This study evaluated the results of 42 patients who underwent arthroscopic repair of full-thickness rotator cuff tears using a side-to-side suturing technique without fixation to bone. At an average follow-up of over 5 years, 98% of patients reported good or excellent results on the UCLA shoulder scale. The mean UCLA score was 33, and the majority of patients reported excellent strength, minimal pain, and full function following the procedure. The study concluded that for select rotator cuff tears, a purely arthroscopic side-to-side repair can provide excellent long-term outcomes without the need for anchoring the repair to bone.
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.
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.
There is no “gold standard” technique for the surgical stabilization of Acromioclavicular joint (ACJ) disruptions and each of the described techniques has a failure rate. The management of failed ACJ stabilizations is a difficult problem and salvage procedures may often be constrained by the original procedure and the resultant anatomy. Reliable anatomical and biomechanically robust revision procedures for failed ACJ stabilization are therefore required. We describe a technique for revision stabilization of the ACJ that utilises a synthetic ligament in combination with augmentation from the coracoacromial ligament and biceps short head aponeurosis (‘biceps flip’ procedure).
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
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.
There is no “gold standard” technique for the surgical stabilization of Acromioclavicular joint (ACJ) disruptions and each of the described techniques has a failure rate. The management of failed ACJ stabilizations is a difficult problem and salvage procedures may often be constrained by the original procedure and the resultant anatomy. Reliable anatomical and biomechanically robust revision procedures for failed ACJ stabilization are therefore required. We describe a technique for revision stabilization of the ACJ that utilises a synthetic ligament in combination with augmentation from the coracoacromial ligament and biceps short head aponeurosis (‘biceps flip’ procedure).
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
Ökad gemenskap, trygghet och bekvämlighet kan få fler äldre att vilja och kunna bo kvar längre. Det är förhoppningen i samverkansprojektet Gôrbra för äldre.
Syftet med Gôrbra för äldre är att Göteborgs stad ska göra strategiska investeringar i tillgänglighet, teknik och gemenskap, så att äldre kan bo hemma längre med större boendekvalitet. Staden satsar sju miljoner i projektet och får ytterligare fem av Hjälpmedelsinstitutet i regeringsuppdraget Teknik för äldre II, där Göteborgs stad är ett av tre nationella försöksområden.
Arthroscopic Single Row Versus Double-Row Suture Anchor Rotator Cuff Repair |...Peter Millett MD
Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row suture anchor rotator cuff repair technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. For more shoulder surgery and rotator cuff studies, visit Peter Millett, MD, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Open debridement and radiocapitellar replacement in primary and post-traumati...Alberto Mantovani
Background: Postmortem and clinical studies have shown an early and prevalent involvement of the radiohumeral
joint in primary and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) prosthesis
has recently been developed for the treatment of lateral elbow arthritis. However, few data have been
published on LRE results.
Materials and methods: A prospective multicenter study was designed to assess LRE preliminary results.
There were 20 patients (average age, 55 years). Preoperative diagnosis were primary osteoarthritis in 11
and post-traumatic osteoarthritis in 9. All patients underwent open debridement and LRE prosthesis.
Patients were evaluated preoperatively and postoperatively with the Mayo Elbow Performance Score
(MEPS), modified American Shoulder Elbow Surgeons (m-ASES) elbow assessment, and the Quick
Disabilities of the Arm, Shoulder and Hand (Quick-DASH). Mean follow-up was 22.6 months.
Results: At the last follow-up, the mean improvement of MEPS and m-ASES was 35 (P ¼ .001) and 34
(P ¼ .001) respectively; the average Quick DASH decreased by 29 (P ¼ .001). Average range of motion
was improved by 35 (P ¼.001). MEPI results were excellent in 12 patients, good in 2, and fair and poor in
3 each. Mild overstuffing was observed in 5 patients, and an implant malpositioning in 3. The implant
survival rate was 100%.
Conclusion: LRE showed promising results in this prospective investigation. Most patients had an
uneventful postoperative course and have shown a painless elbow joint, with satisfactory functional
recovery at short-term follow-up. Further studies with longer follow-up are warranted.
Birmingham mid-head resection arthroplasty of hip for avascular necrosis of f...Apollo Hospitals
To study the outcome of Birmingham mid-head resection (BMHR) arthroplasty of the hip in young and active patients with avascular necrosis of femoral head with gross defects.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
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.
We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women) operated on between January 2004 and December 2010. The mean follow-up period was 27 months (within a range of 12-45 months). For the clinical evaluation, we used modified Merle d'Aubigné scoring system.
In group of Vancouver A fractures, 3 patients were treated with a mean score of 15,7 points (good result). We recorded a mean score of 14,2 points (fair result) in 6 patients with Vancouver B1 fractures, 12,4 points (fair result) in 24 patients with Vancouver B2 fractures and 12,8 points (fair result) in 7 patients with Vancouver B3 fractures. In group of Vancouver C fractures, we found a mean score of 16,2 points (good result) in 7 patients.
Therapeutic algorithm based on the Vancouver classification system is, in our opinion, satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential. Preoperative radiographic images may not be reliable and checking the stability of the prosthesis fixation during surgery should be performed.
Comparison of Modified Kessler Technique versus Four Strand Cruciate Techniqu...Crimsonpublisherssmoaj
Introduction: Hand Tendon injuries are not uncommon. Achieving a satisfactory range of motion and preventing tendon rupture after repair of flexor tendon injuries remains a challenge to hand surgeons.
Objectives: To compare functional outcome of tendon repair with Modified Kessler and four strand cruciate techniques.
Material and Methods: Randomized control trial was conducted from July 2013 to June 2015. Both male and female patients of age 18 to 60 years who had clean lacerated injury proximal to wrist crease (Zone V) were eligible for inclusion in the study. Patients with dirty or infected wounds, or those having multiple injuries other than tendons, having injury to extensor tendons were excluded from the study. Arm A comprised of patients who underwent modified Kessler repair and Arm B included patients whose repair was done via four strand cruciate repair technique. The final outcome at 8 weeks was compared by using Strickland’s evaluation system.
Results: A total of 140 fingers of 44 patients with sharp wrist laceration injury of long flexor tendons of fingers were included in this study. The average age of patients was 28.05 ± 10.42 years. Out of 44 patients, 28 (63.64%) were males and 16 (36.36%) females. At 8th week, satisfactory functional outcome (excellent group according to Strickland evaluation) was observed in 65.7% (46/70) fingers in four strand cruciate repair technique and in 28.6% (20/70) fingers in standard modified Kessler repair technique and the difference was statistically significant (P< 0.001).
Conclusion: Four strand cruciate repair technique is better than standard modified Kessler method for repair of long flexor tendons of fingers.
https://crimsonpublishers.com/smoaj/fulltext/SMOAJ.000518.php
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Comparison of Modified Kessler Technique versus Four Strand Cruciate Techniqu...Crimsonpublisherssmoaj
Introduction: : Hand Tendon injuries are not uncommon. Achieving a satisfactory range of motion and preventing tendon rupture after repair of flexor tendon injuries remains a challenge to hand surgeons..Objectives: To compare functional outcome of tendon repair with Modified Kessler and four strand cruciate techniques.Material and Methods: Randomized control trial was conducted from July 2013 to June 2015. Both male and female patients of age 18 to 60 years who had clean lacerated injury proximal to wrist crease (Zone V) were eligible for inclusion in the study. Patients with dirty or infected wounds, or those having multiple injuries other than tendons, having injury to extensor tendons were excluded from the study. Arm A comprised of patients who underwent modified Kessler repair and Arm B included patients whose repair was done via four strand cruciate repair technique. The final outcome at 8 weeks was compared by using Strickland’s evaluation system. Results: A total of 140 fingers of 44 patients with sharp wrist laceration injury of long flexor tendons of fingers were included in this study. The average age of patients was 28.05 ± 10.42 years. Out of 44 patients, 28 (63.64%) were males and 16 (36.36%) females. At 8th week, satisfactory functional outcome (excellent group according to Strickland evaluation) was observed in 65.7% (46/70) fingers in four strand cruciate repair technique and in 28.6% (20/70) fingers in standard modified Kessler repair technique and the difference was statistically significant (P<0.001). Conclusion: Four strand cruciate repair technique is better than standard modified Kessler method for repair of long flexor tendons of fingers.
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
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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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
2. 882 E. M. WOLF ET AL.
author (E.M.W.) over a 6-year period between Febru- TABLE 1. Modified UCLA Shoulder Rating Scale
ary 1990 and February 1996 were evaluated. Initially,
Patient satisfaction
a retrospective clinical chart review was performed for 0 Patient feels procedure was not successful
each case. Nine patients were lost to follow-up, leav- 5 Patient feels procedure was a success
ing 96 shoulders in 95 patients available for evaluation Active forward flexion range of motion
with an average follow-up of 73 months (range, 48 to 0 Less than 30°
120 months). Forty-two of these patients who under- 1 30°-45°
2 45°-90°
went repair of a full-thickness rotator cuff tear in a 3 90°-120°
side-to-side fashion without anchoring the repair to 4 120°-150°
bone were selected for this study. There were 24 male 5 Greater than 150°
and 18 female patients, and the average age at the time Strength of forward flexion
of surgery was 59.8 years (range, 42 to 79 years). All 0 No active contraction
1 Evidence of slight muscle contraction, no active elevation
patients had been recalcitrant to conservative therapy 2 Complete active forward flexion with gravity eliminated
and continued to experience unacceptable pain and 3 Complete active forward flexion against gravity
weakness in the affected shoulder. 4 Complete active forward flexion against gravity with some
All patients were clinically evaluated by the senior resistance
author. Final outcome assessment was performed by 5 Complete active forward flexion against gravity with full
resistance
an independent surgeon (W.T.P.) by telephone. Each Pain
patient was contacted to assess for pain, function, 1 Present always and unbearable, strong medication frequently
range of motion, strength, return to work date, and 2 Present always but bearable, strong medication occasionally
perceived success of the procedure. Outcome was 4 None or little at rest, present during light activities;
evaluated using a modified UCLA shoulder rating salicylates frequently
6 Present during heavy or particular activities only, salicylates
scale10 (Table 1). This scale designates 10 points each occasionally
for pain and function and 5 points each for active 8 Occasional and slight
forward flexion, strength of forward flexion, and pa- 10 None
tient satisfaction, for a total possible score of 35. Good Function
and excellent results (total UCLA score 28-35 points) 1 Unable to use limb
2 Only light activities possible
are considered satisfactory and fair and poor results 3 Able to do light housework or most activities of daily living
(less than 28 points) are considered unsatisfactory. 6 Most housework, shopping, and driving possible; able to do
Eighty-one percent of patients had repairs of their hair and to dress and undress, including fastening brassiere
dominant shoulder, with 33 right and 9 left repairs. All 8 Slight restriction only, able to work above shoulder level
10 Normal activities
patients also had arthroscopic subacromial decom- Total
pressions. Seven patients had other procedures per- Excellent: 34-35
formed concurrently, including 3 arthroscopic Mum- Good: 28-33
ford procedures, 1 SLAP lesion debridement, 1 Fair: 21-27
debridement of a biceps tendon rupture, and 2 os Poor: 0-20
acromiale excisions.
Surgical Technique
tion of the cuff and of the suture hooks used in the
Routine shoulder arthroscopy was performed with repair. The region of the greater tuberosity of the
the patient in the lateral decubitus position. Initially, humerus was abraded with a full-radius shaver and
the glenohumeral joint was inspected to evaluate for burr to create a bed of bleeding bone to promote
any significant intra-articular pathology. The cuff was healing of the cuff to the tuberosity. The mobility of
inspected from the articular side and the defect in the the rotator cuff was evaluated with a grasper or nerve
rotator cuff tendon was debrided of all frayed, devi- hook. Each tear was assessed individually and re-
talized tissue. The arthroscope was reconfigured into paired with “L” or “V-Y” techniques. All repairs in
the subacromial space and a decompression was per- this report were performed arthroscopically using a
formed using a cutting-block technique. It is important side-to-side technique without fixation of the repair to
to remove all bursal tissue covering the rotator cuff to bone. All tears in this series were evaluated with a
be able to evaluate the extent of the tear. The bursec- nerve hook with an attempt to evaluate the anatomic
tomy was also necessary to provide enough visualiza- relationship between the margins of the torn cuff
3. ARTHROSCOPIC SIDE-TO-SIDE ROTATOR CUFF REPAIR 883
edges. The nerve hook was believed to be better than
a grasper because of its smaller size. Its blunt tip was
used to penetrate various points on the edge of the
cuff, which was then mobilized to determine the ap-
propriate configuration of repair. This evaluation of
the cuff tear with a nerve hook is of foremost impor-
tance to ensure the optimal restoration of the normal
anatomy without producing any undue tension on any
part of the repair.
Burkhart9 has suggested that the deepest point of a
U-shaped tear does not represent tear retraction but is
actually an L-shaped tear under physiologic load.
Chronic rotator cuff tears have tapered edges and may
well have a “U” or “V” configuration, but this can be
appreciated by trying to approximate the deep point of
the U-shaped tear to the greater tuberosity with a
nerve hook and noticing the creation of “dog ears” in
the remainder of the cuff, showing the nonanatomic
relationship of this configuration. The repair is then FIGURE 1. This view from the midlateral subacromial portal is
performed with the appropriate suture passer to pass directed caudally and shows the bursal side of a large U-shaped
tear of the supraspinatus tendon. A bed of cancellous bone in the
sutures that will approximate the tendon edges, clos- humeral head (H) is seen beneath the large defect in the rotator
ing the entire defect over the bleeding trough of bone cuff. The anterior (A) and posterior (P) margins of the torn rotator
that was previously created on the proximal humerus. cuff can be appreciated from this viewing portal. This large tear
appears to be amenable to a side-to-side technique of closure.
It is important to note that during the process of the
side-to-side repair, a suture is often placed in what is
believed to be the anterior corner of the posterior leaf
of the tear followed by passage beneath the transverse exercises after their first visit 5 days postoperatively.
humeral ligament and through the coracohumeral lig- Active exercises began 6 weeks postoperatively. No
ament to help advance the posterior leaf anteriorly. patients were treated with an abduction brace postop-
This tendon-to-tendon stitch provides secure approx- eratively.
imation of the retracted posterior leaf of the tear to the
rotator interval while holding the entire repaired RESULTS
stump over the prepared bleeding trough in the greater
tuberosity. There were no partial repairs performed; Ninety-eight percent of patients had good and ex-
all tears in this series were closed completely and were cellent postoperative scores with 23 excellent (55%),
evaluated arthroscopically from the bursal side of the 18 good (43%), and 1 poor result (2%). The average
tear as the shoulder was placed through a full range of UCLA score was 33. Forty-one of the 42 patients
motion to ensure the maintenance of the relationship (98%) rated their surgery as being successful and were
of the tendon repair to the greater tuberosity of the satisfied with the repair. One patient rated his surgery
humerus. An average of 4 sutures (range, 1 to 7 as unsuccessful.
sutures) were used per cuff repair. A clinical example The UCLA shoulder scoring system evaluated for
of a side-to-side repair of a large U-shaped tear is strength, pain, and function (Table 1). The mean re-
shown in Figs 1-4. sponse in all patients grading their strength was 4.6
Repairs were performed exclusively with absorb- (range 2-5), mean response for pain was 9.0 (range
able PDS suture in 88% of repairs and nonabsorbable 2-10), and mean perceived function grade was 9.3
suture in 12%. This includes 36 shoulders repaired (range 1-10). The average grade for forward flexion of
with No. 1 PDS and 1 shoulder with No. 0 PDS. Four the shoulder was 4.9 (range 1-5).
shoulders were repaired with nonabsorbable No. 2 There were 2 patients in whom this arthroscopic
Ethibond (Ethicon, Somerville, NJ). One repair was repair was a revision of a previous open rotator cuff
performed using No. 2 Mersilene suture. Postopera- repair and 3 patients had previously undergone arthro-
tively, patients were placed in a simple immobilizer scopic assisted mini-open repair on the contralateral
for 6 weeks but allowed to begin pulley and pendulum shoulder. All 3 of these patients stated that they were
4. 884 E. M. WOLF ET AL.
FIGURE 2. This arthroscopic view through the midlateral subacro- FIGURE 4. This final arthroscopic view from the midlateral view-
mial viewing portal shows the passage of a No. 1 PDS suture from ing portal shows complete closure of the rotator cuff defect with
posterior to anterior through a long crescent-shaped suture passing the placement of 3 side-to-side No. 1 PDS sutures.
hook (Linvatec, Largo, FL) through the apex of the U-shaped tear.
with a poor result has failed subsequent open repairs
more satisfied with their side in which the purely as well.
arthroscopic repair was performed and had a percep-
tion of a quicker period of recovery and return to
function than with their open repair. The 1 patient DISCUSSION
Rotator cuff tears are often attritional in nature and
the defect present often involves more than just an
avulsion of the musculotendinous cuff from the
greater tuberosity of the humerus. Burkhart9 has elo-
quently described a broad classification scheme to
which rotator cuff tears can be classified: crescent-
shaped or U-shaped tears. He describes the crescent-
shaped tear as a disruption of the tendinous insertion
from the greater tuberosity of the humerus without a
large element of retraction. The U-shaped tear usually
appears on initial inspection to be a large retracted tear
often medial to the level of the glenoid (Fig 1). Plac-
ing the nerve hook in the base of such a tear and
attempting to approximate the base to the greater
tuberosity usually yields 1 of 2 results with this tear
configuration: approximation of the tendon is not
achievable to the tuberosity secondary to tension, or
approximating the base of the U-shaped tear results in
a “dog-eared” appearance of the repaired cuff, indi-
FIGURE 3. This image again through the midlateral subacromial cating tension mismatch and a nonanatomic repair. It
viewing portal shows the effect of this initial suture placed through is important for the surgeon to recognize this tear
the apex of the previously large-appearing U-shaped tear. The pattern and use margin convergence as the primary
arthroscopic knot pusher is shown securing the initial Duncan
sliding knot of the single suture that was seen in Fig 2. Note the approach to repair. Repairing a U-shaped tear by an-
effect of this single suture on closing the remaining defect. choring the apex of the tear to the tuberosity will result
5. ARTHROSCOPIC SIDE-TO-SIDE ROTATOR CUFF REPAIR 885
in tension overload of the repair, which has been cates a nonanatomic repair and tension mismatch that
shown by Burkhart et al. to be doomed to failure.11,12 will likely fail under cyclic loading.
The use of side-to-side suturing as an element of While other researchers have reported their results
rotator cuff repair has been described previously by of purely arthroscopic repair, this is the first report of
McLaughlin8 in his open approach to treating large a series of patients undergoing arthroscopic repair
retracted tears of the rotator cuff. Although McLaugh- with purely tendon-to-tendon sutures being placed
lin advocated the use of this method to help close large without secure anchor or transosseous fixation to
defects, he also was a proponent of final fixation of the bone. This technique of repair is used only in cases for
tendinous disruption of the cuff to bone in the head of which, after thorough arthroscopic evaluation, it is
the humerus at the point on the tuberosity that it would believed that a configuration exists that tear margin
reach without undue tension with the arm at the pa- convergence can be accomplished with side-to-side
tient’s side.8 This early description is echoed in the closure. All patients in this series had a trough of
repair techniques employed today with the arthro- bleeding bone created in the proximal humerus; when
scopic approach. That is, anatomic restoration of the repair was complete, the repaired tendon stump lay
cuff without the introduction of tension at the site of directly over this bleeding bed of bone through a full
the repair. Burkhart et al. have coined the term “mar- range of motion. All of these repairs were believed to
gin convergence” to describe the observation that dur- be complete repairs because visualization of the bursal
ing side-to-side repair the surgeon can visualize the side of the tear after completion of the repair failed to
free margin of the tear converging toward the greater show any remaining defect in the rotator cuff.
tuberosity with each suture being placed. They agree The 98% good to excellent results compares quite
that using margin convergence in the repair of U- favorably with results previously reported in the liter-
shaped tears decreases the amount of strain at the ature for surgical treatment of full-thickness defects of
tendon bone interface of the repair and therefore the rotator cuff. The minimum duration of follow-up
should be protective to the tendon bone interface of of 4 years with an average of more than 6 years
the repair.9,13 demonstrates an excellent long-term clinical outcome
Cadaveric dissection as well as arthroscopic clinical in this subset of patients.
evaluation has led to an appreciation of the relation- As alluded to earlier and described by other inves-
ship of the rotator crescent and rotator cable. Burkhart tigators, there is an inherent balance of forces through-
et al.14 described a consistently identifiable crescent- out the musculotendinous insertion of the rotator cuff
shaped insertion of the distal supraspinatus and in- into the greater tuberosity of the humerus. Our hy-
fraspinatus tendons into the greater tuberosity of the pothesis to explain such a positive long-term outcome
humerus bordered on its medial margin by a thickened in these patients without secure fixation of the repair
bundle of fibers oriented perpendicular to the axis of to bone is that with the recreation of the anatomy, the
the supraspinatus and infraspinatus tendons.14 The natural balance of the rotator cuff musculature pro-
rotator cable was grossly and histologically confirmed vides an environment that is relatively stress free at
by a cadaveric study performed by Clark and Harry- the tendon-to-bone interface. This allows the distal-
man.15 It has been theorized that the thick rotator most end of the repair that is overlying the bleeding
cable, when intact, provides stress shielding of the trough of bone to heal to the tuberosity during the
rotator cuff crescent much like a suspension bridge.14 period of postoperative convalescence. This hypothe-
We believe that arthroscopic evaluation of the anat- sis is supported by Burkhart’s suspension bridge con-
omy of the rotator cuff tear is an essential step in cept of stress shielding of the rotator crescent by an
restoring the anatomy of the disrupted rotator cuff. intact rotator cuff cable. If the cable is intact and able
Burkhart9 suggests that visualization of the tear from to transfer the stress away from the crescent, this
different arthroscopic portals allows the surgeon to stress-free environment should be conducive to heal-
obtain a 3-dimensional understanding of the tear pat- ing of the tendon-to-bone interface.
tern superior to that obtained by open means. We echo The senior author has previously reported the re-
this sentiment in that arthroscopic repair of the rotator sults of the first 54 purely arthroscopic repairs of
cuff allows a thorough evaluation of the complete full-thickness defects of the rotator cuff. As a compo-
anatomy of the cuff disruption. Furthermore, with nent of this previous study, second-look arthroscopy
each suture passed, the effect may be evaluated by was performed on 23 patients to evaluate the integrity
direct visualization of the impact of the suture on the of the repair at a minimum of 6 months postopera-
entire cuff. The creation of flaps or “dog ears” indi- tively. Nine of these patients had purely side-to-side
6. 886 E. M. WOLF ET AL.
repair of their rotator cuff and the second-look tion of the rotator cuff anatomy by recognizing the
arthroscopy was performed at 5 to 16 months postop- configuration of the tear and performing an anatomic
eratively. When examined, all 9 of these tears were repair of the tendon over a prepared bed of bleeding
completely healed to the greater tuberosity without bone. As a multitude of studies continue to appear at
any evidence of residual defect. Overall, including all meetings and in the literature evaluating the pullout
23 arthroscopies performed, 70% of the repaired cuffs strengths of different types of fixation techniques of
were intact at the time of second-look arthroscopy.1 the musculotendinous unit to bone, this study enforces
We believe that these findings support our hypothesis the importance of methodically approaching each tear
that tendon-to-bone healing does occur despite the individually to first recognize and then restore the
absence of secure tendon-to-bone fixation with this correct anatomic relationship of the rotator cuff. Just
technique. Reviewing the literature one would also as the orthopaedic surgeon is trained to recognize the
find ample evidence that the concept of “watertight” personality of a fracture and use this personality to an
closure of the rotator cuff is difficult to achieve re- advantage when performing stabilization, one may
gardless of the method of fixation of the repaired also keep in mind that, similarly, each rotator cuff tear
tendon to the greater tuberosity. Previous studies eval- has a personality of its own with its own subtleties that
uating the integrity of the rotator cuff have found should be appreciated and used to help achieve opti-
residual rotator cuff defects in 34% to 90% of patients mal end results. Although this report is focused on the
who had previously undergone open rotator cuff re- use of the side-to-side repair technique as a sole treat-
pair, despite secure intraoperative fixation of the re- ment of certain rotator cuff tears, the use of tendon-
pair to the greater tuberosity.16-20 to-bone fixation is obviously still used in the treatment
As discussed in the surgical technique section ear- of the majority of the tears that we encounter. In this
lier, a suture that is often used by the senior author series, 98% of patients had a good to excellent result
when performing repairs with this technique is passed according to the UCLA shoulder score. This study
through the anterior corner of the posterior leaf of the shows that patients with a full-thickness defect of the
tear and then beneath the transverse humeral ligament rotator cuff tendon, with anatomy amenable to side-
and through the coracohumeral ligament anteriorly. to-side closure, may be effectively treated with a
After this suture is tied, there is usually secure ap- purely arthroscopic repair using solely a side-to-side
proximation of the anterior corner of the posterior leaf suturing technique, and have excellent long-term clin-
to the remaining intact rotator cuff anterior to the ical results.
rotator cuff interval. This suture is often useful in
small tears involving only the supraspinatus with ex-
tension anterior into the rotator cuff interval. It is also
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