This document summarizes a study on the treatment of congenital pseudarthrosis of the tibia (CPT) using a combined approach of periosteal grafting, bone grafting, intramedullary nailing of the tibia and fibula, and Ilizarov fixation. The study retrospectively reviewed 20 patients treated with this approach, with a minimum follow-up of 2 years. Union was achieved in all patients after the primary operation. Ten refractures occurred in eight patients, requiring seven secondary surgeries. The combined approach was found to be an effective treatment for CPT.
This document summarizes a study on the influence of heat treatment and boron addition on the sliding wear behavior of a β-type titanium alloy (Ti-35Nb-7.2Zr-5.7Ta) under dry and lubricated conditions. Pin-on-disc tests were used to evaluate the wear resistance of the alloy both with and without 0.5% boron in dry air, Hank's solution, and bovine serum. The results showed that hardness had little effect on wear behavior, and boron addition deteriorated wear properties. Wear rates increased in the order of dry conditions < Hank's solution < bovine serum for both alloys.
This document discusses osteoradionecrosis (ORN), a serious complication of radiation therapy where exposed irradiated bone fails to heal. It can occur spontaneously or after trauma. The mandible is most commonly affected due to its tenuous blood supply. Pathophysiology involves hypoxic, hypocellular tissue with impaired healing ability. Management includes controlling infection, supportive care, and hyperbaric oxygen therapy (HBO) as an adjuvant to surgery to improve tissue oxygenation and revasculation. The Marx protocol uses HBO followed by surgical resection of necrotic bone in stages depending on severity.
JNET classification of colo rectal polypsSamir Haffar
This document discusses the JNET classification of colorectal polyps based on narrow-band imaging (NBI) endoscopy. It provides a brief history of NBI development and discusses the need for a new universal polyp classification system. The Japan NBI Expert Team (JNET) developed a novel 4-type classification system in 2014 using magnifying NBI endoscopy and considering both vessel and surface patterns. Type 1 correlates with hyperplastic/sessile serrated polyps, type 2A with low-grade dysplasia, type 2B can range from low-grade dysplasia to deep submucosal invasion, and type 3 correlates with deep submucosal invasion. A validation study found high accuracy
Computer Modelling of Flow, Shape and Tissue Stress/Strain in Intracranial An...Derek Sweeney
This document discusses a computer modeling study of blood flow, shape, and tissue stress/strain in intracranial aneurysms. It provides background on intracranial aneurysms and the role of hemodynamics in their formation and rupture. It then describes the @neurIST technology which uses computational fluid dynamics to model blood flow and predict wall shear stress, shape measurements, and tissue stress/strain in aneurysms. Live demonstrations are provided of analyses for unstented and stented cases. Validation studies and a study of physical aneurysm characteristics are also briefly discussed.
Dermatoglification Analysis for Selection and Training of Sports TalentsIOSRJPBS
: The term sports talent can be defined as the individual who, through his inherited and acquired conditions, has a special ability for sports performance, above the average of the general population. Fingerprints are genetic markers and can function as indicators of sporting talents. The objective of the present study was to use dermatoglyphics to identify the genetic-physical profile of soccer athletes. Twenty-four athletes belonging to the Palmeiras Sports Society Athletes' Capture Center participated in this study in the Nordeste sub-category category 16. The dermatoglyphic protocol of Cummins and Midlo (1961) was used. Standard fingerprint indices were calculated: the number of drawings for the 10 fingers and the delta index (D10). We also analyzed the types of digital formulas that indicate the representation in individuals of different types of drawings. Based on the classification of Fernandes (2002), the group presented somatofunctional classification for height, velocity and explosive strength, due to the delta index of 11.54. We conclude that dermatoglyphics can be a parameter to identify the potentiality of an individual and can be incorporated into a policy of selection and formation of sports talent.
The document summarizes a study that examined 633 angiographies to identify variations in branches of the human aortic arch. Eight variations were found (Types I-VIII), with Type I being the most common (83%). Type I has three branches - the brachiocephalic trunk, left common carotid artery, and left subclavian artery. The less common variations have between two to four branches arising from the aortic arch. While usually asymptomatic, the variations could cause issues like dysphagia or misinterpretation of medical imaging and complications during surgery when not recognized. A literature review found the study's results were generally consistent with previous reports on frequencies of the variations.
This document summarizes a study on the influence of heat treatment and boron addition on the sliding wear behavior of a β-type titanium alloy (Ti-35Nb-7.2Zr-5.7Ta) under dry and lubricated conditions. Pin-on-disc tests were used to evaluate the wear resistance of the alloy both with and without 0.5% boron in dry air, Hank's solution, and bovine serum. The results showed that hardness had little effect on wear behavior, and boron addition deteriorated wear properties. Wear rates increased in the order of dry conditions < Hank's solution < bovine serum for both alloys.
This document discusses osteoradionecrosis (ORN), a serious complication of radiation therapy where exposed irradiated bone fails to heal. It can occur spontaneously or after trauma. The mandible is most commonly affected due to its tenuous blood supply. Pathophysiology involves hypoxic, hypocellular tissue with impaired healing ability. Management includes controlling infection, supportive care, and hyperbaric oxygen therapy (HBO) as an adjuvant to surgery to improve tissue oxygenation and revasculation. The Marx protocol uses HBO followed by surgical resection of necrotic bone in stages depending on severity.
JNET classification of colo rectal polypsSamir Haffar
This document discusses the JNET classification of colorectal polyps based on narrow-band imaging (NBI) endoscopy. It provides a brief history of NBI development and discusses the need for a new universal polyp classification system. The Japan NBI Expert Team (JNET) developed a novel 4-type classification system in 2014 using magnifying NBI endoscopy and considering both vessel and surface patterns. Type 1 correlates with hyperplastic/sessile serrated polyps, type 2A with low-grade dysplasia, type 2B can range from low-grade dysplasia to deep submucosal invasion, and type 3 correlates with deep submucosal invasion. A validation study found high accuracy
Computer Modelling of Flow, Shape and Tissue Stress/Strain in Intracranial An...Derek Sweeney
This document discusses a computer modeling study of blood flow, shape, and tissue stress/strain in intracranial aneurysms. It provides background on intracranial aneurysms and the role of hemodynamics in their formation and rupture. It then describes the @neurIST technology which uses computational fluid dynamics to model blood flow and predict wall shear stress, shape measurements, and tissue stress/strain in aneurysms. Live demonstrations are provided of analyses for unstented and stented cases. Validation studies and a study of physical aneurysm characteristics are also briefly discussed.
Dermatoglification Analysis for Selection and Training of Sports TalentsIOSRJPBS
: The term sports talent can be defined as the individual who, through his inherited and acquired conditions, has a special ability for sports performance, above the average of the general population. Fingerprints are genetic markers and can function as indicators of sporting talents. The objective of the present study was to use dermatoglyphics to identify the genetic-physical profile of soccer athletes. Twenty-four athletes belonging to the Palmeiras Sports Society Athletes' Capture Center participated in this study in the Nordeste sub-category category 16. The dermatoglyphic protocol of Cummins and Midlo (1961) was used. Standard fingerprint indices were calculated: the number of drawings for the 10 fingers and the delta index (D10). We also analyzed the types of digital formulas that indicate the representation in individuals of different types of drawings. Based on the classification of Fernandes (2002), the group presented somatofunctional classification for height, velocity and explosive strength, due to the delta index of 11.54. We conclude that dermatoglyphics can be a parameter to identify the potentiality of an individual and can be incorporated into a policy of selection and formation of sports talent.
The document summarizes a study that examined 633 angiographies to identify variations in branches of the human aortic arch. Eight variations were found (Types I-VIII), with Type I being the most common (83%). Type I has three branches - the brachiocephalic trunk, left common carotid artery, and left subclavian artery. The less common variations have between two to four branches arising from the aortic arch. While usually asymptomatic, the variations could cause issues like dysphagia or misinterpretation of medical imaging and complications during surgery when not recognized. A literature review found the study's results were generally consistent with previous reports on frequencies of the variations.
2024 State of Marketing Report – by HubspotMarius Sescu
https://www.hubspot.com/state-of-marketing
· Scaling relationships and proving ROI
· Social media is the place for search, sales, and service
· Authentic influencer partnerships fuel brand growth
· The strongest connections happen via call, click, chat, and camera.
· Time saved with AI leads to more creative work
· Seeking: A single source of truth
· TLDR; Get on social, try AI, and align your systems.
· More human marketing, powered by robots
ChatGPT is a revolutionary addition to the world since its introduction in 2022. A big shift in the sector of information gathering and processing happened because of this chatbot. What is the story of ChatGPT? How is the bot responding to prompts and generating contents? Swipe through these slides prepared by Expeed Software, a web development company regarding the development and technical intricacies of ChatGPT!
Product Design Trends in 2024 | Teenage EngineeringsPixeldarts
The realm of product design is a constantly changing environment where technology and style intersect. Every year introduces fresh challenges and exciting trends that mold the future of this captivating art form. In this piece, we delve into the significant trends set to influence the look and functionality of product design in the year 2024.
How Race, Age and Gender Shape Attitudes Towards Mental HealthThinkNow
Mental health has been in the news quite a bit lately. Dozens of U.S. states are currently suing Meta for contributing to the youth mental health crisis by inserting addictive features into their products, while the U.S. Surgeon General is touring the nation to bring awareness to the growing epidemic of loneliness and isolation. The country has endured periods of low national morale, such as in the 1970s when high inflation and the energy crisis worsened public sentiment following the Vietnam War. The current mood, however, feels different. Gallup recently reported that national mental health is at an all-time low, with few bright spots to lift spirits.
To better understand how Americans are feeling and their attitudes towards mental health in general, ThinkNow conducted a nationally representative quantitative survey of 1,500 respondents and found some interesting differences among ethnic, age and gender groups.
Technology
For example, 52% agree that technology and social media have a negative impact on mental health, but when broken out by race, 61% of Whites felt technology had a negative effect, and only 48% of Hispanics thought it did.
While technology has helped us keep in touch with friends and family in faraway places, it appears to have degraded our ability to connect in person. Staying connected online is a double-edged sword since the same news feed that brings us pictures of the grandkids and fluffy kittens also feeds us news about the wars in Israel and Ukraine, the dysfunction in Washington, the latest mass shooting and the climate crisis.
Hispanics may have a built-in defense against the isolation technology breeds, owing to their large, multigenerational households, strong social support systems, and tendency to use social media to stay connected with relatives abroad.
Age and Gender
When asked how individuals rate their mental health, men rate it higher than women by 11 percentage points, and Baby Boomers rank it highest at 83%, saying it’s good or excellent vs. 57% of Gen Z saying the same.
Gen Z spends the most amount of time on social media, so the notion that social media negatively affects mental health appears to be correlated. Unfortunately, Gen Z is also the generation that’s least comfortable discussing mental health concerns with healthcare professionals. Only 40% of them state they’re comfortable discussing their issues with a professional compared to 60% of Millennials and 65% of Boomers.
Race Affects Attitudes
As seen in previous research conducted by ThinkNow, Asian Americans lag other groups when it comes to awareness of mental health issues. Twenty-four percent of Asian Americans believe that having a mental health issue is a sign of weakness compared to the 16% average for all groups. Asians are also considerably less likely to be aware of mental health services in their communities (42% vs. 55%) and most likely to seek out information on social media (51% vs. 35%).
AI Trends in Creative Operations 2024 by Artwork Flow.pdfmarketingartwork
Creative operations teams expect increased AI use in 2024. Currently, over half of tasks are not AI-enabled, but this is expected to decrease in the coming year. ChatGPT is the most popular AI tool currently. Business leaders are more actively exploring AI benefits than individual contributors. Most respondents do not believe AI will impact workforce size in 2024. However, some inhibitions still exist around AI accuracy and lack of understanding. Creatives primarily want to use AI to save time on mundane tasks and boost productivity.
Organizational culture includes values, norms, systems, symbols, language, assumptions, beliefs, and habits that influence employee behaviors and how people interpret those behaviors. It is important because culture can help or hinder a company's success. Some key aspects of Netflix's culture that help it achieve results include hiring smartly so every position has stars, focusing on attitude over just aptitude, and having a strict policy against peacocks, whiners, and jerks.
PEPSICO Presentation to CAGNY Conference Feb 2024Neil Kimberley
PepsiCo provided a safe harbor statement noting that any forward-looking statements are based on currently available information and are subject to risks and uncertainties. It also provided information on non-GAAP measures and directing readers to its website for disclosure and reconciliation. The document then discussed PepsiCo's business overview, including that it is a global beverage and convenient food company with iconic brands, $91 billion in net revenue in 2023, and nearly $14 billion in core operating profit. It operates through a divisional structure with a focus on local consumers.
Content Methodology: A Best Practices Report (Webinar)contently
This document provides an overview of content methodology best practices. It defines content methodology as establishing objectives, KPIs, and a culture of continuous learning and iteration. An effective methodology focuses on connecting with audiences, creating optimal content, and optimizing processes. It also discusses why a methodology is needed due to the competitive landscape, proliferation of channels, and opportunities for improvement. Components of an effective methodology include defining objectives and KPIs, audience analysis, identifying opportunities, and evaluating resources. The document concludes with recommendations around creating a content plan, testing and optimizing content over 90 days.
How to Prepare For a Successful Job Search for 2024Albert Qian
The document provides guidance on preparing a job search for 2024. It discusses the state of the job market, focusing on growth in AI and healthcare but also continued layoffs. It recommends figuring out what you want to do by researching interests and skills, then conducting informational interviews. The job search should involve building a personal brand on LinkedIn, actively applying to jobs, tailoring resumes and interviews, maintaining job hunting as a habit, and continuing self-improvement. Once hired, the document advises setting new goals and keeping skills and networking active in case of future opportunities.
A report by thenetworkone and Kurio.
The contributing experts and agencies are (in an alphabetical order): Sylwia Rytel, Social Media Supervisor, 180heartbeats + JUNG v MATT (PL), Sharlene Jenner, Vice President - Director of Engagement Strategy, Abelson Taylor (USA), Alex Casanovas, Digital Director, Atrevia (ES), Dora Beilin, Senior Social Strategist, Barrett Hoffher (USA), Min Seo, Campaign Director, Brand New Agency (KR), Deshé M. Gully, Associate Strategist, Day One Agency (USA), Francesca Trevisan, Strategist, Different (IT), Trevor Crossman, CX and Digital Transformation Director; Olivia Hussey, Strategic Planner; Simi Srinarula, Social Media Manager, The Hallway (AUS), James Hebbert, Managing Director, Hylink (CN / UK), Mundy Álvarez, Planning Director; Pedro Rojas, Social Media Manager; Pancho González, CCO, Inbrax (CH), Oana Oprea, Head of Digital Planning, Jam Session Agency (RO), Amy Bottrill, Social Account Director, Launch (UK), Gaby Arriaga, Founder, Leonardo1452 (MX), Shantesh S Row, Creative Director, Liwa (UAE), Rajesh Mehta, Chief Strategy Officer; Dhruv Gaur, Digital Planning Lead; Leonie Mergulhao, Account Supervisor - Social Media & PR, Medulla (IN), Aurelija Plioplytė, Head of Digital & Social, Not Perfect (LI), Daiana Khaidargaliyeva, Account Manager, Osaka Labs (UK / USA), Stefanie Söhnchen, Vice President Digital, PIABO Communications (DE), Elisabeth Winiartati, Managing Consultant, Head of Global Integrated Communications; Lydia Aprina, Account Manager, Integrated Marketing and Communications; Nita Prabowo, Account Manager, Integrated Marketing and Communications; Okhi, Web Developer, PNTR Group (ID), Kei Obusan, Insights Director; Daffi Ranandi, Insights Manager, Radarr (SG), Gautam Reghunath, Co-founder & CEO, Talented (IN), Donagh Humphreys, Head of Social and Digital Innovation, THINKHOUSE (IRE), Sarah Yim, Strategy Director, Zulu Alpha Kilo (CA).
Trends In Paid Search: Navigating The Digital Landscape In 2024Search Engine Journal
The search marketing landscape is evolving rapidly with new technologies, and professionals, like you, rely on innovative paid search strategies to meet changing demands.
It’s important that you’re ready to implement new strategies in 2024.
Check this out and learn the top trends in paid search advertising that are expected to gain traction, so you can drive higher ROI more efficiently in 2024.
You’ll learn:
- The latest trends in AI and automation, and what this means for an evolving paid search ecosystem.
- New developments in privacy and data regulation.
- Emerging ad formats that are expected to make an impact next year.
Watch Sreekant Lanka from iQuanti and Irina Klein from OneMain Financial as they dive into the future of paid search and explore the trends, strategies, and technologies that will shape the search marketing landscape.
If you’re looking to assess your paid search strategy and design an industry-aligned plan for 2024, then this webinar is for you.
5 Public speaking tips from TED - Visualized summarySpeakerHub
From their humble beginnings in 1984, TED has grown into the world’s most powerful amplifier for speakers and thought-leaders to share their ideas. They have over 2,400 filmed talks (not including the 30,000+ TEDx videos) freely available online, and have hosted over 17,500 events around the world.
With over one billion views in a year, it’s no wonder that so many speakers are looking to TED for ideas on how to share their message more effectively.
The article “5 Public-Speaking Tips TED Gives Its Speakers”, by Carmine Gallo for Forbes, gives speakers five practical ways to connect with their audience, and effectively share their ideas on stage.
Whether you are gearing up to get on a TED stage yourself, or just want to master the skills that so many of their speakers possess, these tips and quotes from Chris Anderson, the TED Talks Curator, will encourage you to make the most impactful impression on your audience.
See the full article and more summaries like this on SpeakerHub here: https://speakerhub.com/blog/5-presentation-tips-ted-gives-its-speakers
See the original article on Forbes here:
http://www.forbes.com/forbes/welcome/?toURL=http://www.forbes.com/sites/carminegallo/2016/05/06/5-public-speaking-tips-ted-gives-its-speakers/&refURL=&referrer=#5c07a8221d9b
ChatGPT and the Future of Work - Clark Boyd Clark Boyd
Everyone is in agreement that ChatGPT (and other generative AI tools) will shape the future of work. Yet there is little consensus on exactly how, when, and to what extent this technology will change our world.
Businesses that extract maximum value from ChatGPT will use it as a collaborative tool for everything from brainstorming to technical maintenance.
For individuals, now is the time to pinpoint the skills the future professional will need to thrive in the AI age.
Check out this presentation to understand what ChatGPT is, how it will shape the future of work, and how you can prepare to take advantage.
The document provides career advice for getting into the tech field, including:
- Doing projects and internships in college to build a portfolio.
- Learning about different roles and technologies through industry research.
- Contributing to open source projects to build experience and network.
- Developing a personal brand through a website and social media presence.
- Networking through events, communities, and finding a mentor.
- Practicing interviews through mock interviews and whiteboarding coding questions.
Google's Just Not That Into You: Understanding Core Updates & Search IntentLily Ray
1. Core updates from Google periodically change how its algorithms assess and rank websites and pages. This can impact rankings through shifts in user intent, site quality issues being caught up to, world events influencing queries, and overhauls to search like the E-A-T framework.
2. There are many possible user intents beyond just transactional, navigational and informational. Identifying intent shifts is important during core updates. Sites may need to optimize for new intents through different content types and sections.
3. Responding effectively to core updates requires analyzing "before and after" data to understand changes, identifying new intents or page types, and ensuring content matches appropriate intents across video, images, knowledge graphs and more.
A brief introduction to DataScience with explaining of the concepts, algorithms, machine learning, supervised and unsupervised learning, clustering, statistics, data preprocessing, real-world applications etc.
It's part of a Data Science Corner Campaign where I will be discussing the fundamentals of DataScience, AIML, Statistics etc.
Time Management & Productivity - Best PracticesVit Horky
Here's my presentation on by proven best practices how to manage your work time effectively and how to improve your productivity. It includes practical tips and how to use tools such as Slack, Google Apps, Hubspot, Google Calendar, Gmail and others.
The six step guide to practical project managementMindGenius
The six step guide to practical project management
If you think managing projects is too difficult, think again.
We’ve stripped back project management processes to the
basics – to make it quicker and easier, without sacrificing
the vital ingredients for success.
“If you’re looking for some real-world guidance, then The Six Step Guide to Practical Project Management will help.”
Dr Andrew Makar, Tactical Project Management
2024 State of Marketing Report – by HubspotMarius Sescu
https://www.hubspot.com/state-of-marketing
· Scaling relationships and proving ROI
· Social media is the place for search, sales, and service
· Authentic influencer partnerships fuel brand growth
· The strongest connections happen via call, click, chat, and camera.
· Time saved with AI leads to more creative work
· Seeking: A single source of truth
· TLDR; Get on social, try AI, and align your systems.
· More human marketing, powered by robots
ChatGPT is a revolutionary addition to the world since its introduction in 2022. A big shift in the sector of information gathering and processing happened because of this chatbot. What is the story of ChatGPT? How is the bot responding to prompts and generating contents? Swipe through these slides prepared by Expeed Software, a web development company regarding the development and technical intricacies of ChatGPT!
Product Design Trends in 2024 | Teenage EngineeringsPixeldarts
The realm of product design is a constantly changing environment where technology and style intersect. Every year introduces fresh challenges and exciting trends that mold the future of this captivating art form. In this piece, we delve into the significant trends set to influence the look and functionality of product design in the year 2024.
How Race, Age and Gender Shape Attitudes Towards Mental HealthThinkNow
Mental health has been in the news quite a bit lately. Dozens of U.S. states are currently suing Meta for contributing to the youth mental health crisis by inserting addictive features into their products, while the U.S. Surgeon General is touring the nation to bring awareness to the growing epidemic of loneliness and isolation. The country has endured periods of low national morale, such as in the 1970s when high inflation and the energy crisis worsened public sentiment following the Vietnam War. The current mood, however, feels different. Gallup recently reported that national mental health is at an all-time low, with few bright spots to lift spirits.
To better understand how Americans are feeling and their attitudes towards mental health in general, ThinkNow conducted a nationally representative quantitative survey of 1,500 respondents and found some interesting differences among ethnic, age and gender groups.
Technology
For example, 52% agree that technology and social media have a negative impact on mental health, but when broken out by race, 61% of Whites felt technology had a negative effect, and only 48% of Hispanics thought it did.
While technology has helped us keep in touch with friends and family in faraway places, it appears to have degraded our ability to connect in person. Staying connected online is a double-edged sword since the same news feed that brings us pictures of the grandkids and fluffy kittens also feeds us news about the wars in Israel and Ukraine, the dysfunction in Washington, the latest mass shooting and the climate crisis.
Hispanics may have a built-in defense against the isolation technology breeds, owing to their large, multigenerational households, strong social support systems, and tendency to use social media to stay connected with relatives abroad.
Age and Gender
When asked how individuals rate their mental health, men rate it higher than women by 11 percentage points, and Baby Boomers rank it highest at 83%, saying it’s good or excellent vs. 57% of Gen Z saying the same.
Gen Z spends the most amount of time on social media, so the notion that social media negatively affects mental health appears to be correlated. Unfortunately, Gen Z is also the generation that’s least comfortable discussing mental health concerns with healthcare professionals. Only 40% of them state they’re comfortable discussing their issues with a professional compared to 60% of Millennials and 65% of Boomers.
Race Affects Attitudes
As seen in previous research conducted by ThinkNow, Asian Americans lag other groups when it comes to awareness of mental health issues. Twenty-four percent of Asian Americans believe that having a mental health issue is a sign of weakness compared to the 16% average for all groups. Asians are also considerably less likely to be aware of mental health services in their communities (42% vs. 55%) and most likely to seek out information on social media (51% vs. 35%).
AI Trends in Creative Operations 2024 by Artwork Flow.pdfmarketingartwork
Creative operations teams expect increased AI use in 2024. Currently, over half of tasks are not AI-enabled, but this is expected to decrease in the coming year. ChatGPT is the most popular AI tool currently. Business leaders are more actively exploring AI benefits than individual contributors. Most respondents do not believe AI will impact workforce size in 2024. However, some inhibitions still exist around AI accuracy and lack of understanding. Creatives primarily want to use AI to save time on mundane tasks and boost productivity.
Organizational culture includes values, norms, systems, symbols, language, assumptions, beliefs, and habits that influence employee behaviors and how people interpret those behaviors. It is important because culture can help or hinder a company's success. Some key aspects of Netflix's culture that help it achieve results include hiring smartly so every position has stars, focusing on attitude over just aptitude, and having a strict policy against peacocks, whiners, and jerks.
PEPSICO Presentation to CAGNY Conference Feb 2024Neil Kimberley
PepsiCo provided a safe harbor statement noting that any forward-looking statements are based on currently available information and are subject to risks and uncertainties. It also provided information on non-GAAP measures and directing readers to its website for disclosure and reconciliation. The document then discussed PepsiCo's business overview, including that it is a global beverage and convenient food company with iconic brands, $91 billion in net revenue in 2023, and nearly $14 billion in core operating profit. It operates through a divisional structure with a focus on local consumers.
Content Methodology: A Best Practices Report (Webinar)contently
This document provides an overview of content methodology best practices. It defines content methodology as establishing objectives, KPIs, and a culture of continuous learning and iteration. An effective methodology focuses on connecting with audiences, creating optimal content, and optimizing processes. It also discusses why a methodology is needed due to the competitive landscape, proliferation of channels, and opportunities for improvement. Components of an effective methodology include defining objectives and KPIs, audience analysis, identifying opportunities, and evaluating resources. The document concludes with recommendations around creating a content plan, testing and optimizing content over 90 days.
How to Prepare For a Successful Job Search for 2024Albert Qian
The document provides guidance on preparing a job search for 2024. It discusses the state of the job market, focusing on growth in AI and healthcare but also continued layoffs. It recommends figuring out what you want to do by researching interests and skills, then conducting informational interviews. The job search should involve building a personal brand on LinkedIn, actively applying to jobs, tailoring resumes and interviews, maintaining job hunting as a habit, and continuing self-improvement. Once hired, the document advises setting new goals and keeping skills and networking active in case of future opportunities.
A report by thenetworkone and Kurio.
The contributing experts and agencies are (in an alphabetical order): Sylwia Rytel, Social Media Supervisor, 180heartbeats + JUNG v MATT (PL), Sharlene Jenner, Vice President - Director of Engagement Strategy, Abelson Taylor (USA), Alex Casanovas, Digital Director, Atrevia (ES), Dora Beilin, Senior Social Strategist, Barrett Hoffher (USA), Min Seo, Campaign Director, Brand New Agency (KR), Deshé M. Gully, Associate Strategist, Day One Agency (USA), Francesca Trevisan, Strategist, Different (IT), Trevor Crossman, CX and Digital Transformation Director; Olivia Hussey, Strategic Planner; Simi Srinarula, Social Media Manager, The Hallway (AUS), James Hebbert, Managing Director, Hylink (CN / UK), Mundy Álvarez, Planning Director; Pedro Rojas, Social Media Manager; Pancho González, CCO, Inbrax (CH), Oana Oprea, Head of Digital Planning, Jam Session Agency (RO), Amy Bottrill, Social Account Director, Launch (UK), Gaby Arriaga, Founder, Leonardo1452 (MX), Shantesh S Row, Creative Director, Liwa (UAE), Rajesh Mehta, Chief Strategy Officer; Dhruv Gaur, Digital Planning Lead; Leonie Mergulhao, Account Supervisor - Social Media & PR, Medulla (IN), Aurelija Plioplytė, Head of Digital & Social, Not Perfect (LI), Daiana Khaidargaliyeva, Account Manager, Osaka Labs (UK / USA), Stefanie Söhnchen, Vice President Digital, PIABO Communications (DE), Elisabeth Winiartati, Managing Consultant, Head of Global Integrated Communications; Lydia Aprina, Account Manager, Integrated Marketing and Communications; Nita Prabowo, Account Manager, Integrated Marketing and Communications; Okhi, Web Developer, PNTR Group (ID), Kei Obusan, Insights Director; Daffi Ranandi, Insights Manager, Radarr (SG), Gautam Reghunath, Co-founder & CEO, Talented (IN), Donagh Humphreys, Head of Social and Digital Innovation, THINKHOUSE (IRE), Sarah Yim, Strategy Director, Zulu Alpha Kilo (CA).
Trends In Paid Search: Navigating The Digital Landscape In 2024Search Engine Journal
The search marketing landscape is evolving rapidly with new technologies, and professionals, like you, rely on innovative paid search strategies to meet changing demands.
It’s important that you’re ready to implement new strategies in 2024.
Check this out and learn the top trends in paid search advertising that are expected to gain traction, so you can drive higher ROI more efficiently in 2024.
You’ll learn:
- The latest trends in AI and automation, and what this means for an evolving paid search ecosystem.
- New developments in privacy and data regulation.
- Emerging ad formats that are expected to make an impact next year.
Watch Sreekant Lanka from iQuanti and Irina Klein from OneMain Financial as they dive into the future of paid search and explore the trends, strategies, and technologies that will shape the search marketing landscape.
If you’re looking to assess your paid search strategy and design an industry-aligned plan for 2024, then this webinar is for you.
5 Public speaking tips from TED - Visualized summarySpeakerHub
From their humble beginnings in 1984, TED has grown into the world’s most powerful amplifier for speakers and thought-leaders to share their ideas. They have over 2,400 filmed talks (not including the 30,000+ TEDx videos) freely available online, and have hosted over 17,500 events around the world.
With over one billion views in a year, it’s no wonder that so many speakers are looking to TED for ideas on how to share their message more effectively.
The article “5 Public-Speaking Tips TED Gives Its Speakers”, by Carmine Gallo for Forbes, gives speakers five practical ways to connect with their audience, and effectively share their ideas on stage.
Whether you are gearing up to get on a TED stage yourself, or just want to master the skills that so many of their speakers possess, these tips and quotes from Chris Anderson, the TED Talks Curator, will encourage you to make the most impactful impression on your audience.
See the full article and more summaries like this on SpeakerHub here: https://speakerhub.com/blog/5-presentation-tips-ted-gives-its-speakers
See the original article on Forbes here:
http://www.forbes.com/forbes/welcome/?toURL=http://www.forbes.com/sites/carminegallo/2016/05/06/5-public-speaking-tips-ted-gives-its-speakers/&refURL=&referrer=#5c07a8221d9b
ChatGPT and the Future of Work - Clark Boyd Clark Boyd
Everyone is in agreement that ChatGPT (and other generative AI tools) will shape the future of work. Yet there is little consensus on exactly how, when, and to what extent this technology will change our world.
Businesses that extract maximum value from ChatGPT will use it as a collaborative tool for everything from brainstorming to technical maintenance.
For individuals, now is the time to pinpoint the skills the future professional will need to thrive in the AI age.
Check out this presentation to understand what ChatGPT is, how it will shape the future of work, and how you can prepare to take advantage.
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Cpt corr 2008
1. Clin Orthop Relat Res
DOI 10.1007/s11999-008-0556-1
SYMPOSIUM: ADVANCES IN LIMB LENGTHENING AND RECONSTRUCTION
Periosteal Grafting for Congenital Pseudarthrosis of the Tibia
A Preliminary Report
Ahmed M. Thabet MD, Dror Paley MD, Mehmet Kocaoglu MD,
Levent Eralp MD, John E. Herzenberg MD, Omer Naci Ergin MD
Ó The Association of Bone and Joint Surgeons 2008
Abstract The results of treatment of congenital pseudar- angular deformities. We used bisphosphonate as adjuvant
throsis of the tibia (CPT) are frequently unsatisfactory therapy in three patients with refracture without subsequent
because of the need for multiple operations for recalcitrant refracture. We performed no amputations in these 20
nonunion, residual deformities, and limb-length discrepan- patients. All patients were braced through skeletal maturity.
cies (LLD). Although the etiology of CPT is basically Combining periosteal and bone grafting, IM nailing, and
unknown, recent reports suggest the periosteum is the pri- Ilizarov fixation is an effective treatment. IM nailing
mary site for the pathologic processes in CPT. We decreases the severity of subsequent fracture.
hypothesized complete excision of the diseased periosteum Level of Evidence: Level IV, therapeutic study. See the
and the application of a combined approach including free Guidelines for Authors for a complete description of levels
periosteal grafting, bone grafting, and intramedullary (IM) of evidence.
nailing of both the tibia and fibula combined with Ilizarov
fixation would improve union rates and reduce refracture
rates. We retrospectively reviewed 20 patients at two cen- Introduction
ters. The minimum followup was 2 years (mean, 4.3 years;
range, 2–10.7 years). Union was achieved after the primary Congenital pseudarthrosis of the tibia (CPT) is challenging
operation in all patients. Ten refractures occurred in eight of because of the weak healing power of the dysplastic seg-
the 20 patients (two each in two patients, one each in six ment [4, 5, 7, 30, 31], the tendency to refracture until
patients). Seven patients underwent seven secondary sur- skeletal maturity [4, 5, 7, 30, 31], and the difficulty of
gical procedures to simultaneously treat refracture and stabilizing small osteoporotic bone fragments in small
children [4, 5, 7, 30, 31]. Various techniques for the man-
agement of CPT have been described. McFarland [30]
One author (DP) is a consultant for Smith & Nephew, Inc. described a bypass fibular graft. Boyd [4] and Boyd and
(Memphis, TN) and receives royalties from Pega Medical Sage [5] described a double onlay graft taken from the
(Laval, Quebec, Canada). opposite tibia combined with autologous iliac crest graft.
Each author certifies that his or her institution has approved the
human protocol for this investigation, that all investigations were Charnley [7] described intramedullary (IM) rods, and
conducted in conformity with ethical principles of research, and that Sofield [38] added fragmentation and reversal of fragments.
informed consent for participation in the study was obtained. Campanacci and Zanoli [6] described a ‘‘fibula pro tibia’’
technique with fibular fixation to the pseudarthrosis site.
A. M. Thabet, D. Paley (&), J. E. Herzenberg
Other methods include direct current or pulsed electro-
Rubin Institute for Advanced Orthopedics, Sinai Hospital
of Baltimore, 2401 West Belvedere Avenue, Baltimore, magnetic field [34, 35], ipsilateral transfer of the fibula [31]
MD 21215-5271, USA or contralateral free vascularized fibular transfer [12, 13,
e-mail: dpaley@lengthening.us 15, 16, 24, 36, 39, 41], circular external fixation [14, 16, 33,
39, 40], IM rodding [7, 10, 11, 21, 23, 26], and combined
M. Kocaoglu, L. Eralp, O. N. Ergin
Department of Orthopedic Surgery and Traumatology, Istanbul external fixation and IM rodding [14, 16, 33]. Recently,
School of Medicine, University of Istanbul, Istanbul, Turkey bone morphogenetic protein (BMP) [27, 37] and
123
2. Table 1. Review of the literature showing age at surgery, duration of followup, and limb-length discrepancy (LLD)
Author(s) Number of Classification Average age at index Average postoperative Average LLD (range)
patients (Cases) (number surgery in years (range) followup in years (range)
123
of patients) Preoperative Postoperative
Thabet et al.
Lee et al. [27] 5 Crawford [9] 6 (0.6–13) 1.2 (1–1.5) 3.3 cm (1–5 cm) NP
III (3)
IV (2)
El-Gammal et al. 3 Dysplastic (3) 9.7 (7–12) 2.2 (1.5–3) 7 cm (5–10 cm) 0.2 cm (0–0.5 cm)
[13]
Toh et al. [39] 7 Boyd [4] -Type II (7) 2.8 (1.1–5.3) 12.5 (7.3–16.7) NP 1.4 cm (0–6.5 cm)
Paley et al. [33] 15 (16) Andersen [1] 8 (2–17) 4 (2–7) 4 cm (1–8 cm) NP
Cystic (3)
Sclerotic (4)
Dysplastic (9)
Grill et al. [16] 108* Crawford [9] 7.36 (1.2–26) NP NP NP
Type I (6)
Type II (17)
Type III (19)
Type IV (18)
Gilbert and 29 NP 5.5 (0.7–13.6) 11.5 (6–16) 3.5 cm (0–9 cm) NP (0–11 cm)
Brockman [15]
Dobbs et al. [10] 21 Boyd [4] 5.1 (0.9–11) 14.2 (3–20) NP 5 cm (2–9 cm)
Type I (3)
Type II (9)
Type IV (6)
Type V (3)
Boero et al. [3] 21 Cystic (4) 8.8 (1.3–17) Minimum 2-year followup 6.3 cm (0–19 cm) 1.9 cm (0–12 cm)
Hourglass (11)
Normotrophic (1)
Sclerotic (5)
Weiland et al. [41] 19 Andersen [41] 5.1 (1.4–11.4) 6.3 years (2–11 years) NP 1.6 cm (0–4 cm)
Cystic (7)
Dysplastic (12)
Joseph and 14 (skeletally immature) NP Skeletally immature Skeletally immature NP Skeletally immature = NP
Mathew [23] 5 (skeletally mature) = 4.5 (0.5–11) = 3 (1–5.4) Skeletally mature =
Skeletally mature Skeletally mature 4.5 cm (0–10 cm)
= 18.6 (18–20) = 3.7 (2.3–6.3)
Johnston [21] 23 Crawford [9] 3.7 (0.9–9.4) 9 (4–14) NP NP
Type I (5)
Type II (7)
Type III (3)
Type IV (8)
Clinical Orthopaedics and Related Research
3. Periosteal Grafting for CPT
bisphosphonate therapy [18, 37] have been used. The
3.2 ± 3.3 cm (0–15 cm)
results of all the methods have been variable (Tables 1, 2).
More than 100 years ago, Codivilla [8] suggested the
1.5 cm (0–6 cm)
pathologic abnormality resided in the periosteum.
Postoperative
Although resection of hamartomatous fibrous tissue is part
of many treatment protocols, it does not prevent recur-
rence. El-Rosasy et al. [14] published on Paley’s technique
NP
of periosteal grafting of CPT in 2006 based on experience
Average LLD (range)
with this method since 1995. Weber [40] also reported
NP = not provided; *108 tibiae were treated with the Ilizarov device; data from all patients with clinically relevant LLD. Ten patients had LLD of 2 cm.
3.1 cm (0–9 cm)
experience with periosteal grafting of CPT.
Preoperative
We report our preliminary experience, results, and
complications with the Paley method of periosteal grafting
from two centers including the union rate, refracture rate,
NP
NP
the secondary procedures required to achieve union, repair
fractures, and/or correct angular deformities, and amount
of limb length discrepancy.
followup in years (range)
Average postoperative
6.7 ± 5.7 (3.8–21.1)
Materials and Methods
14.1 (5.4–32.9)
4.3 (2–10.7)
We retrospectively reviewed the charts and radiographs of
20 patients with CPT who were treated with periosteal
grafting and bone grafting combined with IM rodding of the
tibia and fibula and circular external fixation by the senior
surgery in years (range)
authors (DP, JEH, MK, LE) between 1997 and 2006 at two
Average age at index
centers (Table 3). The mean age at the index operation was
4.6 ± 3.5 (0.9–15)
4.2 years (range, 1–11.3 years). Eleven patients (55%) had
neurofibromatosis, in seven patients (35%) the condition
2.5 (0.5–8.8)
4.2 (1–11.3)
was idiopathic, and two patients (10%) had osteofibrous
dysplasia. Twelve patients (60%) had no previous surgery,
and eight patients (40%) had undergone at least one
unsuccessful operation (range, 1–14 unsuccessful proce-
dures). All patients had established pseudarthrosis. The
minimum followup from the index operation was 2 years
Dysplastic (45)
Dysplastic (15)
(mean, 4.3 years; range, 2–10.7 years). The mean preop-
Classification
Sclerotic (20)
Andersen [1]
Andersen [1]
Sclerotic (1)
Type IV (3)
of patients)
Type III (3)
Type II (6)
erative limb-length discrepancy (LLD) was 3.1 cm (range,
Cystic (8)
Cystic (4)
Boyd [4]
(number
0–9 cm). No patient treated by this method during the time
of the study was lost to followup (Table 3).
The patients were classified according to four of the
most commonly used classification systems [1, 4, 9, 14]
(Table 3). Because there is no universal agreement as to
which classification to use, we used all four classification
patients (Cases)
systems to make it possible to compare the results with
Number of
most previously published studies.
The patient was placed supine with a bump under the
11 (12)
ipsilateral buttock on a radiolucent table. The entire lower
73
20
extremity and hemipelvis were prepped and draped free. A
sterile tourniquet was placed on the thigh and inflated after
Table 1. continued
Ohnishi et al. [32]
[Current study]
elevation of the lower limb. For El-Rosasy-Paley types I
Weinstein [26]
and II (Fig. 1A–C), the pseudarthrosis site was approached
Paley et al.
Author(s)
through an anterior longitudinal incision. The thick peri-
Kim and
osteum was incised longitudinally. The periosteal incision
ended at the point at which the periosteum thins to a
123
4. Thabet et al. Clinical Orthopaedics and Related Research
Table 2. Review of the literature showing union at final followup and number of refractures
Author(s) Number of Average postoperative Cases that achieved union Number of
patients (cases) followup in years (range) at final followup refractures
Lee et al. [27] 5 1.2 (1–1.5) 1 0
El-Gammal et al. [13] 3 2.2 (1.5–3) 3 1
Toh et al. [39] 7 12.5 (7.3–16.7) 7a 5
Paley et al. [33] 15 (16) 4 (2–7) 16 5 (One leg
refractured twice)
Grill et al. [16] 108b Not provided 82 47
Gilbert and Brockman [15] 29 11.5 (6–16) 28 4
Dobbs et al. [10] 21 14.2 (3–20) 19c 12
Boero et al. [3] 21 Minimum 2-year followup 14 4
Weiland et al. [41] 19 6.3 (2–11) 18 3d
Joseph and Mathew [23] 14 (skeletally immature) Skeletally immature Skeletally immature = 12 Skeletally immature = 0
5 (skeletally mature) = 3 (1–5.4) Skeletally mature = 3 Skeletally mature = 0
Skeletally mature
= 3.7 (2.3–6.3)
Johnston [21] 23 9 (4–14) 11 Not provided
Kim and Weinstein [26] 11 (12) 14.1 (5.4–32.9) 9 4 (One leg
refractured twice)
Ohnishi et al. [32] 73 6.7 ± 5.7 (3.8–21.1) Union = 54 10
Delayed union = 7
Ununited = 7
Amputation = 1
Lost to followup = 4
Paley et al. [Current study] 20 4.3 (2–10.7) 20 10
a
Tibial union achieved in all seven cases; union of the fibula was achieved in only one of the five cases in which both the tibia and fibula were
reconstructed.
b
108 tibiae were treated with the Ilizarov device.
c
Five patients underwent amputation (recalcitrant fracture, two patients; limb-length discrepancy, two patients; chronic lower-extremity
deformity, one patient).
d
Two patients had a fracture through what appeared to be normal bone distal to the vascularized fibular graft. One patient had a non-displaced
fracture of the tibia through a screw hole.
normal thickness. We dissected between the periosteum were shortened by 1 to 2 cm. In a previously unoperated
and the surrounding tissues circumferentially around the case, the only bone resection that was performed was the
tibia. Care must be taken laterally to avoid injury to the minimal required for opening the medullary canal. In a
anterior tibial artery and posteromedially to avoid injury to previously operated case, the tourniquet was released and
the posterior tibial neurovascular bundle. The hamartom- all nonviable bone resected.
atous periosteum was then excised in its entirety. The An IM rod was then inserted across the CPT site. The
proximal segment of the tibia was split in all cases by using implant used depended on age and the diameter of the CPT
multiple drill holes with a Kirschner wire (Fig. 2A–F). bone. One can use a Kirschner wire or Steinmann pin in
These drill holes were usually created in the frontal plane very small-diameter bone or a Rush rod or flexible titanium
then connected with an osteotome. The split was created in rod in larger-diameter bones. The rod was inserted either
such a way that it did not fracture across the tibia proxi- from distal to proximal via the medial malleolus or from
mally. The tibia then resembled an old-fashioned one-piece proximal to distal crossing the proximal physis. Most
wooden clothes pin. The fibular pseudarthrosis was ap- recently, we have used the Paley-modified Fassier-Duval
proached through the same tibial incision. Its periosteal telescopic IM nail system (Pega Medical, Inc., Laval,
hamartoma was also resected. The distal tibia was then Quebec, Canada) from proximal to distal (Figs. 2A–F,
drilled open and its end inserted into the split of the 3A–B, 4A–H). The Paley modification of this nail allows
proximal segment. The proximal fibula was invaginated locking into the distal tibial epiphysis using a Kirschner
into a similar split of the distal fibula. The tibia and fibula wire (Fig. 4A–H). The Paley-modified Fassier-Duval
123
5. Periosteal Grafting for CPT
Table 3. Patient data
Case Age at Diagnosis Classifications LLD (cm) Number of
number surgery previous
(years) El-Rosasy- Boyd [4] Andersen [1] Crawford [9] operations
Paley [14]
1* 7.3 OFD I III Cystic IV 9 11
2* 6.0 Idiopathic I V Dysplastic IV 2.4 0 (bracing
for 6 years)
3* 7.0 NF I II Dysplastic IV 3 0
4* 5.0 Idiopathic II II Dysplastic IV 6.3 3
5* 6.0 NF I II Dysplastic IV 6.5 0
6* 2.0 NF I II Dysplastic IV 0 0
7* 1.2 NF I II Dysplastic IV 2.4 0
8* 1.5 NF I II Dysplastic IV 2 0
9* 2.0 OFD I III Cystic IV 2.5 0
10* 3.0 NF I II Dysplastic IV 4.5 0
11* 1.0 NF I II Dysplastic IV 2.5 0
12* 2.8 NF II II Dysplastic IV 3 2
13 3.6 NF II II Dysplastic IV 0 1
14 3.4 Idiopathic I IV Sclerotic IV 3 1
15 4.3 Idiopathic II II Dysplastic IV 7 2
16 3.4 NF I II Dysplastic IV 1 0
17 6.9 Idiopathic II III Cystic IV 1 2
18 11.3 Idiopathic II II Dysplastic IV 0 14
19 5.6 NF II II Dysplastic IV 5 2
20 1.1 Idiopathic I III Cystic IV 1 0
* Patients who underwent treatment at the U.S. center; patients who underwent treatment at the Turkish center; LLD = limb-length
discrepancy; NF = neurofibromatosis; OFD = osteofibrous dysplasia.
telescopic IM nail system was used in three cases. It is Type l Type lI Type lII
preferable to avoid rodding across the ankle to
prevent stiffness of the joint and permanent poor push-off
strength [21].
An incision was then made along the crest of the ilium.
The apophysis was split and the medial periosteum with the
iliacus muscle reflected medially off the ilium. Cancellous
bone between the tables of the ilium was harvested. If more
bone was needed, the tables were separated under image
intensifier control and the bone in the supra-acetabular
region curetted out. This procedure was especially useful in
very small children. A B C
The medial periosteum of the undersurface of the iliacus
Fig. 1A–C Illustrations show the El-Rosasy-Paley classification of
muscle was then harvested. A knife was used to incise the
CPT: (A) Type I CPT (ie, atrophic [based on radiographic examin-
periosteum in as long and as wide a rectangular piece as ations], mobile, no previous surgery), (B) Type II CPT (ie, atrophic
possible. The periosteum was then separated from the [based on radiographic examinations], mobile, with previous surgery),
overlying muscle. The periosteum immediately shrinks in and (C) Type III CPT (ie, wide ends [based on radiographic
examinations], stiff, with or without previous surgery).
size after it is removed. To restore its size, it was placed
through the skin graft mesher (largest available ratio) and
expanded. The periosteum was then wrapped around the graft and any remaining periosteum were also placed
bone ends of the pseudarthrosis site. The cancellous bone around the fibular site. The wound was then closed over a
graft was placed circumferentially around the pseudar- drain. Recently we have added BMP-2 (Infuse bone graft,
throsis site with the cambium layer facing the bone. Bone Medtronic, Inc., Minneapolis, MN) to the CPT site. One
123
6. Thabet et al. Clinical Orthopaedics and Related Research
A B C D E
F
A B C D E
Fig. 2A–F Treatment for Type I CPT in the lateral and anteropos- Paley modification illustrated) into the fibula and tibia. (D) Periosteal
terior (AP) views is shown. (A) There is longitudinal splitting of the graft is wrapped around the pseudarthrosis and (E) iliac crest bone
proximal tibial and fibular fragments. (B) The bone ends are docked graft is applied to the tibial and fibular docking site. (F) External
and (C) IM rods are inserted (Fassier-Duval telescopic IM nail with fixator is applied.
medium-size package (graft volume, 5.6 cc) of Infuse was osteotomy or hemiepiphysiodesis, equalization of LLD,
used. Infuse bone graft is FDA-approved; however, when it treatment of refracture, pin site problem, rod exchange to a
is used in children or is used to treat CPT, it is considered longer rod, fibular surgery for nonunion after fibular oste-
off-label use. otomy, fibular transport for a short fibula, and distal
After closure, we applied an Ilizarov all-wire frame to tibiofibular synostosis to avoid ankle valgus deformity.
the limb. We used three wires in the proximal metaphysis Followup visits were conducted every month until heal-
(two counterposed olive wires and one smooth wire), three ing was achieved and then every year until skeletal maturity.
distal wires, and foot fixation. The wires should not be in Clinically, we (DP, JEH, MK, LE) assessed pain, ankle
contact with the IM rod. A walking ring was applied range of motion, push-off mechanism, and degree of limp-
postoperatively so the patient does not have to bear weight ing. We obtained erect lower limb radiographs for LLD and
on the foot. residual deformities and anteroposterior and lateral views of
Our approach was to treat associated residual problems the ankle to include the tibia. We (AMT, DP, MK, ONE)
simultaneously with refracture treatment so that the patient assessed radiographs for presence or absence of union, type
would not have to undergo extra surgical procedures. The of union or cross-sectional area, refracture, anterior distal
main indications for secondary surgery after the index tibial angle (ADTA), lateral distal tibial angle (LDTA), and
operation in our series were deformity correction with distal fibular proximal migration in millimeters.
123
8. Thabet et al. Clinical Orthopaedics and Related Research
B
Fig. 3A–B (A) Treatment for Type II CPT for cases in which the illustrated) and external fixation is removed (Panels VIII and IX).
bone defect is greater than 3 cm or when the bone ends are dead from (B) Shown is the treatment for Type II CPT for cases in which the
previous surgical treatment is pictured. Resection of dead bone ends bone defect is less than 3 cm. Resection of dead bone ends is
is combined with bone transport (Panels I–V). After the defect is combined with acute docking with shortening (Panels I and II). An IM
eliminated and lengthening is completed, periosteal and bone graft rod is inserted at the resection site and combined with proximal
is applied to the docking site (Panels VI and VII). Once the tibia is osteotomy for lengthening (Panels III–VII). Periosteal and bone graft
healed at both the docking and lengthening sites, an IM rod is inserted is applied to the docking site during the same surgical procedure
(Fassier-Duval telescopic IM nail with Paley modification is (Panels IV and V).
Results Refracture occurred in eight patients: six experienced
one refracture each, and two experienced two refractures
Initial union was achieved in all patients (Tables 4, 5). The each (Table 6). Six of the eight patients with refracture had
mean duration of treatment with external fixation fibular pseudarthrosis. We excised tissue from the recurrent
was 5.2 months (range, 3–12 months). No patients fracture sites and sent these samples to pathology. No
underwent amputation. neurofibromatosis was found. Fibrous hamartoma was
123
9. Periosteal Grafting for CPT
Fig. 4A–H (A) Anteroposterior
(AP) and (B) lateral view radio-
graphs of a 2-year-old boy with
neurofibromatosis and CPT
(Type I) that had not been pre-
viously treated are shown. (C)
AP view radiograph shows split
of the proximal segment with
invagination of the distal seg-
ment, rodding of tibia from
medial malleolus and of fibula
through lateral malleolus, and
application of Ilizarov external
fixator. (D) AP view radiograph
obtained immediately after exter-
nal fixator removed shows union
of the CPT. (E) AP view radio-
graph shows refracture of the
tibia 1 year later. (F) AP view
radiograph shows retreatment
with an Ilizarov device and
rerodding with Fassier-Duval
telescopic IM nail locked in both
proximal and distal epiphysis.
(G, H) Tibia remains healed
2 years later with good remode-
ling. The telescopic nail has
extended with growth.
noted in each case. The mean time between the index patients with refracture were treated with reapplication of
operation and refracture was 2.3 years (range, 1–5.8 years), the frame and bone grafting (because of atrophic ends).
and the mean time between the index operation and second Consequently, one patient underwent proximal osteotomy
refracture was 4.7 years (range, 3–6.4 years). The mean age for tibial lengthening and another underwent rod exchange,
at the index operation of patients who experienced refrac- both simultaneously with refracture treatment. Three re-
ture was 4 years (range, 1–7.3 years). fractures were treated with casting with or without
Five patients in the refracture group had associated bisphosphonate therapy (zoledronic acid). One of the three
deformities treated by osteotomy or hemiepiphysiodesis; refractures healed with casting alone. One was treated with
the other three had no associated deformities (Table 6). a trial of casting for 3 months without healing, and then
Four patients with refracture were treated with reapplica- healing began after zoledronic infusion was initiated. The
tion of the frame for distraction of the stiff wide ends at the third healed after treatment with casting and zoledronic
pseudarthrosis site without bone grafting. One of the four acid infusion started at the time of refracture diagnosis.
patients underwent rod exchange at the time of frame One patient had persistent fibular pseudarthrosis and fibular
application, and another had a Rush rod inserted through shortening at the time of refracture. These conditions ini-
the subtalar joint at the time of frame removal. Two tially were addressed with fibular transport by using the
123
10. Thabet et al. Clinical Orthopaedics and Related Research
Table 4. Results of treatment
Case Cross section Fibular Ankle Followup Number of EFT Lengthening
number area (union type) shortening (mm) ROM (years) refractures (months) amount (cm)
1* N 0 Stiff 6 1 6 6
2* N 13 Full 1.9 1 4 0
3* N 0 Full 2 1 3.5 0
4* N 8 Full 7.6 0 12 6
5* N 0 Full 6 1 4 6.5
6* N 7 Full 9.75 0 5 0
7* N 0 Full 9 2 4 0
8* N 10 Full 10.7 1 4 0, 5 as second stage
9* N 8 Full 4 0 3 0
10* N 3 Full 5 1 3 0
11* N 13 Full 8 2 5 0
12* N 0 Full 5.5 0 4 3
13 N 18 Full 2.4 0 3 7
14 N 3 Full 3 0 6 3
15 A 8 Full 3.9 0 11 1
16 A 10 Full 1.8 0 4 4
17 A 12 Full 2.4 0 5 5
18 A 11 Full 2.75 0 5 3
19 N 9 Full 2.1 0 6 3
20 A 3 Full 1.6 0 8 1
* Patients who underwent treatment at the U.S. center; patients who underwent treatment at the Turkish center; A = atrophic; EFT = duration
of treatment with external fixation; Fibular shortening = the distance in mm between the fibular growth plate and the ankle joint line;
N = normotrophic; ROM = range of motion.
monolateral frame for 3 weeks to maintain ankle valgus Discussion
correction. Ankle valgus correction was achieved with
eight-plate hemiepiphysiodesis before refracture treatment The goal of this study was to report the number of CPT
and then tibiofibular synostosis concurrently with refrac- cases that achieved union at final followup, number of
ture treatment. Bone grafting, BMP-2, and locking plate for refractures, the secondary procedures required to achieve
internal fixation were used for treatment of refracture. The union, repair fractures, and/or correct angular deformities,
patient received adjuvant zoledronic acid after surgery to and amount of limb length discrepancy. The natural history
maintain the bone graft. At the time of publication, the tibia of CPT is recalcitrant nonunion, progressive LLD and
had healed and a tibiofibular synostosis had formed deformity, and recurrent refracture even after initial union
(Table 6). When zoledronic acid was administered to a [4, 5, 20, 25, 28, 31]. The primary objective of treatment
patient, two infusions were given. No rod breakage for CPT is to obtain union. The secondary objective is to
occurred in the refracture group in our series. Nonunion of maintain union. In addition, many associated deformities of
fibular osteotomy occurred in one patient who had bone length and angulation should be addressed in the compre-
grafting at the time of frame removal; fibular transport was hensive management of CPT. Therefore, unless all patients
performed in two patients to correct ankle valgus defor- have reached skeletal maturity, the refracture rate reported
mity. There was no short-term or long-term bone-periosteal is always lower than actual [4, 5, 31].
graft donor site morbidity. None of our patients had We had no control group in this retrospective study and
reached skeletal maturity at the time of publication. it is therefore difficult to know exactly which factor of our
Limb lengthening was achieved in 12 of 20 patients. The combined approach was responsible for the healing of
average limb length discrepancy for 18 patients was 0 cm CPT. None of the patients in our series had reached skeletal
(range, -7 to 3 cm). The mean lengthening amount was maturity, and the average followup from the index opera-
2.5 cm (range, 0–7 cm); epiphysiodesis of the opposite tion was 4.3 years (range, 2–10.7 years). Additional
side was performed in one patient. refractures are expected until patients reach skeletal
123
11. Periosteal Grafting for CPT
Table 5. Results of treatment Weinstein [26] failed to achieve union in three of 12 cases
Case Union LDTA ADTA Pain Push-off Limping
with average age at treatment of 2.5 years (range, 0.5–
number (degrees) (degrees) strength 8.8 years). Ohnishi et al. [32] failed to achieve union in 15
of 73 using a variety of methods in a Japanese multicenter
1* + 88 76 No Weak Moderate
study in which the average age at treatment onset was
2* + 70 85 No Normal No 4.6 years (range, 0.9–15 years). Johnston [21] failed to
3* + 90 96 No Normal No obtain union in three of 23 and had tenuous or possible
4* + 95 86 No Normal No nonunion in nine of 23 using IM rodding for a group of
5* + 90 96 No Normal No patients whose average age at treatment onset was
6* + 90 102 No Normal No 3.7 years (range, 0.9–9.4 years). Dobbs et al. [10] had two
7* + 92 88 No Normal No of 21 cases that did not unite during a long-term followup
8* + 80 102 No Normal No study in which the average age at treatment was 5.1 years
9* + 87 86 No Normal No (range, 0.9–11 years).
10* + 90 85 No Normal No Refracture in our series occurred in eight of 20 patients
11* + 90 90 No Normal No (Table 2). All were retreated and all obtained union of the
12* + 90 90 No Normal No refracture site. One to five refractures occurred in 47 of 108
13 + 83 96 No Normal Minimum patients treated by the Ilizarov method in the multicenter
14 + 62 100 No Impaired Severe EPOS study [16]. Refracture occurred in 12 of 21 patients
15 + 78 89 No Normal Medium treated with IM rodding in the Dobbs et al. [10] study.
16 + 79 100.5 No Normal Minimum Most other studies [26, 33, 39] show similar or higher
17 + 86 84 No Normal Minimum refracture rates for all the various methods. El-Rosasy et al.
18 + 87 83 No Normal Minimum [14] showed the combination of intramedullary nailing
19 + 85 86 No Normal Minimum with external fixation reduced the refracture rate from 68%
20 + 83 78 No Impaired Moderate (with the Ilizarov device alone) to 29% (IM nailing and
external fixation).
* Patients who underwent treatment at the U.S. center; patients who
underwent treatment at the Turkish center; ADTA = anterior distal The use of the Ilizarov device allows simultaneous
tibial angle; LDTA = lateral distal tibial angle. correction of leg-length difference and ankle valgus
(Table 1). The average LLD at the time of review was
maturity. However, we believe the combination treatment 0 cm (range, –7 to 3 cm). Five of 20 patients had LDTA
(ie, periosteal grafting, bone grafting, internal rodding, and outside of the range of 85° to 95° (Table 5). Seven had
Ilizarov fixation) provides the best combination of biologic ADTA outside of the range of 75° to 90° (Table 5). Some
and mechanical properties for healing and is preferable to of these ankles might need additional surgery in the future.
any of these methods in isolation. The recent addition of Since all the patients use protective orthotic devices, the
pharmacologic management including bisphosphonates foot and ankle position has not been symptomatic.
and rhBMP is promising and is consistent with our shotgun As can be seen from the selected group of studies dis-
technique of management. cussed above, all previous methods resulted in recalcitrant
What is remarkable is that all patients in our study CPT in 13% to 50% of cases. All have used one or more
achieved primary union. In comparison, the initial union parts of the method applied in this series (eg, Ilizarov
rate in the EPOS multicenter study using the Ilizarov fixation, bone grafting, IM rodding, BMP, zoledronic acid,
method was 75.5% (82 of 108 patients) [16]. In another limb lengthening). None have combined all these methods
study, initial union was achieved in 17 of 21 patients [3]. or included the use of periosteal grafting.
Using IM rodding alone, unequivocal union was obtained Some authors suggest the results of treatment are better
in only 11 of 23 patients [21]. In two further recent studies when the patient is older [3, 16, 32]. The average age in
on the use of IM rodding, the initial union was achieved in this series is very young (Table 1). Therefore, observing
18 of 21 patients [10] and four of 12 patients [26]. The use such good results with patients who are so young is even
of BMP with IM rodding failed to achieve union in four of more remarkable.
five patients [27]. Of particular note is that all patients are The pathology of CPT is still unknown. During the
united at the time of followup and at the time of writing of past 100 years, a number of theories have been suggested
this manuscript (Tables 1, 2). There is no other series in the to explain the development of the disease. Pathologic
literature with such a high maintained union rate. Boero changes in the periosteum are one factor that could
et al. [3] reported seven of 21 patients with persistent explain the pathologic changes in congenital pseudar-
nonunion at the time of review with average age at throsis of the tibia [17]. Codivilla [8] was the first to
treatment of 8.8 years (range, 1.3–17 years). Kim and suggest the use of osteoperiosteal grafting from the sound
123
12. 123
Thabet et al.
Table 6. Patients with refractures after initial healing
Patient Site of refracture Diagnosis Treatment of fracture Time between index Classifications – Boyd [4], Age at refracture Fibular PA
number operation and El-Rosasy-Paley et al. [14] (years)
refracture (years)
1 Through different lesion OFD Frame without grafting 3.7 III, II 10.4 Yes
2 Original PA site Idiopathic Casting + zoledronic acid 1.3 V, I 8 Yes
therapy + fibular transport and then
regrafting + tibiofibular synostosis
with two screws + BMP-2 and
LCP; after two treatments of
intravenously administered
bisphosphonate, tibia healed
but fibula not completely consolidated
3 Original PA site NF Casting tried for 3 months (no healing 1.5 II, I 9.4 No
noticed); after zoledronic acid,
healing achieved
5 Original PA site NF Regrafting + external 1.0 II, I 7 Yes
fixation + proximal lengthening
7 Original PA site NF First fracture: FractureFrame + rod First refracture, 1.1 II, I First refracture, 2.3 Yes
exchange without regrafting from Second refracture, 6.4 Second refracture, 6.7
titanium nail to FDN
Second fracture: Frame reapplication,
regrafting, and rod exchange
8 Original PA site NF Frame reapplication without grafting 1.3 II, I 2.8 Yes
and then Rush rod subtalar joint
10 Original PA site OFD Casting + zoledronic acid, healing 5.8 III, I 7.9 No
achieved
11 Original PA site NF First fracture: Healed after 3 months First refracture, 2.8 II, I First refracture, 5 Yes
of casting Second refracture, 3.1 Second refracture, 5.3
Second fracture: Frame without grafting
and rod insertion at time of frame removal
BMP = bone morphogenetic protein; FDN = Fassier-Duval telescopic IM nail; LCP = locking compression plate; NF = neurofibromatosis; OFD = osteofibrous dysplasia;
PA = pseudarthrosis.
Clinical Orthopaedics and Related Research
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BS, for their assistance in preparing the figures for publication; Joy ¨
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Marlowe, MA, for her assistance with the illustrations; and Stacy Short-term safety assessment in the use of intravenous zoledronic
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also thank Amanda Chase, MA, and Dori Kelly, MA, for their 19. Ippolito E, Corsi A, Grill F, Wientroub S, Bianco P. Pathology of
editorial expertise. bone lesions associated with congenital pseudarthrosis of the leg.
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