Public Interest Law Initiative


By B. Riordian. Louisiana State University at Baton Rouge.

Failure of Patellofemoral Surgery: Analysis of Clinical Cases 343 consultant recognized medial patellar disloca- tion purchase alendronate 70mg on-line breast cancer pins. At this point she needed a railing to assist in going up and down stairs order alendronate 70mg mastercard pregnancy symptoms before missed period, with con- stant aching, pain at night, regular stiffness. Genu varum greater on the involved side, recurvatum, pronation of the feet and inward pointing or squinting of both patella, retropatellar crepitation with active knee extension bilaterally, a negative J-sign compared with a markedly positive J-sign on the asymptomatic side, increased medial- lateral patellar excursion, no apprehension moving the patella laterally but severe appre- hension moving the patella medially, signifi- cant quadriceps atrophy, motion −7°–145°, pain at the medial joint line, pain at the lateral retinaculum, Q-angle = 20° bilaterally, negative Figure 21. Example of medial dislocatable patella post realignment. Ober test, foot thigh axis −10°, tibia varum, no Achilles tightness, hip internal rotation 45°, external rotation 50°. Narrowing of the patellofemoral the medial and in the lateral direction and joint, and a shallow sulcus, normal patellar prevents abnormal tilt. The correction was a reconstruction of lateral articular cartilage with excellent with quadriceps graft of the lateral patello- preservation of medial patellar articular carti- femoral ligament. Medial stress CT revealed a complete medial dislocation of the patella. A 26-year-old woman with disabling left knee pain and instability. At age 19 she was struck in the front of the knee by an opponent while playing baseball. She contin- ued to play baseball but because of continued pain one year later she underwent diagnostic arthroscopy and subcutaneous lateral release. She was somewhat worse, so 3 months later underwent a repeat arthroscopy with chon- droplasty of both the patella and femur to cre- ate bleeding bone for stimulation of cartilage growth. She was definitely worse and a con- sultant suggested repeating the lateral release. One year later she underwent an lnsall proxi- mal realignment, repeat lateral release and drilling of the patella. She deteriorated further and began to experience medial dislocations of the patella. A second consultant recom- mended quadriceps exercises, which she per- formed 3 days a week for 3 years. A third consultant recommended 6 weeks of casting, which did not help. On at least 4 occasions a patellar dislocation medially required manip- ulative reduction, twice in the hospital. Loss lateral articular cartilage, shallow Seven years after the original injury a fourth trochlea, post lateral release and arthroscopic chondroplasty. Medial dislocation patella post lateral release showing why medial dislocation causes lateral facet damage. Thirty-four-year-old patient post right Maquet osteotomy with inpointing left patella. She is post-op right intertrochanteric 40˚ medial dislocation. The complication is iatrogenic arthro- sis through removal of articular cartilage and iatrogenic medial dislocation of the patella circumduction gait. Squat only 30° because of through repeated lateral releases plus medial pain, motion −5°–110° bilaterally, ligaments imbrication. Lateral patellofemoral ligament and 20° L, no patellofemoral crepitation but reconstruction with a quadriceps tendon graft weakness of the quadriceps, moderate thigh with the result being significant improvement muscle atrophy, Ober tight at 4 cm without as the instability was treated but ultimately pain, prone hip internal rotation 70°, external not the cartilage loss. AP, lateral, and axial radiographs Case 3 were negative except for CT study for limb History. A 34-year-old woman with anterior knee rotation showing femoral anteversion 54° (vs. Complication was failure to recognize injured by blunt trauma when a metal cart limitation of external hip rotation forcing the carrying 100 Kg struck the anterior knee near knee joint axis to be chronically facing inward. The treatment was external rota- arthroscopy, which did not improve the knee, tional femoral osteotomy (intertrochanteric). There was no operated knee moves straight forward while change in the pain, swelling, and giving way, so in the nonoperated limb the foot swings out- she had a Maquet osteotomy with soft tissue ward. The preoperative pain that had been breakdown requiring a gastrocnemius muscle present for over four years was gone and the flap for coverage (Figure 21.

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Treatment with intravenous methylprednisolone followed by oral prednisone hastens recovery of vision order alendronate 70mg on-line pregnancy 7 weeks 1 day. Even without treatment alendronate 35 mg sale women's health north florida, almost all patients begin to recover vision within 4 weeks. The relationship of optic neuritis to MS is controversial. Some regard optic neuritis as a distinct entity, but oth- ers consider it part of the clinical continuum of MS. More than half of all patients with MS have optic neuritis at some time during the course of disease. Of patients who present with optic neuritis and who have no other neurologic deficit, almost 40% have one or more ovoid periventricular lesions on brain MRI; clinically definite MS eventually develops in 60%. Patients with completely normal results on MRI and comprehensive CSF evaluation seldom progress to MS. A 44-year-old man comes to the hospital complaining of progressive lower extremity weakness and decreased sensation. He also complains of having difficulties with bowel movements and urination. He recalls having an upper respiratory infection 1 or 2 weeks ago. His physical examination is remarkable for decreased sensation starting at the level of T10, symmetrical severe lower extremity weakness, urinary retention, and decreased rectal tone. The muscle tone and deep tendon reflexes in his lower extremities are diminished. T2-weighted MRI of the spinal cord shows a hyperintense lesion that involves the majority of the cross-sectional area of the cord; the lesion extends from T6 to L3. Of the following, which is the most likely diagnosis? MS Key Concept/Objective: To be able to recognize transverse myelitis Acute transverse myelitis is a syndrome of spinal cord dysfunction. It has a rapid onset; it may occur after infection or vaccination or it may occur with no discernible precipitant. Symptoms include paraparesis, which is ini- tially flaccid and then spastic; loss of sensation with a sensory level in the trunk; and bowel and bladder dysfunction. MRI is extreme- ly helpful for excluding other structural lesions and for confirming the presence of an intramedullary lesion, which is typically hyperintense in T2-weighted imaging. No treat- ment has proven to be beneficial, but corticosteroids are often used. Neuromyelitis optica is also known as Devic disease. It is characterized by the simultaneous or sequential involvement of the optic nerves and spinal cord; it often has a malignant course. Acute dis- seminated encephalomyelitis is a monophasic syndrome that is usually preceded by a viral exanthema, an upper respiratory infection, or vaccination. Onset is rapid and is charac- terized by meningeal signs, headache, seizures, and altered mental status. The neurologic deficits include hemiplegia, paraplegia, sensory loss, vision loss, and transverse myelitis. In this patient, the lack of multiple lesions and the monophasic nature of the disease make the diagnosis of MS less likely. A 43-year-old woman with a 14-year history of MS with lower-extremity spasticity presents with increased spasticity, mild confusion, abdominal discomfort, and a temperature of 100° F (37. Which of the following choices best combines medical indication and favorable cost-benefit ratio? Urinalysis Key Concept/Objective: To understand the frequency of UTIs in women with MS and how acute UTI can mimic relapse of acute MS Bladder dysfunction is common in patients with MS; in women especially, bladder dys- function often results in UTIs. Because of loss of sensation, the infections may not cause dysuria but may instead cause more global deterioration of neurologic function, mimick- ing an acute relapse. Lower limb spasticity in particular may accompany urinary retention with overflow incontinence.

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A 58-year-old man with acute myelogenous leukemia received chemotherapy 10 days ago order alendronate 70 mg with amex menstruation or pregnancy. He now pres- ents to the emergency department with severe fatigue and shortness of breath buy cheap alendronate 70 mg on-line zyprexa menstrual cycle. Results of complete blood count are as follows: white cell count, 800/µl; hemoglobin level, 7. Which of the following statements regarding indications for transfusion of blood products is true? In patients with acute blood loss, the first treatment goal is transfusion of packed red blood cells B. Platelet transfusions are contraindicated in autoimmune thrombocy- topenia C. The prevalence of bleeding increases significantly below a threshold of about 10,000 platelets/µl in otherwise asymptomatic patients D. In chronically anemic patients, red cell 2,3-diphosphoglycerate pro- duction is decreased to maximize the red blood cells’ oxygen affinity Key Concept/Objective: To know the indications for transfusion of blood products The decision whether to use red cells depends on the etiology and duration of the anemia, the rate of change of the anemia, and assessment of the patient’s ability to compensate for the diminished capacity to carry oxygen that results from the decrease in red cell mass. Restoration of intravascular volume, usually with crystalloid, ensures adequate perfusion of peripheral tissue and is the first treatment goal for a patient with acute blood loss. In general, the decision to transfuse platelets rests on the answers to two questions: (1) Is the thrombocytopenia the result of underproduction or increased consumption of platelets? Thrombocytopenia can result from decreased production caused by marrow hypoplasia or from increased consumption caused by conditions such as idiopathic thrombocytopenic purpura (ITP). Studies have shown that the prevalence of bleeding increases significantly below a threshold of about 10,000 platelets/µl in otherwise asymptomatic patients. Transfusion is appropriate in a bleeding patient whose platelet count is adequate but whose platelets are nonfunctional as a result of medications such as aspirin or nonsteroidal anti-inflammatory drugs or as a result of bypass surgery. Proper investigation of the causes of thrombocytopenia will iden- tify clinical situations in which platelets should be withheld because they contribute to evolution of the illness. These disorders include thrombotic microangiopathies such as thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, and the HELLP syn- drome (hemolysis, elevated liver enzymes, and a low platelet count). Platelet transfusions will not help patients with autoimmune thrombocytopenia (e. A 33-year-old white man presents with an exacerbation of Crohn disease, which is manifested by bright- red blood from the rectum; abdominal pain; and anemia. You begin therapy for exacerbation of Crohn disease, and you also order the transfusion of 2 units of red blood cells. Approximately 30 minutes after the first unit of red cells is begun, the nurse calls and says the patient has a fever and “doesn’t feel well. Immediate hemolytic reactions are the result of an anamnestic response to an antigen to which the recipient is already sensitized 24 BOARD REVIEW B. Delayed hemolytic reactions occur during primary sensitization and can be as severe as immediate hemolytic reactions C. Until the cause of the hemolytic transfusion reaction is identified, the patient may only receive type O red cells or AB plasma D. Fever without signs of hemolysis can be managed with acetamino- phen; no further laboratory workup is necessary Key Concept/Objective: To understand the potential complications of transfusions Hemolytic transfusion reactions are classified as immediate or delayed, depending on their pathophysiology. Immediate hemolytic reactions are the result of a preexisting antibody in the recipient that was not detected during pretransfusion testing. Delayed hemolytic reactions are the result of an anamnestic response to an antigen to which the recipient is already sensitized. Clinical evidence of hemolysis is likely to be more severe in immediate hemolytic reactions and may include back pain, pain along the vein into which the blood is being transfused, changes in vital signs, evidence of acute renal failure, and signs of developing disseminated intravascular coagulation. Until the antibody causing the immune hemolysis is identified, only type O red cells and AB plasma should be used. Febrile reactions are characterized by the development of fever during transfusion or with- in 5 hours after transfusion. The differential diagnosis for a patient undergoing a non- hemolytic febrile transfusion reaction should always include unrecognized sepsis.

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