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Hamstring Grafts Advantages of Hamstring Grafts The main advantage of the hamstring graft is the low incidence of harvest site morbidity buy discount lady era women's health center jensen beach. The 4-bundle graft is usually 8mm in diameter purchase lady era 100 mg visa women's health clinic on broadway, which is a larger cross-sectional area than the patellar tendon purchase 100mg lady era overnight delivery menopause exhaustion. Graft Selection Disadvantages of Hamstring Grafts The disadvantage of any autograft is the removal of a normal tissue to reconstruct the ACL discount lady era 100mg fast delivery menstruation urinalysis. The harvest of the semitendinosus seems to leave the patient with minimal flexion weakness. One study did show some weakness of internal rotation of the tibia after hamstring harvest. Injury to the saphenous nerve is rare and can be avoided with careful technique. Issues in Hamstring Grafts The major issues with the use of hamstring grafts are: Graft strength. In one of the earlier studies, Noyes reported that one strand of the semi-t was only 70% the strength of the ACL (Fig. The composite hamstring graft is twice the strength and stiffness of the native ACL. This was widely quoted as a reason to use the patellar tendon graft rather than the hamstring. With the advent of the multiple bundles of hamstrings, this graft now has twice the strength of the native ACL (Fig. Sepaga later reported that the semitendi- nosus and gracilis composite graft is equal to an 11-mm patellar tendon graft. Marder and Larson felt that if all the bundles are equally ten- sioned, the double-looped semi-t and gracilis is 250% the strength of the normal ACL. Hamner, however, emphasized that the strength is only additive if the bundles are equally tensioned. Soft Tissue Fixation Techniques There are various techniques for securing the soft tissue to the bony tunnel in ACL reconstruction. Pinczewski pioneered the use of the RCI interference fit metal screw for soft tissue fixation. The use of a similar type of bioabsorbable screw that was used in bone tendon bone fixation was a natural evolution. To overcome the weak fixation in poor quality bone, the use of a round pearl, made of PLLA or bone, was developed. The Endo-button, popularized by Tom Rosenberg, was improved with the use of a continuous polyester tape. This made the fixation stronger and avoided the problems of tying a secure knot in 56 5. The cross-pin fixation has proven to be the strongest, but has a significant fiddle factor to loop the tendons around the post. Weiler, Caborn, and colleagues have summarized the current concepts of soft tissue fixation. The estimates of the force on the normal ACL during activities of daily living are as follows: Level walking: 169N Ascending stairs: 67N Descending stairs: 445N Ascending ramp: 27N Descending ramp: 93N It is commonly quoted that a person needs more than 445N pullout strength of the device just to handle the activities of daily living. However, Shelbourne has reported good results with the patellar tendon graft fixed by tying the leader sutures over periosteal buttons (Ethicon, J&J, Boston, MA). This form of fixation has a low failure strength, but is clinically successful. The gold standard of the interference fit screw fixation of the bone tendon bone, 350 to 750N, has been used to compare the soft tissue fixation. The femoral pullout is higher because the tunnel is angled to the graft and the pull is against the screw that is placed endoscopically. In the tibial tunnel, the graft pulls away from the screw in the direct line of the tunnel. The initial fixation points were at a distance from the normal anatomi- cal fixation of the ACL. The trend has been to move the fixation closer to the internal aperture of the tunnel. This shortening of the intra- articular length has improved the stiffness of the graft. The pullout strength of bioabsorbable screw can vary widely depending on its composition.

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Quotations q Copyright permission is enclosed for lengthy quotations q Lengthy quotes are set apart from the main text of the page buy lady era master card breast cancer 8 cm, and indented from the left margin q Shorter quotations have been included within the body of the text generic lady era 100mg on-line breast cancer uptodate, and are enclosed by quotation marks effective lady era 100 mg menopause question. References q References cited in the text agree with those listed in your reference list 268 WRITING SKILLS IN PRACTICE q Reference list is presented in a format acceptable to the publisher 100 mg lady era with visa menstruation vs pregnancy. Illustrations q All tables, figures and artwork have been submitted in the agreed format q Each one has been numbered and labelled q Position has been indicated in the body of the main text q Written permission on copyright material is enclosed where necessary. 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. 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. 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.

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Whatever your situation buy 100mg lady era mastercard menopause knee joint pain, experience suggests that some form of consultation with others is very desirable discount lady era 100mg line menstruation girls. COURSE CONTENT Content is a broad concept meant to include all aspects of knowledge discount lady era online master card pregnancy yellow discharge, skills and attitudes relevant to the course and to the intellectual experiences of students and their teachers in a course purchase 100mg lady era mastercard pregnancy 26 weeks. While not always easy to achieve, we feel that course content should be made explicit and that this will then put you in a better position to make informed and coherent decisions in your planning. There are several different criteria for selecting content that may be more or less relevant to your work. Academic criteria These criteria focus attention on theoretical, methodologi- cal and value positions. For example: Content should be a means of enhancing the intellectual development of students, not an end in itself. Content that is solely concerned with technical matters has a limited place in university education; content must also involve moral and ethical considerations. Content should contribute to a deep rather than to a surface view of knowledge. Psychological criteria These criteria relate to the application of psychological principles – especially of learning theory – to teaching: Content should be carefully integrated to avoid fragmentation and consequential loss of opportunities for students to develop ‘deep’ approaches to learning (see Chapter 1). Content selection must provide opportunities to emphasise and to develop higher-level intellectual skills such as reasoning, problem-solving, critical thinking and creativity. Content should provide opportunities for the devel- opment of attitudes and values. Content should be selected to assist in the develop- ment of students as independent lifelong learners. Practical criteria These criteria concern the feasibility of teaching something and may relate to resource considerations: Content may be derived from one or two major texts because of a lack of suitable alternative materials. Content should be influenced by the availability of teaching resources: library materials, information- technology resources, people, patients, physical environment, etc. Student criteria These criteria relate to the characteristics of the students you teach. We consider these criteria to be so important that a full section is devoted to them. Student criteria may affect the choice of content (and ways of teaching and assessing) in a variety of ways: 92 Content may be selected to reflect the background, needs and interests of all students. Content should be matched to the intellectual and maturity level of students. How you actually go about selecting content will largely be determined by the kind of person you are (especially by your views about the relative importance of your role as a teacher, the role of students and course content), and the norms and practices in the discipline you teach. STUDENTS Taking account of student characteristics, needs, and interests is the most difficult part of course planning. The reason for this is that teachers now face increasingly heterogeneous groups of students and, at the same time, must take account of legislative requirements to address specific issues such as occupational health and equal opportunities. It is no longer enough to state that planners need to ‘take account of students’ and then to proceed as if they did not exist. Experience shows that students can provide invaluable assistance in course planning by consulting them formally and informally. Institutional responsibilities – which we would encourage you to influence positively – might include: tutorial assistance in the English language, especially for non-native speakers and international students; bridging courses and foundation courses to assist in the process of adjustment to higher education. In addition to accommodating the wide range of personalities, learning styles, social backgrounds, expectations and academic achievement of normal or direct-entry students from school you must also be prepared to teach students from other backgrounds and with ‘different’ characteristics than your own. Five examples of current concern which we will briefly discuss are: women, mature-age students, students with a disability, first-year students and international students. In medical schools in many countries woman are forming an increasingly high proportion of student intakes. However, as the proportion of women in senior clinical and academic positions remains a minority the propensity for bias remains.

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