By Z. Rozhov. Augustana College, Rock Island Illinois.

Process evaluation: this focuses on the conduct of the teaching cheap careprost 3 ml overnight delivery symptoms torn rotator cuff, learning generic careprost 3 ml on line treatment nail fungus, assessment and administration. It is here that the views of students can be sought as they are the only people who experience the full impact of teaching in the course. Questionnaires, written statements, interviews and discussion are techniques that you can consider. Outcome evaluation: this looks at student attainments at the end of the course. Naturally you will review the results of assessment and judge whether they meet with the implied and expressed hopes for the course. Discussion with students and observation of aspects of their behaviour will help you determine their attitudes to the course you taught. In all evaluations, whether of a course or of teaching, it is helpful to keep in mind that there are many sources of information available to you and a variety of methods you can use. We suggest that you look at Chapter 10 on evaluation for more information about this. GUIDED READING For a useful extension of the material in this chapter we suggest you have a look at S. Toohey’s Designing Courses for Higher Education, SRHE and Open University Press, Buckingham, 1999 and J. Biggs’ Teaching for Quality Learning at University: What the Student Does, SRHE and OpenUniversity Press, Buckingham, 1999. For a clear and systematic guide to curriculum planning we recommend Planning a Professional Curriculum by L. Gronlund, How to Write Instructional Objectives, Prentice Hall Inc, Englewood Cliffs, 1995. Many conventional and well-established medi- cal schools have undertaken curriculum reviews and have decided to change to ‘problem-based learning’ (PBL). However, experience has shown that when this approach has been introduced its effectiveness has often been undermined by a lack of understanding of the purpose and process of PBL. This chapter aims to give you guidance if faced with teaching in a problem-based course. It will not attempt to debate the rationale behind PBL in any depth nor will it analyse the research on its effectiveness. The Guided Reading will provide a starting point if you wish to pursue these issues. The traditional way of medical school teaching has been to require students to undertake sequential courses in the pre-clinical and para-clinical sciences as a prerequisite to commencing studies in the medical sciences and clinical practice. Such courses have been the autonomous responsibility of academic departments who have jea- lously guarded their curriculum time and their control over course content and examinations. The degree of integration, particularly in the pre-clinical disciplines, has often been limited. This structure has formed the basis of the curriculum for most medical schools since the Flexner report in 1910 but is starting to collapse in the face of the intolerable load of information that each discipline expects the student to learn. The veritable explosion of scientific knowledge relevant to medicine, and the increasing specialisation of clinical practice, has led to unmanageable requests for the inclusion of more courses and more content without agreement or action on what is to be excluded. Efforts to deal with these issues using strategies such as organ systems teaching have made little impact. An alternative approach has become necessary and PBL is one gaining increasing acceptance. Students work through these problems, under greater or lesser degree of guidance from tutors, defining what they do not know and what they need to know in order to understand (not necessarily just to solve) the problem. The justification for this is firmly based in modern psychological theories of learning which have determined that knowledge is remembered and recalled more effectively if learning is based in the context in which it is going to be used in the future. Thus, if basic science knowledge is structured around representations of cases likely to be encountered in medical practice in the future, it is more likely to be remembered. Problem-based learning is also inherently integrative with the need to understand relevant aspects of anatomy, physiology, biochemistry, pathology and so on being readily apparent in each case. There is some evidence that students do, in the long term, recall more information in the context of patient problems when taught in thePBLway when compared with students taught in the disciplinary-based way. What is strikingly apparent is that students prefer this approach and become much more motivated to learn, a prerequisite to the desirable deep approach to learning discussed in Chapter 1.

His delightful face careprost 3ml amex medicine vocabulary, and soul into the development of arthroscopy and when he talked about arthroscopy in his hospital came to be respected as the world’s leading expo- bed before he died buy generic careprost 3ml on line treatment tinnitus, is an unforgettable memory. In 1960, he developed the Watanabe Type 21 arthroscope, which became the standard instru- ment around the world for almost two decades, and in 1962, after great effort and research, he 347 Who’s Who in Orthopedics was the only means of survival in those days when all hospital work was unpaid. In 1928, he was appointed to the Country Orthopedic Hospital at Gobowen, later to become the Robert Jones and Agnes Hunt Orthopedic Hospital, and also held an honorary appointment at the North Wales Sanatorium, where there were at that time many cases of ortho- pedic tuberculosis. It was oversubscribed and many of those who attended were his equals or elders, which was a great tribute to a young man in his early thirties. However, it must be remembered that he had by Sir Reginald WATSON-JONES then become well known nationally and interna- tionally for his contributions to the literature. The 1902–1972 success of the fracture course prompted his admirers to urge him to write a textbook on the Reginald Watson-Jones was born on March 4, treatment of fractures, and this led him to the first 1902. He died in London after a short illness on of his three great achievements. With his passing, the surgical My first encounter with Watson-Jones was as a world has lost one of its great leaders. My father was medical officer of The First World War was a tragic illustration of health for the County of Denbigh. Orthopedic the fact that injuries can eclipse other causes of clinics were held within the ambit of Gobowen at deformity. Before the war, Robert Jones himself, different centers, including Wrexham, my father’s in his work as surgeon to the Manchester Ship headquarters. I can remember vividly now, 45 Canal, had taken the practice of orthopedic years later, the compelling personality of R. After the war, he realized that industrial, I should later have become his registrar, and then domestic and road accidents would increasingly his assistant and successor at the Royal Infirmary. The great man had a was quick to realize the talent of the young Packard limousine, a chauffeur, a butler, a per- Watson-Jones, and persuaded the Liverpool sonal secretary and assistant; two radiographers Royal Infirmary to appoint him as an honorary and two physiotherapists. A working day started assistant surgeon in charge of a new orthopedic at 6. Robert at the nursing home at Number 1, Gambler Jones made an excuse of asking his protégé to Terrace; then a morning of patients at 88 Rodney make some researches into the literature in order Street; in the afternoon a hospital clinic or oper- to “repay” him by arranging a tour of continental ating session; back to Rodney Street for the paper orthopedic centers as a grooming and preparation work, and letters to doctors; and then home for a for the young man’s new responsibilities. The department at the Royal Infirmary was And so to the book, now irreverently and affec- soon, like all R. The official beds were six, but the Street there was, and still is, a top flat. Passing late at 348 Who’s Who in Orthopedics night or in the small hours, one could see the light tions to the literature, he played a big part in the in the flat. He was vice in January 1940, reprinted 15 times, translated president of the College from 1952 to 1954. In his philosophy, the ideal treatment of appointed director of the orthopedic and accident a fracture or injury would lead to the best possi- department of the London Hospital, and was ble result, and any other form of treatment that joined in this new venture by Osmond-Clarke. It both sides of the Atlantic took a prominent share was not a humble approach, but it worked, and in the launching of the new enterprise, there can in any event he was a realist in his actual treat- be little doubt that it was Watson-Jones’ enthusi- ment of patients; no one could have been more asm and drive that made certain that the idea commonsensical and ready to throw so-called everyone had approved for many years should be principles overboard as soon as they became put into practice. Woe betide anyone who did not from the time of the first number until his death “immobilize the joint above and below” in frac- and, especially in the early years of the journal, a tures of the tibia and the forearm, but when it great deal of its success was due to the countless became inconvenient to immobilize the hip in hours of hard work he put into his job as editor. He had enormous vitality, set a high standard of content and presentation, not only in his working hours but also for any which has been maintained over the years. Because of this, flair for organization made a grand success of the and because of his gentleness and kindness, he whole crowded week. If he Senate House of the University of London by had to reprove or criticize a junior colleague on a the Queen Mother, who was fulfilling her first matter of treatment, the victim would be led to public engagement after the death of King George one side and dealt with gently. I have never known him speak ill of Watson-Jones was knighted in 1945 in recog- anyone. He Watson-Jones was appointed civilian consultant was the Sir Arthur Sims Commonwealth Travel- in orthopedic surgery to the Royal Air Force. Many honors, too numerous to book, came his devoted service to the treatment mention, came his way.

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The grading should be 3ml careprost with visa medicine to increase appetite, negative cheap 3 ml careprost free shipping treatment junctional rhythm, 1+ with endpoint, or positive with no endpoint (Table 2. It is difficult to differentiate between 2+ and 3+ or to compare between examiners, so these grades have little meaning. Value Interpretation 0 Negative 1+ 0–5mm of anterior displacement, sometimes with an end point 2+ 5–10mm of anterior displacement, with no end point 3+ 10mm of anterior displacement, with no end point Pivot-Shift Test This test is more difficult to perform, but is more consistent in repro- ducing the athlete’s symptoms. Holding the heel in one hand and apply- ing a valgus stress in the other hand, the knee is slowly flexed. The tibia, when in internal rotation, slides anterior when the valgus stress is applied. The tibia, as well as the valgus, subluxes easily if anterior force is applied. After the anterior subluxation of the tibia is noticed, the knee is slowly flexed, and the tibia will reduce with a snap at about 20° to 30° of flexion. This reduction can be augmented with an external rotation of the tibia, as noted in Figure 2. The patient will usually indicate that is the sensation experienced when the knee gave out. Value Interpretation 0 Negative shift 1+ A glide 2+ A pivot shift 3+ A gross pivot shift. Range of Motion The physician should always examine the knee for loss of extension by holding both heels clear of the table and comparing the extension of the injured knee against the uninjured knee (Fig. The loss of extension is often the result of the ends of the torn liga- ment impinging anteriorly in the notch. The other common cause of lack of extension is a displaced bucket-handle tear of the meniscus. This may also alert you to a hyperextension and external rotation that indicates an associated posterolateral injury. Effusion The tear of the ACL usually produces a hemarthrosis that will appear immediately after the injury. The acute knee should be aspirated of blood to make the patient Figure 2. If there are visible fat globules on the surface of the blood, this should make you think of an intra-articular fracture. Appropriate imaging studies should be done to detect a tibial plateau fracture. Joint-Line Tenderness Both the medial and lateral joint lines should be palpated for tender- ness (Fig. In chronic cases, the incidence rises to 80% and is more common on the medial side. In acute cases, it is difficult to do a McMurray test described next because of limited flexion. McMurray Test In the chronic situation, the combination of joint-line tenderness, an effusion, and a clunk on the McMurray test confirms a tear of the 18 2. Palpation of the medial joint line for tenderness compatible with a meniscal injury. The McMurray test is performed by fully flexing the knee and rotating the tibia as the knee is slowly extended (Fig. A positive test is painful with full flexion and rotation; a clunk or snap is heard or felt when the knee is extended. The medial tear is elicited initially with the internal rotation followed by the external rotation during extension. This rotation of the tibial plateau will catch the posterior horn of the meniscus between the tibia and femoral condyle, producing a clunk and causing pain. The meniscus tugging on the pain-sensitive synovium at its peripheral attachments produces the pain. The test is notoriously inaccurate, and in most situ- ations the pain with full flexion and rotation is sufficient to confirm an injury to the meniscus. The mechanism of the popping with the McMurray test is demon- strated in the video on the CD.

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Although minimally invasive surgery (MIS) total hip replace- ment has been greeted with enthusiasm by those wishing to embrace the technique; others have voiced concern or even scepticism order careprost 3 ml on line treatment ingrown toenail. Those extolling the virtue of the minimally invasive approach tout the potential benefits cheap careprost 3 ml fast delivery medicine natural, such as reduced soft tissue trauma, reduced postoperative pain, and quicker rehabilitation. Sceptics of minimally invasive hip arthroplasty are concerned by increased operative difficulty, reduced visualization of the operative landmarks, the increased risk of complications, and the obvious downside of a learning curve associated with the introduction of new tech- niques. The question remains “Are minimally invasive hip arthroplasties safe and as efficacious as conventional hip replacements? This chapter reviews the technique and published literature to delineate the advantages and pitfalls of performing minimally invasive total hip arthroplasty surgery. Minimally invasive surgery, Total hip arthroplasty Introduction Less-invasive surgery has become a trend in every surgical discipline. Examples are laparoscopic cholecystectomy which has largely replaced open cholecystectomy in general surgery, minimally invasive robotic heart surgery where stenotomy is not necessary, and in orthopaedics where arthroscopic meniscal surgery has made open menisectomy obsolete. Not surprisingly, interest in less-invasive total hip replace- ment has emerged. What are the driving forces to lead surgeons to try less-invasive hip arthroplasty surgery? First, patients come to surgeons requesting it, often having researched the technique with the aid of the Internet or learned of the procedure through the popular Department of Orthopaedics, London Health Sciences Centre–University Campus, 339 Windermere Road, London, Ontario, N6A 5A5, Canada 183 184 C. Advantages and disadvantages for various different min- imally invasive surgery (MIS) total hip arthroplasty techniques Advantages Disadvantages Two incision Intranervous Fluoroscopy required Anterior Intranervous Femur difficult Direct lateral Small incision? These patients believe that there will be less pain and quicker recovery. Propo- nents of the procedure allege that patients who undergo total hip arthroplasty surgery via a minimally (less) invasive technique have significantly earlier ambulation, less need of walking aids, a more favourable and earlier discharge from hospital, decreased transfusion requirements, and better functional recovery. Less-invasive total hip arthroplasty surgery originated with the work of Heuter, Judet, and Keggi. In recent years it has been rediscovered and popularized by Sculco, Berger, and Dorr [3–5]. Minimally invasive total hip arthroplasty involves a smaller skin incision, usually between half to one quarter the length of a conventional skin incision for this surgery, and attempts to minimize the extent of associated soft tissue trauma. Berger defines MIS as surgery where “muscles and tendons are not cut”. Recent developments to aid successful MIS surgery have been the introduction of specialized instrumenta- tion, computer-assisted surgery, the utilisation of fluoroscopic guidance, and specific MIS implants. The success of conventional total hip arthroplasty surgery has relied on adequate exposure to allow visualization of both the acetabulum and proximal femur. This exposure enabled correct orientation of the implanted prostheses based on visualized anatomical landmarks. One of the concerns with minimally invasive techniques are that with a small incision the surgeon would have poor visualization and this could lead to malposition of the prostheses, neurovascular injury, and poor implant fixa- tion, therefore compromising the short- and long-term results of a procedure which has become one of the most successful advances in surgical technology of the twen- tieth century. Minimally invasive total hip arthroplasty has generated a lot of controversy within the orthopaedic community and a great deal of publicity in the popular press. Randomization was to either undergo total hip arthroplasty through a standard 16-cm incision or a short incision of less than 10cm. The authors concluded that minimally invasive total hip arthro- plasty performed through a single-incision posterior approach by a high-volume surgeon, with extensive experience in less-invasive approaches, was safe and repro- ducible. The study however showed no significant benefit between the groups in terms of the severity of post-operative pain, the use of post-operative analgesic medications, the need for blood transfusion, length of hospital stay, or early functional recovery. Minimally/less-invasive total hip replacement is an umbrella term used to en compass what is actually a “family” of operations. Each of which have advantages and disad- Minimally Invasive Hip Replacement Surgery 185 Fig. Intraoperative photograph shows position of specialized retractors during minimally invasive surgery (MIS) anterior approach vantage (Table 1). This family of less-invasive hip approaches includes anterior, anterolateral, direct lateral, posterior, and two-incision surgical approaches. Anterior Approach Technique A modified Smith–Peterson approach is used for a MIS anterior technique.

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