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In 1915 generic lioresal 25 mg with amex muscle relaxant 5859, he was contribution in the form of a well-illustrated awarded the gold medal of the first class from article in the Lancet on the selection and stan- Aecademia Fisico-Chemica Italiana for distinc- dardization of surgical instruments buy 10mg lioresal with amex spasms in upper abdomen, with micro- tion in science and the humanities. In 1924, he 340 Who’s Who in Orthopedics was elected a fellow of the Society of Antiquar- ies. He returned from Egypt with two war deco- rations, one the Companion of the Bath and the other the Companion of St. He was about medium height, broad-shoul- dered and of distinguished appearance, his com- plexion slightly sallow, with pleasant blue-grey eyes that lent some attraction to his personality. He was an excellent conversationalist, his voice low-pitched and friendly. In 1890, he married Beatrice, the second daughter of William Payne of the Chamber of London. Alfred Tubby was old enough to be familiar with the traditions of pre-antiseptic surgery and young enough to embrace the teaching of Lister. He was therefore well placed to hand on a written account of what was of permanent value in the teaching Kauko VAINIO of the early pioneers and yet well qualified to lead in the advance, under antiseptic precautions, of 1913–1989 open operative correction of deformity. Further- more he stood firm by the definition of orthope- Kauko Vainio a Finnish orthopedic surgeon of dic surgery as the surgery of the entire locomotor outstanding international achievement, was born system. By his incomparable textbook of 1912, he on May 1, 1913 in Sääminki, Finland. The world- helped to raise the prestige of British orthopedic wide application of orthopedic surgery in the surgery. In 1956 he was appointed first senior lecturer of orthopedic rheumatology at the 1. Plarr’s Lives of the Fellows of the Royal College of Since graduating from the Helsinki University Surgeons of England (1930) 2, 438. Bristol, printed Medical School in 1939, Vainio’s early pro- and published for the Royal College of Surgeons by fessional life was dominated by military field John Wright & Sons Ltd 4. Tubby AH (1896) Deformities: a Treatise on surgery, ultimately as a major during Finland’s Orthopedic Surgery. Tubby AH (1912) Deformities Including Diseases followed by the postwar hardship. Tubby AH (1920) A Consulting Surgeon in the Near the Orthopedic Hospital of the Invalid Foundation East. Ltd with a residency at the Anderson Orthopedic Hos- pital in the United States in 1949. Long before the current challenges of the growing organized international university exchange programs and projects, Vainio made unbelievable efforts to- ward a better understanding and relationship between colleagues around the orthopedic world, with special reference to his life’s work—the operative treatment of the rheumatoid limb as an integrated part of the overall plan for the rheuma- toid patient. He is said to have established a 341 Who’s Who in Orthopedics school of about 1,000 residents and visitors from 1939. From 1938 to 1939, Verbiest studied neu- Belgium, Canada, Czechoslovakia, Great Britain, rosurgery in Paris. The outbreak of World War II Israel, Japan, Norway, Poland, Romania, Sweden, forced him to return to Utrecht where, because of and the United States at his department in Heinola wartime conditions, he was appointed head of the until his retirement in 1975. After the war, Ver- Anniversary Vainio Meeting in Heinola was biest became well known for his research, for his attended by 50 international specialists in clinical acumen, and for his surgical skills. He was During his career Verbiest received many a man with innumerable friends and spare-time honors from his own government and from the activities. At a rather early stage in his orthope- international neurosurgical community. He is, dic career, Vainio drew fundamental guidelines perhaps, best remembered for his description of for the operative treatment of the rheumatoid spinal stenosis. One of the classic symptoms of deformities of the foot based on a thorough clas- spinal stenosis, intermittent claudication of the sification of the typical abnormalities and their spine, is called Verbiest’s syndrome. Jean VERBRUGGE 1896–1964 Henk VERBIEST The Belgian medical world, and especially its 1909–1997 orthopedic surgeons, mourn the passing of an eminent surgeon, a good man, and an incompara- Henk Verbiest was born in Rotterdam in 1909. After brilliant intermediary studies at student, Verbiest did research in pigeons on Antwerp, he graduated and gained his degree, in several neurological problems. After graduation, 1921, as a doctor of medicine, surgeon, and obste- Verbiest worked in the department of neurology trician from the University of Brussels, with the until 1937. He was almost immediately this period, he was granted a doctoral degree in awarded a scholarship as a Fellow of the Com- 342 Who’s Who in Orthopedics mittee for Relief in Belgium (CRB Educational stances that could and, indeed, would lead to Foundation) and spent 2 years, up to 1924, at the forgiveness.

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If we wanted to treat all cases the same way purchase lioresal 10 mg mastercard spasms knee, with enlarged weight-bearing area and improved congruency purchase 10 mg lioresal with mastercard spasms with spinal cord injury, as was the case in pre- and initial-stage OA, there is a limit to what we could accomplish. OA Joint Reconstruction Without Replacement Surgery 177 Significance of VFO for Advanced- and Terminal-Stage OA in Middle-Aged Patients Dr. Takatori presented the effectiveness of rotational acetabular osteotomy (RAO). For example, what happens if RAO is performed at the age of 35, as opposed to doing nothing at that age and THR at the age of 45? If a patient did nothing until 45, she would have progression of OA and require THR at 45. Assuming that she enjoys an average life span, she would require a second revision. However, if the patient had an RAO at the age of 35, her first THR would be around the age of 60, and the second THR around 75, and she would only require a single revision surgery in her lifetime. Now the next question is what happens if the patient was not treated by RAO and had VFO at the age of 45, instead of THR. The average course of VFO shows that the patient would require her first THR around the age of 60, and her second THR, or revision, at the age of around 75. Even if the patient is not indicated for RAO because of the advanced or terminal stage of OA, it is questionable whether she should have THR for her first surgery. The question here, however, is the difference of the clinical result that can be expected from THR versus VFO at the age of 45. Thus, it is all up to the surgeon to decide whether one would be willing to accept this, or whether one would prefer multiple revisions. While plans were being made, an nonsteroidal antiinflammatory drug (NSAID) was given on a pro re nata (PRN) basis, and I instructed her to start using crutches. Five years later, almost all orthopedic surgeons must think that THR was definitely necessary with this condition (Fig. However, this was only a radiologic finding, and she was no longer complaining of much pain. JOA scoreJOA score 100100 35 years 35 years 45 years45 years 90 RAORAO THRTHR 90 8080 45 years45 years VFOVFO 7070 nono treatmenttreatment 6060 5050 RAO THRTHR THRTHR 40 VFOVFO THR 40 3535 4040 4545 5050 5555 6060 6565 7070 7575 8080 8585 AgeAge Fig. Estimated curve of Japanese Orthopedic Association (JOA) hip score based on Taka- tori’s relay-type treatment algorithm for OA of the hip. On the other hand, marked development of roof and floor osteophytes can be seen. The formation of a fine set of roof osteophyte and floor osteophyte can be seen on the radiogram. Joint space is very wide, the roof osteophyte has matured, and the joint was reconstructed and regenerated into a nice spherical joint. Osteoarthritis is characterized by the coexistence of wear and a destructive phase and the proliferative, reparative, and regenerative phase. It seems, at the present time, that not only the patients but we, the orthopedic surgeons, hurry too much. It may be that we are nipping the natural reparative capacity in the bud by rushing too much. So, we do not actively recommend an operation on our part until the patient asks for surgery. Only when the patient asks for surgery do we then would provide information about the type of operation that can be offered. Sugioka said in his lecture, hospital administrators need to improve financial status by ensuring a shorter length of stay. On other hand, however, in my day-to-day practice, I strongly feel that osteoarthritis cases should not be dealt with in the same manner as rheumatoid arthritis and other destructive joint diseases. Conclusion I have tried to describe the principles of treatment of OA of younger patients and to share our results and experience with joint preservation surgery in advanced and terminal cases, emphasizing the significance of osteotomy. Osteophytes are formed on the acetabular edge and margin of the femoral head as a result of biological response to the biomechanical environment of the joint, reflect- ing the natural biological regenerative capacity to heal. We need to try to more effec- OA Joint Reconstruction Without Replacement Surgery 179 tively use these osteophytes.

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GUIDED READING The book we can still recommend for further reading is J generic 10 mg lioresal visa muscle relaxant 114. This pocket-sized do-it-yourself guide is not only valuable but also entertaining buy lioresal 10mg mastercard spasms after gall bladder removal. It contains many useful illustrations and good advice about the preparation of visual aids. Race’s Conference Presentations and Workshops, University of Northumbria, 1986 (available through Amazon. Those interested in the organisation and evaluation of medical meetings are referred to a series entitled Improving Medical Meetings, written by D. Richmond and his colleagues, published in the British MedicalJournal (1983), 287, pp. For help with the design of charts and graphs check the references at the end of Chapter 9. This is a comprehensive reference work that has been written by a university lecturer. Later in the chapter we will address the issue of practical and laboratory based teaching. While it is increasingly likely that your institution will provide some form of ‘teach the teachers’ course it is relatively unlikely that it will specifically address clinical teaching. It is a fact that clinical teaching is the most neglected area of all teaching despite being the one where more deficiencies have been found than in any other. The conclusion of one extensive study was that ‘many (clinical) teaching sessions, particularly ward rounds, were hap- hazard, mediocre and lacking in intellectual excitement’. In one study of medical schools in North America, it was stated that there were few students who could report having been monitored in the interview and physical examination of more than one or two patients and that a surprising number had been awarded their degree without ever having been properly supervised in the complete data-collecting process of even one patient! It is our experience, with notable exceptions, that a similar situation can be found in many medical schools in other parts of the world. THE ATTRIBUTES OF AN EFFECTIVE CLINICAL TEACHER These have been identified on the basis of the opinions of experts, the perceptions of students and from the observations of actual clinical teaching. Considering the limited nature of the research there is a remarkable consistency in the results. It might be helpful to start by checking yourself against these attributes. Do you encourage active participation by the students and avoid having them stand around in an observa- tional capacity? Do you focus on the integration of clinical medicine with the basic and clinical sciences or do you spend 72 most of the time on didactic teaching of factual material? Do you closely supervise the students as they inter- view and examine patients at the bedside and provide effective feedback on their performance or do you rely on their verbal case presentations in the teaching room? Do you provide adequate opportunities for your students to practice their skills? Do you provide a good role model, particularly in the area of interpersonal relationships with your patients? Is your teaching generally patient-orientated or does it tend to be disease-orientated? Should your honest answer to some of these questions be ‘no’ then you are probably a typical clinical teacher as many studies have shown that all of these characteristics are rarely present. Just becoming aware of such attributes should encourage you to be more critical of your approach. The remainder of this chapter will deal more specifically with the planning and the techniques which can be introduced to enhance the effectiveness of your clinical teaching. IMPROVING CLINICAL TEACHING If you are a clinical teacher with no responsibilities for the planning of the curriculum, there may be few educational initiatives open to you other than to improve your hospital- based or community-based teaching. What you should aim to do is to try and acquire as many as possible of the attributes described in the previous section. There are no hard and fast rules as to how you can achieve this aim but the following points may be helpful.

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Jody Farr’s health insurance bought her scooter lioresal 10mg otc muscle relaxant euphoria, charging a 20 percent copayment lioresal 25 mg with mastercard spasms temporal area. Health insurance rarely pays for home renovations and other environ- mental changes, large and small, meant to improve mobility and enhance safety. Medicare, for example, views many mobility-related aids as “per- sonal comfort items” and therefore not reimbursable. It refuses payment for grab bars, seeing them as a “self-help device, not primarily medical in nature,” and for raised toilet seats, labeled a “convenience item; hygienic equipment, not primarily medical in nature” (Pope and Tarlov 1991, 228). According to a 1990 federal survey, people themselves pay for almost 78 percent of home accessibility improvements (LaPlante, Hendershot, and Moss 1992, 9). Treat- ing people who fall will cost insurers much more than grab bars, shower chairs, and raised toilet seats. Although health-care costs leveled off during the mid 1990s, recent signs suggest rapid rises ahead. Combined with pressures from expensive new medical discoveries, future costs may tighten coverage on items outside the acute medical paradigm. Stan Jones (personal communication, 6 February 1998) believes “we’re seeing a retrenchment with regard to buying wheel- chairs and a variety of assistive devices and other services” that aim toward improving daily functioning and quality of life. Competition among health plans based on their premiums is causing more and more conservative decisions and making it harder and harder for people to get these services. Sometimes there’re no crite- ria anywhere defining what’s covered under what circumstances. Sometimes plans just don’t offer it or keep it in the background, not offering it unless the person asks. And if they ask, sometimes it’s hard to get, or it takes a long time, so most people give up. Jones believes that society must decide whether funding mobility aids is a priority, “because we’re heading away from covering them. Patrick O’Reilley runs a neighborhood health center where all his patients are poor. Like Christopher Reeve has a great wheelchair because he’s a professional person; he has money. No in- surance company is going to pay for a scooter for some of my pa- tients. They’d be reading the back of Arthritis Today and say, “Oh, I want that scooter! The fa- ther is a physician, retired from practice but still well connected and vigor- ous. Julie, in her mid forties, had quit working several years ago because of MS. Without respite, it waxes and wanes, bringing disheartening new symp- toms and giving her little peace. Julie’s father didn’t ask about cures for MS or techniques to improve her walking. Through his medical connections, she has seen the best neu- rologists and clinical specialists. After many years and countless but ulti- mately ineffective therapies, he and she are realistic. Instead, he wanted advice about improving her mobility for daily life, and he didn’t know who to ask. Despite their extensive medical network and knowledge, they had not found practical advice sensitive to Julie’s changing mobility needs and preferences. She is married with young children and lives in a house with bedrooms upstairs. Julie knows she needs help, but she has put it off, perhaps discouraged or embarrassed, unsure about how mobility aids would fit into her daily routine.

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