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Our therapeutic strategy for Legg-Calvé-Perthes disease Under 5 years If mobility is restricted: physical therapy Check ultrasound scan every 3 months X-rays (AP and axial) every 6 months up to 2 years after the diagnosis generic antabuse 500 mg on line treatment xerostomia, and then annually 5 to 7 years If mobility is restricted: physical therapy If mobility is very restricted: botulinum toxin injection in the adductors 3 Check ultrasound scan every 3 months X-rays (AP and axial) every 6 months up to 2 years after the diagnosis, and then annually If decentering is present: operation Generally intertrochanteric osteotomy (precondition: epiphyseal plate not too steep, no major leg shortening and only slight restriction of abduction) If the preconditions for an intertrochanteric osteotomy are not satisfied, then pelvic osteotomy according to Salter Over 7 years Triple osteotomy of the pelvis (if mobility is greatly restricted poss. Cannon SR, Pozo JL, Catterall A (1989) Elevated growth velocity in more on the personal experience of the surgeon rather children with Perthes’ disease. Coates CJ, Paterson JM, Woods KR, Catterall A, Fixsen JA (1990) Femo- Our therapeutic strategy for Legg-Calvé-Perthes ral osteotomy in Perthes’ disease. Conway JJ (1993) A scintigraphic classification of Legg-Calve-Perthes Our therapeutic strategy for Legg-Calvé-Perthes disease is disease. Cooperman DR, Stulberg SD (1986) Ambulatory containment treat- ment in Perthes’ disease. Crutcher JP, Staheli LT (1992) Combined osteotomy as a salvage pro- crutches only for very severe pain, no total ban on cedure for severe Legg-Calve-Perthes disease. Farsetti P, Tudisco C, Caterini R, Potenza V, Ippolito E (1995) The Her- 1. Adekile A, Gupta R, Yacoub F, Sinan T, Al-Bloushi M, Haider M (2001) ring lateral pillar classification for prognosis in Perthes disease. J Bone Avascular necrosis of the hip in children with sickle cell disease and Joint Surg (Br) 77: 739–42 high Hb F: magnetic resonance imaging findings and influence of 17. Fulford GE, Lunn PG, Macnicol MF (1993) A prospective study of non- alpha-thalassemia trait. Acta Haematol 105: p27–31 operative and operative management for Perthes’ disease. Aigner N, Petje G, Schneider W, Krasny C, Grill F, Landsiedl F (2002) Ju- Orthop 13: 281–5 venile bone-marrow oedema of the acetabulum treated by iloprost. Gallistl S, Reitinger T, Linhart W, Muntean W (1999) The role of in- J Bone Joint Surg Br 84: 1050–2 herited thrombotic disorders in the etiology of Legg-Calve-Perthes 3. Barwood S, Baillieu C, Boyd R, Brereton K, Low J, Nattrass G, Graham disease in the very young child. J Pediatr Orthop B 15: 16-22 H (2000) Analgesic effects of botulinum toxin A: a randomized, pla- 20. Ghanem I, Khalife R, Haddad F, Kharrat K, Dagher F (2005) Recurrent cebo-controlled clinical trial. Dev Med Child Neurol 42: 116–21 Legg-Calve-Perthes disease revisited: fake or reality? Bassett GS, Apel DM, Wintersteen VG, Tolo VT (1991) Measurement of B 14: 422-5 femoral head microcirculation by Laser Doppler Flowmetry. Glueck CJ, Crawford A, Roy D, Freiberg R, Glueck H, Stroop D (1996) Orthop 11: 307–13 Association of antithrombotic factor deficiencies and hypofibrinoly- 6. Hall DJ, Harrison MH, Burwell RG (1979) Congenital abnormalities and déformations caracteristiques de l’extremité supérieure du fémur. Clinical evidence that children with Perthes’ disease Rev Chir 42: 54 may have a major congenital defect. Moberg A, Rehnberg L (1992) Incidence of Perthes’ disease in Up- (1999) Does thrombophilia play an aetiological role in Legg-Calve- psala, Sweden. Hefti F, Clarke NMP (2006) The »Epidemiology« of treatment of Legg-Calvé-Perthes disease: Statistical analysis of 116 hips. An investigation among the members of the Euro- Orthop 11: 153–8 pean Pediatric Orthopaedic Society. Herring JA, Neustadt JB, Williams JJ, Early JS, Browne RH (1992) The Perthes’ disease. Int Orthop 15: 13–6 lateral pillar classification of Legg-Calve-Perthes disease. Pettersson H, Wingstrand H, Thambert C, Nilsson IM, Jonsson K Part II: Prospective multicenter study of the effect of treatment on (1990) Legg-Calve-Perthes disease in hemophilia: incidence and outcome. Pillai A, Atiya S, Costigan PS (2005) The incidence of Perthes‘ disease Legg-Calve-Perthes’ disease. J Bone Joint Surg (Br) 68: versus surgery for Legg-Calve-Perthes disease. Purry NA (1982) The incidence of Perthes disease in three popula- unilateral Perthes’ disease. J Bone Joint Surg (Br) 69: 243–50 tion groups in the eastern cape region of South Africa. Joseph B, Srinivas G, Thomas R (1996) Management of Perthes Kindern und Jugendlichen nach Polychemotherapie. Kalenderer O, Agus H, Ozcalabi IT, Ozluk S (2005) The importance of Femoris und ihre Beziehung zur Hüftkopfnekrose (Morbus Perthes). Kealey W, Mayne E, McDonald W, Murray P, Cosgrove A (2000) The femoral valgus osteotomy in Legg-Calve-Perthes disease. Orthope- role of coagulation abnormalities in the development of Perthes’ dics 25: p513–7 disease. Kealey W, Lappin K, Leslie H, Sheridan B, Cosgrove A (2004) Endo- lateral pillar classification and Catterall classification of Legg-Calvé- crine Profile and Physical Stature of Children With Perthes Disease. J Pediatr Orthop 22: prognostic significance of the subchondral fracture and a two- 464–70 group classification of the femoral head involvement. Kumasaka Y, Harada K, Watanabe H, Higashihara T, Kishimoto H, Surg (Am) 66: 479–89 Sakurai K, Kozuka T (1991) Modified epiphyseal index for MRI in 65. Shang-li L, Ho TC (1991) The role of venous hypertension in the Legg-Calve-Perthes disease (LCPD). Lappin K, Kealey D, Cosgrove A (2002) Herring classification: how 194–200 useful is the initial radiograph? Boston Med ease in Greater Glasgow: is there an association with deprivation? Sponseller PD, Desai SS, Millis MB (1988) Comparison of femoral and Legg-Calve-Perthes disease and the consequences of surgical treat- innominate osteotomies for the treatment of Legg-Calvé-Perthes ment. Livesey J, Hay S, Bell M (1998) Perthes disease affecting three female 68. Stevens D, Tao S, Glueck C (2001) Recurrent Legg-Calve-Perthes dis- first-degree relatives. Stulberg SD, Cooperman DR, Wallenstein R (1981) The natural his- diolucent changes following ischemic necrosis of the capital femoral tory of Legg-Calve-Perthes disease. Margetts B, Perry C, Taylor J, Dangerfield P (2001) The incidence and 70. Van Campenhout A, Moens P, Fabry G (2006) Serial bone scintig- distribution of Legg-Calve-Perthes’ disease in Liverpool, 1982–95. Vasseur PB, Foley P, Stevenson S, Heitter D (1989) Mode of inheri- abduction brace for the treatment of Legg-Perthes diasease. Fractional necrosis of the femoral head Arthrodiastasis in Perthes’ disease.

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Good reviewers do not send positive messages to authors and leave the editor to break the bad news that the paper is not going to be published quality 250mg antabuse medicine rap song. It is a good feeling when authors make the changes requested and reviewers can write feedback such as The revisions that the authors have made have improved this paper considerably generic 250 mg antabuse free shipping medications medicaid covers. The analyses are logical for answering the study aims purchase 250 mg antabuse otc medicine for the people, the limitations of the study are discussed, and the conclusions are a reasonable interpretation of the results presented. This is confirmation that writing and reviewing are complementary processes that promote the publication of high quality scientific papers. This needs to be included and the authors need to present some data to verify the representativeness of their sample. A sensitivity analysis to allow the reader to gauge the effects of selection bias on the prevalence rates reported would be helpful. Many subgroup analyses are presented, although the small numbers in some groups and the wide confidence intervals indicate a lack of statistical power to test the relationships. The subgroup analyses should preferably be deleted or the authors need to discuss the extent to which the results presented could be type II errors. The tables are long and present far too much data to be readily understood. Many outcome variables are presented, which must overlap to a great extent in individuals. The data would be better summarised into exclusive groups that are categorised according to the multiplicity or severity of symptoms. This would give readers a much clearer idea of the burden of illness in the population studied. The analyses have been stratified by gender although there is no a priori reason to suggest a gender difference and the rates of illness appear similar between the genders. Gender effects would be better tested in a single model unstratified analysis, and this would have the additional benefit of improving precision around the estimates of effect. I can find no evidence in the results to support the conclusion that adenoidectomy may influence immune development. This conclusion seems to be speculative and therefore should be removed. Becoming an editor When I asked him [David Sharp, former Lancet editor] what he had enjoyed most during his Lancet years, he replied “The craft of editing” … David’s love, for it was that, of our craft inspired colleagues over several decades. Richard Horton21 Editors are appointed by the journal’s financial owners. The journal’s owners, who are responsible for making business decisions, may be concerned about many performance indicators of their journal such as circulation rates, 143 Scientific Writing advertisements placed, negative and positive feedback from readers, the number of papers submitted, the number of mentions in the press, and so on. Journals naturally select editors who can maintain or improve these indicators. Because editorial independence is valued highly by both readers and subscribers, the hiring and firing of editors is sometimes debated publicly because it raises questions about editorial freedom, the cultures of journals, and the relationship between a journal and its owners. Editors have full authority for determining the content of the journal and for pleasing the target readership. Readers not only want short articles that are easy to read but they must feel confident that the articles are accurate, informative, and up to date. It is the job of the editor to entice potential readers of the journal to pick it up, open it, start reading, keep reading, and, even better, look forward to the next issue. It is the editor’s responsibility to select reviewers carefully, to ensure that their comments are polite and constructive, to rank areas of priority for publication, and to answer specific questions from authors. Following feedback from reviewers and responses from the authors, the editor has the task of trying to balance the two sources of comments, and adjudicate the final decision about publication. This is sometimes difficult when two of the external reviewers have opposing opinions and, ultimately, the editor has to take responsibility for accepting or disregarding reviewers’ comments. When decisions become especially difficult, the editor may refer the paper to an independent advisory committee who considers issues that are contentious or perceived as malpractice. It takes a long time for journals to establish their reputations and to increase their impact factors and it is the editor’s job to maintain or improve these. An editor is sometimes selected on the basis of the reviews that they have undertaken for a journal. Some journals require that potential editors have performed a certain number of reviews each year to establish commitment before they can become involved in the editorial process. Other journals select editors on the basis of their reputation or through an election process. If you want to 144 Review and editorial processes become an editor, it is probably best to ask a senior colleague for advice about how to get there. Acknowledgements King quotes have been reprinted with the permission of Scribner, a Division of Simon & Schuster, Inc. The Skinner Goldsmith, Bollingbrooke, Watson and Ochs quotes have been produced with permission from Collins Concise Dictionary of Quotations 3rd edn. Standard number: BS 5261C: 1976 2 Capital Community College, Hartford, CO, USA http://webster. An Adobe Acrobat version of these proofreading marks can be downloaded References 1 David A. The fate of papers presented at the 40th Society for Social Medicine Conference. Effect of open peer review on quality of reviews and on reviewers’ recommendations: a randomised trial. With practice, this discipline helps you learn how to craft your writing to suit your target audience. Irina Dunn1 The objectives of this chapter are to understand how to: • avoid duplicate publication • share data in large research teams • use the electronic media appropriately • assess the merit of journals and journal articles Duplicate publication A scientific paper is (1) the first publication of original research results, (2) in a form whereby peers of the author can repeat the experiments and test the conclusions, and (3) in a journal or other source document readily available with the scientific community. Infection and Immunity2 Redundant or duplicate publication occurs when results that are published in one paper substantially overlap with results published in another. Duplicate publication is unnecessary and is usually fraudulent since the authors have given a signed assurance that their work has not been published elsewhere. If you have any related information that is published in or has been submitted to another journal then you should include it when you submit your paper. In this way, it becomes the 147 Scientific Writing editor’s responsibility if the journal accepts a piece of work that proves to be duplicated. If more than 10% of a paper overlaps with another paper, the International Committee of Medical Journal Editors3 asks you to send in copies of the other paper so that the editorial panel can make an informed decision about the extent of any duplication of published data. No journal wants to publish papers that duplicate data that are already in press in another journal. If you want to include previous data analyses in your paper, the correct process is to cite them in the reference list. In some cases, secondary publication in another language is justifiable but only with the permission of the journal editor who may impose certain conditions.

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The correct view (with just as does not have any functional significance cheap antabuse 500mg overnight delivery symptoms at 4 weeks pregnant. Treatment: much internal rotation as anteversion) generally shows rotation osteotomy if necessary purchase 250 mg antabuse free shipping symptoms for bronchitis. Flexion contracture Since the growing skeleton is shaped according to The spasticity of the hip flexors together with the fre- the forces acting on it order antabuse 500mg visa medications given for migraines, it must be assumed that the quent flexed posture of the hips not infrequently leads change produced in the daily transfer of forces between to flexion contractures. The lumbar spine becomes the acetabulum and femur as a result of the locomo- hyperlordosed. Physical therapeutic stretching of the tor disorder is the reason for this rotational deformity. Botulinum toxin osteotomy found that the rotational deformity recurred injections can prove helpful temporarily. Resec- recorded after operations on children over 8 years of tion of the iliac crest and dorsal displacement of the age. As a rule, however, motor control and gait ex- spine is an effective way of treating this contracture. Consequently, we cur- lengthening procedures should therefore be viewed with rently prefer the supracondylar osteotomy fixed with aAO caution. The supracondylar procedure offers the advantage of immediate weight-bearing. As a Extension contracture result, the patient, who is already in a poor training condi- While this deformity is described in the literature, the tion, does not lose further power as a result of postopera- cause in our patients has always been a ventral hip sub- tive immobilization. The increased inward rotation and abnormal ad- duction position do not always interfere with function Windswept deformity to the same extent. While the knees will knock together When hip flexion contractures are present, gravity forces in a patient with good walking ability and thus hamper the flexed knees downward on the side on which the progress, the increased internal rotation may be useful if muscle tone is strongest. Since the patients often remain the patient is only capable of a transfer function or stand- fixed in this position asymmetrical contractures can form ing. When patients with poor body control and impaired accordingly: on the one side there is flexion, adduction balance reactions try and remain upright but then sink and internal rotation, while on the other there is flexion, toward the floor, both legs knock against each other and abduction and external rotation. This just about enables sitting, because the patient tends to fall to the side over such patients to stand. If the knee faces forward, or even the adducted and internally rotated hip. This joint is also outwards, the patients will fall to the floor without this at great risk of dislocation. Possible treatment includes form of support and thus lose the ability tosupport the physical therapy and splints. For these reasons we have ceased our prac- present, the deformity must be corrected by interventions tice of correcting the rotational deformity in the femur on the bones and soft tissues. Radiological investigation If the legs are in external rotation, the patient must An AP view with suspended lower legs generally permits shift his center of gravity in front of the knee in order to effective evaluation of the hip situation. In a case of pronounced anteversion the rotated position The right hip is adducted and appears to have poorer acetabular of the hips is important for the centering: In neutral rotation (top)both coverage than the abducted left hip. However, the lateral acetabular hips appear dislocated, while in internal rotation (bottom) they are epiphysis is pointed on both sides centered (the two x-rays were recorded immediately after each other) Mistakes in the evaluation of the standard AP x-ray ▬ Adduction of the leg appears to aggravate the centering of the hip (⊡ Fig. Other useful views ▬ The Dunn-Rippstein view for the evaluation of an- teversion (although this method is associated with a c wide margin of error, it is effective in clinical prac- tice). Measurement of hip centering on the x-ray: center-edge angle according to Wiberg (CE) and migration index accord- ing to Reimers (MI) ▬ CT with three-dimensional reconstruction for unclear dislocation directions or for detecting an anterior or posterior dislocation. Hip centering measurements: The standard measure- ments are the center-edge (CE) angle according to Wi- berg (normally over 15°) and the Reimers migration in- dex according to Reimers (normally below 22%) (⊡ Fig. Both measurements are based on the AP x-ray and can only record the lateral component of a dis- location. The latter method in particular is generally used nowadays for evaluating hip x-rays. Normal results can sometimes be measured for purely anterior or posterior dislocations! Radio- graphs only show the component of a dislocation that is directed parallel to the x-ray plane. The rounded lateral acetabular epiphysis on the left side The appearance of the lateral acetabular epiphysis has also (arrow) is an at-risk sign for dislocation, even in a well centered joint proved an effective indicator: If the lateral acetabular epiphysis is rounded off at the edges the hip must be considered to be at risk despite good centering on the AP view. By contrast, a lateral acetabular epiphysis with sharp edges is an indication of a stable situation even if the joint is slightly off center (⊡ Fig. Frequency and occurrence The worse the motor control of a patient’s locomotor ap- paratus, the more likely it is that hip dislocation will oc- cur. In cases of severe spastic tetraparesis the frequency is as high as 60–70%, whereas dislocations are rare in spastic hemiparesis or diparesis (7%). Pathogenesis Dislocation develops as a result of the exertion of constant pressure by the femoral head against the lateral acetabular epiphysis, often as a result of the unfavorable positioning of the patient. If the patient lies on his side, one hip will be constantly adducted, while the other will be abducted ⊡ Fig. Patients with severe cerebral locomotor dis- legs press against each other under the influence of gravity and tilt orders move very little and tend to lie in the same position the pelvis obliquely. Since such soft tissue procedures are not without their own Another dislocation-promoting factor is the absence of problems however, we adopt a cautious approach, particu- motor control and thus the non-functional dynamic hip larly as regards the adductors, and consider such surgery stabilizers. Poor proprioception may be an additional fac- to be indicated only in patients with radiological changes tor, resulting in inadequate or lacking motor responses on to the lateral acetabular epiphysis without decentering of ligamento-capsular stress. An Preventive measures adductor operation may prove helpful in these cases. We The purpose of preventive measures is consistently to restrict ourselves strictly to the aponeurotic lengthening avoid the unfavorable positioning of the patient. If necessary, held loosely in slight abduction, slight internal rotation the psoas muscle can be lengthened, likewise at the apo- and possibly slight flexion. While the injection of botulinum toxin into these If the hips are already dislocated, such braces can prove muscle groups does represent an alternative solution, it is painful and are no longer capable of centering the joint.. Despite the correction of these situations as they increase the intraarticular pres- these mechanical factors, it is often not possible to prevent sure without reducing the hip joint. We therefore con- In most cases the hip adductors are considered to be sider another important factor, in addition to the motor the cause of the dislocation because abduction is already disorder, to be the sensory impairment that is also usually restricted in subluxation and the adductors appear short- present ( Chapter 4. If the centers of rotation of the head and acetabulum of sensing tension situations in the capsule and thus acti- do not match, the gap between the points of muscle inser- vating the muscles dynamically to stabilize the joint. In this position the length of the adductors is too short relatively, thereby preventing Course and development of hip dislocation the abduction required for centering of the joint. However, The consistent application of the same type of pressure no direct evidence can be inferred from this for a causal and in the same direction by the femoral head on the lat- component for the hip dislocation. Nor should the fact be eral acetabular epiphysis causes the latter to roll out and overlooked that the hip adductors also stabilize the hip and be pushed away, producing a groove-shaped deformity in the absence of this muscle group increases joint instabil- the acetabulum (⊡ Fig.

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