This document discusses Kienbock's disease, a condition caused by avascular necrosis of the lunate bone in the wrist. It begins with an introduction to the disease and its challenging diagnosis and treatment. Subsequent sections cover the debated etiology, staging classifications, clinical presentation, natural history, and surgical treatment options. The literature review discusses studies comparing various treatment approaches. The document concludes with details on the author's experience with a scapholunate triquetrum fusion procedure for late-stage Kienbock's disease, finding it provides reliable pain relief while maintaining carpal height.
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State fo the art on Kienbock's disease (avascular necrosis of the lunate). One handred years after its first description, it remains a source for controversies. What is new and what is outdated? Where do we go next?
Η Άσηπτη Νέκρωση του Μηνοειδούς: Τι δεν μάθαμε σε 100 χρόνια- Kienbock's dise...Nikos Darlis
State fo the art on Kienbock's disease (avascular necrosis of the lunate). One handred years after its first description, it remains a source for controversies. What is new and what is outdated? Where do we go next?
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This video explains Cervical Stenosis and Cervical Spondylosis/Arthritis. When stenosis begins to affect the spinal cord this is called Cervical Spondylotic Myelopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Stenosis/Arthritis for a Laminoplasty feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1
Dr. Donald Corenman (http://neckandback.com 970.479.5895) is a spine surgeon and spinal cord expert practicing at the Steadman Clinic in Vail, CO. He created this Power Point presentation on cervical spine injury and the evaluation of the cervical spine with an injury. The cervical spine (C spine) represents the neck area of the upper spine.
This presentation--clearing the cervical spine--offers an in-depth look at cervical spine injury of the neck (C spine) including fractures, cervical nonskeletal injuries, and also offers a 3-view radiograph approach into the exam.
Dr. Corenman is a spine expert and treats nonskeletal injuries such as ligamentous instability, sciwora and central cord injury. He is an expert in myelopathy, sciatica, degenerative disc disease, scoliosis and slipped disc.
Madelung deformity is an abnormality of the palmar ulnar part of the distal radial physis in which progressive ulnar and volar tilt develops at the distal radial articular surface, with dorsal subluxation of the distal ulna.
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Willie Nelson is a name that resonates within the world of music and entertainment. Known for his unique voice, and masterful guitar skills. and an extraordinary career spanning several decades. Nelson has become a legend in the country music scene. But, his influence extends far beyond the realm of music. with ventures in acting, writing, activism, and business. This comprehensive article delves into Willie Nelson net worth. exploring the various facets of his career that have contributed to his large fortune.
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Introduction
Willie Nelson net worth is a testament to his enduring influence and success in many fields. Born on April 29, 1933, in Abbott, Texas. Nelson's journey from a humble beginning to becoming one of the most iconic figures in American music is nothing short of inspirational. His net worth, which estimated to be around $25 million as of 2024. reflects a career that is as diverse as it is prolific.
Early Life and Musical Beginnings
Humble Origins
Willie Hugh Nelson was born during the Great Depression. a time of significant economic hardship in the United States. Raised by his grandparents. Nelson found solace and inspiration in music from an early age. His grandmother taught him to play the guitar. setting the stage for what would become an illustrious career.
First Steps in Music
Nelson's initial foray into the music industry was fraught with challenges. He moved to Nashville, Tennessee, to pursue his dreams, but success did not come . Working as a songwriter, Nelson penned hits for other artists. which helped him gain a foothold in the competitive music scene. His songwriting skills contributed to his early earnings. laying the foundation for his net worth.
Rise to Stardom
Breakthrough Albums
The 1970s marked a turning point in Willie Nelson's career. His albums "Shotgun Willie" (1973), "Red Headed Stranger" (1975). and "Stardust" (1978) received critical acclaim and commercial success. These albums not only solidified his position in the country music genre. but also introduced his music to a broader audience. The success of these albums played a crucial role in boosting Willie Nelson net worth.
Iconic Songs
Willie Nelson net worth is also attributed to his extensive catalog of hit songs. Tracks like "Blue Eyes Crying in the Rain," "On the Road Again," and "Always on My Mind" have become timeless classics. These songs have not only earned Nelson large royalties but have also ensured his continued relevance in the music industry.
Acting and Film Career
Hollywood Ventures
In addition to his music career, Willie Nelson has also made a mark in Hollywood. His distinctive personality and on-screen presence have landed him roles in several films and television shows. Notable appearances include roles in "The Electric Horseman" (1979), "Honeysuckle Rose" (1980), and "Barbarosa" (1982). These acting gigs have added a significant amount to Willie Nelson net worth.
Television Appearances
Nelson's char
Characterization and the Kinetics of drying at the drying oven and with micro...Open Access Research Paper
The objective of this work is to contribute to valorization de Nephelium lappaceum by the characterization of kinetics of drying of seeds of Nephelium lappaceum. The seeds were dehydrated until a constant mass respectively in a drying oven and a microwawe oven. The temperatures and the powers of drying are respectively: 50, 60 and 70°C and 140, 280 and 420 W. The results show that the curves of drying of seeds of Nephelium lappaceum do not present a phase of constant kinetics. The coefficients of diffusion vary between 2.09.10-8 to 2.98. 10-8m-2/s in the interval of 50°C at 70°C and between 4.83×10-07 at 9.04×10-07 m-8/s for the powers going of 140 W with 420 W the relation between Arrhenius and a value of energy of activation of 16.49 kJ. mol-1 expressed the effect of the temperature on effective diffusivity.
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Please visit our website: https://kuddlelife.org
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Micro RNAs (miRNAs) are small non-coding RNAs molecules having approximately 18-25 nucleotides, they are present in both plants and animals genomes. MiRNAs have diverse spatial expression patterns and regulate various developmental metabolisms, stress responses and other physiological processes. The dynamic gene expression playing major roles in phenotypic differences in organisms are believed to be controlled by miRNAs. Mutations in regions of regulatory factors, such as miRNA genes or transcription factors (TF) necessitated by dynamic environmental factors or pathogen infections, have tremendous effects on structure and expression of genes. The resultant novel gene products presents potential explanations for constant evolving desirable traits that have long been bred using conventional means, biotechnology or genetic engineering. Rice grain quality, yield, disease tolerance, climate-resilience and palatability properties are not exceptional to miRN Asmutations effects. There are new insights courtesy of high-throughput sequencing and improved proteomic techniques that organisms’ complexity and adaptations are highly contributed by miRNAs containing regulatory networks. This article aims to expound on how rice miRNAs could be driving evolution of traits and highlight the latest miRNA research progress. Moreover, the review accentuates miRNAs grey areas to be addressed and gives recommendations for further studies.
"Understanding the Carbon Cycle: Processes, Human Impacts, and Strategies for...MMariSelvam4
The carbon cycle is a critical component of Earth's environmental system, governing the movement and transformation of carbon through various reservoirs, including the atmosphere, oceans, soil, and living organisms. This complex cycle involves several key processes such as photosynthesis, respiration, decomposition, and carbon sequestration, each contributing to the regulation of carbon levels on the planet.
Human activities, particularly fossil fuel combustion and deforestation, have significantly altered the natural carbon cycle, leading to increased atmospheric carbon dioxide concentrations and driving climate change. Understanding the intricacies of the carbon cycle is essential for assessing the impacts of these changes and developing effective mitigation strategies.
By studying the carbon cycle, scientists can identify carbon sources and sinks, measure carbon fluxes, and predict future trends. This knowledge is crucial for crafting policies aimed at reducing carbon emissions, enhancing carbon storage, and promoting sustainable practices. The carbon cycle's interplay with climate systems, ecosystems, and human activities underscores its importance in maintaining a stable and healthy planet.
In-depth exploration of the carbon cycle reveals the delicate balance required to sustain life and the urgent need to address anthropogenic influences. Through research, education, and policy, we can work towards restoring equilibrium in the carbon cycle and ensuring a sustainable future for generations to come.
Diabetes is a rapidly and serious health problem in Pakistan. This chronic condition is associated with serious long-term complications, including higher risk of heart disease and stroke. Aggressive treatment of hypertension and hyperlipideamia can result in a substantial reduction in cardiovascular events in patients with diabetes 1. Consequently pharmacist-led diabetes cardiovascular risk (DCVR) clinics have been established in both primary and secondary care sites in NHS Lothian during the past five years. An audit of the pharmaceutical care delivery at the clinics was conducted in order to evaluate practice and to standardize the pharmacists’ documentation of outcomes. Pharmaceutical care issues (PCI) and patient details were collected both prospectively and retrospectively from three DCVR clinics. The PCI`s were categorized according to a triangularised system consisting of multiple categories. These were ‘checks’, ‘changes’ (‘change in drug therapy process’ and ‘change in drug therapy’), ‘drug therapy problems’ and ‘quality assurance descriptors’ (‘timer perspective’ and ‘degree of change’). A verified medication assessment tool (MAT) for patients with chronic cardiovascular disease was applied to the patients from one of the clinics. The tool was used to quantify PCI`s and pharmacist actions that were centered on implementing or enforcing clinical guideline standards. A database was developed to be used as an assessment tool and to standardize the documentation of achievement of outcomes. Feedback on the audit of the pharmaceutical care delivery and the database was received from the DCVR clinic pharmacist at a focus group meeting.
5. Etiology
Summary
No single factor can be isolated. It is a combination of
load , either repeated compression or single fracture,
vascular risk, mechanical predisposition and
unavoidable continuous stress on the lunate resulting in
AVN , progressive collapse , carpal derangement and
ultimate arthrosis
6. Staging
Lichtman 1988
Stage 1 Normal XR increased bone scan MRI diagnostic
Stage 2 Increased sclerosis Lunate on XR
Stage 3 Lunate collapse
A. Normal carpal alignment without fixed
scaphoid rotation
B. Altered carpal alignment with fixed
scaphoid rotation
Stage 4 Lunate collapse with carpal OA
8. Clinical presentation
• 20- 40 years of age
• Active individual , manual
labourer
• Dominant hand
• May or may not be a history of
trauma
• Chronic wrist pain
• Decreased ROM /dorsal
tenderness/ swelling/ synovitis
• Youngest 8 yrs , oldest 71 yrs
• Most 2-3 yrs of wrist pain that
becomes more acute following
a trivial injury
9. Natural History
• In terms of bony changes there is sclerosis, progressive
loss of height of the lunate and fragmentation. This
results in dissociation within the proximal row allowing
the scaphoid and triquetrum to rotate in opposite
directions, scaphoid into palmar flexion and triquetrum
into dorsiflexion net effect is loss of carpal height and
eventually degenerative changes develop.
• So overall although their is relentless progression of XR
changes, these changes are only weakly assoc with
symptoms
• Hence treatment and outcomes are still debated with
conflicting opinions
10. Questions
• The problem is AVN but the result is instability
• Is the pain from the avascular lunate, the carpal collapse and
instability or a combination of the above?
• Does the capitate in fact migrate if the lunate is excised?
• Why do we see very few stage 4 SLAC wrists in kienbocks but
frequently see in scapholunate dissociation
• How SLAC is a SLAC wrist ,or are we dealing with different
pathologies
• Aetiology unknown therefore Rx not goal directed but rather
symptomatic and salvage directed , hence unpredictable results
11. Surgical Options
Depends on age, stage, ulna variance and presence of arthrosis
1. Conservative splinting intra-articular injection
2. Denervations
3. Revascularization / Bone grafting. Used in 1,2,3a Variety of
techniques dorsal metacarpal artery /Pronator Quadratus /
pisiform
4. Joint levelling procedures Decrease pressure transmission
through Lunate Useful in ulna minus , advantages ,
disadvantages Up to 40 % reduction in force transmision
5. Radial closing osteotomy
6. Ulna procedures
12. Surgical Options
Limited carpal Fusions Useful stage 3B
1. STT arthrodesis :most commonly used
Rationale: Designed to stabilize midcarpal joint, prevent carpal
collapse and decompress lunate by shifting force transmission
thru radioscaphoid joint
Problems: pseudarthrosis rate 40%,Accelerated degeneration
mid-carpal and radioscaphoid joint
2. Scaphocapitate fusion. Similar biomechanical effect, prevents
collapse, unloads lunate addresses scaphoid flexion and simple
to achieve arthrodesis
3. Capito-hamate fusion
14. Literature Review
• Conservative treatment vs. STT arthrodesis for Kienbock’s disease
(Foucher G; 2006: Chirurgie de la Maine)
- 104 patients over 18 Yrs Conservative 59 STT 25
- STT group increased pain ,stiffness , rehab time
• Wrist fusion vs. limited carpal fusion in advanced Kienbock’s disease
(I Trail ,J StanleyL; 2005: International Orthopaedics)
- 18 patients 6 total fusions; 12 limited 5 yr follow up
- total fusions better DASH scores , patient satisfaction scores , less
failures
• Long term outcome of radial shortening with or without ulna shortening
for the treatment of Kienbock’s disease (Zenzai J; Hand Surgery 2005)
- 36 patients stages 1to 3 Average of 19 yr follow up
- Overall good results No significant progression of the disease
15. Literature Review
• Arthroscopic assessment and classification of Kienbock’s Disease
Bain; Techniques in Hand and Upper Extremity Surgery 2006
16. Stage 1,2 3a
Conservative
Ulna -ve
Radial Shortening and
PIN denervation
Ulna neutral or +
Core Decompression
and PIN denervation
18. Lunate excision for stage3b
Pros
• Gillespie: 88% good to
excellent results in 24 cases
• Dornan: 16 cases good to
excellent results
• Kawai JBJS 1988: 70 B 18
cases , 12 year follow up good
to excellent , minimal
degenerative changes
Cons
• Stahl: 1947 14 patients poor
results
• Therkelsen: 1949 excision
worse than leaving in place
20. Method
• Our series attempt to deal with the avascular lunate and carpal
instability with a single procedure
• Based on the anatomy of the dorsal radiocarpal ligament and inter-
carpal ligament
21. Method
• Dorsal incision 3rd
4th
compartments
• Identify dorsal inter-carpal and radio-carpal ligaments
• Elevate as a flap (trapdoor) leaving the triquetral attachment intact
• Cut the scapho-lunate lig keeping as close to the lunate as possible
• Remove the lunate
• Suture DIC ligament to SL ligament
• Routine closure backslab for 10 days then mobillize
Scaphoid
Dorsal intercarpal lig
22. Demographics
• Average age: 36 yrs
• 5 Females and 1 Male ( 1 patient lost to follow up )
• 1 bilateral Kienbock’s ( 56 yr female )
• Average duration symptoms: 6.6 yrs
• 2 patients with history of trauma , 3 with no history of trauma
25. Conclusion
• Viable salvage operation in (failed) grade 3b Kienbock’s
• Simple procedure
• Reliable pain relief but decreased range of movement
• No statistically significant change in carpal height ratio
• Lunate gap remains the same ie no capitate migration
26. Conclusion
• Conservative +++
• Treatment symptom directed rather
than radiologically directed
• No surgical procedure entirely
effective
• Stepwise approach
