Harry C Dietz, III, M.D.

• Director, William S. Smilow Center for Marfan Syndrome Research Institute of Genetic Medicine
• Professor of Genetic Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002765/harry-dietz

American Academy of Urthopaedic Surgeons Chapter 25: Shoulder Instability this systematic review examined the outcomes of Hill-Sachs remplissage in conjunction with anterior labral repair acne drugs buy online accutane. Individuals in the upper quartile for glenoid retroversion were approximately six times more likely to sustain a posterior subluxation than those not in the upper quartile skin care face 5 mg accutane free shipping. The pooled data support modern arthroscopic techniques with suture anchors as the most reliable method to return patients to previous levels of function skin care 90036 discount accutane master card. Chen D skin care obagi order 30mg accutane with visa, Goldberg] acne 26 year old female generic 20mg accutane amex, Herald] acne 6 dpo order accutane 30 mg otc, Critchley I, Barmare A: Effects of surgical management on mu ltidirectional insta- bility of the shoulder: A meta-analysis. Obesity and a contralateral rotator cuff defect were found to be independent risk factors. A study of the contralateral shoulder in 224 patients being treated for a symptomatic rotator cuff defect found 113 full-thickness defects and 56 partial-thickness defects in the asymptomatic contralateral shoulder at the time of study enrollment; 50 contralateral shoulders had no apparent defect. A second study corroborated those findings by following 50 asymptomatic full-thickness defects over 3 years New pain developed in 36% of these shoulders and was associated with defect enlargement. An analysis of a database from the state of New York found that in 1995 the incidence of rotator cuff repair was 23. For example, rotator cuff ten- dinopathy is a common cause of shoulder pain, and lateral epicondylitis and distal biceps tendinopathy are common causes of elbow pain. Recent research has added to the understanding of the optimal treatments and outcomes for shoulder and elbow tendinopathies. Keywords: calcific tendinitis; distal biceps tendinopathy: lateral epicondylitis: rotator cuff repair: rotator cuff tendinopathy Introduction Shoulder and elbow tendinopathies are common and account for a substantial use of healthcare resources and lost productivity. The treatments include exercise, bracing, anti-inflammatory and nonnarcotic pain medication, injections, and surgery. Dr: Lee or an immediate family member has received royalties from Biomet, serves as a paid consultant to Biomet, has received research or institutional support from Biom at, and serves as a board member, owner; officer; or committee member of the American Drthopaedic Association, the American Society for Surgery of the Hand, and the Association of Bone and Joint Surgeons. Neither Dc McKeon nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: 65 years, the percentage of repairs rose from 53. J rotator cuff tear, the patient may recall a fall immediately followed by shoulder pain and decreased strength. In a patient with a chronic, attritional defect, pain onset may be acute or insidious. Advanced Imaging is not correlated with the size of the defect, and even a accurately identify a normal snpraspinatns and detect a full-thickness defect. A large multicenter study evaluated 452 patients with a full-thickness rotator cuff defect who were treated with a 12-week course of physical therapy. At 2-year follow~up, less than 25% trast, a randomized controlled study of 56 patients with a full-thickness rotator cuff defect who were randomly assigned to physical therapy or surgical repair found that those assigned to surgical repair had better pain and disability scores. Another study suggested that a home exercise program is at least as effective as formal physical therapy. The difference between out- Rotator Cuff Repair Although surgeons agree that the goal of repairing the rotator cuff is to restore its footprint on the greater tuberosity, debate continues as to the best technique for accomplishing this goal. One point of contention is whether a single- or double-row repair yields better results. A meta-analysis of nine studies, including five randomized controlled studies, compared single- and double-row fixation. Patients treated with double-row fixation had a significantly better notable in patients with a defect larger than 30 mm. Because an acromial spur can cause impingement and lead to a degenerative defect of the rotator cuff, removing any acromial spurs during rotator factor that best predicted an unsatisfactory outcome was repair. Forty-one patients were satisfied with the outcome of their shoulder operation 34%. In a 10-year study, 17 of 13 patients 94% had a recurrent defect at 2-year follow-up despite significantly improved pain and outcome scores, which were maintained at 10-year follow-up. Some patients have a good outcome after rotator cuff repair despite defect recurrence, but others have recurrent pain. Several recent studies attempted to determine which patients are at risk for an unsatisfactory outcome. A retrospective study identified 61 patients with a recurrent rotator cuff defect, of whom 33 had a satisfactory outcome and 23 had an unsatisfactory outcome. At 2-year follow-up of 95 patients randomly assigned to rotator cuff repair with or without acromioplasty, there were no between-group differences in outcome scores or visual analog scale pain scores. A retrospective study evaluated pared them with similar patients with a primary rotator cuff repair. At 2-year follow-up, the patients who had undergone revision repair had worse pain, range of motion, strength, and satisfaction than those who had undergone only a primary repair. Recent studies suggested that a shorter period of immobilization may lead to similar or better outcomes, however. After arthroscopic rotator cuff repair, 124 patients were randomly assigned to 6 weeks of immobilization or a more aggressive protocol in which passive range-of-motion exercise was initiated within 1 week of surgery and active range-of-motion exercise was Postoperative Rehabilitation Protocol initiated 6 weeks after surgery. No between-group difference was found in strength, range of motion, or functional assigned to 4 or 8 weeks of immobilization after arthrou 3: Upper Extremity scores. There was no between-group Treatment of an Irreparable Defect A massive, chronic rotator cuff defect may not be reparable because muscle retraction and fibrosis have occurred. A retrospective study of 31 patients evaluated outcomes after a partial repair of a massive rotator cuff defect. One study evaluated 79 patients with 15-year follow-up after mini-open rotator cuff final follow-up and were dissatisfied with the outcome. Because the results of partial repair were not promising, extensive soft-tissue release of a massive rotator cuff defect has been tested, but the benefit of this procedure has not been supported. Forty-one patients with a massive rotator cuff defect underwent a partial repair or a Drthopaedic Knowledge Update 12. American Academy of Drthopaedic Surgeons Chapter 26: Shoulder and Elbow Tendinopathy complete repair after extensive soft-tissue release using the anterior and posterior slide techniques. Repeat radiographic imaging revealed a 91% recurrent defect rate 2 years after complete repair. A latissimus dorsi muscle transfer to restore strength and function is another repair option for patients with a massive defect of the posterosnperior rotator cuff. Long-term outcomes were reported in two studies, both of which found that the transfer improved function and that the results were sustained 10 years after the index procedurefi"! These findings suggest that latissimus dorsi transfer improves shoulder pain, motion, and function after a massive rotator cuff defect but does not restore normal status. Because of concern about the longevity of reverse shoulder arthroplasty, this procedure typically is reserved for patients of advanced age who have low physical demands. In 35 patients younger than 65 years who underwent needling had significantly better pain relief and outcome questionnaire scores as well as significantly more radiographic resorption of the calcium deposits, compared with patients who received extracorporeal shock wave therapy. Lateral Epitondylitis Epidemiology Mucoid degeneration in the common extensor origin at the lateral epicondyle is particularly common in middle-aged patients. History and Physical Examination the symptoms of lateral epicondylitis include pain over the lateral aspect of the elbow that becomes worse with gripping. The physical examination findings include tenderness over the lateral epicondyle, pain with resisted wrist extension, and pain with resisted extension of the reverse shoulder arthroplasty for a massive rotator cuff defect, the rate of complications was high at 5- to 15-year follow-up 37. Calcific Tendinitis the term calcific tendinitis represents a subset of rotator cuff tendinopathy characterised by painful calcium deposits in the rotator cuff. Multiple nonsurgical treatments have been used including subacromial steroid injection, ultrasound-guided needling and lavage also called barbotage], and extracorporeal shock wave ther- apy. In a randomised study, 43 patients received subacromial corticosteroid injections or ultrasound-guided needling and lavage. The extensor carpi radialis brevis tendon origin is the most commonly affected part of the common extensor origin. Microscopic analysis of the tissue reveals hyaline degeneration and vascular proliferation. The second line of treatment involves injections and other percutaneous interventions. Patients who received ultrasound-guided needling and lavage also had significantly greater rates of calcium deposit resorption on radiography. A second study randomly assigned 54 patients to receive extracorporeal shock wave therapy or ultrasound-guided needling with steroid injection. Relatively recent research has posited that arthroscopic debridement can lead to a quicker recovery. Significant improvement in pain at rest was reported within 1 month of arthroscopic dehridement. With an intact biceps tendon, the muscle belly should migrate from proximal to distal with passive forearm pronation. The biceps crease interval is an objective measurement of the distance between the antecubital crease of the elbow and the cusp of distal descent of the biceps muscle. An unequivocally positive result on all three tests was found in 35 of the 48 patients; this combination was 100% sensitive and 100% specific for distal biceps tendon rupture. The patient retains most elbow flexion strength but loses approximately one-half of supination strength. Pain scores, elbow range of motion, and grip strength were not significantly different between patients in the two groups. Smoking and an elevated body mass index were associated with an increased likelihood of injury. The use of steroids or testosterone derivatives also may be a contributing factor. History and Physical Examination the history and physical examination usually are diag- nostic, especially if the distal biceps tendon rupture is acute. Patients typically recall a sudden pop and pain in the anterior elbow that occurred while lifting an object. Bruising and 3: Upper Extremity tenderness over the antecubital fossa, a so-called Pop- eye deformity in which the biceps muscle belly retracts proximally, and the absence of a palpable biceps tendon all suggest the diagnosis. A formal approach was found to improve the sensitivity and specificity of the distal biceps tendon examination. American Academy of Drthopacdic Surgeons Chapter 26: Shoulder and Elbow Tendinopathy Surgical Treatment of an Acute Rupture Surgical treatment of an acute distal biceps tendon rupture involves reattachment of the tendon to its footprint on the biceps tuberosity of the proximal radius. Traditionally, the reattachment was done through bone tunnels using two incisions. Recent studies do not offer strong evidence in favor of one repair method; all of the evaluated techniques led to good clinical outcomes. One patient in the transosseous suture group had substantial heterotopic ossification that evaluated 41 patients who underwent repair using an EndoButton technique or repair through bone tunnels (20 and 21 patients, respectively]. This study found no significant between-group differences in strength, range of motion, or Disabilities of the Arm, Shoulder and Hand scores. There were no complications requiring reoperation, although four patients in the single-incision EndoButton group and one patient in the bone-tunnels group had decreased sensation in the superficial branch of the radial nerve distribution. A retrospective analysis compared two single-incision techniques; an EndoButton with an interference screw was used in 20 patients, and suture anchors were used in 1 The small significant differences in range of motion and Disabilities of the Arm, Shoulder and Hand scores had questionable clinical significance. Surgical Treatment of a Chronic Rupture Muscle retraction can pose a difficult challenge if a distal biceps tendon rupture is surgically treated more than 2. Complications included two transient posterior In some chronic ruptures, the tendon can be reduced to the tuberosity with the elbow held in flexion. The surgeon must decide whether to augment the repair with an allograft or to repair the tendon primarily and rely on postoperative therapy for restoration of elbow extension. Three patients had transient neurapraxia of the lateral antebrachial cutaneous nerve and one had rerupture at the myotendinous junction. Complications of Surgical Repair the most common complication after repair of a distal biceps tendon rupture is a transient neurapraxia in a sensory nerve, especially in the lateral antebrachial cutaneous nerve. Other common complications, such as formation of a small amount of heterotopic ossification or a superficial infection, rarely require surgical intervention. Less common but more serious complications include a rerupture of the tendon and injury to the posterior interosseous nerve. A retrospective study evaluated 190 repairs of a complete distal biceps rupture or tendinopathy at a single institution. Although a postoperative palsy of the posterior interosseous nerve typically resolves without intervention, the time required for recovery has not been determined. Nine patients with a complete postoperative posterior interosseous nerve palsy were identified after a single-incision biceps tendon repair with an EndoButton or suture anchors. Nine months after allograft reconstruction for treatment of a chronic, symptomatic distal biceps tendon rupture, all 13 patients had regained full range of motion, and their average strength was rated at 4. If the tendon cannot be reduced Rotator cuff tendinopathy, lateral epicondylitis, and distal biceps tendinopathy have been heavily researched. Investigation continues into the epidemiology, nonsurgical management, surgical indications, surgical technique, and postoperative rehabilitation of these conditions. I Distal biceps tendon rupture can be conclusively diagnosed with physical examination alone. The newly symptomatic patients had higher rates of rear progression, muscle atrophy, and biceps tendon pathology.

Occasionally it can occur after a surgical procedure where the uterus is instrumented or following fitting of an intrauterine device acne buy cheap accutane 40 mg on line. Some women also report right upper quadrant pain and abnormal vaginal bleeding including post-coital and intermenstrual bleeding skin care 6 months before wedding cheap accutane online master card. On physical examination acne treatments that work buy accutane 20 mg amex, the patient may be pyrexial and is usually tender across her lower abdomen skin care doctors edina buy accutane 30 mg line. On bimanual examination acne cleanser cheap accutane 30 mg mastercard, adenexal tenderness and cervical motion tenderness are common features acne keratosis generic accutane 30 mg without prescription. Differential diagnosis of lower abdominal pain in young women includes ectopic pregnancy, endometriosis, appendicitis, ovarian cyst torsion or rupture and urinary tract infection. Urinalysis and blood tests including a full blood count, electrolytes and liver function should be performed in anyone with abdominal pain and suspected infection. In patients who are pyrexial, blood cultures and an arterial blood gas should also be performed. Endocervical swabs should be taken to look for gonorrohoea and chlamydia, as well as a high vaginal swab to investigate for other genital infections such as bacterial vaginosis and candidiasis. A transvaginal ultrasound scan of the pelvis may also be performed to investigate for other causes of pelvic pain and the presence of a tuboovarian abscess. This woman needs to be admitted for broad-spectrum intravenous antibiotics according to trust policy and requires fluid resuscitation. Intravenous therapy should be continued for 24 hours after clinical improvement and then stepped down to oral medication. Removal should be considered if the patient requests it or if her symptoms have not resolved within 72 hours. If it is removed, you must find out from the patient whether she has had sexual intercourse in the last 7 days and whether she would like emergency contraception. Patients should be advised not to have unprotected intercourse until they and their partner(s) have completed the course of treatment and attended follow-up. The need for contact tracing, screening and treatment should be discussed to prevent reinfection. She says that she noticed a pea-sized swelling on her right vulva that appeared around 3 weeks ago, but she had not paid much attention. Over the last 2 days, it has rapidly increased in size and is now very large and painful. She does not have any vaginal bleeding or discharge and has never had this before. She has a right labial swelling, which is extremely tender to touch and extends anteriorly from the level of the posterior introitus. If a blockage occurs in either of the ducts, a tense cyst forms that commonly becomes infected due to their location forming an abscess. Clinical features include a unilateral swelling near the posterior aspect of the vulva. This will be very painful especially on movement or sitting and will be erythematous and tense. It is important to establish if it is fluctuant and therefore whether it can be drained. If the swelling is discharging fluid, a swab should be taken and sent to the laboratory for microscopy, culture and sensitivity. If the patient is pyrexial, blood tests including a full blood count, C-reactive protein and blood cultures may also be taken. The abscess must be drained surgically and the pus sent for culture, as well as giving analgesia and a course of oral antibiotics. The most common method of drainage in the United Kingdom is via marsupialisation of the cyst/abscess. Part of the cyst wall is then excised, and the edges are sutured to the skin to allow continued drainage, and subsequent healing from the base. The cavity may then be packed with ribbon gauze, which is removed within a few hours. It is important to note that the area is highly vascular and there can be significant blood loss. Therefore, surgical intervention is usually reserved for a recurrent, large or multilocular cyst/ abscess. Small asymptomatic cysts (measuring less than 2 cm) do not require surgical drainage and can be treated conservatively with warm baths, compressors, analgesia and a course of antibiotics. Word catheters are inserted in the clinic and can be performed under local anaesthetic. She initially noticed abdominal bloating; however, this has significantly increased over the last 2 days. She has been vomiting this morning and has found herself increasingly short of breath today. She has also noticed that she has been passing small amounts of dark urine over the last couple of days. Examination Vital signs: heart rate of 95 bpm, blood pressure of 105/70 mmHg, respiratory rate of 18, temperature of 36. Respiratory examination reveals decreased air entry at the left base but heart sounds are normal. The effects of proinflammatory mediators lead to increased vascular permeability and a loss of fluid from intravascular to third space compartments. This gives rise to ascites, pleural effusions and in some cases pericardial effusions. This occurs following the injection used to promote final follicular maturation before oocyte retrieval. There may be a palpable mass per abdomen or signs and symptoms of intraperitoneal fluid. The decrease in intravascular volume gives rise to dehydration and haemoconcentration and leads to oliguria and thromboembolism in severe cases. Alternative differential diagnoses of abdominal pain and distension include intra-abdominal haemorrhage, pelvic inflammatory disease, ectopic pregnancy, appendicitis, haemorrhagic ovarian cyst, bowel perforation, liver disease, ovarian cyst torsion and rupture. Patients should have a full workup including a full blood count, electrolytes, clotting profile, serum osmolality and C-reactive protein. The haematocrit and white cell count are of particular importance when grading severity. Urinalysis and a urinary pregnancy test should also be performed on all women of reproductive years that present with abdominal pain. Physical examination should include body weight and abdominal girth at the umbilicus. The patient should be assessed for the presence of ascites, pleural effusion and thrombosis in the form of a pulmonary embolism or deep vein thrombosis. Caution should be taken with pelvic examinations to avoid trauma to enlarged ovaries. An ultrasound scan may be performed to assess ovarian size and the presence of any pelvic and abdominal free fluid. Patients should be encouraged to drink to thirst to correct the intravascular dehydration, but in the acute phase, intravenous fluids may be needed for initial correction of the dehydration. Patients should be monitored with daily weights, blood tests, fluid balance and abdominal girth measurements to monitor progress. In most cases, mild pleural effusions spontaneously resolve with supportive management. Paracentesis should be considered in patients with tense and painful abdominal distension, shortness of breath or respiratory compromise and/or oliguria despite fluid replacement, all secondary to ascites. Women and their partners should be counselled that the management is mainly supportive until it resolves spontaneously. For very unwell patients, a multidisciplinary team approach may be required in the intensive care setting to manage these patients appropriately. She has been suffering with a headache for the last 3 days, but today noticed that this has become significantly worse and that she has been seeing flashing lights. Over the last week, she had some mild epigastric pain, which she just put down to indigestion. She has also noticed that she has developed leg swelling in both legs over the past few weeks. Examination On examination, her blood pressure is 170/101 mmHg and heart rate is 75 bpm. She has bilateral pitting oedema to mid-calves and hyper-reflexia is noted in the upper and lower limbs. Pre-eclampsia is a multi-system disorder characterised by pregnancy-induced hypertension occurring after 20-week gestation and significant proteinuria. In severe cases, this can lead to eclampsia, defined as the occurrence of one or more convulsions on the background of pre-eclampsia. Risk factors for the development of pre-eclampsia include extremes of age, primigravida, multigravida with a new partner, previous history of preeclampsia, obesity and African ethnic origin. Women with pre-eclampsia must have a raised blood pressure, which may be graded as mild, moderate or severe (Table 95. Common features in the history include symptoms of severe headache, visual disturbances and epigastric pain with or without vomiting. When examining a patient with suspected preeclampsia, look for clonus, papilloedema, hyper-reflexia, oliguria and peripheral oedema. It is important to distinguish pre-eclampsia from chronic hypertension, which existed prior to pregnancy. It is useful to look at the blood pressure at the time of booking to assess this and to check whether there was any protein in the urine at booking that may indicate underlying renal disease. Measurement of blood pressure is a key part of assessing such patients; however, it is important to ensure that this is measured accurately. Remember that the cuff must be of the appropriate size and should be placed at the level of the heart to establish a baseline blood pressure. Serial blood pressures should be performed every 15 minutes until the patient is stabilised. Two plus of protein on the urine dipstick can be taken as significant proteinuria; however, this must be confirmed by a more accurate test including either a spot albumin:creatinine ratio (30) or a 24-hour urine collection (>0. In an acute setting, a fetus above 28 weeks gestation must be monitored with cardiotocography, and later a growth scan with foetal Dopplers should be arranged to assess for foetal wellbeing. Oral nifedipine and intravenous hydralazine can also be used for acute management. Atenolol, angiotension-converting-enzyme inhibitors and angiotension-receptor blockers should be avoided antenatally. Every trust should have its own stepwise protocol on the management of pre-eclampsia. This patient will require urgent transfer to the High Dependency Unit or labour ward for stabilising and monitoring as she is at risk of an eclamptic fit. She will need admission until the blood pressure is stabilised and a maintenance regime has been established. In cases of uncontrollable blood pressure or eclampsia, delivery of the fetus via an emergency caesarean section may be required. She complains of breathlessness that came on suddenly during the early hours of the morning and has worsened throughout the day. It is associated with right-sided tight chest pain, which is worse on inspiration. She has never experienced these symptoms before and has no significant past medical or surgical history. The baby has been moving around well and otherwise the pregnancy has been low-risk. Examination Vital signs: heart rate of 113 bpm, blood pressure of 89/55 mmHg, respiratory rate of 22 bpm, oxygen saturation of 91% on room air. Pregnancy increases the risk of developing a venous thromboembolism by four to five times, compared to nonpregnant women of the same age. It is therefore essential to risk-assess patients early at booking and during their antenatal care. Dyspnoea, pleuritic chest pain and haemoptysis may all be features of the history, although symptoms can be absent. On examination, the patient may have a raised respiratory rate, tachycardia and low oxygen saturations. She may have a raised jugular venous pressure and signs of a deep vein thrombosis in the leg. Although safe beyond this, it is difficult to optimise, requires regular monitoring and can cause problems with excessive bleeding if not stopped early enough before delivery. Anticoagulation should be continued for the duration of the pregnancy and for at least 6 weeks postnatally, and at least 3 months of treatment should be given in total. As this patient is hypoxic and tachycardic, she should be admitted for investigation and management until her observations stabilise. The patient should be followed up regularly in antenatal clinic upon discharge and where possible should be seen in an obstetric medicine or joint obstetric haematology clinic postnatally.

Sutures used in ophthalmic surgery 12 Ophthalmic Surgical Suture: Properties skin care 40 year old buy accutane 40 mg free shipping, Design acne grading scale discount accutane 5mg without a prescription, and Selection strength changes dramatically over time (Table 5 delex acne buy cheap accutane 5mg on line. Erring on the side of longer suture duration is preferable to selecting a suture that cannot provide adequate wound support for the necessary amount of time skin care tips in hindi purchase discount accutane line. Sutures that possess the required tensile strength for the closure should be selected acne before period purchase accutane 10 mg mastercard, including anticipated changes in wound tension that will occur postoperatively from swelling acne 24 purchase generic accutane, active muscle contraction, or increases in intraocular pressure. Sometimes this requirement will be based on selecting the appropriate gauge, and other times it can be addressed by the number of stitches used or the number of layers used. In general, the smallest gauge thread possessing the necessary tensile strength should be chosen to minimize suture bulk and scar formation. The tensile strength of the suture should at least match, though need not significantly exceed, the tensile strength of the tissue to withstand tearing, and the tension on the wound should never exceed the tensile strength of the tissue (which may change depending on the state of healing). Sutures that make the particular task at hand as simple as possible should be selected. Although needle choice is a key element in this regard, overall thread length, tissue drag, and pliability of the suture for knot tying are also important features. Sutures that maximize patient comfort, particularly on the ocular surface, should be chosen. In this context, small gauge, low reactivity, and good pliability to minimize knot bulk are important variables. For example, small gauge monofilament thread that ties easily and allows easy rotation to bury the suture knot is typically chosen for use on the cornea. The use of an appropriately dyed suture will help greatly to promote visualization. Braided suture, because of its structure, allows fibroblasts to adhere tightly to the intertwined fibers, making subsequent removal difficult and painful. In children, where suture removal from the eye or lids may be especially challenging, and healing rates are fast, it may be advantageous to use an absorbable suture with relatively short absorption times. Fortunately there is an exceptionally wide range of needles to choose from, and the thought process used to select the one best suited for a particular purpose begins with an understanding of the fundamental properties inherent to each. The tip is extremely sharp, and is designed to penetrate into or cut through tissue. The body determines the length and curve of the needle, and its resistance to bending. The swage holds the suture thread, and is typically created by laser drilling an opening into the end of the body, into which the thread is placed and physically secured by crimping. Unlike the other tips, the taper point does not cut the tissue, but rather pierces and separates it as the body of the needle passes. Conventional cutting tips, with cutting edges on both sides as well as the inner curve are also available, but less commonly utilized. Their major disadvantage relative to the reverse cutting tip is that they place a cut in the tissue on the side of the pass that will experience the stress of the wound closure the most. This is a potentially less stable situation compared to that created by the reverse cutting tip, where the inner surface of the needle tract is left intact. The spatulated tip has cutting edges on the sides only, and its flattened body is designed to maintain a constant depth in the cornea or sclera, where the connective tissue is uniquely organized into a lamellar architecture, and full-thickness passes are to be avoided. Although tapered and reverse-cutting tips are utilized widely across many surgical specialties, spatulated needles are designed specifically for ophthalmic use. The body of the ophthalmic needle is curved, and does not have cutting edges, but passes easily through the opening in the tissue made by the sharp tip. The shape of the body may be low trapezoidal (spatulated), triangular (reverse cutting), or semi-rounded (taper). Corneal suturing, for example, requires a short, spatulated, 3/8 circle needle to accommodate the steep entry and tight curve, while a 1/4 circle may be a better choice for sclera. For the skin of the eyelid, a longer needle with a reverse-cutting tip may be a better choice, allowing the surgeon to easily cut through several layers of soft tissue, making long semicircular passes. Taper point needles are not typically used in the lid, cornea, sclera, or extraocular muscles. In all cases, the goal is to achieve the desired tissue penetration as easily as possible, while causing as little damage or alteration to the tissue as possible. They are designed to securely hold the needle for passage, using jaws that are appropriately sized for the given needle. An appropriate match between jaw size and needle size is important, not only to hold the needle with the proper and necessary force required, but also to maximize visualization of the ophthalmic tissues while passing the needle. Using a needle holder with jaws that are too small can result in poor control of the needle tip and torqueing of the needle body during a pass through fibrous tissue. On the other hand, using a needle holder with jaws that are too big can reduce the effective length of the needle available for penetrating the tissue, as well as potentially obstructing the view of the tissue being penetrated. Ridged jaws may improve the grip on larger needles, providing increased stability. This is especially important when dealing with relatively dense tissues offering significant resistance. Ridged jaws are generally not necessary for passing the small spatulated needles typically used for conjunctiva, cornea, sclera, and extraocular muscle. Forceps with teeth (either opposed or interlocking) are used to obtain a firm hold on soft tissue while a suture needle is passed through. The size and design of the teeth varies, allowing the surgeon to select the best one based on the tissue characteristics on which it is to be used. When the tips are properly aligned, the single tooth fits in an interlocking fashion in the space between the two opposing teeth. In that situation, it is preferable to select forceps with smooth or slightly textured tips, rather than ones with teeth. Non-toothed forceps or needle holders with smooth tips are always preferred for tying knots. Unlike soft tissue, which can be held more securely by biting into it with teeth, the opposite is true for suture. The use of smooth forceps or needle holders to handle suture will also minimize any iatrogenic damage to the thread that might weaken it. Forceps with fine tips are generally the preferred instruments for tying a very small gauge suture. This combination facilitates the formation of loops for knotting the suture and improves ergonomics. The scrub nurse will often be the person to initially load the needle into the needle holder, but in many cases the surgeon will need to reload it multiple times on the surgical field as the suturing proceeds. The first step in loading the needle into the needle holder is obtaining a stable grasp of the needle. This can be done with the fingertips, a smooth forceps, or a second needle holder. Handling the needle with the fingertips rather than instruments is generally the fastest way to proceed but must be done with caution to avoid injury. Reaching directly for the needle is to be avoided, as this is perhaps the most certain way to guarantee an injury. Instead, it is very safe to hold the thread, away from the needle, between the thumb and index finger, and then use the other hand to draw the needle backward until the swage rests against the fingertips (Video 8. At that point, the needle is well controlled and may be loaded into the needle holder in the correct orientation for the intended pass. When operating under a microscope, a needle may be loaded into the needle holder using two techniques. A smooth instrument, such as a tying forceps, can be used to dangle the needle by its thread onto the ocular surface, allowing it to then be grasped by the needle holder (Video 8. When this technique is used it is helpful if the ocular surface is thoroughly wetted with balanced salt solution. The surface tension of the fluid layer helps hold and stabilize the needle body in position. Alternatively, the needle can be held directly with smooth forceps and then grasped by the needle holder in the appropriate orientation and position. It may be easier to perform these maneuvers under lower magnification, as this permits a longer and wider depth of field. When using a needle holder with curved jaws, it is important to load the needle with the tip extending from the convex surface and the swage extending from the concave surface (Video 8. The needle should be loaded with the tip pointing in the direction of the intended pass, whether or not the surgeon will make the pass in a forehanded or backhanded manner. For an intended backhand pass, the needle will be loaded in the same orientation as it would be for a forehand pass by the opposite hand. For example, a forehand pass with the left hand is loaded in the same orientation as a backhand pass with the right hand (Video 8. The needle is grasped near the tip of the needle holder jaws, between one-half and twothirds of the distance from the needle tip to the swage. Note that a needle loaded for a backhand pass with one hand is oriented the same way in the needle holder as for a forehand pass with the opposite hand. The further back on the needle body that it is loaded, the greater the torque experienced at the tip, and the less stable the control. On the other hand, the distance from the tip of the needle to the needle holder determines the distance the needle can travel through tissue without re-grasping. Therefore, the needle should be loaded far enough back from the tip to achieve the necessary length of the pass, but no further. This will optimize the balance between control of the needle and length of the pass. The further the needle is loaded back toward its swage the greater the torque experienced at the tip. In addition to the control issues mentioned above, greater torque at the tip also increases the potential for bending the needle or allowing the needle to unintentionally shift direction during the pass (Video 8. The rationale for maintaining clear visualization is self-evident, but requires proper positioning of the hands (Video 8. Grasping the tissue close to the intended entry point greatly improves control and precision. If there is a freely mobile tissue edge, as is often the case with a tissue flap, stabilization will be maximized if the tissue is held on the side of the free edge, while passing the needle on the anchored side (Video 8. To optimize visualization and tissue stabilization, as well as contend with various anatomic constraints, it may be helpful or even necessary to alter which hand holds the tissue and which hand passes the suture. The principles of optimal wound healing, anatomic integrity, and cosmesis that were discussed in Chapter 3 and Chapter 4 should be kept in mind when planning and executing wound closure. For skin closures, these principles require that the 22 Suturing: Basic Skills and Techniques Video 8. Maintaining anatomic integrity requires that identical layers are carefully reapproximated, and extraneous tissues are not inadvertently incorporated into the closure. Achieving these goals can be facilitated in many cases by having a surgical assistant provide appropriate tissue retraction. It may also be helpful to gently pull up on the tissue being sutured to help define and separate it from the underlying layers. This can be done with either hand, using a forehand or backhand technique, depending on the particular requirements and ergonomics of the situation (Video 8. When using a locking needle holder, the locking mechanism should be released by compressing and maintaining compression of the flexible handles prior to entering the tissue (Video 8. This will allow 23 Suturing: Basic Skills and Techniques an easy release of the needle at the completion of the pass, and avoid any difficulties with the release mechanism while the needle tip may still be in the tissue. It may also be advantageous, if the situation permits, to pass the needle through both sides of the wound in a single pass. This requires a needle of sufficient length and proper curvature, but doing so will result in fewer overall manipulations of the needle, improving efficiency and reducing the risk of damage to the sharp tip. Although it seems counterintuitive, bringing the tip of a curved needle back to the surface of the tissue generally does not require major torque to be applied to the needle body. Only a mild rotational force must be exerted to redirect the tip as the needle is advanced. Applying strong torque to the body of a delicate ophthalmic needle in an effort to force or drive the tip outward will not be effective, and should be avoided. This is particularly true for the longer scleral passes often utilized in strabismus surgery employing thin spatulated needles. Finally, it is helpful to hold the distal wound edge securely in place until the needle is re-grasped, particularly if there is any tendency for tissue retraction. This will minimize the potential for the needle to retract back into or out of the tissue when it is released from the needle holder (Video 8. This may seem like a subtle technical consideration, but it is extremely important for two reasons. It is a major determinant of the quality and uniformity of the stitch, and it can prevent unintended ocular perforation or entry into deeper tissue layers. For skin, muscle, tendon, tarsus, fascia, and conjunctiva, a steep, roughly perpendicular entry and exit are preferred (Video 8. Although the same is true for cornea, much greater precision is required to avoid full-thickness penetration. For corneal sutures, this is best accomplished by using a very sharp, tightly curved, spatulated needle. For sclera, on the other hand, a shallow trajectory for needle entry is required (Video 8.

In these treated with arthrescepic sta- Athletes participating in centact spurts are at greater 20 years) skin care for pregnancy order accutane 30 mg line. In anether 2014 study cemparing a greup ef 93 patients with anterier instability treated with a Latarjet precedure with a greup ef 93 patients treated with arthrescepic Bankart seft-tissue stabilizatien skin care solutions cheap accutane 40 mg otc, the anthers feund that 10% ef the Latarjet greup (9 patients) and 22% ef the Bankart greup (20 patients had sustained instability recurrence at a mean fellew-up cf 4 years skin care urdu tips discount accutane 5mg with amex. A 2014 study used intraeperative ries in 34 patients treated with the Latarjet precedure acne hormonal imbalance buy accutane in india. Similarly acne hat cheap accutane 20 mg overnight delivery, the anthers ef anether 2015 study reperted en 57 adelescents [61 sheulders] treated with intraeperatively skin care nz proven 40mg accutane, mest cemmenly during gleneid expesure and graft insertien. Section 3: Upper Extremity commonly affected, followed by the musculocutaneons nerve. Procedures have been developed to address humeral bony deficiency when clinically relevant, however. Modern remplissage, which means "to fill," involves arthroscopic tenodesis of the infraspinatus tendon into the humeral defect, making the defect extra-articular. More invasive osteochondral allograft reconstructions or hemiarthroplasty typically are reserved for larger lesions. Several authors recently investigated arthroscopic remplissage for the treatment of anterior instability, although most support for the procedure consists of low-level evidence. A 2015 study compared 35 patients with anterior instability and engaging Hill-Sachs defects who were treated with isolated arthroscopic labral repair and 37 patients treated with labral repair with posterior capsulo4:lesis. In a 2014 systematic review of the outcomes of Hill-Sachs remplissage in conjunction with anterior labral repair, 1157"r patients from six studies were evaluated at a mean follow-up of 27 months after surgery The diagnosis is supported by physical examination maneuvers that stress the posterior labrum and pathologic anatomy on magnetic resonance arthrography. Individuals in the upper quartile for glenoid retroversion were approximately six times more likely to sustain a posterior subluxation event. An arthroscopic approach along with treatment of soft-tissue lesions associated with posterior instability are preferred over an open approach because of the extensive surgical dissection needed. An extensive 2015 review of posterior instability treatment analyzed data from 53 publications. Although outcomes were generally good, the return to previous levels of function was not as reproducible in overhead throwers as in other athletic populations. The understanding of its patho- it is being recognized increasingly as a symptom generator Patients with multidirectional instability have a patulous inferior capsule without a distinct labral lesion. Treatment for multidirectional instability may be nonsurgical or surgical [Table 3. Pathoanatomy Traumatic posterior dislocations are far less common than anterior dislocations. Posterior instability typically results labral complex during activities that place the arm in a flexed, internally rotated, and adducted position. Patients from repetitive microtrauma to the posterior capsulo- Nonsurgical Treatment Exercises to strengthen the rotator cuff and periscapular musculature can help manage symptoms. The authors of a 2014 study reviewed seven studies of exercises for multidirectional instability that met their inclusion criteria. They found that the results were highly variable and that the studies were of generally poor quality. Axial magnetic resonance arthrography demonstrates abnormal intro-articular dye extravasation between the posterior labrum and the glenoid articular margin arrow, indicating a posterior Iabral tear. Note the chondral injury at the articular margin of the glenoid glenolabral articular disruption; arrows]. Arthroscopic view shows the posterior Iabral tear following anatomic repair to restore stability. Surgical Treatment If nonsurgical management does not achieve satisfactory results, a patient can be considered for surgical treatment. A sound understanding of its pathogeneoptions helps in the management of this condition. Recent attention has focused on understanding the causes of recurrence in anterior instability and on improving surgical decision making as svell as techniques to optimize results. Arthroscopic skyboa view shows a patulous capsule in a patient with multidirectional instability. Arthroscopic view of the capsule plicated using suture anchors placed at the glenoid articular margin to reduce intracapsular volume. Bids M, Ellis R, Donaldson K, Parmar P, Kersten P: Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: A systematic review and meta-analysis. Br] Sports Med establish the correct diagnosis and treatment plan for an unstable shoulder. A diagnosis of instability is alflflg With "113-31113 to support the clinical dlagflflfls: I Glenoid and humeral-side bone loss are becoming based on the histor and the h sical examination, Y P 3",. At a mean 13-year follow-up, 69 of lflfl shoulders 69% showed radiographic evidence of ber of preoperative dislocations, older age at the time of the initial dislocation, and the number of anchors used degenerative changes. Students with a self-reported history of shoulder instability were approximately five times more likely to sustain an instability event during the 4-year period than those who did not report prior shoulder instability. American Academy of Drthopaedic Surgeons Chapter 25: Shoulder Instability Nakagawa S, Dzaki R, Take Y, Iuchi R, Mae T: Relationship between glenoid defects and Hill-Sachs lesions in shoulders with traumatic anterior instability. The force required to translate the humeral head was tested with combinations of glenoid and Hill-Sachs defects of various sizes. Although 33 of 45 athletes 23 % were able to return to competition after a mean of 5 days lost, only 12 of the 45 athletes 22% were able to finish their respective seasons without recurrence. Gigis I, Heikenfeld R, Kapinas A, Listringhaus R, Godolias G: Arthroscopic versus conservative treatment of first anterior dislocation of the shoulder in adolescents. The 33 shoulders that underwent early arthroscopic stabilization had a dramatically lower redislocation rate than the 2 A study of the biomechanical effects of bipolar bone loss using a computer-generated model was conducted. Sequential glenoid and humeral defects were analyzed to demonstrate the additive effect of Hill-Sachs lesions on glenohumeral instability in external rotation in the setting of glenoid bone loss. This systematic review of 31 studies 2,313 shoulders conducted over a 20-year period that examined the treatment of primary anterior shoulder dislocations demonstrated an overall recurrence rate of 32. Patients treated with acute surgical stabilization had a substantially lower rec urrcnce rate than those treated with physiotherapy 9. American Academy of firthopaedic Surgeons Drtbopaedic Knowledge Update 12 Section 3: Upper Extremity 15. At a mean 11-year follow-up, no significant difference in the recurrence rates between open 3% and arthroscopic 11% techniques was found P = 0. Moroder P, Udorizni M, Piazinini 5, Demeta E, Resch H, Moroder P: Upen Bankart repair for the treatment of anterior shoulder instability without substantial osseous glenoid defects: Results after a minimum follow-up of twenty years. Wesserstein D, Dwyer T, Veillette C, et al: Predictors of dislocation and revision after shoulder stabilization in Latarjet procedure. The sling effect provided by the conjoined and subscapularis tendons contributed 51% to 62% of the stability to the humeral head translation in midrange motions and 26% to F Mixuno N, Denard P], Raiss P, Melis B, Walch G: Long-term results of the Latarjet procedure for anterior instability of the shoulder. Sixteen of the 63 patients 23% demonstrated new or progressive radiographic evidence of arthrosis at the final follow-up. Yamamoto N, Kijima H, Nagamoto H, et al: Outcome of Bankart repair in contact versus non-contact athletes. At a mean follow-up of 4 years, a 10% recurrence rate was reported in the Latarjet group 9 of 93 patients, compared with a 22% recurrence rate after arthroscopic soft-tissue stabilization [20 of 93 patients]. I Sboulder Elbow Surg A cohort study of 139 patients with rotator cuff tears found that none of the studied physical examination maneuvers was highly sensitive. In a case-control study of 331 patients with a rotator cuff tear and 220 control subjects, the odds ratio was higher for patients with a body mass index higher than 3! The lift-off test was highly specific for predicting full-thickness subscapularis tears. Plateaus in the level of sensitivity greater than 90% and specificity [greater than 35 93 were reached after the first 100 examinations. D H ural history of asymptomatic rotator cuff tears: A Urthopaedic Knowledge Update 12. American Academy of Urthopaedic Surgeons Chapter 26: Shoulder and Elbow Tendinopathy 12. After 2 months of treatment, there was no significant difference between the groups. Xu C, Zhao J, Li D: Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears. Double-row repairs led to lower rates of retearing, especially in tears larger than 30 mm. At 24 months postoperatively, the only difference between the groups was more patients with stiffness in the 8-week group 33% and 13%, respectively. Bell 5, Lim Y], Coghlan J: Long-term longitudinal follow-up of mini-open rotator cuff repair. Seven randomized controlled clinical studies were included in a meta-analysis of single- and double-row repairs. Single-row repairs led to a higher rate of retearing, but there were no significant between-group differences in outcome measures. American Academy of Urthopaedic Surgeons Urthopaedic Knowledge Update 12 Section 3: Upper Extremity and 34% were satisfied with the result of the shoulder surgery. Improvement in pain and shoulder function in the remaining 90% was well maintained. Patient outcome scores had remained stable between 2- and 10-year follow-up, but radiographs showed advancing arthropathy. Patients with labor-intensive occupations were less likely to have a good outcome after retear. Thirty-five patients younger than 65 years who underwent reverse shoulder arthroplasty for massive rotator cuff tears were evaluated. Improvements in pain, range of motion, and outcome scores were well maintained at a mean of 93 months postoperatively. Those who received ultrasound-guided needling and lavage had better clinical and radiographic outcomes. Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. Those who received ultrasound-guided needling had better clinical and radiographic outcomes. At 2-year follow- up of 31 patients who underwent partial repair of an irreparable rotator cuff tear, one-half of the patients were dissatisfied with their outcome 43. American Academy of Urthopaedic Surgeons Chapter 26: Shoulder and Elbow Tendinopathy 35. ElMaraghy A, Devereaux M, Tsoi K: the biceps crease interval for diagnosing complete distal biceps tendon ruptures. Uki G, Iba K, Sasaki K, Yamashita T, Wada T: Time to functional recovery after arthroscopic surgery for tennis elbow. Uutcome scores were better in those treated with an anconeus muscle flap, but there was no between-group difference in pain or range of motion. M, Voloshin I: Distal biceps brachii tendon repairs: A single-incision technique using a cortical button with interference screw versus a double-incision technique using suture fixation through bone tunnels. Section 3: Upper Extremity At 9-month follow-up of 13 patients who underwent distal biceps tendon reconstruction with allograft, average supination and flexion strength was 4. In all patients the nerve had recovered fully at an average 86 days after surgery (range, 41 to 145 days. In patients who are elderly and have low physical demands, consideration should be given to nonsurgical treatment, which can lead to an acceptable functional outcome with fewer complications than surgical treatment. Total elbow arthroplasty is a viable treatment option for elderly patients with a distal humerus fracture and low physical demands, management of radial head fractures should be pursued unless there is a mechanical block to motion. Nonsur- gical management of a displaced olecranon fracture in an elderly infirm patient results in an acceptable functional outcome despite radiographic nonunion. Coronoid fractures are managed based on the stability of the elbow, and the lateral ulnar collateral ligament is repaired when necessary. Nonsurgical ing a durable, functional elbow over time in a healthy, active patient. Consequently, there has been renewed interest in nonsurgical treatment for relatively inactive patients in less-than-optimal health. Fowler nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter. Autumn; Jaddn 1E Introduction plate breakage, one had tension band breakage, and three had nonunion with screw loosening. Twenty of 85 patients 23% had a complication, including revision surgery in 3 patients 9%. Radiolucent lines around the prosthesis were present in 7 of the 15 patients, and heterotopic ossification was present in 6 patients. Mean elbow flexion and total are of motion were similar in the two patient groups. Fourteen patients in the osteotomy band wiring or plates and screws used in fixation of the osteotomy. The choice of exposure for fixation of a bicolumnar fracture remains a matter of surgeon preference and judgment. Research into the alignments that influence motion, pain, group underwent revision surgery to remove tension gical time (114 minutes versus 39 minutes, greater blood and arthrosis would be useful. Perhaps limited exposures might be designed to achieve limited goals for example, anterior translation of the trochlea, smooth medial ulnohumeral and radiocapitellar articulation rather than to fully restore alignment.

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