By P. Ugrasal. Pratt Institute.

Classification of skeletal malalignment Frontal plane Sagittal plane Horizontal plane Location Location Location Varus Femur Prominent trochlea Femur Inward-pointing Femur (internal torsion) Tibia knee Ligaments Tibia (external torsion) Subtalar joint complex (hyperpronation) Valgus Femur Shallow trochlea Femur Outward-pointing Femur (external torsion) Tibia knee Ligaments Tibia (internal torsion) Subtalar joint complex Aplasic tuberosity Tibia Increased TT-TG Tibia > 20 mm Decreased TT-TG is the angle between the femur shaft and tibia Rotational (Horizontal or Transverse) shaft and is usually 5 purchase 100 mg aurogra mastercard erectile dysfunction treatment dallas. Different investi- Plane Alignment gators found no difference between males and Rotational plane alignment can be determined females in these angles aurogra 100 mg with visa doctor for erectile dysfunction philippines. Common measurements are the torsion of the femur, torsion of the tibia, version or the relationship of the distal femur and prox- imal tibia, and the relationship between the femur and the tibial tuberosity (TT-TG). Bone Torsion Femoral torsion is defined as the angle formed between the axis of the femoral neck and distal femur and is measured in degrees. To assess femoral torsion with CT scan a line from the center point of the femoral head to the center point of the base of the femoral neck is created. This second point is more easily selected by locating the center of the femoral shaft at the level of the base of the neck where the shaft becomes round. Based on the classic tabletop method, the condylar axis is defined as the line between the two most posterior aspects of the femoral condyles. Alternatively a line connect- ing the epicondyles can be used. Then, the angle formed by the intersection of these two tangents is measured (Figure 11. For assessment of tibial torsion a line is drawn across the center of the tibial plateau. As this line is not easy to locate, some authors use the tangent formed by the posterior cortical margin of the tibial plateau. The femoral epicondylar axis might also be selected as it is easier to locate and would appear to be valid because it is the relationship of the knee joint axis to the ankle joint axis that is of concern. Whole limb standing radiograph with mechanical axis ing the center point of the medial malleolus with added showing varus. Skeletal Malalignment and Anterior Knee Pain 189 Figure 11. CT rotational study shows 43° of femoral anteversion. Line 1 represents the proximal femoral axis; line 2 is the distal femoral axis (tan- gent to the posterior condyles). The angle formed by the intersection of axis (SD 8°). His values generally agree with those these two lines is measured to determine the tib- reviewed in the literature that he tabulated. Conversely, lateral tibial torsion aver- torsion determinations in normal individuals aged 24° with a significant difference between using CT scan. The authors measured torsion in males and females at 21° (SD 5°) versus 27° (SD 505 femurs and 504 tibia and found femoral 11°). Furthermore, even greater differences were anteversion of 24. No correlation to sex which must reflect increases in subtalar position, could be established. Yoshioka45 made direct although this was not mentioned in their paper. Although this hypothesis is attractive, his findings have not been corrobo- rated by other authors. This relationship can be evaluated and quantified by the measurement of the TT-TG. The TT-TG is the distance measured in mm between two perpendiculars to the bicondylar axis. CT rotational study shows 55° of external tibial torsion. The measurements are of the medial and lateral malleolus). A TT-TG distance of less than 20 mm is considered Figure 11. Sagittal Plane Alignment In the sagittal plane the osseous factors to be eval- uated include the trochlea, the tibial tuberosity, Outerbridge. Dejour’s third criterion is the the patellar height, flexion, and length of the actual distance of the floor of the trochlea below radius of curvature for the trochlea.

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The most useful and safest methylxanthine is caffeine aurogra 100 mg sale erectile dysfunction under 25, normally used at a concentration of 1% to 2% generic 100 mg aurogra with visa erectile dysfunction drugs india. It offers good skin penetration and is therefore rapidly absorbed, leading to rapid action. Caffeine acts directly on adipocytes, promoting lipolysis through the inhibition of phosphodiesterase by augmentation of cAMP (31). All methylxanthines activate the enzyme triglyceride lipase and transform triglycerides into free acids and glycerol. Caffeine also has a stimulating effect on the cutaneous microcirculation. Table 1 lists botanical sources of methyl- xanthines, extracts of which are very common in anticellulite agents. Beta-adrenergic agonists such as isoproterenol and adrenaline, and alpha-adrenergic antagonists such as yohimbine, piperoxan, phentolamine, and dihydroergotamine have also shown the ability to cause lipolysis. In vitro studies have shown that both the methyl- xanthines and the beta-adrenergic agonists stimulate lipolysis and a reduction in adipocyte size through an increase in cAMP inhibition of phosphodiesterase (32,33). Greenway and Bray demonstrated a statistically significant reduction in the anthropo- metric measurement of the medial thigh by a double-blind placebo-controlled study, which utilized topical isoproterenol (a beta-adrenergic agonist), aminophylline (a methyl- xanthine with phosphodiesterase inhibitory properties), and yohimbine (an alpha-adrenergic antagonist) (34). The reduction in thigh measurement was greatest when all active drugs were used together, three to five times a week for four weeks’ duration. Of the results obtained when the three agents were used separately, the best results were obtained with use of aminophylline. The effects of methylxanthines can be enhanced by coenzyme A and the amino acid l-carnitine (23). These agents work by stimulating the mobilization and destruction of free TOPICAL MANAGEMENT OF CELLULITE & 165 fatty acids and inducing their active transport through the membranes of the mitochon- dria. This is important because free fatty acids may cause saturation of the system, leading to negative feedback of lipolysis. Also, the mobilization and destruction process of free fatty acids generates adenosine triphosphate, which increases lipase activity, enhancing hydrolytic breakdown of triglycerides. Yohimbe (Corynanth yohimbe, Pausinystalia yohimbe, and Rauwolfia serpentine)and alpha yohimbe are alkaloid derivatives extracted from the leaves, shell, and roots of Rubiaceas and Apocynaceas (19). They are adrenergic blockers capable of stimulating the catabolism of fat due to the presence of alkaloids that act directly on the fat cells (19). AGENTS THAT RESTORE THE NORMAL STRUCTURE OF THE DERMAL AND SUBCUTANEOUS TISSUE Retinol (vitamin A) and the retinoids have been evaluated for their effectiveness in the treatment of cellulite. Topical retinoic acid and related vitamin A derivatives have been used to stimulate circulation, decrease the size of adipocytes, and increase collagen deposi- tion in the dermis (9,35). Based on the capacity of all-trans-retinoic acid (tretinoin) to pro- mote the synthesis of glycosaminoglycans in normal skin and increase the deposition of collagen in the photodamaged dermis, Kligman et al. The premise for its use in cellulite treatment is that topical retinol can be used to increase the thickness and firmness of the dermis, disguising the effect of the superficial fat histologically present immediately beneath it. The use of retinol was pro- posed instead of tretinoin due to its better tolerability and the evidence that retinol is meta- bolized to retinoic acid in the skin. Of the 19 patients, twelve demonstrated greater clinical improvement on the actively treated side on clinical evaluation and laser Doppler velocimetry. In a rando- mized, placebo-controlled study combining the use of retinol with gentle massage, skin elas- ticity was increased by 10. The main retinol-related change consisted of a two- to fivefold increase in the number of factor XIIIa þ dendrocytes both in the dermis and in the fibrous strands of the hypodermis. This is all indicative of increased skin firmness and smoothened appearance of the surface. In addition, some topical ingredients such as vitamin C may help by stabilizing collagen and/or stimulating collagen deposition (3,4,9). Bladderwrack (Fucus vesiculosus) is a brown marine algae that contains sulfated polysaccharides, iodine compounds, and alginic acid.

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