Objective Clinical Examination Research Articles

Z-Bunionectomy: Retrospective long-term study

Long-term patient satisfaction and objective clinical and radiographic examinations of patients who had undergone the Z-bunionectomy at the University of Chicago Medical Center were evaluated. Fifty-six surgeries were performed on 31 patients, with a follow-up range of 5 to 9 years. The University of Maryland 100-Point Painful Foot Center Scoring System was modified to be more specific to bunion surgery, and we used this modification to measure patient satisfaction. Patient satisfaction was rated good to excellent by 90% of the patients. Radiographic findings included: intermetatarsal angle-mean, 7.1 degrees; hallux abductus angle-mean, 8.96 degrees; tibial sesamoid position-mean, 2.8. The mean protrusion was -1.64 mm. Radiographic findings consistent with osteonecrosis were noted of one patient, one foot, although the patient was clinically asymptomatic. The objective findings were as follows: dorsiflexion, mean, 60 degrees; plantarflexion, mean, 14 degrees. No patients had pain or crepitus, nor were they tract-bound in their first metatarsophalangeal joint range of motion. In addition, stance dorsiflexion had a mean of 21 degrees, and the purchase power was 88% good to excellent on plantar paper pull-out testing. First ray motion qualitatively demonstrated 1 1/2 to 2 times dorsiflexion to plantarflexion. There were no subsecond metatarsal head keratoses. Generalized ligamentous laxity was not seen. For the resting calcaneal stance position the mean was 3.5 degrees everted, with 24% of the patients maximally pronated in this position. We were unable to correlate any structural and functional postoperative features with patient satisfaction.

Treatment of critical limb ischemia in the elderly

Acute critical limb ischemia (CLI) is a rather frequent clinical event in elderly patients. Atherosclerotic plaques or cardiopathies (atrial enlargement and fibrillation, ventricular thrombosis) are the most frequent clinical situations related to peripheral embolization. Rapid diagnosis followed by suitable treatment allows us to obtain good results even in elderly patients. The decision about the treatment of acute CLI is related to the clinical and functional condition of the patient. Anamnesis must inquire about recent ischemic or hemorrhagic events in the cardiovascular, gastro-intestinal and urinary apparatuses, or the presence of disorders of coagulation and fibrinolysis. An objective clinical examination and a multidimensional assessment must evaluate the degree of functional impairment and provide the basis of a therapeutic strategy (cost/benefit ratio). Diagnostic examination in the frail elderly patient (FP) involves only the ultrasonographic method, to localize the level of thromboembolic occlusion, which is followed by angiography in the non-frail patient (NFP). In the case of proximal occlusion (of the iliac or femoro-popliteal arteries), the elective treatment in both groups of patients is thromboendarterectomy, plus transcutaneous angioplastics or by-pass in NFP, followed by prostacyclin or heparin infusions. Distal occlusion (below the popliteal artery) in FP is treated only with prostacyclin or heparin, whereas in NFP, fibrinolysis is the elective treatment, followed by prostacyclin or heparin. In the cases of distal gangrene, before amputation is performed, a "limb salvage" operation must be considered. After the acute phase of medical or surgical treatment, vasoactive or antiplatelet drugs are employed in FP, whereas in NFP the use of coumadin is the preferred treatment to counteract the rethrombosis and prevent new embolizations. Antiplatelet therapy could be selected when coumadin is contra-indicated.

Comparison of arthroscopic and open techniques in carbon fibre reconstruction of the anterior cruciate ligament: Long-term follow-up after 5 years

Two groups of patients with chronic, symptomatic anterior cruciate ligament deficiency were reconstructed with carbon fibre. In 15 patients, the prosthesis was inserted through an anterolateral arthrotomy; in 14, it was inserted arthroscopically. Both groups also received a MacIntosh extraarticular lateral substitution. Assessment included subjective functional rating and objective clinical examination for instability. No significant difference in subjective functional rating was present after a minimum of 5 years; however, a reduced complication rate and diminished return of clinical instability was evident in the arthroscopic group during this period. Reconstruction was satisfactory in 47% of the arthrotomy group and 64% of the arthroscopy group when subjective and objective criteria were combined to assess the final outcome. This study supports the proposition that, in combination with extraarticular lateral substitution, arthroscopic insertion of cruciate prostheses compares favourably with conventional “open” techniques.

Diagnosis in psychosomatic dermatology

Franz Alexander 1 proposed that the term “psychosomatic” should be used only to indicate an investigative method for diagnosis and therapy with simultaneous and coordinated application of somatic (ie, physiologic, anatomic, pharmacologic, surgical, and dietetic) and psychological concepts and methods. Correct diagnostic methodology in psychosomatic dermatology could not, therefore, avoid subverting some of the procedures habitually used in medicine. In fact, in a traditional somatic approach the fundamental points are the progressive evaluation of the data resulting from the anamnesis, objective clinical examination of the patient, and the laboratory findings, from which diagnosis is deduced, by exclusion. 2 Dermatology—the science of evidence—has not subtracted itself from this interest aimed, above all, at “the apparent,” sometimes with scarce propensity for “what lies underneath,” what is not immediately in the foreground, what is not concretely evaluable.

Anterolateral rotatory instability of the knee

In an attempt to correct anterolateral rotatory instability of the knee, 30 consecutive patients underwent a surgical procedure similar to that described by Ellison (Ellison AE: A modified procedure for the extra-articular replacement of the anterior cruciate ligament. American Orthopaedic Society for Sports Medicine Symposium, New Orleans, LA, July 15, 1975), called the iliotibial band transfer. Fashioning the passageway for the transfer closer to the attachment of the fibular collateral ligament on the femur and meticulous fascial closure over the transplant were not found to be crucial to success. Twenty-nine of the 30 patients were injured during athletic activities, and the remaining patient was injured in a motorcycle accident. They often complained of an unstable knee with symptoms of pain and giving way. Twenty-eight patients with a minimum followup of nine months (the average followup was 25 months) were evaluated subjectively by an interview and by objective clinical examination. Subjective results (including asymptomatic return to their previous level of athletic activity) and clinical improvement of anterolateral rotatory instability (based on the flexion-extension-valgus test or the Slocum anterolateral rotatory instability test) were encouraging. Areas of concern were that a small number of patients developed asymptomatic varus instability and a few had relative strength deficits which may or may not have long-term significance.

An objective undergraduate clinical examination in child health.

A new type of test used to examine medical students' clinical skills in paediatrics is described. Each student has to circulate round a number of timed stations. At each one he performs a specified clinical procedure--such as history taking, physical examination, urine analysis, and radiological interpretation--and is marked according to his performance. This type of test is objective and can be extended to cover different aspects of clinical methods; it readily informs the student about his progress, and enables the teacher to look critically at his own technique.

Clinical pharmacology in normal volunteers of praziquantel, a new drug against schistosomes and cestodes. An example of a complex study covering both tolerance and pharmacokinetics.

The tolerance of Praziquantel (2-cyclohexylcarbonyl-1, 3, 4, 6, 7, 11b-hexahydro-2H-pyrazino-[2, 1-a]isoquinoline-4-one) in oral doses of 1 X 20 mg/kg, 1 X 50 mg/kg, 3 X 10 mg/kg and 3 X 25 mg/kg body weight (tau = 4 h) was tested in a complex study involving 36 healthy volunteers. In addition to the usual assessment of clinical chemistry, haematology, coagulation physiology, urinalysis, clinico-physiological examination including EEG, and medical examination, clinico-psychological parameters were also recorded and special neurological investigations were performed. No clinically relevant changes were found in any of the laboratory parameters, nor in the medical-neurological or clinico-physiological examinations. Based on a few clinico-psychological parameters and subjective comments, the largest daily dose tested (3 X 25 mg/kg = 75 mg/kg) produced a slight, transient disturbance in general well-being, which was barely detectable on objective clinical examination. The pharmacokinetic behaviour was dominated by rapid metabolism and pronounced first-pass metabolism of praziquantel, which greatly limits the value of results obtained by GC analysis of unchanged drug in serum. The peak concentration in serum was reached after 1--2 h, and the elimination half-life for the period 2--8 h was 1--1.5 h.