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Acute motion loss Gross deformity Traditional methods for treatment of chondral lesions Acute neurovascular deficit include the judicious use of nonsteroidal anti-inflam- Mechanical symptoms (catching discount kamagra super 160 mg with visa erectile dysfunction drugs sales, locking purchase kamagra super 160 mg visa impotence causes and cures, sensation of a loose body) matory drugs combined with activity modification. Failed nonsurgical management greater than 3 months in duration Oral chondroprotective agents such as glucosamine Repeated giving way or complaints of instability 50 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE SURGICAL MANAGEMENT quality and volume of repair tissue (fibrocartilage) is variable. These procedures are used in low demand patients with larger lesions (>2 cm2) or in higher Various surgical modalities exist for the treatment of demand patients with smaller lesions (<2 cm2). The goals are to reduce symptoms, and abrasion arthroplasty for several reasons: (1) it is improve joint congruence by restoring the articular sur- less destructive to the subchondral bone because it cre- face with the most normal tissue (i. Postoperative rehabilitation PALLIATIVE consists of nonweight bearing for 6 to 8 weeks and may include continuous passive motion (CPM) to improve Arthroscopic debridement and lavage is used to the extent and quality of the repair tissue. As MSTs are remove degenerative debris, cytokines, and proteases low-cost and relatively low-morbidity procedures, they that may contribute to cartilage breakdown. It is ide- remain the mainstay for the initial management of ally indicated in the patient with defect area less than small chondral lesions. Postoperative rehabilitation involves weight- bearing as tolerated and early strengthening exercises. RESTORATIVE In the absence of meniscal pathology, the results fol- lowing arthroscopic debridement are at best guarded. This restorative procedure results in the depth of chondrocyte death and cellular necrosis in hyaline-like cartilage which is believed to be superior the treated area and thus remains investigational. Postoperative reha- bilitation entails aggressive CPM and nonweight bear- ing for 6 weeks with a gradual increase to full-weight REPARATIVE bearing from 6 to 12 weeks. ACI is a costly procedure with a relatively lengthy recovery period and is most Marrow stimulating techniques (MST—microfracture, often used as a secondary procedure for the treatment abrasion arthroplasty, and subchondral drilling) involve of medium to larger focal chondral defects (>2 cm2). The resulting and articular cartilage which can be obtained from the TABLE 9-6 Surgical Management of Chondral Lesions PROCEDURE INDICATIONS OUTCOME Arthroscopic debridement Minimal symptoms, short-term relief Palliative and lavage Thermal chondroplasty Partial thickness defects, investigational Palliative (laser, radiofrequency energy) Marrow stimulating techniques Smaller lesions, persistent pain Reparative Autologous chondrocyte Small and large lesions with or without Restorative implantation subchondral bone loss Osteochondral autograft Smaller lesions, persistent pain Restorative Osteochondral allograft Larger lesions with subchondral bone loss Restorative CHAPTER 9 ARTICULAR CARTILAGE INJURY 51 TABLE 9-7 Results of Arthroscopic Debridement and Lavage AUTHOR N MEAN FOLLOW-UP RESULTS Owens et al, 2002 19 patients 24 months Fulkerson score 12 mos – 80. Osteochondral allograft can be used to treat larger ing the three-dimensional surface contour. Tissue matching and immunologic sup- using the patient’s own tissue; however, the lim- pression are unnecessary as the allograft tissue is ited amount of donor tissue confines this tech- avascular and alymphatic. The risk of tion consists of immediate CPM and nonweight donor-site morbidity increases as more tissue is bearing for 6 to 12 weeks. Postoperative rehabilitation includes often used as a secondary treatment option for early range of motion and nonweight bearing for 2 failed ACI in larger defects. It is most commonly indicated comes studies for arthroscopic debridement and for the primary treatment of smaller lesions con- lavage, microfracture, ACI, and osteochondral auto- sidered symptomatic and for similarly sized grafts and allografts. TABLE 9-8 Results of Microfracture AUTHOR N MEAN FOLLOW-UP RESULTS Steadman et al, 2003 71 knees 11 years 80% improved Age ≤ 45 years (7 to 17 years) Lysholm 59 → 89 Tegner 6 → 9 Majority of improvement 1st year Maximal improvement 2 to 3 years Younger patients did better Steadman, Rodkey, 75 patients 11. TABLE 9-10 Results of Osteochondral Autografts AUTHOR N LOCATION MEAN FOLLOW-UP RESULTS Hangody et al, 2001 461 F >1 year 92% good/excellent 93 P/Tr >1 year 81% good/excellent 24 T >1 year 80% good/excellent Kish, Modis, and 52 F in competitive athletes >1 year 100% good/excellent Hangody, 1999 63% returned to full sports 31% returned to sports at lower level 90% <30 years returned to full sports 23% >30 years returned to full sports Bradley, 1999 145 18 months 43% good/excellent 43% fair 12% poor Hangody et al, 1998 57 F, P 48 months 91% good/excellent ABBREVIATIONS:F= femur; Tr = trochlea; P = patella; T = tibia. TABLE 9-11 Results of Osteochondral Allografts AUTHOR N LOCATION MEAN FOLLOW-UP RESULTS Aubin et al, 2001 60 F 10 years 84% good/excellent Mean age 27 years 20% failure Bugbee, 2000 122 F 5 years 91% success rate at 5 years Mean age 34 years 75% success rate at 10 years 5% failure Chu et al, 1999 55 F, T, P 75 months 76% good/excellent Mean age 35 years 16% failure Gross, 1997 123 F, T, P 7. CHAPTER 9 ARTICULAR CARTILAGE INJURY 53 TABLE 9-12 Survivorship Analysis of Osteochondral Allografts AUTHOR N LOCATION 5/7. DECISION MAKING of disease progression, primary versus secondary treatment and patient activity demand. This algorithm The choice of surgical intervention is complex and is currently evolving and will undoubtedly change as involves the consideration of many factors, including we acquire new information from animal studies and defect size, depth, location, chronicity, response to clinical trials. Multiple options often exist for similar lesions and there is not necessarily a consensus regarding the opti- REFERENCES mal treatment. Ann rently amenable to a menu-driven decision making Pharmacother 32:574–579, 1998. Clin Orthop 253:197–202, These include: location and size of the injury or extent 1990. A survivor- ular defects in osteochondritis dissecans of the lateral femoral ship analysis. Blevins FT, Steadman JR, Rodrigo JJ, et al: Treatment of articu- Ghazavi MT, Pritzker KP, Davis AM, et al: Fresh osteochondral lar cartilage defects in athletes: An analysis of functional out- allografts for post-traumatic osteochondral defects of the knee. Gill TJ, Steadman JR, Rodrigo JJ, et al: Indications and long- Osteologie 9:17–25, 2000. Gillogly SD, Voight M, Blackburn T: Treatment of articular car- Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep car- tilage defects of the knee with autologous chondrocyte implan- tilage defects in the knee with autologous chondrocyte trans- tation.

When it is used on superficial burns cheap kamagra super 160 mg erectile dysfunction causes cycling, a yellow–grey pseudoeschar typically forms after several days buy 160mg kamagra super overnight delivery erectile dysfunction heart disease diabetes, which can be confusing and misleading to inexperienced surgeons. A good diagnosis and treatment plan must be established before its application, because pseudoeschar may pose difficulties in future management decisions. This film of pseudoeschar, which is several millimeters thick, results from interaction between the cream and the wound exudate (Fig. It is harmless and can be easily lifted; however that action may prolong healing time and is accompanied by different degrees of procedural pain. FIGURE 2 Pseudoeschar formed on a superficial burn treated with silver sulfadia- zine. Although harmless, it can be misleading in inexperienced hands and diag- nosed as full-thickness eschar. Superficial Burns 167 Cerium nitrate–silver sulfadiazine was introduced in the mid-1970s, but its popularity increased 10 years later. It is frequently used in Europe, especially in centers where deep burns are managed with a more conservative approach. Cer- ium is one of the lanthanide rare earth series of elements that has antimicrobial activity in vitro and is relatively nontoxic. Wound bacteriostasis may be more efficient with its use in major burns than with silver sulfadiazine. The efficacy of cerium nitrate–silver sulfadiazine may be due in part to an effect on immune function. Methemoglobinemia due to nitrate reduction and absorption has been rarely observed with this agent. Initial application of cerium nitrate–silver sulfadi- azine can be painful, but this problem resolves after few applications. Perilesional rash may also appear on initial application and it may be difficult to differentiate from true cellulitis. A leathery hard eschar with deposition of calcium occurs in deep dermal and full-thickness burns, which prevents bacterial invasion and per- mits easy delayed tangential excision (Fig. Conversion of partial-thickness wound to full-thickness skin loss has occurred as well as deepening of donor sites with the use of this agent. It should be reserved for use in cases of deep partial and full-thickness burns awaiting excision. It is a good alternative in elderly patients who are not candidates for surgical intervention. Facial burns can also be treated with cerium nitrate–silver sulfadiazine. After regular application FIGURE 3 Typical appearance of burn wounds treated with cerium nitrate–silver sulfadiazine. Note the leathery hard scar with deposition of calcium, which often prevents invasive burn wound infections. It creates a wound that is easily treated with delayed tangential excision. Superficial and deep partial burns heal uneventfully and separate the pseudoeschar. The use of many other topical antimicrobials depends on the surgeon’s choice, characteristics of the wound, and anatomical site of the burn. Nevertheless, the most commonly used topical antimicrobial in partial-thickness wounds contin- ues to be 1% silver sulfadiazine. Mafenide acetate is the only agent with good eschar penetration, and it is particularly suited for infected wounds. However, it presents with systemic toxic- ity since it is a potent carbonic anhydrase inhibitor. It produces considerable pain on application, and it should be reserved for short-term control of invasive burn wound infections.

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In doubtful cases quality kamagra super 160 mg acupuncture protocol erectile dysfunction, an MRI scan should show whether disk degeneration is already present buy generic kamagra super 160 mg on-line erectile dysfunction best pills. Spondylolisthesis (Grades III–IV) or spondyloptosis If a spondylolisthesis of more than 50% is present (Mey- erding III or IV), surgical stabilization is likewise indi- cated. Provided no kyphosis is present (lumbar index over 90°), fusion in situ will be sufficient, either in the form of a posterolateral fusion or an anterior spondylodesis. We personally prefer the anterior fusion, since further pro- gression cannot be prevented with a purely posterolateral a b c fusion. Schematic presentation of the procedure for correcting If kyphosis is present, i. In the first screws into vertebral bodies L4 and S1 (the pedicles of L5 cannot usu- ally be reached initially). Reduction from the posterior side: particularly stage, the disk must be removed from the anterior side lordosing, the translation is only corrected by up to 50% (because of and the space filled with cancellous bone. Lateral x-rays: a preoperatively; b 1 year postoperatively after spondylolysis screw fixation. The olisthesis was partially reduced by the concurrent correction from the ventral and dorsal sides operation 107 3 3. On the other hand, of the olisthesis from 67% to 37% and after correction the kyphosis correction has a much greater effect than the of the kyphosis by 19°. While the preoperative neuro- posterior displacement on the forward shifting of the cen- logical symptoms (in five patients) had disappeared, two ter of gravity of the upper body. For functional purposes patients (with no preoperative neurological problems) therefore, the angular correction is more important than had a persistent foot levator muscle weakness after the the rectification of the slippage (⊡ Fig. Follow-up examination of the first 18 patients con- firmed that all patients were pain-free after reduction Our therapeutic strategy for spondylolysis and spondylolisthesis The therapeutic strategy for spondylolysis and spondylo- listhesis in our hospital is shown in ⊡ Table 3. Albanese M, Pizzutillo PD (1982) Family study of spondylolysis and spondylolisthesis. Beutler W, Fredrickson B, Murtland A, Sweeney C, Grant W, Baker D (2003) The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Capasso G, Maffulli N, Testa V (1992) Inter- and intratester reli- ability of radiographic measurements of spondylolisthesis. Danielson BI, Frennered AK, Irstam LK (1991) Radiologic progression of isthmic lumbar spondylolisthesis in young patients. Dick WT, Schnebel B (1988) Severe spondylolisthesis: Reduction and internal fixation. Elke R, Dick W (1996) The internal fixator for reduction and stabili- zation of grade III-IV spondylolisthesis and the significance of the sagittal profile of the spine. Grobler LJ, Robertson PA, Novotny JE, Pope MH (1993) Etiology of spondylolisthesis. Schematic presentation of the shift in the center of gravity joint morphology. Spine 18: 80–91 in severe spondylolisthesis (grade IV) with kyphosis between L5 and 7. Hefti F, Brunazzi M, Morscher E (1994) Spontanverlauf bei Spondy- the sacrum (dark). Therapeutic strategy for spondylolysis and spondylolisthesis Growth age Spondylolysis with or without spondylolisthesis grade 0–II, No treatment no symptoms Spondylolysis with or without spondylolisthesis grade 0–II, Physiotherapy, avoid lordosing exercises; if persists for more typical pain than 6 months, poss. Hennrikus WL, Rosenthal RK, Kasser JR (1993) Incidence of spon- dylolisthesis in ambulatory cerebral palsy patients. Ivanic G, Pink T, Achatz W, Ward J, Homann N, May M (2003) Direct poses problems for the lung. Konermann W, Sell S (1992) Die Wirbelsäule – Eine Problemzone im Kunstturnhochleistungssport. Eine retrospektive Analyse von Congenital deformity of the axial skeleton at one or 24 ehemaligen Kunstturnerinnen des Deutschen A-Kaders. Sport- more levels leading to axial deviations in the sagittal verletz Sportschaden 6: 156–60 (congenital kyphoses) and frontal (congenital scolioses) 12. Konz RJ, Goel VK, Grobler LJ, Grosland NM, Spratt KF, Scifert JL, planes, possibly combined with rotation. Sairyo K (2001) The pathomechanism of spondylolytic spondy- lolisthesis in immature primate lumbar spines in vitro and finite Etiology element assessments. Lenke L, Bridwell K (2003) Evaluation and surgical treatment of Most congenital malformations of the spine are acquired high-grade isthmic dysplastic spondylolisthesis.

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In addition 160 mg kamagra super with visa erectile dysfunction low testosterone, there are a group of conditions commonly observed in chronic pain patients that are not necessarily psychiatric in nature cheap kamagra super 160 mg free shipping erectile dysfunction in 60 year old, which in addition do not satisfy formal Diagnostic and Statistical Manual (DSM) criteria. These observations include such things as pain behaviors, sleep disturbance, somatization, nonorganic physical findings, Grabow/Christo/Raja 92 and impaired functional status out of proportion to physician expectations based on objective findings. Psychiatric Disease in CRPS Patients with CRPS commonly suffer from psychological dysfunction. In fact, patients with CRPS experience a significant amount of depression, anxi- ety, and phobia. However, attempts to establish a unique ‘CRPS personality’ have been unsuccessful. In general, early studies lacked validity due to various flaws in methodological design. For example, studies failed to examine pre- morbid personality data, study investigators used heterogenous definitions of psychiatric terminology, and psychometric instruments had not been ‘normed’ on pain populations. Nevertheless, reported prevalence of psychiatric disor- ders in patients with CRPS ranges from 18 to 64%. Psychological exami- nation using the Structured Clinical Interview (SCID) of the DSM-IV demonstrates a high frequency of affective disorder (46%), anxiety disorder (27%), and substance abuse disorder (14%) in patients with CRPS. However, the prevalence of psychiatric disorders in patients with CRPS may not be much different from chronic pain patients in general. Finally, Bruehl and Carlson reviewed data strictly from studies which used the Minnesota Multiphasic Personality Inventory (MMPI) and concluded that patients with CRPS, like patients with chronic pain in general, are somatically preoccupied, depressed, and use repres- sion as a psychological defense mechanism. There has been historical debate whether chronic pain or psychiatric ill- ness is the primary process. The reciprocal relationship between pain and psy- chological dysfunction in patients with CRPS is evident from a recent study of daily diaries which demonstrated that yesterday’s depressed mood contributed to today’s increased pain and that yesterday’s pain also contributed to today’s depression, anxiety, and anger. Several literature reviews have examined whether psychological dysfunction was the cause or effect of CRPS [9, 10, 13]. In general, the majority of historical studies suffered from flaws in methodol- ogy such as lack of consistent and homogenous diagnostic groups, lack of con- trol groups and significant statistical tests, lack of objective measures of psychological disease, poorly defined behavioral criteria, and incorrect use of psychiatric or psychological terminology. As a result, Lynch con- cluded there is no valid evidence that certain personality traits or psychological factors predispose one to the development of CRPS. Similarly, due to the methodological weakness of the literature, Bruehl and Carlson concluded CRPS Psychological Dysfunction 93 there is insufficient data to draw meaningful conclusions whether or not preex- isting psychological factors predispose to the development of CRPS. In summary, most authors have concluded that comorbid psychological disease in patients with CRPS is a consequence of the chronic pain rather than its cause [9, 13]. Furthermore, there is no evidence that individuals with certain personality types are predisposed to developing CRPS. Finally, there are no consistent psychological differences between CRPS and non-CRPS pain patients [14–22] (table 2). Factitious Disorder The overall prevalence of factitious disorder in chronic pain patients is between 0. Patients with conversion disorder and factitious ill- ness may have similar clinical presentation to patients with CRPS. Moreover, neurophysiological investigation suggests that certain positive motor signs (dystonia, tremors, spasms, irregular jerks) identified in patients with CRPS type I are in fact psychogenic in origin and represent pseudoneurologi- cal illness. Strain and Distress in Caregivers Caregivers of patients with CRPS experience significant levels of strain and susceptibility to depression measured by the Caregiver Strain Index (CSI) and General Health Questionnaire-12 (GHQ-12), respectively. Thus, physicians should not only implement psychosocial interventions directed at patients but also at caregivers of patients with CRPS. They reported that 54% of patients had a worker compen- sation claim and that 17% had a lawsuit related to the CRPS. The effect of litigation on pain severity and clinical outcomes for patients with CRPS is unknown. Neglect-Like Symptoms Patients with CRPS often display signs of motor dysfunction that appear to be related to voluntary guarding in order to avoid exacerbation of pain. Psychological comparisons of CRPS and chronic pain patients Study Comparison group Psychological Conclusion measure(s) Haddox et al.