drawn between the medial-proximal aspect of 1st metatarsal base and the medial-distal aspect of the talonavicular articulation. A second line is drawn between the lateral-proximal aspect of the 4th metatarsal base and the lateral-distal aspect of the calcaneocuboid joint. Next, the angle is measured between a line drawn perpendicular to this third line and a line drawn down the longitudinal shaft of the 2nd metatarsal. Shoes, orthotics Splints (Ganley), braces Treatment, Surgical (soft tissue) Children between 2 and 6 or 8 years of age, soft tissue procedures are recommended. Classification Preaxial: Involves the hallux (15%) Central: Involving digits 2, 3, or 4 (6%) Postaxial: Involving the 5th digit (79%), six subtypes 693 Postaxial polydactyly can also be divided into: Type A: Well-formed articulated digit Type B: Rudimentary often without skeletal component Treatment Supernumerary digits are removed for cosmetic reasons and for comfort in shoes. Surgery should be avoided until at least 1 year of age when the full pattern of skeletal involvement becomes clear and when the child can better tolerate anesthesia. Usually involves toes 1st, 2nd, or 3rd May be associated with neurofibromatosis Blood vessels and tendons are not affected. Poor circulation because blood vessels have not enlarged with the digit Can often affect the metatarsal head as well as the phalanges Involvement of 2 or 3 adjacent digits is more common than single digit involvement. Classification Static deformity—growth rate is proportional to other digits (most common). Progressive deformity—disproportionately fast growth rate until puberty 695 Treatment Condition is not painful, and treatment is performed for cosmetic and shoe fitting purposes. Epiphysiodesis—the soft cartilage of the physis is surgically resected with a scalpel or by multiple drilling; this will stop the bone from lengthening, but the bone will still increase in girth. Most commonly affects the 1st or 4th metatarsal Most commonly B/L and symmetrical Females to males (25:1) Becomes evident between 4 and 15 years Plantar callus may develop on adjacent metatarsal heads. Clinical signs include a floating toe/short toe and a plantar fissure of sulcus where the metatarsal head should be. Associated conditions: Down syndrome Pseudohypoparathyroidism Pseudo-pseudohypoparathyroidism Poliomyelitis Trauma Idiopathic Albright Turner syndrome Classification 696 Treatment Palliative treatment includes orthotics and accommodative devices. This can be accomplished by lengthening the short metatarsal via bone graft or callus distraction or shortening long adjacent metatarsals. Dorsal surface of the foot may be in contact with the anterior surface of the leg. The condition usually resolves spontaneously with growth but may require serial casting. Pseudohypertrophy is an apparent hypertrophy of certain muscles specifically the calves. Although these muscles may look overdeveloped, they are actually weaker than normal. Keeping patients active is important; inactivity often leads to worsening of the underlying muscle disease. Plantaris runs between the gastrocnemius and soleus muscle and inserts on the medial aspect of the posterior calcaneus. The triceps surae muscle is referred to the two heads of the gastrocnemius muscle and the soleus muscle. Silfverskiold Test Tests for gastrocnemius equinus Passive dorsiflexion is measured with the knee extended and again with the knee flexed. If the amount of dorsiflexion increases with knee flexion, there is an equinus due to a tight gastrocnemius, because the 700 gastrocnemius crosses the knee joint and the soleus does not. By advancing the insertion of the Achilles anteriorly on the calcaneus, the muscles lose some mechanical advantage and decrease the equinus. This weakens the triceps surae at the ankle joint by 50% but weakens toe-off ability by only 15%. Z-Plasty (Sagittal plane) 708 Z-Plasty (Frontal plane) 709 Hauser Section posterior 2/3 proximally and medial 2/3 distally 710 White Section anterior 2/3 distally and medial 2/3 proximally 711 Hoke Triple hemisection with first and last cut medially and second cut laterally These incisions are made through skin stab incisions. Varus foot should be avoided at all cost; these patients end up with pain and callus formation under the lateral midfoot and forefoot. Sliding the calcaneus posteriorly on the talus will raise the arch, and sliding the calcaneus anteriorly on the talus will lower the arch. Post-op Apply Jones compression dressing immediately post-op for 2 to 3 days; casting is generally avoided because of swell. Although they are commonly referred to as subtalar joint implants, they are not inserted into the joint. They are considered direct impact implants because the implants physically block the motion of the talus. Classifications Intraosseous Intraosseous implants have a stem that is fit into a hole drilled into the floor of the sinus tarsi and requires some bone resection. These intraosseous implants are falling out of favor and slowly being discontinued. Extraosseous Extraosseous implants are simply screwed into the sinus tarsi with no bone resection required. A hybrid design is also available, which comes with a polyethylene sleeve over the lateral portion, offering a softer more forgiving interface. Wright Medical 723 GaitWay Sinus Tarsi Implant Titanium Cannulated Flat sides are designed to improve load-bearing distribution that may decrease incident of reactive synovitis. Undercut threads designed to resist extrusion forces This product has been discontinued. OrthoPro 726 Talar-Fit Titanium, cone shaped Cannulated Blunt threads for reduced bone irritation OsteoMed 727 SubFix Titanium, cone shaped Cannulated Fine medial threads allow immediate soft tissue fixation. Lateral portion is smooth to limit trauma to the periosteum of the lateral process of the talus and calcaneus. Inverted meaning the threads become thicker as they extend out from the body of the implant. Trestle structure—there are holes from top to bottom through the threads, where they meet the body of the implant. After the portal has been established, the trochar is removed, leaving the cannula in place. Used to penetrate the joint when placing the cannula in an already-established portal. Instruments Sweeping Side-to-side and up-and-down movement of the scope to view anatomical areas Pistoning Moving the scope in for magnification and moving the scope out for better orientation Triangulation Triangulation refers to bringing the scope and another instrument together, through two different portals at a specific site in the joint. Irrigation Normal saline or Ringer solution may be used, but Ringer’s is preferred because it is less damaging to chondrocyte metabolism. Ingress refers to where the irrigation fluid enters the joint, and egress refers to where the irrigation leaves the joint. Common Portals Anteromedial Portal The anteromedial portal is made medial to the anterior tibialis tendon and lateral to saphenous vein and saphenous nerve. Anterolateral Portal The anterolateral portal is made just lateral to the peroneus tertius tendon. Care should be taken to avoid the superficial peroneal nerve branches (medial and intermediate dorsal cutaneous nerves). Transillumination is a technique 737 where the arthroscope is inserted through the medial portal and directed laterally to transilluminate the soft tissues. This technique is useful for proper portal placement and avoiding critical structures. The sural nerve, lesser saphenous vein, and peroneal tendons should all be lateral to the portal. Posterior-Central Portal Also called the trans-Achilles, portal is created directly through the posterior aspect of the Achilles tendon at the level of the ankle. While this portal involves splitting the Achilles tendon, it is farther from any local nerves as compared with the other portals. Lateral Gutter The lateral gutter is the space between the lateral articular surface of the talus and the fibula. These injuries are considered contaminated, but if they are left without treatment for 6 to 8 hours, they are considered infected. Classification (Gustilo and Anderson) Type I Fracture with an open wound less than 1 cm in length Clean, with minimal soft tissue damage/necrosis Fracture is usually simple (transverse or short oblique) with minimal or no comminution. Most infecting bacteria are skin flora, and so a first- generation cephalosporin is a good choice (e. Vancomycin and/or aminoglycoside antibiotic–impregnated polymethylmethacrylate beads may also be beneficial. Wound closure should be performed as soon as possible under minimal skin tension to prevent nosocomial infections. These forces are seen in people with overuse and repetitive activities, such as runners and athletes. Ninety-five percent of stress fractures occur in the lower extremity, most notably the neck of the 2nd metatarsal. They may take 14 to 21 days to present radiographically after a bony callus has developed. If x-rays are inconclusive, a three-phase technetium bone scan may be positive as early as 2 to 8 days after onset of symptoms.

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H. Gelford. California Lutheran University.