Orthopedics

Inflammation Mastery / Functional Inflammology, Volume 1 (2014, updated and expanded in 2016). This work is the culmination of several thousand research publications combined with Dr Vasquez's many years of clinical experience and teaching graduate-level students and doctorate-level clinicians worldwide. With radiographs, photos, acronyms, illustrations, flowcharts, and detailed-yet-simplifying explanations, Dr Vasquez makes it easier than ever for clinicians to grasp important concepts in integrative care and functional medicine and then to translate the basic science research and molecular biology into treatment plans that can be explained and used in " the real world " of clinical practice with patients. The associated video tutorials and recorded live conference presentations further help students and clinicians " get it " via Dr Vasquez's effective teaching style which embraces complexity while always emphasizing clinical applicability and psychosocial context. The Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammation Mastery & Functional Inflammology series of books and videos Inflammology series of books and videos Inflammology series of books and videos Inflammology series of books and videos translates important concepts and nutritional/biomedical science into easy and practical clinical applications for the prevention and treatment of disorders of sustained inflammation, which Dr Vasquez describes as " patterns of metabolic disturbance and inflammatory dysfunction " existing in three sequential and overlapping categories: 1) metabolic inflammation, 2) allergic inflammation, 3) autoimmune inflammation. This book includes access to video presentations which introduce the origin and components of the Functional Inflammology Protocol and FINDSEX ® acronym. Post-publication updates to this information and important social and clinical contextualization are made available in videos and online repositories (access provided in the book), and the e-newsletter available from ICHNFM.ORG. This textbook also provides access, via reprints or hyperlinks, to Dr Vasquez's published articles—an example of which is his recent paradigm-shifting editorial published in the journal Alternative Therapies in Health and Medicine (2014 January). The updated section on pain management allows students and clinicians to understand and apply manual, pharmacologic, nutritional and botanical medicine treatments for musculoskeletal pain, thereby providing better relief for patients and avoiding the hazards of NSAIDs, coxibs, steroids, opioids, immunosuppressants and biologics.

Evidence-based medicine (EBM) is the combination of the best available research evidence with clinical experience and patient needs. The concept of EBM as a part of clinical decision making has become increasingly popular over the last decade. In the hierarchy of studies meta-analysis and systematic reviews occupy the highest levels. A systematic review of a clinical question can be performed by following a relatively standard form. These techniques as described here can be performed without formal training. Systematic reviews conducted in this fashion can be used as a higher form of current concepts or as review articles and replace the traditional expert opinion narrative review.

Study Design. Cross-sectional study. Objective. The present study compared activity of deep and superficial cervical flexor muscles and craniocervical flexion range of motion during a test of craniocervical flexion between 10 patients with chronic neck pain and 10 controls.

Cryotherapy is perhaps the simplest and oldest therapeutic modality in the treatment of acute soft-tissue injuries. It is proposed that by decreasing tissue temperature, ice can diminish pain, metabolism, and muscle spasm, minimizing the inflammatory process and thereby aiding recovery after soft-tissue trauma. The majority of research studies and reviews to date have used healthy human subjects to investigate these proposed physiological effects. Although there is evidence that cryotherapy can reduce deep-tissue temperature in both animal 2 and human subjects, 16,46,65 the degree of cooling seems to depend on the method and duration of application, the initial temperature of the ice, and even the depth of subcutaneous fat. 40

Patients presenting with musculoskeletal pain and injury challenge the office internist with extensive differential diagnoses and management considerations. The acutely traumatized patient should be rapidly evaluated for the presence of life-or limb-threatening injuries. Any evidence of significant head, spinal, chest, abdominal, or pelvic injuries should precipitate rapid transfer to the closest emergency department. Similarly, patients who have open musculoskeletal trauma, obvious extremity deformity, or severe pain and those who are nonambulatory are better served in the emergency department than in the office.

We propose standardized definitions and criteria for documenting subjective results for clinical orthopedic studies in veterinary medicine. To our knowledge, no common terminology or basis for describing results in this manner has been published. This lack of standardization limits our abilities to communicate study results in a consistent manner, interpret data appropriately, and compare results across studies, centers, and techniques. An initial step toward addressing these deficiencies is to provide clear definitions and criteria for time frames of data collection, subjective outcomes, and complications. These definitions and criteria are recommended for use based on consensus among the authors who have experience and expertise in small animal and equine orthopedic clinical research. Our hope is that this terminology will be implemented so that data collection and reporting are more consistent and effective in veterinary orthopedic reports.

PURPOSE: Report the test-retest reliability, construct validity, minimum clinically important difference (MCID), and minimal detectable change (MDC) for the Neck Disability Index (NDI). STUDY DESIGN/SETTING: Cohort study of patients presenting to outpatient physical therapy clinics. PATIENT SAMPLE: Ninety-one subjects with a primary complaint of neck pain, with or without concomitant upper extremity (UE) symptoms, who were participants in a randomized clinical trial. OUTCOME MEASURES: NDI and the 15-point Global Rating of Change (GRC) self-report measures. METHODS: All subjects completed the NDI at baseline and at a 3-week follow-up. Additionally, subjects completed the GRC scale, which was used to dichotomize patients into improved or stable groups. Changes in the NDI were used to assess test-retest reliability, construct validity, MCID, and MDC. RESULTS: Test-retest reliability was moderate for the NDI (intraclass correlation coefficient, 0.64; 95% confidence interval, 0.19-0.84). For the NDI, the MCID was 7.5 points and the MDC was 10.2 points. CONCLUSIONS: The NDI appears to demonstrate adequate responsiveness based on statistical reference criteria when used in a sample that approximates the high percentage of patients with neck pain and concomitant UE referred symptoms. Because the MCID is within the bounds of measurement error, a 10-point change (the MDC) should be used as the MCID. Ó

Background: Although the headgear appliance has been used extensively to correct anteroposterior discrepancies, its treatment effects have not yet been adequately assessed in an evidence-based manner. Objective: Aim of this systematic review was to assess the therapeutic and adverse effects of early headgear treatment from controlled clinical trials on human patients in an evidence-based manner. Search methods: An unrestricted electronic search of six databases from inception to December 2015. Selection criteria: Randomized and prospective non-randomized controlled trials assessing the effects of headgear treatment on human patients. Data collection and analysis: After duplicate study selection, data extraction, and risk of bias assessment according to the Cochrane guidelines, random-effects meta-analyses of mean differences (MDs) and relative risks (RRs), including their 95% confidence intervals (CIs) were performed, followed by subgroup and sensitivity analyses. Results: A total of 18 unique studies with a total of 930 (56% male/44% female) patients were included. Headgear treatment was associated with a posterior translation of the anterior maxilla border in the short term, as seen by the mean annualized change in the SNA angle (MD = −1.63°/ year; 95% CI = −2.20 to −1.06°/year; high quality evidence) compared to untreated patients. This effect was independent of the rotation of the palatal plane and the inclination of the upper incisors, while a proportional relationship with the initial discrepancy in SNA was seen. The clinical significance of this improvement diminished in the long term, although only limited evidence existed. Additionally, early headgear treatment might decrease the risk of dental trauma during the following years (RR = 0.34; 95% CI = 0.14 to 0.80; moderate quality evidence). Low quality evidence on the effect of headgear on the rotation of the palatal plane, the nasolabial angle, the occlusal outcome, and signs of temporomandibular disorders precluded robust assessments, due to risk of bias, inconsistency, imprecision, and small-study effects. Conclusions: Based on existing trials, headgear is a viable treatment option to modify sagittal growth of the maxilla in the short term in Class II patients with maxillary prognathism. Registration: PROSPERO (CRD42015029837). Funding: None.

BACKGROUND: Competency-based education and simulation are being used more frequently in surgical skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become more active participants in the learning process while maintaining expert guidance and supervision.

D Di ip pl lo om ma ad do o e en n E Ed du uc ca ac ci ió ón n ( (I IP PL LA AC C --D De er rr ra am ma a M Ma ag gi is st te er ri ia al l) ) M Ma ae es st tr rí ía a e en n I In nv ve es st ti ig ga ac ci ió ón n y y D Do oc ce en nc ci ia a e en n E Es st to om ma at to ol lo og gí ía a ( (U UN NF FV V) ) C Cu ur rs so o d de e P Po os st tg gr ra ad do o e en n O Or rt to od do on nc ci ia a y y O Or rt to op pe ed di ia a M Ma ax xi il la ar r ( (A AA AP PO OM M) ) E Ex x --D Do oc ce en nt te e d de e O Op pe er ra at to or ri ia a D De en nt ta al l y y B Bi io om ma at te er ri ia al le es s d de e l la a F Fa ac cu ul lt ta ad d d de e E Es st to om ma at to ol lo og gí ía a( (U UP PC CH H) ) D Do oc ce en nt te e I In nv vi it ta ad do o e en n l lo os s D Di ip pl lo om ma ad do os s d de e E En nd do od do on nc ci ia a y y O Od do on nt to ol lo og gí ía a E Es st té ét ti ic ca a ( (U UC CS S) ) D Do oc ce en nt te e A Au ux xi il li ia ar r ( (C Cu ur rs so o B Bá ás si ic co o) ) d de e l la a A As so oc ci ia ac ci ió ón n A At te en ne eo o P Pe er ru ua an no o d de e O Or rt to op pe ed di ia a M Ma ax xi il la ar r Para el tratamiento de la Maloclusión Clase II División 1, como la llamamos convencionalmente ahora, Norman Kingsley (1880) había desarrollado su aparato para adelantar la mandíbula (bite the jumping) y, aunque quizás haya sido el primero en la historia de la ortopedia funcional, le debemos al anatomista Roux (1881) la filosofía que implica el manejo de los estímulos funcionales y el proceso de adaptación funcional. A partir de esos años, otras luminarias han hecho notables aportes respecto para el entendimiento de la ortopedia funcional; por ejemplo Wolf (1892), quien plantea y comprueba la ley que relaciona a la función con la forma, planteando que: "Todo cambio en la forma y función de un hueso o en su función solamente, es seguido por ciertos cambios definidos en su arquitectura interna y por una alteración secundaria igualmente definida en su conformación externa, de conformidad con leyes matemáticas". O Eschler (1965), quien aclaró la importancia de la musculatura en la determinación de la morfología en las arcadas dentarias. P 1,2 PAsí

Implant stability is not only a function of strength but also depends on the fixation established with surrounding tissues [Robertson DM, Pierre L, Chahal R. Preliminary observations of bone ingrowth into porous materials. J Biomed Mater Res 1976;10:335-44]. In the past, such stability was primarily achieved using screws and bone cements. However, more recently, improved fixation can be achieved by bone tissue growing into and through a porous matrix of metal, bonding in this way the implant to the bone host. Another potentially valuable property of porous materials is their low elastic modulus. Depending on the porosity, moduli can even be tailored to match the modulus of bone closer than solid metals can, thus reducing the problems associated with stress shielding. Finally, extensive body fluid transport through the porous scaffold matrix is possible, which can trigger bone ingrowth, if substantial pore interconnectivity is established [Cameron HU, Macnab I, Pilliar RM. A porous metal system for joint replacement surgery. Int J Artif Organs 1978;1:104-9; Head WC, Bauk DJ, Emerson Jr RH. Titanium as the material of choice for cementless femoral components in total hip arthroplasty. Clin Orthop 1995;85-90].

Background: The American edition of The Journal of Bone and Joint Surgery (JBJS-A) has included a level-of-evidence rating for each of its clinical scientific papers published since January 2003. The purpose of this study was to assess the type and level of evidence found in nine different orthopaedic journals by applying this level-of-evidence rating system.

Objective To gain insights into the diagnosis and management of contracted (frozen) shoulder (CFS) in a sample of UK physiotherapists, underpinning the development of evidence-based clinical guidelines. Methods An anonymous online questionnaire was developed and distributed via iCSP, targeting physiotherapists who treat CFS. For treatments, respondents were invited to consider 'pain-predominant' and 'stiffness-predominant' scenarios, choose from listed treatment options, and specify any unlisted conservative options they might consider. Frequency analysis was used for closed-ended questions, and content analysis was used for open-ended questions. Results In total, 289 valid responses were received. All respondents thought that movement restriction informed diagnosis. Of those specifying the manner of testing movements, 98% (121/123) included passive testing. Of those describing specific patterns of restriction, 71% (93/131) emphasised external rotation. Fifty-four percent (152/282) of valid respondents would consider suggesting/requesting imaging investigations, usually to exclude bony abnormalities. For treatment, only 46 respondents reported considering any unlisted conservative options, usually liaison regarding medication. For pain-predominant CFS, the preferred physiotherapeutic options were advice/education (96%; 277/288), injection (80%; 230/288), gentle exercise (79%; 228/288), superficial heat/cold (69%; 199/288) and acupuncture (68%; 196/288). For stiffnesspredominant CFS, the preferred options were stretching (93%; 268/288), advice/education (88%; 252/288), joint mobilisations (87%; 250/288), function-based exercises (75%; 216/288) and hands-on soft-tissue techniques (59%; 170/288). Some dissociation was noted between clinical practice and research evidence. Eighty-five percent (253/284) of respondents would consider referring for an orthopaedic opinion. Conclusions Acknowledging restricted passive external rotation (vs the capsular pattern) as diagnostic of CFS would standardise and might improve the clinical aspect of diagnosis. The value of X-rays in differential diagnosis was under-recognised. Modalities used to treat CFS were dichotomised by pain-predominant and stiffness-predominant classifications, which may be more useful than existing classifications.

Calcium phosphate materials are similar to bone in composition and in having bioactive and osteoconductive properties. Calcium phosphate materials in different forms, as cements, composites, and coatings, are used in many medical and dental applications. This paper reviews the applications of these materials in dentistry. It presents a brief history, dental applications, and methods for improving their mechanical properties. Notable research is highlighted regarding (1) application of calcium phosphate into various fields in dentistry; (2) improving mechanical properties of calcium phosphate; (3) biomimetic process and functionally graded materials. This paper deals with most common types of the calcium phosphate materials such as hydroxyapatite and tricalcium phosphate which are currently used in dental and medical fields.

The possible association between orthodontic treatment and temporomandibular disorders (TMD) is a topic of great interest in the current literature. The true role of orthodontic therapy on the etiology of TMD, however, is still uncertain. From the clinical prospective, a thorough examination of the stomatognathic system is always necessary in order to detect possible TMD signs and symptoms prior to the beginning of the orthodontic therapy. Caution should be exercised when planning, performing and finalizing orthodontics, especially in patients who with history of signs and symptoms of TMD. The clinician must always eliminate patient's pain and dysfunction before initiating any type of orthodontic mechanics. Muscle incoordination, unstable disc-condyle relationship and bone alterations are usual TMD conditions that can interfere with the presenting occlusal relationship. This article reviews these aspects and presents a detailed clinical guide for the examination of the orthodontic patient, considering aspects related to facial pain and dysfunction.

The RDP Classifier is a widely used bioinformatic program that performs taxonomic classification of 16S rRNA gene sequences. However, the accuracy of the program is not clear when it is applied to common PCR products of the 16S rRNA variable regions, which are heavily used in microbiome projects. In this study, fulllength 16S rRNA gene alignments from the SILVA database were used to simulate the PCR products of the combined variable regions (i.e., V1-V3, V3-V5, and V6-V9). The classification accuracies obtained from RDP Classifier were evaluated for each of the simulated 16S rRNA regions, at different confidence score thresholds. Although minor bias was observed, the RDP Classifier achieved overall similar and accurate classification results when using the combined variable regions of the 16S rRNA gene, i.e., V1-V3, V3-V5, and V6-V9. Additional analysis showed that V2 and V4 were the most accurate among individual regions (i.e., V1 to V9).

Transverse maxillary deficiency, no matter in adolescents or in adults, is frequently seen in the patients seeking orthodontic
treatment. The treatment goal of detaching the midpalatal suture can be achieved using an expansion device. In present
article we give a review on various palatal expansion appliances and treatment protocol. A comprehensive search of the
literatures was performed to observe the regime of different maxillary expansion appliances and therapies.
Keywords: Maxillary Expansion; Maxillary Deficiency; Orthopedic Treatment.

Ancient Egypt might be considered the cradle of medicine. The modern literature is, however, sometimes rather too enthusiastic regarding the procedures that are attributed an Egyptian origin. I briefly present and analyze the claims regarding orthopedic surgery in Egypt, what was actually done by the Egyptians, and what may have been incorrectly ascribed to them. I reviewed the original sources and also the modern literature regarding surgery in ancient Egypt, concentrating especially on orthopedic surgery. As is well known, both literary sources and the archaeological/osteological material bear witness to treatment of various fractures. The Egyptian painting, often claimed to depict the reduction of a dislocated shoulder according to Kocher's method, is, however, open to interpretation. Therapeutic amputations are never depicted or mentioned in the literary sources, while the specimens suggested to demonstrate such amputations are not convincing. The ancient Egyptians certainly...

Cerebral palsy (CP) is a nonprogressive disorder of motion and posture caused by a brain insult or injury occurring in the period of early brain growth (less than 2 years of age). Although improvements in both prenatal and perinatal care have been directed at minimizing injury to the central nervous system, an increased survival from neonatal intensive care units has left the incidence of CP fairly constant. The prevalence remains approximately 1 to 5 per 1000 in Western countries40; however, a change has occurred in the type of presentation as a result of improved neonatal care. For example, athetosis caused by hyperbilirubinemia occurs much less frequently, but diplegia and hemiplegia occur more f r e q~e n t l y .~~

Broeren J, Rydmark M, Sunnerhagen KS. Virtual reality and haptics as a training device for movement rehabilitation after stroke: a single-case study. Arch Phys Med Rehabil 2004;85:1247–50.To investigate whether training in a virtual environment with a haptic device will improve motor function in the left hemiparetic arm of a stroke subject.Single case, A-B-A design.University hospital research laboratory.A man in his late fifties (right handed), with a right-hemisphere lesion that caused a deficit in the left upper extremity.The subject trained with a 3-dimensional computer game during a 4-week period that consisted of twelve 90-minute sessions.Three tests (Purdue pegboard test, dynamometer hand-grip strength, upper-extremity test) and a subjective interview were used to evaluate motor performance.Improvements were found in fine manual dexterity, grip force, and motor control of the affected upper extremity. The subject reported that there was a change in his day-to-day use of the upper extremity and that he was able to use it in activities that were previously impossible for him.Training with virtual reality and haptics can promote motor rehabilitation.

Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution of "damage control orthopedic surgery."

Calcifying tendonitis of the shoulder is a common, acute or chronic, painful disorder characterized by calcifications in the rotator cuff tendons. A natural cycle exists during which the tendon repairs itself. In chronic calcific tendonitis, however, this cycle is blocked at one of the healing stages. Because chronic presentation with exacerbations is usual, initial treatment should be conservative, including rest, physical therapy, nonsteroidal anti-inflammatory drugs, and, in later stages, subacromial infiltration with corticosteroids. Surgery is recommended when conservative treatment fails. This article discusses advances in imaging and medical, physical, and surgical management, as well as current evidence for the treatment of calcifying tendonitis of the shoulder.

MRI has become an important diagnostic tool in the evaluation of rotator cuff pathology and the technology continues to evolve. Direct MR arthrography, diagnosisspecific sequencing such as fat suppression, special positioning such as abducted externally rotated (ABER) views and ultra high field magnets allow for an unprecedented level of detail in imaging. In this article, we review MRI findings in patients with rotator cuff abnormalities that are anatomic variants or incidental findings. Although MRI findings may be diagnostic in some cases, we find that clinical correlation with history and physical examination is critical to differentiate between anatomic variants, incidental findings, and true pathology. We conclude that good communication between the orthopedic surgeon and the radiologist is necessary to optimize diagnostic yield.

This chapter reviews recent developments in biodegradable synthetic polymers focusing on tailoring polymer structures to meet material specification for emerging applications such as tissue engineered products and therapies. Major classes and new families of synthetic polymers are discussed with regard to synthesis, properties and biodegradability, and known degradation modes and products are summarized based on studies reported during the past 10-15 years. Polyesters and their copolymers, polyurethanes, polyphosphazenes, polyanhydrides, polycarbonates, polyesteramides and recently developed injectable polymer systems based on polypropylenefumarates, polyurethanes and acrylate/urethane systems are reviewed. Polyesters such as polyglycolides, polylactides and their copolymers still remain as the major class of synthetic biodegradable polymers with products in clinical use. Although various copolymerization methods have addressed needs of different applications, release of acidic degradation products, processing difficulties and limited range of mechanical properties remains as major disadvantages of this family of polymers. Injectable polymers based on urethane and urethane/acrylate have shown great promise in developing delivery systems for tissue engineered products and therapies. (P. Gunatillake). The ultimate fate of glycolic acid in vivo is considered to be the conversion into carbon dioxide and water, with removal from the body via the respiratory system . However, Hollinger has suggested that only lactic acid (LA) follows this pathway, and that glycolic acid is converted into glyoxylate (by glycolate oxidase), which is then transferred into glycine after reacting with glycine transaminase.

Advances in orthopedic and arthroscopic surgical procedures of the knee such as, knee replacement, ligamentous reconstruction as well as articular cartilage and meniscus repair techniques have resulted in a significant increase in the number of patients undergoing knee arthroscopy or open surgery. As a consequence postoperative MR imaging examinations increase. Comprehensive knowledge of the normal postoperative MR imaging appearances and abnormal findings in the knee associated with failure or complications of common orthopedic and arthroscopic surgical procedures currently undertaken is crucial. This article reviews the various normal and pathological postoperative MR imaging findings following anterior and posterior cruciate ligament, medial collateral ligament and posterolateral corner reconstruction, meniscus and articular cartilage surgery as well as total knee arthroplasty with emphasis on those surgical procedures which general radiologists will likely be faced in their daily clinical routine.

Os fatores prognósticos das fraturas de fêmur proximal no idoso são de extrema importância no cunho da medicina, principalmente no ortopédico, pelo fato de poder antecipar os tipos de intervenção ao qual pode se submeter um idoso, antecedendo o estudo do assunto, ou seja, da intervenção cirúrgica e seus problemas e dessa maneira tornando-se mais apto para lidar com o assunto, um tanto comum na idade mais avançada, com ossos mais frágeis e susceptíveis a quebras. A intervenção com qualidade e de modo correto, sem necessidade de novas intervenções, a recuperação de forma correta, tornam as medidas prognósticas de extrema importância no estudo do tema.

Palavras-Chave: Ortopedia, Fatores Prognósticos, Fraturas de Fêmur Proximal, Idoso

Purpose Elbow flexion contractures are a common sequela in obstetric brachial plexus palsy. The etiology and best management of these contractures is unclear. Nonsurgical treatment involving serial casting and splinting is supported in the literature. The purpose of this study is to evaluate the effectiveness of serial casting and splinting of elbow flexion contractures in children with obstetric brachial plexus palsy.

The scapula is a large triangular-shaped bone that is situated on the posterior thorax. The pseudojoint between the scapula and the thorax is one of the least congruent of the Snapping scapula is a painful crepitus of the scapulothoracic articulation. This crepitus is a grinding or snapping noise with scapulothoracic motion that may or may not accompany pain. This condition is commonly seen in overhead-throwing athletes. Treatment of patients with this syndrome begins with nonoperative methods; when nonoperative treatment fails, several surgical options exist. This article will discuss both nonoperative and operative management of this common shoulder condition.