Robert Alan Wood, M.D.

• Director of Pediatric Allergy & Immunology
• Professor of Pediatrics

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002049/robert-wood

A large curette can be used to separate the scar and synovium from the posterior capsule impotence zoloft cheap super p-force online mastercard. Longitudinal strokes will avoid perforating the capsule and disturbing the neurovascular structure in the popliteal fossa erectile dysfunction doctor melbourne cheap super p-force online american express. A lateral patellar retinacular release aids mobilization of the extensor mechanism and creates a pocket into which the patella may be everted zyrtec impotence buy super p-force master card. Care should be taken to dissect to erectile dysfunction medication shots discount super p-force 160mg visa, but not including erectile dysfunction natural cures cheap super p-force 160mg with amex, the collateral ligaments22 except where division is specifically indicated in cases of ankylosis or chronic knee dislocation erectile dysfunction doctors in louisville ky generic super p-force 160mg with mastercard. The plane between the scar and normal tissue can be identified at the level of patella by removing the meniscus of scar around the patellar component. Proximally, a plane can usually be found between the deep surface of the quadriceps tendon and scar. The tibia is exposed by sharp dissection and elevation of the deep medial collateral ligament from its insertion posteromedially beyond the midcoronal plane but staying beneath the superficial medial collateral ligament. It is usually necessary to completely release the posterior cruciate ligament in revision knee arthroplasty surgery. Further motion may be gained by releasing the capsule posteriorly either off the tibia or off the femoral condyles. It is far safer to mobilize the posterior capsule rather than penetrate it, as it is tethered by the genicular arteries to the popliteal artery. It runs horizontally just distal to the vastus lateralis muscle in the same plane, deep to the synovium. It may be preserved, even when a lateral release is performed, by careful dissection. Scuderi showed a higher incidence of cold bone scans of the patella after lateral releases. Extensive scarring of the extensor mechanism 3376 TexTbooK of orThopedics and Trauma Patellar Turn-down Coonse and Adams described a V-Y turndown procedure of releasing the extensor mechanism proximal to the quadriceps attachment of the patella for exposure of knees with significant scarring and contracture of the extensor mechanism. Proximal releases, however, are contraindicated when the quality of soft tissues proximal to the patella is poor and the contractility of the muscle is limited. This incision avoids the muscular fibers and dissects the tendinous insertion of the vastus lateralis. Dissection continues through the lateral retinaculum terminating in the anterior fibers of the iliotibial tract. The extensor flap is reflected distally and laterally giving access to the knee joint. The lateral incision should stop short of the vessels arising from the inferior lateral geniculate artery. The blood supply to the patella is maintained through the inferior lateral geniculate artery and the vessels within the fat pad supplying the inferior pole of the patella. At the time of closure, the medial and apical portions of the incision are repaired. It is possible to do advancement in order to lengthen a scarred extensor mechanism. The lateral retinaculum can be left open as a lateral release to facilitate patellar tracking. The repair is tested by flexing the knee and determining what degree of flexion places excessive tension on the repair. Postoperatively, an extensor lag is common but ultimately causes little impairment. The choice to extend the incision proximally, distally or in combination should be decided on an individual basis. Proximally, relaxation of the quadriceps tendon can be achieved by a quadriceps snip which is easier but results in less exposure than the quadriceps turn-down technique. On occasion, it may be necessary to dissect the collateral ligaments from the distal femur using a femoral peel or an epicondylar osteotomy. Extensile Approaches If the patellar tendon is tight and the degree of flexion of the knee is insufficient to safely extract the components and insert new ones, an extensile approach is necessary. The extensile approach chosen will depend on the capsular route taken, on the degree of stiffness and on specific requirements such as the removal of deep intratibial cement. Quadriceps Snip the quadriceps snip also termed the "rectus snip" is a recently, described but frequently used extensile technique for mobilizing the extensor expansion. The quadriceps snip is used when the standard medial parapatellar approach has failed to give adequate exposure of the joint and a small amount of additional exposure is required. If the patella cannot be everted or laterally mobilized, a lateral release and excision of further lateral gutter scar tissue may assist the exposure. The capsulotomy is simple to repair and allows a normal postoperative physiotherapy program. This technique may be modified by starting the snip more distally with the advantage of an improved exposure, but at the cost of increased tension on the repair. This approach maintains the musculotendinous bridge of vastus medialis and of vastus lateralis facilitating a normal rehabilitation program. It is safe and simple to do, and does not lead to quadriceps weakness compared to contralateral knee replacements. It is not an option after a lateral capsular or subvastus approach, and should be used with caution in very stiff knees as it may not give adequate exposure. It is also very useful when bone cement needs to be accessed a long way down the tibial shaft. Mobilizing the extensor mechanism by tibial tubercle osteotomy provides superior visualization than turn down techniques,30 and has the potential for lengthening and realignment of the extensor mechanism. The osteotomy, however, is technically more demanding and has been associated with increased morbidity when compared to proximal mobilization of the extensor mechanism. There have been several reports of tibial fractures occurring after tibial tubercle osteotomy. This can be achieved by protected weight-bearing in the cooperative patient, or by bypassing the osteotomy with a press-fit stem. When a short stem is used on the tibial component, the tibial tubercle osteotomy causes concentration of stress in the anterior tibial cortex and increases the risk of fracture. Moreover, too short an osteotomy fragment often can be associated with fracture of the tubercle fragment itself. An additional modification of this technique includes preserving a small bone shell immediately above the tibial tubercle to stabilize the fragment against proximal migration (Chandler H, personal communication; Wiedel J, personal communication). If the knee cannot be flexed to allow adequate exposure after release of the lateral gutters and scar excision, the tibial tubercle osteotomy is performed. To perform the osteotomy, the incision is extended distally from the medial side of the tibial shaft an additional 10 cm. The osteotomy is performed with an oscillating saw from the medial to lateral direction. The osteotomy is incomplete on the lateral side, maintaining the periosteum and muscular attachments to stabilize the osteotomy from proximal migration. The osteotomy is hinged open laterally, and the lateral attachments of the quadriceps expansion are left attached to the lateral tibial flare. Whiteside reattached the fragment using two or three cerclage wires passed around the tibial tubercle and around the tibial component within the canal. Following insertion of a press-fit stern, the wires are tightened on to the shaft, and the remaining joint is closed in a routine manner. During active knee extension, tensile forces are lower in the patellar tendon than in the quadriceps tendon, theoretically giving the tubercle osteotomy an advantage over the quadriplasty. Femoral Peel Mobilization of the extensor mechanism is usually sufficient to afford adequate exposure of the components during a revision arthroplasty. However, in cases where the exposure remains tight and particularly in stiff knees with a fixed flexion deformity, release of the capsular attachments to the distal femur may be indicated. The exposure of the joint is completed by stripping the posterior capsule from the back of the femur. Release of the medial and lateral heads of the gastrocnemius may also be necessary. The knee is destabilized in flexion permitting the tibia to be externally rotated and angled into valgus. The patella is dislocated in its valgus position without further mobilization of the extensor mechanism. Medial Epicondylar Osteotomy this is also indicated in very tight or ankylosed knees. The adductor magnus, the epicondyle and the attached collateral ligament are raised as a continuous flap. The wafer of bone is hinged from the femur exposing the posteromedial joint capsule. Fibers of the posterior oblique ligament and posteromedial joint capsule may need to be released from the posterior margin 3378 TexTbooK of orThopedics and Trauma 3. Technical considerations of total knee arthroplasty after proximal tibial osteotomy. Midline or parapatellar Incision for knee arthroplasty: a comparative study of wound viability. The relationship of lateral releases to patellar viability in total knee arthroplasty. Postoperative patellar complications with or without lateral release during total knee arthroplasty. Stress fracture of the patella following duopatellar total knee arthroplasty with patellar resurfacing. It is then possible to evert the patella and open the knee by external rotation and hinging into valgus. The femoral epicondylar osteotomy is inherently stable as the adductor tendon inserting into the bone fragment creates proximal stability, and the collateral ligaments provide distal stability. It is possible to perform this approach laterally as well by elevating the lateral femoral epicondyle. This may be necessary in cases of allograft reconstruction of the distal femur allowing complete skeletonization for exposure and removal of the components. The lateral epicondyle will reposition much as the medial epicondyle during closure of the capsule and can be reattached with staples or screws. Quadriceps Myocutaneous Flap this approach which has been described for tumor resection,37,41 can be used for unusually complex revision knee arthroplasties where a circumferential exposure of the distal femur is necessary. The extensor mechanism is accessed using a U-shaped myocutaneous flap based on the quadriceps muscle. As the quadriceps muscle is still attached to the deep fascia and skin, wound necrosis is not a problem. Surgeons performing difficult revision cases should have a sound knowledge of the local anatomy, and should be familiar with a broad range of approaches. Prior to embarking upon a revision, it is necessary to decide whether a standard approach can be used. If not, consideration should be given to an extensile or dedicated revision approach. Osteotomies and soft-tissue incisions should be adequate and avoid uncontrolled bone and soft-tissue disruption. The appropriate surgical exposure should be determined by careful preoperative planning based on a knowledge of the previous exposures used, an assessment of the type of implant to be removed, and on the extent of bone deficiencies to be reconstructed. Joint line restoration and flexion extension balance with revision total knee arthroplasty. The use of a modified V-Y quadricepsplasty during total knee replacement to gain exposure and improve flexion in the ankylosed knee. The technical challenges include maintenance of joint line and alignment of the limb, ligament balance as well as the ways of dealing with the loss of bone stock. The bone defects are classified as follows: Type 1 defect: Intact metaphyseal bone-Minor bone defects that do not compromise the stability of the component. Type 2 defect: Damaged metaphyseal bone-Loss of cancellous bone that requires substitution with cement, bone graft or augments to restore joint level. Type 2 defects can be in one femoral condyle or tibial plateau (2A), or in both condyles and plateaus (2B). Type 3 defect: Deficient metaphyseal segment-Bone loss compromises a major portion of either condyle or plateau. These are usually associated with collateral or patellar ligament detachment and usually require bone grafts or custom implants. Biology of Osteolysis Polyethylene wear is responsible for the biological reaction that leads to osteolysis. Every motion between the artificial knee surfaces produces submicron polyethylene particles within the joint. This poly wear is particularly severe if there is any instability or mechanical malalignment of the knee. The submicron particles of polyethylene stimulate macrophages to release cytokines and other enzymes and this leads to destruction of bone at the cement bone interface. If revision surgery is not undertaken early, osteolysis continues and presents major challenges in revision surgery.

The gases which go in or come out depend on surface area of bubble which is more in rarefaction erectile dysfunction non prescription drugs buy super p-force 160mg low price. Thus pump for erectile dysfunction buy generic super p-force 160mg on-line, the gas that goes out in compression is less as compared to the gas goes in the bubble in rarefaction erectile dysfunction causes premature ejaculation buy 160 mg super p-force visa. Electrical and chemical phenomena have been described as result of gaseous cavitations erectile dysfunction raleigh nc discount 160 mg super p-force with amex. Mechanical destruction may also be produced when the cavities collapse or when the gas bubbles grow large enough to vibrate in resonance with sound waves erectile dysfunction miracle discount super p-force 160 mg on-line. This occurrence of gaseous cavitations can be prevented by application of external pressure of sufficient magnitude garlic pills erectile dysfunction cheap super p-force 160 mg fast delivery. The depth of penetration is defined as that depth at which the intensity drops to one-half of its value at surface. Reflection can occur at interfaces between tissues of different acoustic impedance. Thus, around 30% energy is reflected at surface of bone, the same thing occurs at the surface of metallic implant. Therapeutic Temperature Distribution Ultrasound is most effective heating agent with higher temperature in musculature and comparatively little elevation of temperature in superficial tissues. Ultrasound selectively heat interfaces between tissues of different acoustic impedance because of reflection, formation of shear waves, and selective absorption in superficial layers of tissues with high coefficient of absorption. The high degree of reflection at the surface of bone as well as high coefficient of absorption in bone tissues eliminates possibility of heating distant side of bone and joint. This principle can be utilized to selectively heat capsule, synovium or other joint structures. In individuals with less than 8 cm tissue cover over bone, higher temperature was obtained at lower wattage. At higher wattage, the temperature in front of bone at pain is higher in tissues with thick absorbing tissue cover than thin individuals. Temperature measured in the same place without implant was higher than with implant. Technique of Application To minimize the effect of attenuation by absorption, the coupling medium should only be thin film between applicator and skin. It should not contain any gas bubbles that would significantly reflect or scatter ultrasound. Strokes are comparatively short of the order of one inch in length; each stroke overlaps partially the area of the other, with the applicator moving in direction perpendicular to the area of stroke. The temperature obtained in the tissues depends on total output of the applicator, time of application, size of the field treated. It is advisable to continue until the pain is felt by the patient and then either the output is reduced or the field size is increased. Cooler the temperature of coupling medium or applicator, greater the heat loss at skin and deeper the peak temperature 3544 TexTbook of orThopedics and Trauma Radiant Heat 1. Mechanism: Once the photons have penetrated in the tissues, they are absorbed and converted into heat. If the applicator warms up noticeably after one field is treated, it should be placed in tap water before next field is treated. Technique Heating elements are made out of carbon metal alloys or special quartz tubes. To test this, carbon blackened paraffin is poured into a pan and allowed to solidify. Dosimetry: Intensity can be varied by changing wattage and distance of lamp from skin. Temperature distribution: the highest values are found at skin surface with a rapid drop and no significant elevation of temperature in musculature. Nonthermal effects like streaming of fluid in the ultrasonic field and resultant stirring effect. Gaseous cavitations-destructive reaction as hemolysis may occur if concentration of cells is low. With stationary technique, blood cell aggregates form resulting in cessation of blood flow. The amount of heat that flows through body by conduction is directly proportional to the time of flow, the area through which it flows, the temperature gradient and the thermal conductivity. They are heated in a thermostatically controlled water bath, where gel absorbs and holds a large amount of water with its high heat content. This was originally designed for patients of polio to relieve muscle soreness and muscle spasm. Electricalheatingpads: the heat can be adjusted by increasing or decreasing the wattage. The heat output steadily increases over a long period of time until equilibrium is reached. By rotating the container a compartment is broken that allows ingredients to come together and produce elevation of temperature by an exothermic reaction. The ingredients are irritating or harmful when the outer pack breaks and its contents come in contact with skin. Superficial Heating Agents the hallmark is that they produce the highest temperature at the surface of the body. Deep effect may be achieved by reflex mechanisms with direct response in superficial tissues. Presence of melted and solid paraffin together is another indication of right temperature. Dip method: the patient inserts hand into liquid paraffin, withdraws it when a thin layer of solid paraffin is formed, and repeats the dipping until a thick glove of paraffin envelops the hand. Loosely bound electrons are accelerated by strong electrical field associated with laser pulse. Superficial Heating by Convection Hydrotherapy Mode of heat transfer is through convection. Water is moved by agitation so that after the layer of water in contact with skin has cooled off, it is replaced by another layer of water with higher temperature. Temperaturedistribution: Highest temperature is produced at skin with a rapid drop off. Myofacial pain syndromes and nerve conduction effects are useful in treatment of trigeminal neuralgia, postherpetic neuralgia, sciatica. Therapeutic Cold Role in Muscle Spasm, Spasticity and Muscle Re-education Spasm seems to be reduced by direct action on muscle spindle, i. The effect lasts for long period of time because the insulating fat layer with vasoconstriction slows down the rewarming of the muscle from outside and because of the vasoconstriction the rewarming from inside is also delayed. Some patients develop reflex spasms initially may be because of increased excitability of alpha motor neuron, through stimulation of the exteroceptors of the skin. In addition to the effect on the spindle, other factors were involved in reducing the reflex muscle tone, including slowing of the contraction of muscle or motor nerve fiber and prolongation of twitch contraction and half relaxation time. Pain may be reduced directly through an effect on sensory endings and pain fibers or by relieving muscle spasm. Contrast Bath Hyperemia is produced by submersing the affected part in hot water for 3 minutes, then in cold water for 1 minute, followed by cycles of 4 minutes in hot water and 1 minute in cold water, until a sum of 30 minutes has elapsed. Fluidotherapy Thermostatically controlled hot air is blown through a pad of finely divided solids. This produces a dry, warm, semifluid mixture into which the hand, the foot or the part of the extremity can be immersed. Use of Cold in Arthritis the benefit is due in part to the vasoconstriction with reduction of edema. Pain is indirectly relieved in this way and also by direct effect on nerve fibers. Laser Therapy Laser is a columnated beam of photons with same frequency and wavelength in phase. To reduce spasticity, it will take at least 10 minutes before it begins to cool in thin individuals and probably half an hour to do the same in obese individual. Special precaution should be taken to prevent nerve damage, limiting ice application to 20 minutes and compression of peroneal nerve. In the acute conditions, heat application reduces the hospital stay as compared to ice application. In chronic conditions, ice is more effective in reducing the hospital stay than the heat application. In acute or subacute phases of joint diseases like rheumatoid arthritis, the purpose is not to heat the joint but to relieve secondary symptoms, so same above principles are applied. In fibromyositis, superficial heating modalities are often used in conjunction with friction massage. The muscle soreness often called spasm in poliomyelitis responds very well to kenny packs. Exaggerated peristalsis leads to cramping of the smooth musculature of gastrointestinal tract as in colics and menstrual cramps can be reduced by superficial heat application in the form of hot packs or hot water bottles or heating pads to abdominal wall. Inflammation Associated with Infection Furuncle or other skin infections-heat will lead to pointing. In pelvic inflammatory disease, intavaginal or intrarectal electrodes for chronic states may be used. Ultraviolet Therapy this produces direct photochemical reactions when it interacts with body. For large joint with little soft tissue ultrasound, wrap around coil may be used for periarthritis shoulder. For chronic ankylosing spondylitis, ultrasound therapy to costovertebral joints may be used. Erythema: this occurs due to absorption of ultraviolet photons by proteins in the prickle layer of skin. Iontophoresis Introduction of electrically charged molecules or atoms into tissues using electrical field. Various drugs that can be introduced are local anesthetics, epinephrine, water soluble corticosteroids, antiviral medications and chemotherapeutic medications. Functional Electrical Stimulation Production of functional movement by electrical stimulation of muscle or nerve. Squeezing: this is performed with larger portions of muscle either between hands or between hand and solid object such as bone. Wringing: Soft tissues are picked up between fingers and manipulated in an alternating fashion, so that there is motion within the muscle itself. It is used to mobilize tissue fluid and create intramuscular motions to stretch adhesions. Percussion (Tapotement) these are alternating movements performed to produce stimulation. If the hands are cupped, the deeper sound produced may be of some psychological benefit. Indications Any condition in which relief of pain, reduction of swelling, mobilization of contracted structures are desired. Massage Systematic and scientific manipulation of body tissues, best performed by hands, for the purpose of affecting neuromuscular system and general circulation. It is given with care in debilitated individuals and in areas where skin has been damaged by burns or where it is thin. Therapeutic Exercise Definition Prescription of bodily movement to correct impairment improves musculoskeletal function or maintains state of wellbeing. Exercises to Increase Mobility in Soft Tissues Physiology of Fibrous Connective Tissue Types: Collagen, elastin reticulin, fibrin. Clothing should not be tight and clothes should be removed from the area to be treated. Loose Connective Tissue It forms between organs other structures, such as joint capsule, fascia, intermuscular layers and subcutaneous tissues where movement occurs repeatedly. When a part is immobilized, the collagen and reticular networks become contracted, and the distance between the attachments between networks is shortened, so that the tissue becomes dense and hard and loses the suppleness of the normal areolar tissue.

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These anom alies m ay also take the form of cleft lip and palate (with a defect involving the lip erectile dysfunction korean ginseng super p-force 160mg free shipping, alveolus erectile dysfunction pills natural purchase super p-force 160 mg without a prescription, and palate) importance of water order super p-force 160mg with mastercard. Note: the nasal cavit y (whose oor is form ed by the hard palate) com m unicates with the nasopharynx by way of the choanae impotence from smoking generic super p-force 160mg otc. The close topographical relationship bet ween the nasal cavit y and hard palate can be appreciated in this view impotence occurs when buy generic super p-force from india. This defect should be closed with a plate im m ediately after birth to perm it satisfactory oral nutrition erectile dysfunction treatment in india quality 160mg super p-force. Anterior clinoid process Septum of sphenoid sinus Optic canal Ostium of sphenoid sinus Pterygoid fossa Inferior orbital fissure Choana Palatine bone Median palatine suture c Incisive foram en Superior orbital fissure Middle concha Vom er Inferior concha Pterygoid process, lateral plate Pterygoid process, m edial plate Palatine process of m axilla 39 Hea d and Neck 2. The m andible is connected to the viscerocranium at the temporomandibular joint, whose convex surface is the head of the m andibular condyle. This "head of the m andible" is situated atop the vertical (ascending) ram us of the m andible, which joins with the body of the m andible at the m andibular angle. The teeth are set in the alveolar processes (alveolar part) along the upper border of the m andibular body. This part of the m andible is subject to t ypical agerelated changes as a result of dental developm ent (see B). The m ental branch of the trigem inal nerve exits through the m ental foram en to enter it s bony canal. The location of this foram en is important in clinical exam inations, as the tenderness of the nerve to pressure can be tested at that location. It transm it s the inferior alveolar nerve, which supplies sensory innervation to the m andibular teeth. This view displays the coronoid process, the condylar process, and the m andibular notch bet ween them. The coronoid process is a site for m uscular at tachments, while the condylar process bears the head of the m andible, which articulates with the mandibular fossa of the temporal bone. A depression on the m edial side of the condylar process, the pterygoid fovea, gives at tachment to portions of the lateral pterygoid m uscle. Because the angle of the m andible adapt s to changes in the alveolar process, the angle bet ween the body and ram us also varies with age-related changes in the dentition. The alveolar part is still relatively poorly developed because the deciduous teeth are considerably sm aller than the perm anent teeth. Note: the resorption of the alveolar process with advanced age leads to a change in the position of the m ental foram en (which is norm ally located below the second prem olar tooth, as in c). This change m ust be taken into account in surgery or dissections involving the m ental nerve. The hyoid bone is suspended by m uscles bet ween the oral oor and larynx in the neck (see p. The physiological m ovem ent of the hyoid bone during swallowing is also palpable. In hum an dentition, both the m axilla and m andible each contain 16 teeth, which are aligned in a bilateral-sym m etrical fashion and are adjusted to di erent chewing functions. Coronoid process Interalveolar septum Molars Interradicular spetum Prem olars Note: While the front teeth grab the food and bite o pieces for m astication, it is the side teeth that actually perform m astication. After rem oval of teeth (see left side in each im age) the alveolar process, which holds the teeth, becom es visible. Particularly in the front teeth area, the dental roots in the alveoles curve the jawbone in part s heavily to the vestibular to the extent that they becom e palpable as so-called Juga alveolaria. The Septa interveolaria separates the alveoles of t wo adjacent Dental alveoli with cribiform plate Canine Incisors b teeth. The Septa interradicularia separates the tooth cham bers of m ulti-rooted teeth (for structure of the alveolar bone see p. Bones, Liga ments, a nd Joints E Number of cusps, roots, and root canals of the permanent teeth of the maxilla and mandible Data about the frequency was taken from Lehm ann et al. The area where a root is divided into t wo branches is called bifurcation and trifurcation for three root branches. The rst m olar often possesses an additional cusp, the tuberculum (cusp of) carabelli (see E for comparison). M3 (18/28) m ostly 3 (extrem ely inconsistent in shape) Number of Cusps Root s often interm ingled (socalled taproots) Number of Roots Mandibular Tooth Enam el (dental enam el) Dentin Crown Pulp cham ber Number of Root Canals I1 (31/41) incisal edge 1 1 (ca. Progressing in a clockwise fashion (from the perspective of the dentist), the teeth of the upper arc are num bered 1 to 16, and those of the lower are considered 17 to 32. It refers to the course of the root of the tooth, which bends distally and thus slightly deviates from the axis of the tooth. The angle form ed by the incisal edge and the sides of the crown is shorter on the m esial surface compared to the distal surface. It shows that the proxim al surface radius of curvature is longer on the m esial than on the distal surface, m eaning teeth are signi cantly m ore dense m esially. Further distinguishing features include the cervical line of a tooth (course of the cem entoenam el junction), the tooth equator (anatom ical equator), the crow n escape (particularly pronounced in m andibular teeth) as well as the root cross section. While the canines (dentes canini) have a split incisal edge in the shape of a biting edge composed of a single large cusp, the m olars (dentes prem olars and m olars) all have at least t wo biting edges (see p. On an individual basis, one distinguishes bet ween cusp tip, cusp ridge, fossae, ssures, and m arginal ridge (a). Dent s at cross points and junctions of the tooth have a predilection to becom e decayed. Inside the cusps of a chewing surface one distinguishes bet ween supporting and nonsupporting cusps (see p. Accessory cusps, so-called tubercula anom alia, are not rare (for exam ple tuberculum carabelli at the m esio-palatal cusp of the 1. Note: While the anatomical chewing surface is de ned by both the marginal ridges as well as the ridge of the cusp edge, the functional chewing surface overlaps with the outside surface of the supporting cusps. Nowadays, it s clinical de nition describes the plane extending bet ween both the dorsal soft tissue point s (left and right tragus) and the anterior subnasale. Inferior dental arch Occlusal plane a Distobuccal cusp of m andibular second m olar C Upper and low er dental arch In the m axilla and m andible, the teeth are positioned in the shape of an arch (so-called dental arches: Arcus dentalis superior and inferior respectively). The dental arches relate to the curve form ed by the cut ting edges of the incisors, crown tips of the m olars and buccal cusp tips of the prem olars and m olars. Due to the di erent shapes of the t wo dental arches, both the m axillary incisors and m olars overhang their m andibular counterpart s, thereby covering the incisor edges and the buccal cusps. Note: Due to the convex proxim ate surfaces, the teeth form ing the dental arch touch only at certain point s (so-called proxim al contact point s). The contact point s are usually situated in the upper third of the crown and help to give interdental support and stabilization of t wo adjacent teeth (see B). Maxillary central incisor Occlusal plane Incisal point b Mandibular central incisor a Curve of Spee Curve of Wilson Buccal cusp Lingual cusp 1st m olar b 1st m olar B Occlusal plane a Left-front and above view of occlusal plane; b vestibular view of occlusal plane. D Sagittal and transversal occlusal curve a Sagit tal occlusal curve (so-called curve of Spee), vestibular view; b transversal occlusal curve (so-called curve of Wilson), distal view. According to Spee (1870), that curve touches the anterior area of the temporom andibular joint capsule; its center is supposed to be situated in the m iddle of the orbita. The course of the transversal occlusal curve is the result of the lingual cusps of the m andibular teeth lying lower than the buccal cusps. Note: Both the sagit tal and transversal occlusal curve is important when installing arti cial teeth. Bones, Liga ments, a nd Joints E Di erent types of occlusal forms Occlusion m eans the contact of teeth of the m axilla and m andible. Maxim al intercuspation refers to the position of the m axilla and m andible when brought into m axim um contact, m eaning the cusps of the teeth of both arches fully interpose them selves with one another. The overlapping of the buccal cusps of the m axillary teeth with the m andibular teeth is at tributable to the sam e cause. Stated is the m edium m esio-distal width of the teeth in m illim eters (according to Carlsson et al. The tip of the upper canine is situated bet ween the lower canine and the following lower prem olar, the m esiobuccal cusp of the 1. The cusps, which reach into the ssure and fossa of their antagonists respectively, are called supporting and working cusp respectively and have a rather round shape unlike the non-supporting cusps. The m axillary supporting cusps are palatal cusps and buccal cusps in the m andible. Note: the prim ary function of the chewing surfaces in the posterior tooth region is chopping and grinding food bet ween the cusps. The palatal surfaces of the t wo upper incisors have t wo m arginal ridges each, in bet ween which a tuberculum dentis is located in the m edial incisor and a foram en cecum in the lateral incisor. Sim ilar characteristics are considerably less distinct in both the lower incisors. Their com m on characteristic is a single cusp form ed by a divided incisal surface. Usually, canines are single-rooted, have a relatively long root and support the incisors (longer and m ore pointed canines in m am m als are considered fangs). Bones, Liga ments, a nd Joints Buccal Distal Lingual 32 Occlusal view Buccal Distal Lingual 31 30 Buccal Distal Lingual 29 28 Buccal Distal Lingual 27 26 25 Labial Distal Lingual b Labial Distal Lingual Labial Distal Lingual Labial Distal Lingual surface has t wo well pronounced m arginal ridges, a m edian line and a tuberculum dentis. The prem olars represent a transitional form from incisors to m olars and have cusps and ssures. In order to ab- sorb the powerful chewing pressure, the m axillary m olars have three roots, compared with usually t wo in the m andible. Only the root s of the third m olars (wisdom teeth, which usually erupt not before age 16- at if all) are often fused together (see E, p. There, the gingival epithelium (multi-layered, usually parakeratinized strati ed squamous epithelium), which has a light pink shade, blends into the considerably more reddish alveolar epithelium (multi-layered, not parakeratinized strati ed squamous epithelium). Since it is at tached to both the neck of the tooth and the alveolar crest through dentogingival bers, which run horizontally, it often has a speckled texture. The deep outer layer of basal lam ina represents the border to the gingival connective tissue and further extends to the basal lam ina of the oral sulcus epithelium. Note: the integrit y of the junctional epithelium is a precondition for the health of the entire periodontium. If bacterial colonization leads to in am m ation of the neck of the tooth (t ypical plaque form ation as a result of poor oral hygiene), the junctional epithelium loses it s attachm ent to the tooth and gingival pocket s form in the area around the gingival sulcus (periodontosis). It consists of a complex system of collagen bers (cem entum or dental alveolar collagen ber bundles), which holds the tooth in place in the bony socket in a spring-like m anner. The bers run in di erent directions (see D), which enables them to counteract all m ovem ents of the tooth (axial pressure, lateral tilt, and torsional m otion) and develop tension. The tensile stress, which is constantly present during the chewing process, helps stim ulate perm anent regeneration in bones and collagen bers. In addition, highly active broblasts are responsible for a high turnover of collagen bers in the periodontal ligam ent. Their collagen synthesis, which is dependent on vitam in C, occurs four tim es faster compared to skin synthesis (which explains rapid ber loss as a result of vitam in C de ciency). In a toothless jaw, the alveolar process gradually atrophies, a fact that further underscores the signi cance of m asticatory forces for the bone. Head (condyle) of m andible Buccal Mesial root of M2 Distal root of M2 Cribriform plate Coronoid process Alveoli Pterygoid fovea b Root canals Mesial Desm odontal gap Distal c Interradicular septum Lingual M3 Lingula Mandibular foram en Section plane of b and c Angle of m andible Mandibular canal M1 M2 I1 I2 C P1 P2 Spongy bone Compact bone a Dental root E Structure of the alveolar bone a Right side of a hum an m andible, oral view (the compact layer of bone on the m andible is rem oved); b and c horizontal section of tooth socket s with (b) and without dental roots (c). Cranial view (based on prepared specim en slides part of the anatom ical collection of the Universit y of Kiel). With regard to their structure, the alveolar processes of maxilla and mandible are lamellar bones with an inner (lingual/palatal) and outer (vestibular/buccal) compact layer as well as a central spongy layer, which lies in bet ween. An additional component is the alveolar bone, which form s part of the alveolar pocket (socket). The alveolar sockets resem ble cups with numerous holes in their bony walls, the cribriform layer of bone. Blood and lymphatic vessels enter the periodontal ligam ent through these holes into the desmodontal gap where they form a dense lat ticework surrounding the dental roots. Note: Deciduous teeth are given Rom an num erals and the perm anent teeth Arabic num bers. Knowledge of the eruption pat tern is clinically important since corresponding data helps to diagnose growth delay in children.

Our personal experience of 42 patients suggests the conversion of girdle stone to total hip should be done erectile dysfunction doctor in phoenix purchase 160mg super p-force amex. The most common causes are due to secondary condition associated with variety of inflammatory impotence prozac discount super p-force 160mg fast delivery, metabolic and post-traumatic conditions impotence age 45 best buy super p-force. Primary or idiopathic forms of protrusio were described by Otto in 1824 and which we commonly referred as Otto pelvis erectile dysfunction protocol real reviews purchase super p-force 160mg with mastercard. Any femoral head or cup medial to this line more than 2 mm is considered as protrusio erectile dysfunction diagnosis discount super p-force 160mg on line. Superior migration is measured from horizontal line and medial migration is measured from vertical line sudden erectile dysfunction causes generic super p-force 160 mg amex. The medial deficiency intraoperatively also has been classified according to the size of medial defect. Ranawat developed a method to locate the correct anatomical position of acetabulum and he described isosceles triangle as location of normal acetabulum location. Hasting reported 71% of protrusio who where on corticosteroid therapy or active rheumatoid disease who had progressive protrusio. The principle of treating protrusio is to normalize the center of rotation and healing of medial wall. Any approach can be considered but in general posterior approach is more preferred. Fair degree of soft tissue release is required including insertion of gluteus maximus and proximal part of femur. Frequently we need to release iliopsoas to get better exposure which facilitates the reduction. Gradual release of soft tissue with internal rotation will facilitate to see part of the neck. Once you see part of the neck you have to gently flex adduct and internal rotate to dislocate the hip. To dislocate the hip, forceful internal rotation should be avoided which can lead to spiral fracture of femur. Most protrusios have osteoporotic femur hence one should be careful in dislocating the hip. If you are able to see the part of the head in some degree of flexion adduction and internal rotation then only you should dislocate the hip. In mild and severe protrusio it is better to do the neck osteotomy in situ after exposing the part of the neck. One spike is put anterior to neck and second inferior to neck this gives good visualization of neck for osteotomy under vision. The neck osteotomy also should be careful either by using a small saw blade or doing multiple drills and then use sharp osteotomes. The reason of putting this retractor at this position is to avoid neurovascular injury, secondly this is the thickest part of acetabulum anteriorly which will avoid fracture. The posterior structures should be protected with a spike into the ischial tuberosity. In protrusio the transverse acetabular ligament may not be good anatomical land mark due to osteophytes. If there is fibrous ankylosis of the femoral head it better to rim with small acetabular reamer. The crucial part of the acetabular reamer preparation will be making the acetabulum circumferential. After reaming the mouth with proper degree of anteversion the trial cup should be used, better to ream 1 mm less or same size of reamer as the trial cup. Once you know the depth of the trial cup, mark the peripheries on remaining anterior and posterior rim. Keeping the trial cup inside, access the amount of protrusio, which has to be grafted. Try and avoid anterior reaming as in most protrusio, anterior wall is usually very thin. The fibrous tissue on medial wall should be removed with a sharp curette but the action should be gentle as most medial wall is very thin and papery and there are chances that you may create fracture of the medial wall. If cancellous bone has been exposed well this multiple drilling may not be required. The bone grafting of the medial wall must be done with matchstick bone graft from the patient own femoral head (autograft). The technique of preparation of bone graft from the femoral head is first take out all cartilage and hard sclerotic bone from the femoral head. If you are using autograft please do not wash this graft and keep the graft in patients own blood. Then these grafts are washed with normal saline multiple times to clean bone debris fat and soft tissue. After lavaging these grafts make it dry and add patients own blood from operating area with blood soaked gauge. Gradually the grafts are added and they are impacted with hemispherical metal punch. The amount of graft will be assessed by using a acetabulum trial which is around 2 mm smaller to see the previous anterior and posterior marks. The grafting is considered adequate with this trial when the grafts are fully touching on the trial. Component Choice the result of cemented cup in protrusio has not been very satisfactory. Cemented cup if used then the dome and posterior wall need multiple step drilling to as to open the cancellous bone for micro interlock. The technique follows as hypotensive anesthesia, multiple anchoring holes, pulsatile lavage, medial grafting, cement pressurization and use flang socket. After implantation the additional posterior, inferior and anterior osteophytes must be removed. If these osteophytes are not removed there are chances of impingement leading to dislocation. There result concluded 2 cases of aseptic loosening and 1 case of ischial osteolysis due to wear. Two commonly used reconstructs are (1) by using Bush Sneider cage which needs a cemented cup (2) is Octopus cage which is uncemented. When cemented cup has to be used one precaution that is to be taken is to keep the acetabulum cup in good anteversion and in a closed fashion. Do the stability test and depending on that the original lip liner can be rotated. The surgical aim in the treatment of protrusio is to bring the normal center of rotation build the medial wall and lateralize the cup which has been emphasized by Ranawat. We looked into our own series of 150 cases of rheumatoid arthritis who underwent total hip replacement. Finally lateralize the cup with normal center of rotation and strengthen the medial wall. Tuberculosis of Hip Secondary arthritis of hip due to tuberculosis is well known in India. Prevalence of the hip involvement in children is around 15% which is next common to spine. Unfortunately most patients present with severe degree of hip involvement with destruction of joint. Total hip arthroplasty is well established treatment of choice in a healed tuberculosis of the hip. Good 3280 TexTbook of orThopedics and Trauma Mycobacterium tuberculosis has biologically very specific behavior than pyogenic organism. The Mycobacterium lesions represent planktonic form which reproduces slowly with minimal adhesion molecules and slime. Unfortunately the nidus perpetuate the tuberculosis infection hence it is mandatory to give a chemotherapy of atleast minimal of 12 months postoperatively. Today recommendation is to establish tissue diagnosis before anti-tubercular treatment. If it is only synovial affection then continue anti-tubercular treatment for 1 year. In patients with sickle cell disease the red cells contain sickle hemoglobin (HbS) which is abnormal type of hemoglobin. Sickle cell disease is endemic in part of North America, Africa, Mediterranean countries, Middle East and India. Sickle cell disease is due to homozygous and Sickle cell trait is due heterozygous contribution. Sickle cell traits often are asymptomatic and sickling can only occur due to very low oxygen tension (below 3 kpa). The differentiation between sickle cell disease and sickle cell trait can only be done by Hb electrophoresis. Patients with sickle cell disease may develop painful avascular necrosis of femoral head. The incidence of avascular necrosis in a sickle cell disease is difficult to judge due to small number of prospective studies. The study of 2,590 patients, radiological evidence of avascular necrosis patients reported was 9. The rate of infection is higher because these patients are more susceptible for Salmonella infection. Infection is common in sickle cell due to splenic dysfunction as spleen is unable to filter microorganisms. Encapsulated organisms like Streptococci pneumonia are unable to get filtered out. The second cause of infection is dysfunction of IgG and IgM antigenic response hence they require aggressive antibiotic management. These patients do need multiple blood transfusions to maintain adequate oxygenation. How does Sickle Cell Crisis Take Place (Flow chart 1) Clinical crisis have three distinct forms: 1. During surgery and postoperative period, inspired oxygen concentration should be 40%. Avoid acidosis, aim is to have mild respiratory alkalosis and the pH should be around 7. Maintain the temperature of body: Hypothermia produces peripheral vasoconstriction, which can lead to sickle crisis. With modern antibiotic, intraoperative care, postoperative management and uncemented component these patients have shown promising result. The life expectancy in this group of patients has improved with medical management hence benefit of surgery must be given to these patients. Postoperative Protocol Postoperative Rehabilitation Ultimate goal of the hip arthroplasty is to achieve pain relief, maximum functional recovery and ability to perform daily activities. To achieve this one requires team approach comprising physician, physiotherapist, occupational therapist with a surgeon as a team leader. In femur with intramedullary infarcts, opening of the medullary canal is difficult. The chances of perforation of the femoral canal are high due to hard cortical bone which has no expansile capacity. The other part of the education how to get up from the bed, high sitting, use of commode, use of walker, getting into the car and getting out of car. Patient must get up from the side of operation and this will avoid adduction and reduce chances of dislocation. Video films are more impressive and it is one of the teaching tools in preoperative education. Postoperative Patients should be monitored for oxygenation, hence supplement oxygen either by nasal prong or oxygen mask for at least 48 hours postoperatively. Antibiotic prophylaxis must be considered and the drug of choice is penicillin and ofloxacin. Exercise Preoperative exercise program has shown significant improvement in postoperative walking distance. Main exercise program are quadriceps sets, gluteal sets, ankle pumps and active hip flexion with heel slide. The bridging is extremely vital exercise which is done with flexion of the contalateral hip with weight on both elbows. Faisal Al-Mousawi 78 reported in Baharain medical bulletin, 41 hip replacements with very high rate of complications. These include excessive bleeding in 6 patients, acetabulum perforation in 7 patients, femoral shaft injury in 5 patients, sickle cell crisis in 6 patients, wound hematoma in Functional Activities Functional activities include transfers, gait training, stair climbing and dressing. While climbing the stairs one should use uninvolved 3282 TexTbook of orThopedics and Trauma Flow chart 2 Postoperative infections leg first and while climbing down the stairs operated limb should be used first.