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The Introduction importance of these lines of research is that they Patellar dislocation can lead to disabling seque- have focused attention on (1) the pathological lae such as pain and recurrent instability 100 mg celebrex overnight delivery arthritis medication australia, par- anatomy of the initial dislocation event purchase celebrex 200 mg visa arthritis and arthropathy, and (2) ticularly in young athletes. This represents a novel prevention of recurrent patellar instability after approach to the clinical problem of the unstable the initial dislocation. The purpose of this article is to bring appropriate treatment. Widespread reports of the results and implications of this body of mixed results9,13,19-27 or outright failure11,12 research into perspective within the context of of surgical treatment suggest that such uncer- the prevailing literature on patellar dislocation. Warren and Marshall,47 Kaplan,48 Reider,49 and These components are: (1) bony constraint due Terry. The Layer 1 includes the superficial medial retinacu- combination of articular buttress and soft tissue lum (SMR), which courses from the anterome- tension determines the limits of passive patellar dial tibia and extends proximally to blend with displacement. The medial patellotibial liga- the patellofemoral joint between 30 and 100 ment (MPTL) is an obliquely oriented band of degrees of knee flexion, Ahmed29 reported that fibers coursing from the anteromedial tibia and mediolateral patellar translation was controlled blending with the fibers of the retinaculum to by the passive restraint provided by the topo- insert on the medial border of the patella. In particular, patellar medial-lateral patellofemoral ligament (MPFL), along with the translation was controlled by the trochlear superficial medial collateral ligament (MCL), to topography, while retropatellar topography also be part of layer 2. Heegard28 observed tubercle,31,50 anterior to the medial femoral epi- that constraint within the femoral groove domi- condyle51 or superoposterior to the medial nated over the stabilizing effect of the soft-tissues femoral epicondyle,52,53 to the superomedial through most of the range of motion in normal two-thirds of the patella. At full extension, however, when anteriorly, its fibers fuse with the undersurface there was little or no contact between patella and of the vastus medialis tendon as shown in femur, the influence of the retinacula was great- Figure 5. The differences lar fat pad,32 which inserts on the inferomedial between the intact and dissected knee kinematics one-third of the patella, distal to the MPFL suggested that patellar motion was controlled by insertion. Reider could not even identify the Farahmand34 measured the patellar lateral medial patellofemoral ligament in some speci- force-displacement behavior at a range of knee mens. Both these knees patella had constant lateral stability) up to 60 demonstrated greater than average lateral degrees knee flexion, with a significant increase mobility. In a study of 9 fresh frozen cadavers, in the force at 90 degrees knee flexion. These studies suggest again was present in all specimens. Axial view of the patellofemoral articulation at (a) 0˚, (b) 60˚, and (c) 120˚ flexion with a 1 kg load applied to the quadriceps. Anterolateral view of the patellofemoral articulation at (a) 0˚, (b) 60˚, and (c) 120˚ flexion with a 1 kg load applied to the quadriceps. When the VMO is reflected, the (a) MPFL can be seen. Nomura53 observed in 2 of 30 knees that the MPFL inserted not directly into the medial bor- der of the patella, but into the medial aspect of the quadriceps tendon immediately proximal to its insertion at the patella. Nomura reported the dimensions of the MPFL in detail along its length, and described the relationship of the MPFL to the VMO tendon. Nomura measured MPFL dimensions at several points tionship of the MPFL to the VMO as they along its length. Nomura52 studied the anatomy and contribu- tions of the medial patellofemoral ligament (MPFL) and superficial medial retinaculum in restraining lateral patellar displacement using 10 fresh frozen human knee specimens. Lateral shift ratios were measured during the applica- tion of a 10 N laterally directed force with the knee in 20–120 degrees of flexion. Isolated sec- tioning of the MPFL greatly increased lateral displacement in the range of knee flexion stud- ied, and isolated MPFL reconstruction restored patellar displacement to within normal limits. Conlan reported the MPFL contributed 53% of the restraining force against lateral patellar dis- placement. The MPFL and VMO as seen from the perspective of the 80%) of the restraining force against lateral patellar displacement in cadaver knees. With respect to resisting lateral direction of joint compressive forces affect patellar displacement, the orientation of the patellofemoral kinematics. This is particularly VMO varies greatly during knee flexion, as true during active muscle contraction.
Fibromuscular disease is the most common cause of renovascular hypertension in younger patients purchase celebrex 100 mg without a prescription rheumatoid arthritis of the hip, especially women between 15 and 50 years of age buy discount celebrex 100 mg online arthritis relief herbs; it accounts for approximately 10% of cases of renovascular hypertension. Athero- matous disease is the most common cause of renovascular hypertension in middle-aged and older patients and accounts for approximately 90% of cases of renovascular hyper- tension. The prevalence of atheromatous renal artery disease increases with age and is common in older hypertensive patients, especially in those with diabetes or with athero- sclerosis in other vascular beds. Most patients with atheromatous renal vascular disease and hypertension have essential hypertension. A 55-year-old man presents to establish primary care. His medical history is significant only for 40 pack- years of smoking. On physical examina- tion, the patient’s blood pressure is 158/98 mm Hg, and he is moderately obese (body mass index, 27); the rest of his examination is normal. His laboratory examination, including a chem 7, CBC, TSH, and urinalysis, is normal, as is his electrocardiogram. Repeated blood pressure measurements over the next month are similar to the values first obtained. With respect to this patient’s blood pressure, what therapeutic option should be offered to this patient now? Lifestyle modifications, including decreased alcohol consumption, weight loss, smoking cessation, and moderate exercise for 6 months ❏ D. Given his smoking history, he has greater than or equal to 1 risk factor for CV disease, which puts him in risk group 2. On the basis of the JNC VI (Joint National Committee on Prevention, Detection, and Treatment of High Blood Presssure) recommen- dations, it is appropriate to try lifestyle modifications (weight loss, dietary modification such as adherence to the DASH [Dietary Approaches to Stop Hypertension] diet, and mod- erate exercise) for 6 months before starting medications. The patient in Question 18 adhered to your recommendations, but his blood pressure remains elevated to the same degree. He is interested in controlling his blood pressure but is worried about the cost of medications. What should be the first-line pharmacologic therapy for this patient? Hydrochlorothiazide, 25 mg/day Key Concept/Objective: To know the recommended first-line medications for treatment of hyper- tension Thiazide diuretics for the treatment of high blood pressure have been shown most consis- tently to have the best outcomes with respect to stroke and CV disease, mortality, and patient compliance. Given that the benefits of treating high blood pressure accrue only over the long term, the last of these attributes is especially important. Also, hydrochloro- thiazide is by far the least expensive of all of the medications listed. Three months after starting therapy, the patient in Question 18 returns for follow-up. His blood pressure is 145/92 mm Hg, and blood pressure values that he has obtained outside the clinic are similar. He says that he has been taking hydrochlorothiazide as directed and has noted no unpleasant side effects. He is doing his best to adhere to the lifestyle modifications that you recommended. What is the best step to take next in the management of this patient? Double the dose of hydrochlorothiazide to 50 mg/day ❏ D. Add amlodipine, 5 mg/day Key Concept/Objective: To understand the goals of antihypertensive therapy and to be able to select an appropriate second medication to achieve those goals The goal for the treatment of hypertension is a blood pressure lower than 140/90 for most people (although this number is arbitrary, and some experts recommend still lower tar- gets). Given that your patient is compliant with his current therapy and has done as much as he can to achieve lifestyle modification, it is appropriate to add a second agent. Atenolol is the best choice because of its low cost and proven mortality benefit. Doses of hydrochlorothiazide higher than 25 mg/day will not improve blood pressure control, and higher doses of hydrochlorothiazide have been associated with increased mortality. Amlodipine is a reasonable choice, but it is expensive, and there are no data to suggest that the calcium channel blockers improve mortality.
From a biomechanics view purchase 100 mg celebrex visa running with arthritis in the knee, articular cartilage may be described as a poroelastic material composed of solid and ﬂuid constituents order 200mg celebrex with amex rheumatoid arthritis headache. When the cartilage is compressed, liquid is squeezed out, and, when the load is removed, the cartilage returns gradually to its original state by absorbing liquid in the process. The time-dependent behavior of cartilage suggests that articular cartilage might also be modeled as a viscoelastic material, in particular, as a Kelvin solid. The capsule wall is externally covered by the ligamentous or ﬁbrous structure (ﬁbrous capsule) and internally by synovial membrane which also covers intra-articular ligaments. Synovial membrane secretes the synovial ﬂuid which is believed to perform two major functions. It serves as a lubricant between cartilage surfaces and also carries out metabolic functions by providing nutrients to the articular cartilage. Cartilage and synovial ﬂuid interact to provide remarkable bearing qualities for the articulating joints. More informa- tion on properties of articular cartilage and synovial ﬂuid can be found in a book chapter written by the author in 1978. Capsular ligaments are formed by thickening of the capsule walls where func- tional demands are greatest. As the names imply, extra- and intra-articular ligaments at the joints reside external to and internal to the joint capsule, respectively. These types of ligaments appear abundantly at the articulating joints. However, only the shoulder, hip, and knee joints contain intra- articular ligaments. The cruciate ligaments at the knee joint are probably the best known intra-articular ligaments. Further information about the structure and mechanics of the human joints is available in Reference 1. Returning to the modeling aspects of the articulating joints, in particular kinematic behavior of the joints, we can state that in each articulating human joint, a total of six degrees-of-freedom exist to some extent. One must emphasize the point that degrees-of-freedom used here should be understood in the sense the phrase is deﬁned in mechanics, because the majority of the anatomists and the medical people have a different understanding of this concept; e. Major articulating joints of the human have been studied and modeled by means of joint models possessing single and multiple degrees-of-freedom. Among the various joint models the hinge or revolute joint is probably the most widely used articulating joint model because of its simplicity and its single degree-of-freedom character. When the articulation between two body segments is assumed to be a hinge type, the motion between these two segments is characterized by only one independent coordinate which describes the amount of rotation about a single axis ﬁxed in one of the segments. Although the most frequent application of the hinge joint model has been the knee, the other major joints have been treated as hinge joints in the literature, sometimes with the assumption that the motion takes place only in a particular plane, especially when the shoulder and the hip joints are considered. When the degrees-of-freedom allowed in a joint model are increased from one to two, one obtains a special case of the three-degrees-of-freedom spherical or ball and socket joint. Two versions of this spherical joint which have received some attention in the literature. In the ﬁrst version, no axial rotation of the body segment is allowed and the motion is determined by the two independent spherical coordi- nates φ and θ as shown in Fig. In the second version, the axial rotation is allowed but the motion is restricted to a particular plane passing through the center of the sphere. Again, most of the major joints have been modeled by the two-degree-freedom spherical joint models by various investigators. If we increase the degrees-of-freedom to three, we get the two obvious joint models, namely, the ball and socket joint model and the planar joint model. For the ball and socket joint model in addition to φ and θ, a third independent coordinate, ψ, which represents the axial rotation of one of the body segments, is introduced. The planar joint model, as the title suggests, permits the motion on a single plane and is characterized by two Cartesian coordinates of the instantaneous center of rotation and one coordinate, θ, deﬁning the amount of rotation about an axis perpendicular to the plane of motion. Dempster6 appears to be the ﬁrst to apply the instant centers technique to the planar motion study of the knee joint. The six-degrees-of-freedom joint (general joint) allows all possible motions between two body seg- ments. A good example of a general joint is the shoulder complex, which exhibits four independent articulations among the humerus, scapula, clavicle, and thorax.
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