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Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot T...CrimsonPublishersOPROJ
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot Treatment by Mario Lampropulos* in Crimson Publishers: Orthopedic Research and Reviews Journal
Megaprosthetic replacement of knee in a young boy of 14 yearsApollo Hospitals
Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like osteosarcoma around the knee has become a common indication for TKR in young. We report, here a histologically confirmed osteosarcoma in right
proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery using Global Modular Replacement System (GMRS, Stryker).
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot T...CrimsonPublishersOPROJ
Calcaneal Lengthening Using Bone Substitute Graft for Neurological Flatfoot Treatment by Mario Lampropulos* in Crimson Publishers: Orthopedic Research and Reviews Journal
Megaprosthetic replacement of knee in a young boy of 14 yearsApollo Hospitals
Now a days, Total Knee Replacement (TKR) is a common for elderly patients but is an uncommon procedure in young individuals. Recently, limb conservation surgery for malignant bone tumours like osteosarcoma around the knee has become a common indication for TKR in young. We report, here a histologically confirmed osteosarcoma in right
proximal tibia of a 14-year-old boy who was managed successfully by limb salvage surgery using Global Modular Replacement System (GMRS, Stryker).
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hams...Apollo Hospitals
In this study, we analyzed the clinical outcomes at two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.
this presentation focus on a specific problem for patients with multiple hereditary exostosis who suffered from forearm deformity . It introduce a new technique to correct the deformity while preserving the epipyseal plate to maintain the growth of the bone.It avoids the complex surgery of distraction osteogenesis.
Corrective Surgery for Malunited Tibial Plateau Fractureiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The role of radiation diagnostic methods in pathological changes of the hip j...SubmissionResearchpa
Endoprosthesis replacement-operational treatment of diseases and damages of hip joint. The problem of prevention of complications and their negative effects is extremely actual today. However the role of different beam techniques in identification of adverse effects and complications of endoprosthesis replacement of joints is studied insufficiently. Results of clinic and diagnostic and beam researches of 40 patients with pathology of hip joint are analyzed. The used beam methods of research - roentgenography, multispiral computed tomography. At presurgical stage the main objective was detection of pathology of joint, definition of indications and planning of operative measure. Situation and relationship of components of endoprosthesis, condition of bone tissue, and also bone cement round cup and leg of prosthesis were key parameters of radiological assessment of outcomes of endoprosthesis replacement. Complex use of radiological techniques (roentgenography and spiral computed tomography) allows to specify and add semiotics of changes of bone tissue at the level of acetabular hollow and proximal department of femur after endoprosthesis replacement. by Janibekov J. J 2020. The role of radiation diagnostic methods in pathological changes of the hip joint before and after endoprosthetics. International Journal on Integrated Education. 3, 11 (Dec. 2020), 203-205. DOI:https://doi.org/10.31149/ijie.v3i12.918. https://journals.researchparks.org/index.php/IJIE/article/view/918/866 https://journals.researchparks.org/index.php/IJIE/article/view/918
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hams...Apollo Hospitals
In this study, we analyzed the clinical outcomes at two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.
this presentation focus on a specific problem for patients with multiple hereditary exostosis who suffered from forearm deformity . It introduce a new technique to correct the deformity while preserving the epipyseal plate to maintain the growth of the bone.It avoids the complex surgery of distraction osteogenesis.
Corrective Surgery for Malunited Tibial Plateau Fractureiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The role of radiation diagnostic methods in pathological changes of the hip j...SubmissionResearchpa
Endoprosthesis replacement-operational treatment of diseases and damages of hip joint. The problem of prevention of complications and their negative effects is extremely actual today. However the role of different beam techniques in identification of adverse effects and complications of endoprosthesis replacement of joints is studied insufficiently. Results of clinic and diagnostic and beam researches of 40 patients with pathology of hip joint are analyzed. The used beam methods of research - roentgenography, multispiral computed tomography. At presurgical stage the main objective was detection of pathology of joint, definition of indications and planning of operative measure. Situation and relationship of components of endoprosthesis, condition of bone tissue, and also bone cement round cup and leg of prosthesis were key parameters of radiological assessment of outcomes of endoprosthesis replacement. Complex use of radiological techniques (roentgenography and spiral computed tomography) allows to specify and add semiotics of changes of bone tissue at the level of acetabular hollow and proximal department of femur after endoprosthesis replacement. by Janibekov J. J 2020. The role of radiation diagnostic methods in pathological changes of the hip joint before and after endoprosthetics. International Journal on Integrated Education. 3, 11 (Dec. 2020), 203-205. DOI:https://doi.org/10.31149/ijie.v3i12.918. https://journals.researchparks.org/index.php/IJIE/article/view/918/866 https://journals.researchparks.org/index.php/IJIE/article/view/918
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
The Principe of high tibial osteotomy is to reduce the stresses of the internal compartment of the knee by valgizing the tibia.The
total knee arthroplasty on this tibia with a “malunion” presents technical difficulties related to the initial approach, the presence of osteosynthesis material, the presence of malunion and the change of bone density. The objectives of this study are to determine the clinical and radiographic results of patients undergoing Total Knee Arthroplasty (TKA) after High Tibial Osteotomy (HTO). This is a retrospective descriptive study including patients undergoing Total Knee Arthroplasty (TKA) after an High Tibial Osteotomy (HTO) at the Hospital of Mont de Marsan (France) from 2008 to 2017 with a minimum follow-up of 12 months. Thirty knees (27 patients) were recruited. The sex ratio was 1.72. The average age was 70.33 years (54years-88years). The average time between High Tibial Osteotomy (HTO) and Total Knee Arthroplasty (TKA) was 10.83 years (1 year-26 years). The medial opening was 63.33% and lateral closure for the rest. Clinical improvement was observed, with an average gain of 24.97 points for pain, 1 point for stability, 1 point for knee mobility and 5 points for walking distance. The clinical result was perfect in 13.33%, excellent in 42% and medium in 36.67% of cases. The alignment was obtained in 76.67% of cases (p = 0.0039). The posterior tibial slope, epiphyseal varus, patellar height were corrected in 80% of cases respectivly (p = 0.000011, p = 0.44, p = 0.15). Residual pain was observed in 26.66%, joint stiff ness in 16.66%, skin healing disorder in
16% and infection in 6.66% of cases. Total knee arthroplasty made it possible to recover the failure of an high tibial osteotomy.
Comparison Results between Patients with Developmental Hip Dysplasia Treated ...CrimsonPublishersOPROJ
Comparison Results between Patients with Developmental Hip Dysplasia Treated with Either Salter or Pemberton Osteotomy by Dello Russo Bibiana* in Orthopedic Research Online Journal
Severe
patellofemoral arthritis secondary to patellofemoral
malalignment
treated by Fulkerson osteotomy plus tricortical
bone graft. A retrospective cohort of 45 knees.
Corrigendum to “Special surgical technique for knee arthroplasty”Apollo Hospitals
We typically operate more than 1200-1800 cases a year, out of which we have included 300 cases randomly for the study. All these selected cases were local residents and easy to follow-up.
Guided Growth for Angular Knee Deformities in Nutritional Rickets ChildrenTamer El-Sobky
Nutritional rickets in children is a global health concern. It manifests in generalized skeletal deformities including angular or coronal plane knee deformities. Guided growth surgery is a recognized treatment option for angular knee deformities in general. However, there is insufficient citations on its use in the treatment of angular knee deformities in children with nutritional rickets. Rachitic lower limb deformities can be complex. They are usually multiostotic, multiapex and multiplane and require extensive corrective osteotomies. However osteotomies are fraught with complications and can be technically demanding. In this presentation we present our experience with the use of surgical guided growth as a minimally invasive treatment option to correct angular knee deformities in children with nutritional rickets.
Surgical relapse /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...
Complete subtalar release for older children with neglected CTEV - البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن
1. This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
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websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
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2. Author's personal copy
Foot and Ankle Surgery 16 (2010) 38–44
Complete subtalar release for older children who had recurrent clubfoot
deformity
Freih Odeh Abu Hassan FRCS*, Samir Jabaiti FRCS, Tarek El tamimi MD
Department of Orthopedics Surgery, Department of Plastic & Reconstructive Surgery, Jordan University Hospital, Amman, Jordan
1. Introduction
Patients presenting for treatment of previously failed clubfoot
or severe neglected club deformities are still common in many
parts of the world. These feet are often rigid and severely
deformed, complete release of these clubfoot is the prevailing
option to obtain a plantigrade foot, but leaves a quite wide residual
defect with exposed tendons, joints, bones and neuro-vascular
bundles. 13–50% of surgically treated clubfeet had relapse, this will
lead to persistent and residual deformities which necessitate
surgical correction [1].We assume that these results are due in part
to the treating orthopaedic surgeons being familiar with this
condition. If this is the case we anticipate even higher incidence of
relapse in cases treated by an orthopaedic surgeon who treat these
cases less frequently. The main aim of surgical treatment of
clubfoot is to achieve a pain free, functional, and plantigrade foot.
The long-term aim is to enable the patient to wear normal shoes.
However the best method to achieve these objectives remains a
controversial issue among all orthopaedic surgeons. Revision
surgery entails repeated or further soft-tissue releases usually
combined with one or more osteotomies in older children to
correct residual deformity. The presence of scarred tissue from
repeated operations highlights the challenges facing the treating
A R T I C L E I N F O
Article history:
Received 11 January 2009
Received in revised form 24 April 2009
Accepted 7 May 2009
Keywords:
Clubfoot
Flap
Deformity
Complete subtalar release
A B S T R A C T
Background: Neglected idiopathic clubfoot deformities, and severe recurrent deformity after previous
surgery presents technical difficulties for correction and challenges for surgeons to achieve primary skin
closure.
Methods: Between 2000 and 2006, 18 children (30 feet), had complete subtalar release (CSTR) for failed
previous surgery in 28 feet and severe neglected congenital talipes equinovarus (CTEV) in 2 feet followed
by cross leg fasciocutaneous flaps for reconstruction of residual defect at the ankle and foot after full
correction of the deformity.
Mean patients followed up were 4.5 years (average 2–8 years). 23 feet were classified as Dimeglio III
and 7 feet as Dimeglio IV.
Results: All cases achieved a plantigrade foot, better walking ability (p < 0.03), and parental satisfaction
with the result (p < 0.001).
Ankle joint doriflexion increased from mean (21.338) preoperatively to (12.58) postoperatively. All
cases showed postoperative improvement in their radiographic findings. The mean preoperative
talocalcaneal angle increased from (15.78 to 30.038). The talo-first metararsal angle improved from a
preoperative mean of 168 mean of 5.538 postoperatively. At the final follow-up cosmetically acceptable
plantigrade foot was achieved in all feet. Four legs (14.28%) developed hypertrophic scars at the donar
flap site. One patient developed 1.5 cmmarginal necrosis of the flap, which did heal after debridement by
secondary intention. None of the feet had recurrence at the final follow up. Despite the enormous
improvement clinically and radiologically, their was no statistical significant difference between
preoperative and postoperative radiological angles (p 0.069).
The number of previous surgical interventions had no influence on the outcome. All the previously
treated feet had inadequate release of important tethered soft tissue.
Conclusion: This is indicative of the enormous value of complete subtalar release combined with cross
leg fasciocutaneous flap without the need for bony intervention in previously operated failed feet or
neglected deformities.
2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
* Corresponding author at: P.O. Box 73/Jubaiha 11941, Amman, Jordan.
Tel.: +962 6 5240 346.
E-mail address: freih@ju.edu.jo (F.O.A. Hassan).
Contents lists available at ScienceDirect
Foot and Ankle Surgery
journal homepage: www.elsevier.com/locate/fas
1268-7731/$ – see front matter 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2009.05.002
3. Author's personal copy
F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44 39
Fig. 1. Case number 18: This is an 8.5 years old male patient who had multiple previous surgeries for his bilateral CTEV. (A) Preoperative photograph of the patient from front
while standing showing the significant deformity in both feet. (B) Preoperative photograph of the patient from behind while standing showing the prominent equinus
deformity and varus heels. (C) Intraoperative photograph showing the extensive soft-tissue defect medially and posteriorly after full correction of the deformity. (D)
Postoperative photograph of the patient from front while standing showing the plantigrade alignment and full correction of the deformity in both feet. (E) Postoperative
photograph of the patient from behind while standing showing the neutral alignment of both heels with visible flap covering the posterior aspect of the feet. (F) Postoperative
photograph of the patient from front while standing with abduction of the feet showing normal medial arches with visible flap covering the medial aspect of the feet.
surgeon of such difficult cases. Various surgical procedures were
described to re-align the foot to alleviate pain and allow
plantigrade weight bearing with adequate joint motion despite
the subnormal radiographic presentation [1,3,6–10].
Ilizarov technique has been used as a distraction method in
different directions for realignment of the foot to be plantigrade
with various success rates [11–14].
All the previous methods have some degree of success in
managing the deformity but have certain problems. The objective
of this retrospective review is to evaluate the results of acute
surgical correction of residual and recurrent congenital clubfoot
using complete subtalar release (CSTR) without bony surgery
followed by cross leg fasciocutaneous flaps for reconstruction of
soft-tissue defect.
2. Patients and methods
Eighteen children (30 feet), 12 were bilateral and 6 were
unilateral, treated for severe rigid clubfoot deformity. All children
were treated between 2000 and 2006 by complete subtalar
surgical release for recurrent or neglected foot deformities. The
procedure was performed in 11 boys (17 feet) and 7 girls (11 feet).
Patients ranged in age from 3–11 years Mean 5.6 year. Thirteen
patients (23 feet) had failed surgery of idiopathic congenital talipus
equinovarus (CTEV), 3 patients (5 feet) had failed surgery for
neuromuscular clubfoot and 2 patients (2 feet) had two untreated
idiopathic CTEV. All primary surgical release was performed by
general orthopaedic surgeon at different hospitals using poster-omedial
release similar to the technique described by Turco. They
had an average of 2.8 (range 1–5) operations for CTEV. Medical
records of these patients were reviewed for age, sex, number of
previous surgical procedures, sidedness of deformity, degree of
deformity and complications. The preoperative assessment was
based on clinical evaluation and imaging study. The clinical
evaluation consisted of identification of main complaint, patients’
or parents’ expectations, gait pattern assessment, range of
movement of the ankle and subtalar joint, categorising the type
of clubfoot (primary, revision or neuromuscular), condition of skin
and soft tissues, demographic data of the patient and assessment of
the various components of the residual deformity. In all patients
we obtained digital photographs of the foot and ankle in the
standing position from the front, back and sides, this served as a
preoperative reference (Figs. 1 and 2). We have recognized three
main objectives of deformity correction: a plantigrade foot that fits
in a normal shoe, a stable foot that allows better gait and
cosmetically better looking foot. In all feet the severity of the
deformity was graded preoperatively and postoperatively accord-ing
to the Dimeglio’s method [15]. Twenty-three feet were graded
as severe (grade III), and seven, were very severe (grade IV)
(Table 1). Imaging study included plain X-ray, computed tomo-graphy,
and 3D CT reconstruction when possible Fig. 2a and b).
Four views were performed to allow appropriate preoperative
planning and postoperative evaluation. These were standing AP of
the ankle, standing lateral projection radiographs of the ankle and
foot, mortice ankle view, 458 Oblique and standing AP of the foot.
Alignment axes were measured preoperatively and postopera-tively,
talus-first metatarsal angle, talocalcaneal index and shape of
talar dome recorded. Revision surgery was performed through a
Cincinnati approach [16,17] with complete posteromedial–lateral
release and lengthening all structures causing the deformity
(Fig. 1). All patients had the same surgical soft-tissue release by the
first author and cross leg flap by the second author at the same
surgical setting.
2.1. Operative technique
With the patient lying supine, above knee tourniquet applied,
cleaning and draping both feet and legs to the level of midthigh.
After partial exsanguination the tourniquet was elevated to 200/
mmHg. Every foot in this study group underwent a comprehensive
posteromedial–lateral release using a Cincinnati incision. A
transverse incision that extends from the anteromedial (region
of navicular-cuneiform joint) to the anterolateral (just distal and
medial to the sinus tarsi) aspect of the foot and over the back of the
ankle at the level of the tibiotalar joint was observed. The skin
incision was deepened down to the level of deep fascia without
dissection in the subcutaneous tissue. The neurovascular bundle
was identified and mobilized and held by vascular tape. All four
quadrants of the foot were approached to enable the release of all
contracted tissues (Table 2). In each foot the surgery consisted of
elongation of the Achilles tendon in the frontal plane, a posterior
capsulotomy of the posterior aspect of the ankle and subtalar joint
was performed. Medially, the following structures were included
in the release: Z-lengthening of the tibial posterior, flexor hallucis
and flexor digitorum muscles was performed at the musculoten-doneous
junction above the level of the ankle. There was a release
of the superficial deltoid ligament and spring ligament complex,
and capsulotomy of the talonavicular and medial and anterior
aspect of the subtalar joint. Plantar fascia, abductor hallucis, flexor
digitorum brevis and the long and short plantar ligaments were
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40 F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44
Fig. 2. (a) Case number 13: 8 years old male presented with neglected CTEV. (A and B) Preoperative photograph of the patient from front and behind while standing showing
the significant deformity of the left foot. (C) Anterior–posterior and lateral preoperative plain radiograph of the left foot showing the gross malalignment of the foot. (D)
Preoperative 3D computerized axial tomography scan of the left foot showing the abnormalities in ankle and foot. (b) Same case number 13. (A) Standing postoperative
photograph of the patient from front, showing the plantigrade alignment and full correction of the deformity in left foot. (B) Standing postoperative photograph of the patient
from behind, showing the slight valgus alignment of left heel with visible flap covering the posterior aspect of the foot. The posterior aspect of the right leg showing
hypertrophic scar at the donar site. (C) Postoperative photograph of the patient while lying, showing good active dorsiflexion of both feet. (D) Standing postoperative lateral
plain radiograph of the left foot showing, well aligned talocalcaneal angle and correction of the deformity. (E) Postoperative 3D computerized axial tomography scan of the left
foot and ankle showing the restoration of anatomy in ankle and foot.
released. The deep deltoid and interosseous talocalcaneal liga-ments
were preserved.
The posterolateral corner behind the lateral ankle was easily
approached and release of peroneal sheath, calcaneofibular and
posterior talofibular ligament was carried out. There was a
capsulotomy of the lateral portions of the talonavicular and the
subtalar joints. Release of the calcaneocuboid joint and calcaneo-navicular
ligament were performed. The reduction of the
talonavicular was stabilized with one temporary horizontal
Kirschner wire in all feet, and the talocalcaneal joint with one
vertical Kirschner wire in 6 feet. The foot was put in fully corrected
position and the tendons were sutured, including the restoration of
the tendon sheaths, followed by haemostasis. In all cases the
lateral wound could be closed primarily, the medial and post
aspects of the wound were large enough to be closed (Fig. 1). The
next step is the covering the wound defect in all feet with
a proximally based fasciocutaneous flaps by the second author.
Marking the flap on the posterior aspect of the opposite leg,
based on the axial blood supply of the posterior descending
subfascial cutaneous branch of the popliteal artery. Dissection was
started from the distal end of the flap towards the base, incision
was made perpendicular to the skin plane, including the skin,
subcutaneous tissue and deep fascia, when the pedicle reached a
trial was made to fit the flap to the defect, so the flap was raised
with minimal dissection that is only sufficient to cover the defect
without tension and kinking of the pedicle. After meticulous
haemostasis the donor site was closed primarily. After skin closure
correction was maintained by plaster casts applied below the knee.
A window was subsequently made in the cast to check on possible
kinking or tension of the skin flap pedicle. When the cast hardened
a window was made opposite to the pedicle for later flap
inspection. Patients received one dose of second-generation
cephalosporin (Zinacef) preoperatively and an additional dose
postoperatively. Three weeks later, division of the flap and closure
of the defect with suturing the divided edge of the flap to the foot
was performed.
Kirschner wires were removed and a complete plaster of Paris
below the knee was applied for another 4 weeks in the corrected
foot position. After removal of the plaster cast, physiotherapy was
advised and an ankle foot orthosis (AFO) was used for 2 months.
2.2. Statistical analysis
The Wilcoxon signed-rank test (SPSS 16.00 for Windows) was
used to compare pre- and postoperative variables. p values of 0.05
or less were considered significant.
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F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44 41
Table 1
Demographic patients data and Dimeglio’s preoperative and postoperative scoring values.
Demographic patients data Preoperative score Postoperative score
ID Age/year Sex Side Type of CTEV Equinus Varus Derotation Adduction Total Equinus Varus Derotation Adduction Total
1 11 M Rt Primary/idiopathic 4 4 4 3 15 1 1 1 1 4
2 9 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
9 F Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3 3 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 1 4
3 F Lt Revision/N.M. 3 4 4 2 13 1 1 1 2 5
4 6 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
5 6 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 5 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
7 6 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
8 7 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
7 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
9 6 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 F Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
10 5 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
11 6 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
6 F Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
12 6 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
13 8 M Lt Primary/idiopathic 4 4 4 4 16 1 1 1 1 4
14 3 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
15 3 F Lt Revision/idiopathic 4 4 4 3 15 1 1 1 1 4
3 F Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
16 3 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
17 3 F Lt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
3 F Rt Revision/N.M. 4 4 4 3 15 1 1 1 2 5
18 8 M Lt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
8 M Rt Revision/idiopathic 3 3 3 3 12 1 1 1 1 4
3. Results
The mean average follow-up period was 4.5 years (range 2–8
years). From clinical point, in all cases parents were satisfied at the
time of the final follow up with their child’s results in terms of
distinct subjective improvement in the shape of the foot with
regard to cosmetic appearance and subjective complaints such as
pain and difficulty in walking (p 0.001).
There were no plantigrade feet preoperatively, whereas all
cases had a plantigrade foot that fits in a normal shoe post-operatively,
both in stance and during ambulation (p 0.03).
At the last follow up the range of the ankle joint movement was
increased in all feet from mean preoperative doriflexion (21.338)
range (10/408), to mean postoperative doriflexion (12.58) range
(10–258) (Table 3). While mean preoperative plantarflexion was
(36.168) range (30–508) and mean postoperative plantarflexion
(33.168) range (30–408). All cases showed postoperative improve-ment
in their radiographic findings. The mean preoperative
talocalcaneal angle in standing lateral profile was (15.78) (range,
11–228), and the mean postoperative range talocalcaneal angle
was 30.038 (range, 24–418). Finally, the talo-first metatarsal angle
improved from a preoperative mean of 168 (range, 35 to 108)
to a mean of 5.538 (range, 0–108) at follow up, indicative of
sufficient correction of forefoot adduction. Both angles showed a
statistical trend towards improvement, but failed to reach
statistical significance (p = 0.069). None of the patients required
a further correction using the same technique. Statistically, the
number of previous operations had no influence on the outcome
(p 0.05). When we started this study the Outcome Evaluation in
Clubfoot generated by the International Clubfoot Study Group
(ICSG) and now advocated as one of the instruments to be used for
outcome measures were not available [18].We found the system of
Dimeglio as the most reliable evaluation method [15].
Before operation there were 23 feet (76.66%) grade III (severe)
and 7 feet 23.33%). Grade IV (very severe) deformities. At the last
follow up 26 feet (86.66%) was graded as grade I (benign) and 4 feet
(13.33) as grade II. Mean total preoperative score was 12.76 (range,
12–16) while the mean postoperative score was 4.13 (range, 4–5).
86.66% of the feet (26 feet) were painless during daily activities,
13% (4 feet) had occasional mild pain after strenuous activity, but
Table 2
Surgical procedures performed during revision surgery.
Surgical procedures Number of feet
Lengthening of tendoachilis 28
Peritalar release 28
Medial release 28
Lengthening of flexor hallucis 28
Lengthening of flexor digitorum 28
Lengthening of tibialis posterior 28
Lateral release 24
Peroneal sheath release 28
Plantar fascia release 18
K-wiring of talonavicular joint 28
K-wiring of talocacaneal joint 11
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42 F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44
Table 3
Radiographic measurements of the alignment of the foot and ankle preoperatively and postoperatively.
Demographic data Radiographic value TC–TM (8) Ankle (DF/PF) (8)
ID Age/sex Side Type of CTEV Preoperative Postoperative Preoperative Postoperative
1 11/M Rt Primary/idiopathic 17/10 29/8 40/30 10/30
2 9/F Rt Revision/idiopathic 20/10 31/6 20/30 10/30
9/F Lt Revision/idiopathic 15/20 30/5 10/40 10/30
3 3/F Rt Revision/N.M. 13/18 25/0 15/30 20/30
3/F Lt Revision/N.M. 16/10 28/5 10/35 15/30
4 6/M Rt Revision/idiopathic 20/14 35/7 40/50 10/40
6/M Lt Revision/idiopathic 10/25 30/6 30/30 20/30
5 6/M Rt Revision/idiopathic 15/35 37/5 20/35 15/35
6/M Lt Revision/idiopathic 27/15 40/8 15/40 25/40
6 5/F Rt Revision/N.M. 19/18 30/6 20/35 10/30
7 6/M Rt Revision/idiopathic 12/12 27/4 40/50 10/30
6/M Lt Revision/idiopathic 17/18 35/4 20/30 10/30
8 7/M Rt Revision/idiopathic 15/28 25/5 10/40 10/30
7/M Lt Revision/idiopathic 17/15 41/8 15/30 20/30
9 6/F Rt Revision/idiopathic 14/23 40/5 10/35 15/30
6/F Lt Revision/idiopathic 15/23 30/4 40/50 10/40
10 5/M Lt Revision/idiopathic 11/18 39/5 30/30 20/30
11 6/F Rt Revision/idiopathic 13/20 33/5 20/35 15/35
6/F Lt Revision/idiopathic 14/18 40/8 15/40 25/40
12 6/M Rt Revision/idiopathic 22/22 33/5 20/35 10/30
13 8/M Lt Primary/idiopathic 11/18 28/6 40/50 10/35
14 3/M Lt Revision/idiopathic 11/15 26/5 20/30 10/40
15 3/F Lt Revision/idiopathic 18/15 33/8 10/40 20/30
3/F Rt Revision/idiopathic 16/12 28/6 15/30 20/30
16 3/M Lt Revision/idiopathic 12/17 30/5 10/35 25/30
3/M Rt Revision/idiopathic 11/18 24/5 20/45 15/40
17 3/F Lt Revision/N.M. 15/18 25/10 30/30 20/35
3/F Rt Revision/N.M. 19/15 40/4 20/30 15/35
18 8/M Lt Revision/idiopathic 16/10 24/5 15/40 25/40
8/M Rt Revision/idiopathic 20/12 28/7 20/35 15/30
TC: talocalcaneal angle on standing lateral view. TM: talo-first metatarsal angle on standing AP view of the foot. DF: dorsiflexion. PF: plantarflexion.
none complained about frequent pain. The most common
procedure in the original surgery was lengthening of the Achilles
tendon followed by posterior capsular release and the least dealt
with pathology was peroneal sheath and lateral release (Table 4).
Four legs (14.28%) developed hypertrophic scars at the donar flap
site. One patient developed 1.5 cm marginal necrosis of the flap,
which did heal after debridement by secondary intention.
4. Discussion
Recurrent deformity with scarring of the foot from previous
surgery makes it more difficult to correct with remanipulation and
recasting, although there is a place for this in some feet.
The most common persistent deformities in the residual
clubfoot are forefoot adduction and midfoot deformities [2–4,19].
All patients had deformity of the forefoot, midfoot and hindfoot,
equinovarus being the most common. Neglected idiopathic
clubfoot deformities and severe recurrent deformity after
previous surgery not only presents technical difficulties for
correction, but also challenges surgeons to achieve primary skin
closure and prevent skin necrosis. These problems can be
minimized by placing the foot in under-correction at the end of
surgery followed by gradual correction of the deformity byweekly
manipulations and casting. This will need prolonged post-operative
casting, loss of initial correction, and inability to
under-correct if the subtalar and talonavicular joints have been
transfixed in the corrected position [20]. All our patients are of
older childrenwith recurrent clubfeet with marked scarring at the
site of surgery which is difficult to apply these options. Others
suggested the use of soft-tissue expander to provide sufficient
skin, but it is liable to infection, skin necrosis, and premature
exposure of the expander [21,22]. Despite the great variety of
flaps, the choice of the most suitable reconstruction remains
debated. Different types of local, rotational or regional faciocu-taneous
flaps were used for covering defects of clubfeet for
children less than 3 years, but the use of complicated skin
incisions gave rise to the risk of ischaemic change in the flap,
which could be prone to ischaemic changes [23–26]. Other well-defined
lower extremity fasciocutaneous flaps based on a named
Table 4
Surgical procedures performed in the original surgery for correction of
clubfoot.
Surgical procedures Number of feet
Lengthend tendoachilis 28
Posterior release of ankle 24
Medial release 20
Lengthening of flexor hallucis 16
Lengthening of flexor digitorum 19
Lengthening of tibialis posterior 19
Tendon transfer 3
Lateral release 2
Peroneal sheath release 2
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F.O.A. Hassan et al. / Foot and Ankle Surgery 16 (2010) 38–44 43
perforator or branch were used in adult traumatic injuries but
requires a much more meticulous dissection to determine the
source of the perforator, which frequently may be anomalous
[27,28]. The sacrifice of a major limb vessel would not be
acceptable in clubfeet if other options were available.
Cross leg fasciocutaneous flaps are dependent on multiple
suprafascial vessels entering their base from predictable sources
[29]. Although relapse is a common problem in clubfoot surgery,
there are very few reports concerningmid- and long-termresults
of this challenging problem [30,31]. Closingwedge osteotomy of
the cuboid, a cuneiform osteotomy, and an anterior tibial tendon
transfer is suggested in addition to repeated release procedures
[32]. Numerous osteotomies were described in the literature for
older children with clubfoot and can be broadly classified in
terms of which deformity they aim to correct. Mid-tarsal
osteotomies, calcaneocuboid fusion, and excision of the distal
calcaneus, cuboid decancellation or triple arthrodeses are used to
correct the deformity in a single or combined procedure [32]. No
doubt such surgery leads to a shortening of the foot and,
inevitably, to an irreparable growth disturbance of the foot
skeleton. Until skeletal maturity, additional shortening of these
already small feet is a regular occurrence. The cosmetic result
will therefore be poor with the risk of skin or soft-tissue necrosis
and infections that may result from bone surgery on the foot.
None of our patients required bony surgery or tendon transfer
procedures.
The most common cause of relapse is often the consequence
of inadequate primary surgery [5]. This is highly concurrent with
all revision cases. From our experience of limited number of
patients, peritalar release will result in good cosmetic correction
with no shortening, a plantigrade foot and no complications.
Since damage to the foot skeleton during childhood is avoided,
the proportions of the foot are preserved until the end of growth
[33].
Gradual correction using the Ilizarov system and the Taylor
Spatial Frame have been used alone or with soft tissue or bone
surgery or combination for correction of recurrent clubfoot, with
a reliable correction of individual components of the deformity.
It is usually combined with either a midfoot or calcaneal
osteotomy, although purely soft-tissue Ilizarov correction has
been performed in older children with good early results [34].
But as any other procedure it has its problems, pin site problems,
intraoperative vascular injuries, and tendon impingement,
pseudo-aneurysm, wire breakage, and wire cut-through [35–37].
Results of Ilizarov correction are variable with frequent late
complications, spontaneous ankylosis, recurrence of deformity
and requirement for surgical arthrodesis [38,39]. At the final follow
up, cosmetically acceptable plantigrade foot was achieved in
all patients without shortened feet.
5. Conclusion
Complete subtalar release for revision clubfoot surgery through
a circumferential Cincinnati incision gave good postoperative
results, which was achieved in all our patients. We observed a
statistical trend towards improvement in radiological forefoot and
hind foot correction and all of our patients were able to wear
normal footwear.
This indicates the enormous value of revision surgery without
the need for bony intervention in previously operated feet.
Conflict of interest
No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the
subject of this article.
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