Development of the double level osteotomy in severe varus osteoarthritis showed good outcome by preventing oblique joint line.

INTRODUCTION: The purpose of the study was to describe the development of the surgical technique of double level osteotomy in patients with severe varus malalignment and to investigate the clinical and radiological outcome. It was hypothesized that good clinical results without a higher complication rate can be achieved by double level osteotomy to normalize joint angles and avoid joint line obliquity even in cases of progressed osteoarthritis. MATERIALS AND METHODS: Between 2011 and 2014, 33 patients (37 knees) undergoing double level osteotomies (open wedge HTO and closed wedge DFO) were included; of these, 24 patients (28 knees) were available in mean of 18 ± 10 months for the follow-up examination. Indication was symptomatic varus malalignment and medial compartment osteoarthritis. Postoperatively, these patients were assigned to 20 kg partial weight-bearing using two crutches for 6 weeks followed by full weight-bearing. No braces or casts were used. Full weight-bearing long leg anteroposterior radiographs were obtained preoperatively, after 6 weeks and at the time of final follow-up. Mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA) and medial proximal tibia angle (MPTA) were measured. Clinical outcome was evaluated using Lequesne-, Lysholm-, Oxford-, and IKDC-score at the time of follow-up. RESULTS: The preoperative mTFA of - 11 ± 3° increased to 0 ± 2° at final follow-up. The difference between mTFA-planning and final follow-up was - 2 ± 3° (p < 0.0006). At final follow-up, MPTA and mLDFA were 89.2 ± 2° and 87 ± 2°, respectively. The Lysholm, Oxford, Lequesne, and IKDC scores were 88 ± 13, 44 ± 3, 2 ± 2, and 77 ± 12, respectively. CONCLUSIONS: This study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalises the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis. LEVEL OF EVIDENCE: Case series, Level IV.

Injuries presenting to Army physiotherapy in north Queensland, Australia.

OBJECTIVE: To analyze archival physiotherapy records at a major military base in North Queensland, Australia, to investigate the epidemiology of injuries associated with sports and training, examining for possible risk factors for military training injury. METHODS: A retrospective study was undertaken during a 62-month period, from 1987 to 1992, at Lavarack Barracks, Townsville, Australia, which services a dynamic population base of some 5,000 uniformed staff. Sociodemographic basic data, as well as treatment-related data (treatment area, number and type, interval between onset and initial treatment, reported cause), were used. Admission records were recoded according to the Orchard Sports Injury Classification System (version 2.0) standard. RESULTS: During the 62-month period from 1987 to 1992, 4,993 personnel, 96.2% (4,803/4,993) males and 3.7% (190/4,993) females, were referred for 5,025 physiotherapy treatments. The incidence of injuries requiring physiotherapy was 80.4 new patients per 5,000 personnel per month, and the incidence rate of injury was 19.3% per year or 0.19 injuries per person per year. The mean age of patients was 25.7 +/- 6.2 (SD) years, and the median age was 24 years, with a range of 17 to 59 years. Injuries were related to military training (29.3%, 1,471/5,025), diverse causes (21.2%, 1,072/5,025), sports (13.8%, 694/5,025), insidious onset (11.8%, 589/5,025), football (11.7%, 586/5,025), manual handling (4.2%, 211/5,025), motor vehicle crashes (4.1%, 206/5,025), and surgery (3.9%, 196/5,025). The four major body areas treated by physiotherapists were the knee joint (37.0%, 1,321/3,612), lumbar spine (29.8%, 1,075/3,612), ankle (19.9%, 719/3,612), and shoulder joints (13.8%, 497/3,612), which accounted for nearly three-quarters of all admissions. Of these, most were referred without definitive diagnosis (71.1%, 2,572/3,612), with the remainder comprising joint injuries (17.5%, 634/3,612), other types of pathology such as chest infections or neurological involvement, soft-tissue injuries (3.5%, 128/3,612), and bone damage (1.0%, 38/3,612). Most injuries (59.0%, 2,959/5,019) occurred during the 6 months between April and September referred to as the winter season, during which 71.8% of all football and 66.8% of all sports-related referrals were made. Significant associations were found between gender and injury cause (p < 0.001), gender and injury type (p < 0.01), body area affected and injury type (p < 0.00001), body area affected and injury cause (p < 0.00001), injury cause and injury type (p < 0.00001), and season and injury cause (p < 0.00001). Pretreatment interval was significantly associated with cause of injury (p < 0.00001), body area affected (p < 0.0001), and type of injury (p < 0.0001). Total number of consecutive treatments provided was significantly associated with both body area affected (p < 0.05) and injury type (p < 0.001). CONCLUSIONS: This study has used archival physiotherapy records for the purpose of exploring injury reporting patterns associated with a military population. The incidence profile for injuries using physiotherapy admissions is likely to be conservative because the patients are a group of injured military personnel selected by medical officers for physiotherapy treatment. This selection process needs further study, particularly because the majority of injuries referred for physiotherapy treatment are undiagnosed. This may be attributable in part to the cumulative and diverse nature of some injuries. Injury prevention needs to focus on activities relating to military training and football and other sports. Improved systems for recording detailed and accurate physiotherapy admission, treatment, and follow-up information are needed.

How--and why--to request an autopsy.

Autopsy remains the touch-stone of diagnosis, but clinicians are often reluctant to request the procedure because of their discomfort in approaching the family. Fundamental to a successful autopsy request is sensitivity for the family's feelings, which bespeaks respect for the deceased and the family. For example, in announcing the death and requesting autopsy, the clinician should bring the family to the hospital and talk with them privately. If they have questions or reservations about autopsy, the clinician should answer honestly and simply, stressing the benefits of the procedure to the family and society as a whole. Since the manner of request influences the family's decision in about one third of cases, efforts at overcoming personal reluctance in requesting autopsy are worthwhile. Clinical excellence develops through effort and practice in this activity as in any other.

Stimulus parameters that produce age differences in block design performance.

Administered block designs that varied according to two parameters, Task Uncertainty and Perceptual Cohensiveness, to 83 persons 49 years of age or older. Performance was adjusted to remove motor speed differences. Performance changed significantly over the age span as a function of Task Uncertainty. From 49 years up, performance did not change as a function of Perceptual Cohesiveness. An analysis that included a group of 20 persons 30 years of age or younger yielded an interaction of Age and Perceptual Cohesiveness. From 49 years on, analytic or image segmentation processes do not seem to change, but other information processing becomes slower.

Age differences in symbol-digit substitution task performance.

A decline in performance on the Digit Symbol Substitution test related to aging is well documented. There is no agreement on the reason for the decline, however. In part, the lack of consensus with regard to changes on the test may be attributed to the limitations imposed by comparing groups on a single performance measure. In the present study, three forms of a Symbol-Digit Substitution task that varied in difficulty level were administered to 125 persons between the ages of 30 and 92. On all forms there was a clear performance decline associated with age. The differences observed among the age groups were interpreted as evidence for a change in a sensorimotor component and in two information-processing operations: Symbol encoding and visual search.

The pathologist and the hospital clinical laboratory.

In this article, the author conceptualizes problems in pathology through the perspective of a wide angle lens. He explores how the role of the clinical pathologist evolved into what it is now as well as what, in his view, it ideally should be. The author encourages his peers to analyze, critique, and comment on the opinion he sets forth in the following pages.

Normative data for the Symbol Digit Substitution Task.

Administered three forms of a Symbol-Digit Substitution task to normals, 16 to over 80 years of age, to schizophrenic and other hospitalized groups. Their data are presented for normative purposes. The three forms vary in difficulty and provide a measure of visual information processing ability, Clinical and research implications of the data are discussed.

Neuroendocrinoma of the jejunum: electron microscopic and biochemical analysis.

A 56-year-old woman presented with a sudden, severe hemorrhage per rectum. Angiography localized a jejunal tumor, which was excised. Light microscopy suggested a neuroendocrine tumor, but neither a smooth muscle tumor nor a lymphoma could be excluded. Electron microscopy showed dense cored, single membrane bound secretory granules 150--220 nm in diameter; myofilaments were not observed. Biochemical analysis of tumor tissue yielded considerable amounts of catecholamines. VMA, 5-HIAA, and metanephrines. These combined ultrastructural and biochemical observations establish the diagnosis of neuroendocrine tumor; however, in this case neither type of information is sufficiently specific to define the tumor as either a paraganglioma or a carcinoid. Although paraganglia and mucosal endocrine cells in the GI are currently thought to constitute distinct cell types, they share numerous structural and functional properties, and they are both thought to be part of the APUD cell system. These parallels and similarities are shared by the neoplasms derived from them which often display features of both. In the absence of specific granule types or specific substances isolated from tumor tissue, only the application of specific immunocytochemistry techniques may allow the precise "functional" classification of such tumors.

Dyssegmental dwarfism. A lethal anisospondylic camptomicromelic dwarfism.

Dyssegment dwarfism is a lethal anisospondylic camptomicromelic form of growth retardation that appears to have autosomal recessive inheritance. It is characterized by short neck, cleft palate, narrow chest, severe shortening of long bones and trunk, reduced joint mobility, inguinal hernia, and probably hirsutism and hydroureter/hydronephrosis. Some cases are seen with occipital exencephalocele. The long bones are short and bent with metaphyseal flaring. The vertebral bodies are of different size and many consist of separate ossified masses. The iliac bones are small with hypoplasia of the horizontal and inferior margina. Maturation of cartilage cells at the epiphyseal plates is grossly disturbed and there are puddle-like spaces among the resting cartilage cells.