2 research outputs found
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Evolving treatment landscape: 18 years of managing melanoma in a single patient.
A 57-year-old woman diagnosed with primary melanoma was managed with a wide variety of treatments over 18 years. Given her long history of disease, the array of therapies she has received range from those no longer recommended to those recently approved. This case highlights the extraordinary rate at which both the medical and surgical melanoma treatment landscape has evolved, alongside how professional consensus has changed over the past two decades. It also demonstrates the innovation and collaboration required between the patient and the multidisciplinary team, as well as how external factors such as national guidelines, eligibility for clinical trials and drug funding in the National Health Service (NHS) alter a management plan, presenting yet another set of challenges when managing cancer patients in the modern era
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Optimal location for fibular osteotomy to provide maximal compression to the tibia in the management of delayed union and hypertrophic non-union of the tibia.
BACKGROUND: Tibial shaft fractures are the commonest long bone fracture, with early weight-bearing improving the rate of bony union. However, an intact fibula can act as a strut that splints the tibial segments and holds them apart. A fibular osteotomy, in which a 2.5 cm length of fibula is removed, has been used to treat delayed and hypertrophic non-union by increasing axial tibial loading. However, there is no consensus on the optimal site for the partial fibulectomy. METHODS: Nine leg specimens were obtained from formalin-embalmed cadavers. Transverse mid-shaft tibial fractures were created using an oscillating saw. A rig was designed to compress the legs with an adjustable axial load and measure the force within the fracture site in order to ascertain load transmission through the tibia over a range of weights. After 2.5cm-long fibulectomies were performed at one of three levels on each specimen, load transmission through the tibia was re-assessed. A beam structure model of the intact leg was designed to explain the findings. RESULTS: With an intact fibula, mean tibial loading at 34 kg was 15.52 ± 3.26 kg, increasing to 17.42 ± 4.13 kg after fibular osteotomy. This increase was only significant where the osteotomy was performed proximal to or at the level of the tibial fracture. Modelling midshaft tibial loading using the Euler-Bernoulli beam theory showed that 80.5% of the original force was transmitted through the tibia with an intact fibula, rising to 81.1% after a distal fibulectomy, and 100% with a proximal fibulectomy. CONCLUSION: This study describes a novel method of measuring axial tibial forces. We demonstrated that a fibular osteotomy increases axial tibial loading regardless of location, with the greatest increase after proximal fibular osteotomy. A contributing factor for this can be explained by a simple beam model. We therefore recommend a proximal fibular osteotomy when it is performed in the treatment of delayed and non-union of tibial midshaft fractures