Recurrent acromioclavicular joint dislocation with an associated coracoid fracture following acromioclavicular joint reconstruction.

Acromioclavicular joint injuries are common and account for up to 12% of all shoulder girdle injuries and have been reported as being as high as 50% in sports-related shoulder injuries. While the majority of acromioclavicular joint dislocations can be treated non-operatively, there are certain injury configurations, which can include high-grade dislocations in overhead athletes, where surgery may be indicated. The surgical management of acromioclavicular joint instability has moved towards recreating the action of the coracoclavicular ligaments by resuspending the clavicle on to the coracoid. Multiple techniques using high-strength sutures, synthetic ligaments, tendon allografts or autografts passed either around or through the coracoid process have been described. However, an unusual, but significant, complication associated with these techniques is an iatrogenic fracture of the coracoid process. We report the case of a patient with an iatrogenic coracoid fracture following two failed acromioclavicular joint resuspensory reconstructions using a synthetic ligament. This injury was successfully treated with an autologous hamstring graft reconstruction, initially protected with a hook plate.

Lateral epicondylitis: a review of pathology and management.

Lateral epicondylitis, or 'tennis elbow', is a common condition that usually affects patients between 35 and 55 years of age. It is generally self-limiting, but in some patients it may continue to cause persistent symptoms, which can be refractory to treatment. This review discusses the mechanism of disease, symptoms and signs, investigations, current management protocols and potential new treatments.

Frozen shoulder: a clinical review.

Frozen shoulder is a common condition which can cause considerable morbidity for a prolonged duration. With recognition of the condition's time scale, management can be directed to help reduce the morbidity. Many treatments are recognized and the gold standard is still to be identified.

The use of hydroxyapatite-coated CAD-CAM femoral components in adolescents and young adults with inflammatory polyarthropathy: ten-year results.

Between June 1991 and January 1995, 42 hydroxyapatite-coated CAD-CAM femoral components were inserted in 25 patients with inflammatory polyarthropathy, 21 of whom had juvenile idiopathic arthritis. Their mean age was 21 years (11 to 35). All the patients were reviewed clinically and radiologically at one, three and five years. At the final review at a mean of 11.2 years (8 to 13) 37 hips in 23 patients were available for assessment. A total of four femoral components (9.5%) had failed, of which two were radiologically loose and two were revised. The four failed components were in patients aged 16 years or less at the time of surgery. Hydroxyapatite-coated customized femoral components give excellent medium- to long-term results in skeletally-mature young adults with inflammatory polyarthropathy. Patients aged less than 16 years at the time of surgery have a risk of 28.5% of failure of the femoral component at approximately ten years.

The classification of phocomelia.

We studied 24 patients with 44 phocomelic upper limbs. Only 11 limbs could be grouped in the classification system of Frantz and O' Rahilly. The non-classifiable limbs were further studied and their characteristics identified. It is confirmed that phocomelia is not an intercalary defect.

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thrombo-embolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (up to March 2002), MEDLINE (1966 to March 2002), EMBASE (1980 to March 2002), CINAHL (1982 to February week 4 2002), Current Contents (1993 week 26 to 2002 week 12), reference lists of published articles and contacted trialists and other workers in the field. Date of most recent search: March 2002. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into five categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, heparin versus mechanical, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 31 included trials involved at least 2958 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and five trials of 373 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (124/474 (26%) versus 219/519 (42%); relative risk (RR) 0.60; 95% confidence interval (CI) 0.50 to 0.71). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was no statistically significant difference in overall mortality (42/356 (12%) versus 38/374 (10%); RR 1.16; 95%CI 0.77 to 1.74). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Five trials, involving 487 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (16/221 (7%) versus 52/229 (22%); RR 0.31; 95%CI 0.19 to 0.51) and pulmonary embolism. Data were insufficient to establish any effect on the incidence of fatal pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or an overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin and low dose aspirin should be considered.

Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection.

Arthroscopic acromioplasty and distal clavicle resection has now become an accepted method of treatment for acromioclavicular (AC) joint arthritis. Complications following arthroscopic acromioplasty are relatively uncommon and include instrument breakage, hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and recurrence of symptoms. Although heterotopic ossification within the soft tissues has also been reported, complete reossification of the resected clavicle has not. We report a case of reossification of the clavicle and fusion across the AC joint following arthroscopic acromioplasty and distal clavicle resection.

The stability of impact of assistive devices.

PURPOSE: Abandonment of an assistive device (AD) is a frustrating issue yet is very common. An important reason for abandonment is that the device fails to improve the quality of life of the adopter. METHOD: By means of a new questionnaire, the Psychosocial Impact of Assistive Devices Scale (PIADS) the impact on quality of life of any AD can be measured. This study tested the hypothesis that the impact of the adoption of an AD would wane with time, as the user becomes more adapted to the AD. The study attempted to do a one year follow up on all patients at a leading Canadian clinic who had received first-time prescriptions for eyeglasses. RESULTS: The results showed that the positive impact, present on adoption, did not diminish significantly for those who retained the use of the device. CONCLUSION: The PIADS provides clinicians with a reliable and economical method for assessing the role of psychosocial factors in the retention or abandonment of an AD.

Rotator cuff disease.

The important role played by the rotator cuff in the stability and movement of the glenohumeral joint make it susceptible to damage and injury in patients of all age groups. A number of extrinsic and intrinsic mechanisms have been described for the development of rotator cuff disease, although it is more likely that the actual etiology in any one individual is multifactorial. The key to successful management in a particular patient is an accurate diagnosis of the underlying cause by thorough clinical examination and the use of appropriate investigations. The mainstay of treatment of patients with rotator cuff disease is nonoperative. Surgical intervention is usually considered only after failure of at least 6 months of conservative therapy. However, there are a few situations where early surgical intervention is indicated.

Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

BACKGROUND: Hip fracture patients have a high risk of thromboembolic complications following surgical management. OBJECTIVES: To examine the effects of heparin (unfractionated (U), and low molecular weight (LMW) heparins), and physical methods (compression stockings, calf or foot pumps) for prevention of deep venous thrombosis (DVT) and pulmonary embolism after surgery for hip fracture in the elderly. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline, Embase, and reference lists of published papers and books. We contacted trialists and other workers in the field. Date of most recent search: September 1996. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the use of heparins and physical agents for prevention of DVT and pulmonary embolism in patients undergoing surgery for hip fracture. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. Trials were grouped into four categories (heparin versus control, mechanical versus control, LMW heparin versus U heparin, and miscellaneous) and results pooled where possible. MAIN RESULTS: The 26 included trials involved 2600 predominantly female and elderly patients. Overall, trial quality was disappointing. Ten trials involving 826 patients which compared U heparin with control, and four trials of 471 patients which compared LMW heparin with control, showed a reduction in the incidence of lower limb DVT (121/511 (24%) versus 203/519 (39%); Peto odds ratio 0.41; 95% confidence interval 0.31 to 0.55). There were insufficient data to confirm the efficacy of either agent in the prevention of pulmonary embolism. There was a non significant increase in overall mortality in the heparin group (46/420 (11%) versus 35/423 (8%); Peto odds ratio 1.39; 95% confidence interval 0. 86 to 2.23). Data were inadequate for all other outcomes including wound complications. There is insufficient evidence from five trials, involving 644 patients, to establish if LMW heparin was superior to U heparin. Most trials evaluating heparins had methodological defects. Four trials, involving 442 patients, testing mechanical pumping devices were also methodologically flawed, and so pooled results need to be viewed cautiously. Mechanical pumping devices may protect against DVT (12/202 (6%) versus 42/212 (19%); Peto odds ratio 0.24; 95% confidence interval 0.13 to 0.44). Although the limited data indicated a potential benefit, they were inadequate to establish any effect on the incidence of pulmonary embolism and overall mortality. Problems with skin abrasion and compliance were reported. REVIEWER'S CONCLUSIONS: U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or overall benefit, or to distinguish between various applications of heparin. Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem. Good quality trials of mechanical methods as well as direct comparisons with heparin should be considered.

The soft tissue management of children's open tibial fractures.

A series of 49 children admitted with a diagnosis of open tibial fracture was reviewed with particular regard to soft tissue management. Injuries were grouped according to the Gustilo classification. Twenty-two patients had Grade I fractures, 11 Grade II and 16 Grade III (4 Grade IIIa, 11 Grade IIIb and one Grade IIIc). Patients were managed by early lavage and debridement under general anaesthesia, followed by immobilisation. Local transposition flaps were utilised in 10 patients and provided reliable soft tissue cover. A free tissue transfer was performed in only one patient. Complications appeared to be associated with delayed involvement by plastic surgeons.

A comparison of low vision clinic data with low vision survey and blindness registration information.

PURPOSE: To determine whether low vision demographic data provided by low vision clinic data are comparable to that provided by blindness registration and disability questionnaire information. METHODS: Low vision demographic data for Canada and Ontario within the postcensus Health and Activity Limitation Survey (HALS 1991) were obtained from Statistics Canada. These data were compared with 4744 reports of low vision examinations obtained in a multi-center low vision clinic study in Ontario, Canada (1991-1994) and appropriate annual figures from the Canadian National Institute for the Blind (CNIB). RESULTS: Data from the low vision clinic study and the CNIB were similar. The low vision clinic study (and CNIB) reported far fewer adults (15 to 64 years) and far more seniors (65+ years) obtaining low vision examinations than suggested by HALS. CONCLUSIONS: HALS does not report on patients with low vision, as defined in low vision clinics. The differences between survey, low vision clinic, and blindness registration data are presented.

The epidemiology of humeral shaft fractures.

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system. The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.

Extra-articular fractures of the proximal tibial diaphysis: their epidemiology, management and outcome.

In a study of 523 consecutive tibial fractures, 33 were located in the proximal extra-articular segment. There were two fracture groups with different epidemiological characteristics and prognoses: group 1 fractures were metaphyseal in location, follow low-velocity injuries and have a good prognosis with non-operative treatment; group 2 injuries are high-energy diaphyseal fractures. Treatment of these latter fractures proved difficult, with all methods showing significant complications. Overall there was a 26% incidence of malunion, 7% deep infection and 7% compartment syndrome. Only 44% of patients with group 2 fractures returned to full function. Epidemiological analysis showed that proximal tibial fractures are closer to comminuted and segmental fractures in severity than to middle- and distal-third fractures. It is suggested, on the basis of our results, that they should be treated with either compression plating or closed external fixation.

Dissolved hydrogen concentration as an on-line control parameter for the automated operation and optimization of anaerobic digesters.

The use of dissolved hydrogen as an early warning signal of digester failure and a control parameter to operate anaerobic digesters was investigated. A sensitive, on-line method was developed for measuring trace levels of dissolved hydrogen in a semi-permeable membrane, situated within the biomass of a 1 L laboratory anaerobic digester, using trace reduction gas analysis. At normal operating conditions, the dissolved hydrogen partial pressure (2 to 8 Pa) was found to be linearly correlated with the loading rate of the digester, and was a sensitive indicator of the effect of shockloads as well as gradual overloading. An increase in hydrogen partial pressure above a critical concentration of 6.5-7 Pa indicated the initial stage of digester overloading (i.e., volatile fatty acids accumulation). A H(2)-based computer control system, using a critical hydrogen partial pressure of 6.5 Pa as the setpoint, was found to be effective for the safe operation of a laboratory digester close to its maximum sustainable loading rate. The existence of a relationship between hydrogen level and organic loading rate was also confirmed on a 600 m(3) industrial digester, with digester overloading occurring at hydrogen concentrations above 7 Pa. The results suggest that the dissolved hydrogen concentration is capable of being a sensitive on-line parameter for the automated management of anaerobic digesters near their maximum sustainable loading capacity. (c) 1997 John Wiley & Sons, Inc. Biotechnol Bioeng 56: 626-634, 1997.

The Waterloo Vision and Mobility Study: postural control strategies in subjects with ARM.

Binocular vision function and standing balance control was assessed in 16 subjects with age-related maculopathy (ARM) (mean age 73.9 +/- 7.4 years) and 19 controls (mean age 69.1 +/- 5.5 years). Balance control was assessed using the center of pressure signal from force plate data. It was quantified using the root mean square (RMS) error of the amplitude, sampled over a 1 min period. This was evaluated during normal standing, and while the input from the kinesthetic and/or visual systems were disrupted. The two subject groups showed significantly different RMS values across conditions (P < 0.005). The differences in RMS between ARM and control groups were only significant when the input to the kinesthetic sensory system was disrupted. Our results suggest that in the normal standing condition, the kinesthetic and vestibular systems compensated for the lack of useful information from the visual system in ARM subjects. When kinesthetic system input was disrupted, balance control of the ARM group was significantly poorer than the control. There was a weak correlation between postural control and contrast sensitivity. Various strategies for preventing falls in elderly patients with low vision are suggested.

Design elements of professional ethics courses.

Optometrists face ethical dilemmas daily in the practice of their profession. Students training to become optometrists also face ethical dilemmas, some of which are unique in their role as students. The focus on ethical practice has been heightened by the increasing scope of optometric practice, the greater demand of society for professional accountability, the greater diversity of membership and viewpoints, the decrease in available dollars for health care delivery, and the conflicting roles of ophthalmology and opticianry with optometry. These factors have led to the addition or expansion of professional ethics courses in optometry programs. This paper examines the difficulties inherent in defining professional ethics and designing ethics courses. Curricular issues are examined, including course objectives, instructors, content, evaluation, timetabling, teaching strategies, student assessment, and resource implications. Much of the research in this area has been done in medical education. Although the content of ethical dilemmas encountered by medical students and physicians may not be applicable to optometry, the process by which they learn to approach the dilemmas is the same.