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The abnormally lax patient will present problems in achieving stability buy methotrexate 2.5mg low cost medicine for runny nose. Semitendinosus The conventional wisdom is that the young pivoting contact sport athlete should have a patellar tendon reconstruction best 2.5 mg methotrexate medicine zanaflex. Patients with pre- existing patellofemoral symptoms or who are only involved in recre- ational activities should undergo a semitendinosus reconstruction. The metaanalysis of the five studies in the literature that compare the ham- strings and the patellar tendon grafts concluded that the outcome is vir- The Controversies 189 tually the same for the two procedures. The only significant difference is that with the patellar tendon graft there is a 20% greater chance of returning to the same level of preinjury sports participation. In most cases only the soft tissue needs to be removed to visualize the over the top position. Pretensioning of the Graft, Especially the Semitendinosus This has become less of an issue since we have moved to the inter- ference screw fixation of the semitendinosus. The fixation is near the tunnel entrance and reduces the bungee effect of periosteal fixation. Tensioning of the Graft The graft should be tensioned with about 10lb to 15lb of tension at 20° of knee flexion. Fixation: BioScrew The fixation of grafts with the bioabsorbable screw is evolving into the preferred method of fixation. The blunt metal screw has become the standard, and the bioabsorbable screw has advantages over the metal screw, so it should become the standard of the future. Timing of Return to Sport The most important advance in ACL reconstruction in the past decade has been the concept of accelerated rehabilitation as proposed by Shelbourne. This has reduced the problems of limited range of motion and patellofemoral pain and has increased the return to sports partici- pation. It has also reduced the time of return to sports from 12 months to 4 months. Recently, the popular press has discussed athletes who return to sports in six to eight weeks. In the author’s opinion, the athlete may be rehabilitated, but has the biology of soft tissue healing had a chance to incorporate the graft? Most surgeons feel that it takes four to six months for the athlete to recover after autogenous ACL graft reconstruction. Results Use of a Brace The use of a functional brace after ACL reconstruction is still a debat- able issue. The author feels that if a patient undergoes a reconstruction, a brace is not necessary for return to sport. If the patient elects to undergo conservative treatment, the functional brace is a mainstay of that treatment. Conclusions The patellar tendon is a reliable graft that allows the athlete to resume sports early. The procedure has significant postoperative patellofemoral pain and stiffness. This may be reduced with aggressive rehabilitation to regain extension and to mobilize the patella. The disadvantages are the variable graft size and longer time to return to sports. The author is suggesting that the surgeon should have more than one option available to offer to the patient. The more important issue in ACL reconstruction is not the graft choice, but is in placing the tunnels in the correct position (Fig. There are several guides available for both the tibial and the femoral tunnels that help the surgeon place the guide wire in the proper posi- tion. At that time, if the surgeon is not sure of the positioning, then the fluoroscopy can be used to determine the correct position. The assessment of the outcome of the treatment should be done by both subjective and objective functional outcome measurements. Several measurement scales are available, such as the International Knee Documentation Committee form or IKDC. When the outcome measurements are made on this scale, they can be interpreted by anyone. At the present time, only 43% of the members of the ACL study group use this form; most say that the form is not user friendly. We must continue to strive for a universal system that will make it easier to judge the success of different types of treatment of the ACL injured knee. The Future The current surgical technique of autogenous graft harvest, with tunnel preparation, will change very little. The changes will come in the evo- lution of graft fixation with bioabsorbable materials. The graft of the future will be a synthetic collagen scaffold selected off the shelf and injected with fibroblastic cells to produce collagen in vivo. The profession will look back on the patellar tendon not as the gold standard, but as a barbaric procedure!

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Organisation q Each chapter starts on a new page q Pages are numbered consecutively in the top right-hand corner q The manuscript is arranged in the order requested by the publisher 2.5mg methotrexate otc medications while breastfeeding. Submission q One or two printed copies for publisher q One copy in plain text or ASCII on disk for publisher q Each disk has been labelled with your name and the title of the manuscript q One copy on disk for yourself q One printed version for yourself buy 2.5 mg methotrexate amex symptoms ketoacidosis. PRESENTING YOUR WORK 269 Summary Points ° Manuscripts must be typed or printed on one side of A4 paper. It is not meant to be a definitive account, and the reader is advised to refer to the relevant legislation. Always seek legal advice if you are in any doubt about copy­ right or contractual matters. The Copyright, Designs and Patents Act of 1988 provides, amongst other things, protection for original literary works and the typographical ar­ rangements of published editions. It is useful for authors to note that copyright applies to the form in which ideas are expressed, and not to the ideas themselves. Copyright does not subsist in the literary work until it is recorded in writing or other simi­ lar means. However, if the author has completed the work as part of his or her duties as an employee, then the employer has ownership. The author may also assign copyright to the publisher, a com­ mon practice when work is published in journals. In these cases authors who try to resell an article, without the permission of the journal’s pub­ lisher, will infringe copyright law. In the United Kingdom, copyright is usually the life of the author plus 70 years. Copyright for the typographical arrangement of a published edition expires at the end of 25 years. However, there are variations in copyright, 270 PROTECTING YOUR RIGHTS 271 especially between countries, so never assume that copyright has expired. You need to get permission to reproduce original or adapted versions of the following: 1. Illustrations such as photographs, figures, drawings, graphs and tables. Single quotations of more than 300 words or several quotations from the same source that are equivalent to more than 300 words (Churchill Livingstone 1996). However, it should be noted that the Act states that ‘substantial parts of the work’ are measured in terms of quality and not quantity, so use the above word limit with caution. Seek the advice of your publisher or contact the copyright owner if you are unsure. You will need to acknowledge the original source of any copyrighted material you use in your own work. Indicate the granting of permission within the text of your work, for example, ‘Reproduced with the kind per­ mission of…’. Write to the copyright holder to obtain written permission for using mate­ rial. Give precise details of what you want to copy, for example the title of the work and the page and line numbers. Explain why you want to use the work and give assurance that the author or copyright owner will be ac­ knowledged. Send a copy or copies of this writ­ ten permission to the publisher with your completed manuscript. You may legitimately make a single copy of written material for private study or re­ search. However, this must be no more than 5 per cent of the whole work, for example a single chapter. If you are copying an article from a journal you may only copy one item from that issue. There are some exceptions to these rules; for instance, an educational institution may be licensed by the Copyright Licensing Agency to make multiple copies if these are for use in class. PROTECTING YOUR RIGHTS 273 ° copyright (confirmation that the author’s name will appear with due prominence along with the copyright notice) ° index (relates to payment for professional indexer if required) ° illustrations (again relates to conditions when payment might be necessary) ° author’s liability to revise ° author’s copies (authors are usually allowed between 4 to 6 free copies) ° termination (circumstances under which the contract might be terminated). A one-off payment is usually made for journal articles, although it is also a perfectly feasible method of payment for a book. The amount is set by the publisher and agreed with the author via a publishing agreement. The payment is usually received a few months after publication and is not affected by the amount of subsequent sales. Royalties are paid as a percentage of the net sales receipts received by the publisher from the sale of the book.

He was equally prepared lesser commitments so that he could devote more to investigate a procedure that gave good results time to the task of building his new department buy generic methotrexate 2.5 mg online medicine 44 159, although the reason was not apparent generic methotrexate 2.5 mg line treatment nausea. His attitude but it was uphill work and many years were to to manipulative surgery is a good example. At first he was confronted in his daily practice by patients had one outpatient clinic a week, but no beds with a variety of complaints who failed to respond except such as he could borrow from the less con- to the orthodox treatment of contemporary prac- servative of his colleagues. When finally he tice, and yet afterwards were quickly relieved by convinced them that orthopedics had passed out bone setters. He set out to investigate this phe- of the strap-and-buckle stage, he was rewarded nomenon and became acquainted with Herbert with three male and three female beds in his own Barker, who was famous as an unqualified manip- right, and a few cots in the children’s ward. It was ulator, watched him work and saw his patients not until the new hospital was completed in 1935 afterwards. As a result, Bankart was convinced that he had his own wards, and the organization that patients with certain ailments were helped by of a unified fracture service was delayed until manipulation whereas he himself would not have after the Second World War. When his assistant benefited them (and on the other hand Barker surgeon went into the army he ran the department, was a wise enough man to learn something from together with an additional 100 temporary beds at Bankart of the dangers of indiscriminate mani- Mount Vernon Hospital, with little help except pulation). Bankart therefore began to perform from student house surgeons, and although he manipulations himself, found out when it was reached the official retiring age in 1944, he gladly indicated and added the technique to his thera- continued for a further 2 years. He reduced the claims of Bankart made many contributions to orthope- manipulators from “ miracles” to plain facts, dics, the best known being his operation for recur- showed how simple the procedure was, made it rent dislocation of the shoulder. The described it in 1923, it did not attract much notice culmination of this work was his book, Manipu- outside the circle of his immediate colleagues. He was a founder member was well received; and although surgeons as a of the Société Internationale de Chirurgie whole were slow to adopt it, perhaps because it is Orthopédique et de Traumatologie and an technically a little difficult, it is now performed honorary member of the Société Française throughout the world. He was a founder member of the cedure for the treatment of recurrent dislocation British Orthopedic Association, honorary secre- of the shoulder that can be relied upon, and tary from 1926 to 1931, and in 1932 and 1933 he upwards of 100 different operations have been had the distinction of serving as its president. Bankart had few hobbies and his life centered In addition to his own contributions, Bankart around his surgery. In the evenings he was to be had a great influence on British orthopedics as a found as often as not in his study in his lovely whole because of the directness of his approach, home in Edwardes Square, surrounded by open which excluded careless thought and slipshod books and with a part skeleton or a new instru- work. Pondering his vast clinical expe- ficial argument, and the publication of a paper rience and drawing on his great knowledge of 21 Who’s Who in Orthopedics physiology, he elaborated the theories on which these qualities of greatness. A man of strong con- of his active professional career, orthopedic victions and supreme personal honesty, he could surgery had the greatest period of growth and not be diverted from the course he believed to be development in its history; throughout this time true; and when he had decided that a certain pro- Joseph Barr was among the leaders in the growth cedure was the best, even when he had devised a of his specialty. Few significant developments new operation, it was practiced on the next occa- took place following World War II in which he sion it was called for, were the patient a million- did not play a part. Joseph Barr was born on a farm near Wellsville, Although a man of courtly bearing and great Ohio, on October 16, 1901. His college education charm, he did not easily establish intimate per- was at the College of Wooster, in Ohio, from sonal relations with his colleagues. This often which he received a BS in 1922 and 30 years later, puzzled those who were attracted by his manner in 1952, an honorary degree of Doctor of Science. He was a connoisseur of life and appreciated the entered Harvard Medical School in 1922 and 4 good things it holds, especially other people. After a surgical internship at the Peter shyness was overcome contributed to the Bent Brigham Hospital under the great Harvey company in full measure. Toler- He served with distinction in the Children’s ant of error, intolerant of fools, a giant among Hospital–Massachusetts General Hospital ortho- men. After completion of this The sudden death of Bankart on April 8, 1951 training in 1929, he was asked by Dr. In 1947, after an active and distin- guished career in the United States Navy during World War II, Dr. Smith-Petersen as the Chief of the Orthopedic Service at the Massachusetts General Hospital, having become a member of its staff in 1930. Jason Wixter of the role of rupture of the inter- vertebral disc, in sciatic pain. Their thorough and excellent study of this lesion and their classical report in 1934 changed the thinking of the medical profession concerning the etiology of low-back pain and sciatica. Before their ideas were accepted, such terms as sacra-iliac strain Joseph Seaton BARR and lumbosacral sprain were in constant use; 1901–1964 these terms are seldom heard today. Barr was the author or coauthor of 12 papers on the inter- Vision and capability are the first requisites for vertebral disc syndrome and lectured on this leadership in all walks of life, but nowhere more subject in England, in Sweden, and at many inter- than in medicine. The thousands of low-back 22 Who’s Who in Orthopedics sufferers all over the world who have been tee for the Study of Surgical Materials that was relieved by disc surgery should be forever thank- composed of representatives of the American ful to Joseph Barr for the part he played in the College of Surgeons, American Medical Associa- demonstration of this syndrome and its treatment. All meetings of the Committee were writings, which number over 80 publications, attended by selected representatives of the manu- concerned poliomyelitis. This was the fore- coauthor of 16 articles on this subject, including runner of the present American Surgical Materials seven papers on muscle and tendon transplanta- Association, which is now beginning to take its tion. In his work as a consultant to the Division place as an effective organization.

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When you’re surfing the net purchase 2.5 mg methotrexate medications given for bipolar disorder, there are some extra precau- tions you can take to check the reliability and quality of the information you have found: X Try to use websites run by organisations you know and trust buy 2.5mg methotrexate with mastercard treatment resistant depression. X Check the About Us section on the web page for more information about the creator and organisation. X Use another source, if possible, to check any informa- tion of which you are unsure. For example, if you’re interested in medical information you can check the HOW TO CONDUCT BACKGROUND RESEARCH / 43 credentials of UK doctors by phoning the General Medical Council. X You should check the national source of the data as in- formation may differ between countries. X For some topics specific websites have been set up that contain details of questionable products, services and theories. Interlibrary loans If you are a student your institutional library will prob- ably offer an interlibrary loan service which means that you can access books from other university libraries if they are not available in your library. This is a useful service if, when referencing, you find that a small amount of infor- mation is missing (see Example 5 below). EXAMPLE 5: GILLIAN Nobody told me the importance of keeping careful re- cords of my background research. I just thought it was something you did and then that was it, you got on with 44 / PRACTICAL RESEARCH METHODS your own research and forgot about what you’d done. Of course then I had to write my report and in the ‘background’ section I wanted to include loads of things I’d read when I first started the work. Even then I still forgot to write down the name and location of the publisher, so I had to go back to them again. My advice would be to look at how bibliographies are structured and imprint that in your brain so you don’t forget anything. Keeping records When you begin your background research, keep accurate records of what data was gathered from which source as this will save you plenty of time and frustration later, especially when you come to write your research proposal, or final report. A useful way to organise your background research is to have two files – one for primary research and one for secondary research. Each file can be divided into topics with the relevant notes slotted into each. Primary research For the primary research file, notes from each contact can be separated by a contact sheet which gives the name of the person, the date and time you met and a contact num- ber or address. Secondary research In the secondary research file, each page of notes can be headed by details of the publication in the same format that will be used in the bibliography – author and initials; date of publication; title of publication; place of publica- HOW TO CONDUCT BACKGROUND RESEARCH / 45 tion and publisher. If it is a journal article, remember to include the name of the journal; the page numbers of the article and the volume and number of the journal. It is also useful to include the location of this publication so that it can be found easily if needed again (website or li- brary shelf location). TABLE 2: SOURCES OF BACKGROUND INFORMATION PRIMARY SECONDARY Relevant people Research books Researcher observation Research reports Researcher experience Journal articles Historical records/texts Articles reproduced online Company/organisation records Scientific debates Personal documents (diaries, etc) Critiques of literary works Statistical data Critiques of art Works of literature Analyses of historical events Works of art Film/video Laboratory experiments SUMMARY X There are two types of background research – primary and secondary research. X Primary research involves the study of a subject through firsthand observation and investigation. X Secondary research involves the collection of informa- tion from studies that other researchers have made of a subject. X Any information obtained from secondary sources must be carefully assessed for its relevance and accu- racy. X Notes from primary and secondary sources should be carefully filed and labelled so that the source can be found again, if required. X When noting details for books, reports or articles which may appear in the final report, include all the details which would be needed for the bibliography. By now you should have decided what type of peo- ple you need to contact. For some research projects, there will be only a small number of people within your research population, in which case it might be possible to contact everyone. However, for most pro- jects, unless you have a huge budget, limitless timescale and large team of interviewers, it will be difficult to speak to every person within your research population. SAMPLING Researchers overcome this problem by choosing a smaller, more manageable number of people to take part in their research. In quantitative research, it is believed that if this sample is chosen carefully using the correct procedure, it is then possible to generalise the re- sults to the whole of the research population. For many qualitative researchers however, the ability to generalise their work to the whole research population is not the goal. Instead, they might seek to describe or explain what is hap- pening within a smaller group of people. This, they believe, might provide insights into the behaviour of the wider re- search population, but they accept that everyone is different 47 48 / PRACTICAL RESEARCH METHODS and that if the research were to be conducted with another group of people the results might not be the same. Market research- ers use them to find out what the general population think about a new product or new advertisement. When they re- port that 87% of the population like the smell of a new brand of washing powder, they haven’t spoken to the whole population, but instead have contacted only a sam- ple of people which they believe are able to represent the whole population. When we hear that 42% of the popula- tion intend to vote Labour at the next General Election, only a sample of people have been asked about their voting intentions.

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