搜索结果：The Journal of head trauma rehabilitation

The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 11 Aspects of Current ManagementFree AccessCurrent concepts in the management of femoroacetabular impingementJ. R. Crawford, R. N. VillarJ. R. CrawfordOrthopaedic Specialist RegistrarCambridge Hip and Knee Unit, BUPA Cambridge Lea Hospital, Impington, Cambridge CB4 9EL, UK.Search for more papers by this author, R. N. VillarConsultant Orthopaedic SurgeonCambridge Hip and Knee Unit, BUPA Cambridge Lea Hospital, Impington, Cambridge CB4 9EL, UK.Search for more papers by this authorPublished Online:1 Nov 2005https://doi.org/10.1302/0301-620X.87B11.16821AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Secondary osteoarthritis of the hip occurs due to a known precipitating cause. In primary or idiopathic osteoarthritis the cause remains unknown although some studies1,2 have suggested that femoroacetabular impingement (FAI) may be responsible for the progression of degenerative changes in this group of patients. FAI is a distinct pathological entity and can be defined as the abutment between the proximal femur and the acetabular rim.3 It affects active, young adults and presents clinically with groin pain. FAI can occur either in patients with an abnormal morphology of the hip or in patients with a normal anatomical structure but who have an excessive range of hip movement.Mechanism of femoroacetabular impingementA widening of the femoral neck or a decreased offset at the anterolateral head-neck junction results in decreased joint clearance.4 This results in repetitive contact between the femoral neck and the acetabular rim which is responsible for a range of injuries including anterior hip pain, labral tears and damage to the acetabular articular cartilage.5 Several studies have shown that FAI can cause a progressive degenerative process and lead to early osteoarthritis of the hip.1,2,6,7There are two distinct types of FAI. The first type, ‘cam impingement’, is more common in young, athletic men. It is commonly due to a nonspherical portion of the femoral head abutting against the acetabular rim especially in flexion and internal rotation.1,8 This causes an outside-in abrasion of the acetabular cartilage which may result in its avulsion from the labrum and subchondral bone. Damage to the acetabular cartilage occurs in the anterosuperior area of the acetabulum and can lead to separation of cartilage from the labrum.9The second type of FAI, ‘pincer impingement’, is more common in middle-aged athletic women. It is due to the contact between the femoral head-neck junction and the acetabular rim. Repeated abutment leads to degeneration of the labrum resulting in intrasubstance ganglion formation, ossification of the acetabular rim and deepening of the acetabulum. The chondral damage is located more circumferentially and usually includes only a narrow strip of acetabular cartilage. Changes in the labrum occur at adjacent areas often present as ossification of the labrum.9Cam and pincer impingement rarely occur in isolation. In their study of 149 hips, Beck et al9 found that only 26 hips had an isolated cam and 16 hips had an isolated pincer impingement. They found that most cases of FAI involve a combination of these two mechanisms and are classified as having mixed campincer impingement.Histologically, FAI is characterised by a gentle chronic irritation of the labrum located at the site of rupture that elicits a degenerative reaction.10 In a study of 25 patients with symptomatic FAI, there was no difference in the histopathological features of the acetabular labrum between cam and pincer impingement.10AetiologySeveral predisposing conditions reduce the femoral head-neck offset resulting in cam impingement.1 These include slipped capital femoral epiphysis with posterior tilt of the femoral head,2,11 femoral head necrosis with subsequent flattening,12 previous fracture of the femoral neck with minor rotational mal-union13 or a femoral head with a nonspherical extension anterosuperiorly.14 Histological analysis of these resected nonspherical lesions suggests that this is the cause of the impingement rather than the result of repetitive trauma.15Pincer impingement may be due to acetabular retroversion where the anterolateral acetabular edge obstructs flexion16 or due to coxa profunda which increases the relative depth of the acetabulum.17Establishing a diagnosisFAI effects young and middle-aged active adults who typically present with groin pain and little or no history of precipitating trauma. The pain is usually exacerbated by activities and also by sitting for long periods. Clinical examination reveals some restriction of movement of the hip especially in flexion with adduction and internal rotation and a positive impingement test.18 Posteroinferior impingement can be detected by extending the patient’s legs over the end of the bed and rotating them externally which reproduces their symptoms.Plain radiographs of the hip may detect underlying bony abnormalities. The anteroposterior view may show a flattened head-neck junction or pistol-grip deformity of the proximal femur.19 Herniation pits are often present in the femoral neck.20,21 The lateral radiograph can also show a pistol-grip deformity with a resultant loss of the anterior femoral neck offset.5 There may be specific acetabular changes present such as an os acetabulare or ossification of the acetabular rim. More generalised changes detectable radiologically include hip dysplasia, coxa vara, coxa valga, protrusio acetabuli and coxa profunda.Magnetic resonance imaging (MRI) is now commonly used in the evaluation of hip pain in the young adult, particularly if plain radiographs are normal. One study has found reduced femoral neck anteversion and head-neck offset on MRI scans of hips in patients with symptomatic impingement.1 Magnetic resonance arthrography (MRA) is fast becoming the standard investigation for FAI. It is helpful in detecting nonsphericity of the femoral head, a decreased head-neck offset, herniation pits or rim ossification. MRA is also good at detecting labral tears and chondral damage but has poor specificity for detecting chondral separations that remain undetached.Non-operative treatmentAn initial trial of non-operative treatment for patients presenting with FAI is recommended by some authors.3 This may include modification of activity, avoiding excessive hip movement and regular non-steroidal anti-inflammatory medication. Usually, only temporary relief of symptoms is achieved and surgical intervention may subsequently be required.Operative treatmentThe aim of surgery is to improve the clearance for hip movement and to alleviate the abutment of the proximal femur against the acetabular rim.3 Both open17,22,23 and arthroscopic24 techniques have been described. For either technique it is important to address both the damage to the labrum and the underlying cause.9Open surgery for femoroacetabular impingementOperative technique.The open surgical approach is a well-recognised technique for the treatment of FAI.3,22 The patient is placed in the lateral position and either a lateral or a posterior approach can be used. A trochanteric osteotomy is usually performed to improve exposure. Care must be taken to protect the medial femoral circumflex artery which is the main blood supply to the femoral head. Specific sites of FAI may be identifiable before dislocation of the hip. Dislocation is necessary to provide a 360° view of both the femoral head and the acetabulum.If the femoral head-neck junction is the cause of FAI due to a nonspherical femoral head or a prominent anterior femoral neck then an excision osteoplasty can be performed. The aim is to recreate the normal concave contour of the femoral neck by sequential osteotomies of small sleeves of bone from the femoral head-neck junction.3 In one cadaver study, it has been shown that the total amount of bone resected should not exceed 30% of the antero-lateral quadrant of the head-neck junction due to the increased risk of a subsequent fracture.25Retroversion of the acetabulum describes a posteriorly-orientated acetabular opening with reference to the sagittal plane.16 It is a predisposition to the development of osteoarthritis.26 The prominent anterolateral rim of the acetabulum can affect hip flexion and internal rotation, causing impingement with subsequent anterior labral disruption and adjacent cartilage lesions.4 This can be treated by resection of the excessive anterior acetabular rim. Alternatively, some authors advocate performing a periacetabular osteotomy as an effective way to reorientate the acetabulum. In one study of 29 patients, 26 had a good or excellent result after this procedure.27If the acetabular articular cartilage remains intact but there is a lack of posterior cover, a reverse periacetabular osteotomy can be performed.3 If there is adequate posterior cover an excision osteoplasty may be preferred. Any labral tears should be treated with partial resection or repair as appropriate.Results of open surgeryOutcomes after open surgical procedures for the treatment of FAI have been encouraging. In a study of 19 patients undergoing open surgery with a mean follow-up of 4.7 years, 14 had a good outcome and there were no cases of osteonecrosis.17 In another study, 23 patients underwent open surgical debridement and were followed up for between two and 12 years.23 At their last follow-up seven patients had required total hip arthroplasty, one had a further arthroscopic debridement of a recurrent labral tear and 15 had no further surgery. No patients in this study developed osteonecrosis.Arthroscopic surgery for femoroacetabular impingementOperative technique.Arthroscopic assessment of the hip can include examination of both the central and peripheral compartments.28 The central compartment includes the labrum and all structures located further medially. The peripheral compartment consists of all the structures that are lateral to the labrum but are inside the capsule which includes the femoral head, the femoral neck with its synovial folds and the joint capsule itself.29 Arthroscopy of the peripheral compartment is increasingly undertaken and is certainly indicated when impingement from osteophytes is suspected.30Hip arthroscopy can be performed with the patient placed in the lateral or supine position31–33 with traction applied using a standard distractor and a perineal post. Image-intensifier screening is essential to ensure safe entry of the guide wire and trocars into the joint. Anterolateral and anterior portals are usually required and an additional posterolateral portal may be used if necessary. Characteristic findings include a tear of the labrum anterolaterally and damage to the acetabular cartilage anteriorly which can also extend from the mid-lateral to the posterior portions.24 The labral lesions and any areas of chondral damage are debrided until they are stable.34 Labral repair may be possible for specific tears although the long-term outcome is not yet known.35 For areas of exposed subchondral bone a microfracture technique36 may be performed.After completing arthroscopy of the central compartment, the traction is released and the peripheral compartment is entered with the arthroscope from the anterolateral portal (Fig. 1). A partial capsulectomy may be required to achieve a satisfactory exposure.24 Any osteophytes located around the femoral head-neck junction can be resected using a burr or a radiothermal device to restore the concavity of the femoral neck (Figs 2 and 3). The external portion of the labrum can also be visualised and rim osteophytes can be resected.Results of arthroscopic surgeryArthroscopy has helped to determine the role of FAI in the development of labral tears and to establish appropriate treatment.37 Favourable results have been reported for the treatment specifically of FAI.24 In a study of 158 patients who underwent arthroscopic surgery, most patients found that 50% of their pain had resolved by three months, 75% by five months and 95% by one year. These results are comparable with those reported for open procedures,17 although the patients recovered much earlier after arthroscopic surgery.Outcome and future developmentsFrom the limited number of studies performed addressing the treatment of FAI, surgery gives good results in patients with early degenerative changes of the hip. However, it is not as effective in patients with extensive articular damage or advanced osteoarthritis.Initial results of arthroscopic surgery for FAI are very favourable and allow a faster post-operative recovery. Early correction of FAI may improve hip pain but long-term studies are still required to determine whether such treatment prevents the progression of osteoarthritis of the hip.Fig. 1 Flouroscopic image showing the arthroscope in the peripheral compartment at the inferior aspect of the femoral neck.Fig. 2 Operative photograph showing an impingement lesion at the antero-superior aspect of the femoral neck (FH, femoral head; IL, impingement lesion; C, capsule).Fig. 3 Operative photograph showing resection of the impingement lesion using a burr (FH, femoral head; IL, impingement lesion; C, capsule).References1 Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect: a MRI based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg [Br] 2001;83-B:171–6. Link, Google Scholar2 Leunig M, Casillas MM, Hamlet M, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand 2000;71:370–5. Crossref, Medline, Google Scholar3 Lavigne M, Parvizi J, Beck M, et al. Anterior femoroacetabular impingement. Part I: techniques of joint preserving surgery. Clin Orthop 2004;418:61–6. Crossref, Google Scholar4 Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after peri-acetabular osteotomy. Clin Orthop 1999;363:93–9. Crossref, Google Scholar5 Tanzer M, Noiseux N. Osseus abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop 2004;429:170–7. Crossref, ISI, Google Scholar6 Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop 2003;417:112–20. Google Scholar7 Leunig M, Beck M, Woo A, et al. Acetabular rim degeneration: a constant finding in the aged hip. Clin Orthop 2004;413:201–7. Google Scholar8 Notzli HP, Wyss TF, Stoecklin CH, et al. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg [Br] 2002;84-B:556–60. Link, Google Scholar9 Beck M, Kahlhor M, Leunig M, Ganz R. Hip morphology influences the pattern of acetabular cartilage damage. J Bone Joint Surg [Br] 2005;87-B:1012–18. Link, Google Scholar10 Ito K, Leunig M, Ganz R. Histopathological features of the acetabular labrum in femoroacetabular impingement. Clin Orthop 2004;429:262–71. Crossref, ISI, Google Scholar11 Rab GT. The geometry of slipped capital femoral epiphysis: implications for movement, impingement and corrective osteotomy. J Pediatr Orthop 1999;19: 419–24. Crossref, Medline, ISI, Google Scholar12 Kloen P, Leunig M, Ganz R. Early lesions of the labrum and acetabular cartilage in osteonecrosis of the femoral head. J Bone Joint Surg [Br] 2002;84-B:66–9. Link, Google Scholar13 Eijer H, Myers SR, Ganz R. Anterior femoroacetabular impingement after femoral neck fractures. J Orthop Trauma 2001;15:475–81. Crossref, Medline, ISI, Google Scholar14 Siebenrock KA, Wahab KHA, Werlen S, et al. Abnormal extension of the femoral head epiphysis as a cause of cam impingement. Clin Orthop 2004;418: 54–60. Crossref, Google Scholar15 Wagner S, Hofstetter W, Chiquet M, et al. Early osteoarthritic changes of human femoral head cartilage subsequent to femoro-acetabular impingement. Osteoarthritis Cartilage 2003;11:508–18. Crossref, Medline, ISI, Google Scholar16 Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum: a cause of hip pain. J Bone Joint Surg [Br] 1999;81-B:281–8. Link, Google Scholar17 Beck M, Leunig M, Parvizi J, et al. Anterior femoroacetabular impingement. Part II: midterm results of surgical treatment. Clin Orthop 2004;418:67–73. Crossref, Google Scholar18 Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome: a clinical presentation of dysplasia of the hip. J Bone Joint Surg [Br] 1991;73-B:423–9. Link, Google Scholar19 Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop 1986;213:20–33. Google Scholar20 Nokes SR, Vogler JB, Spritzer CE, Martinez S, Herfkens RJ. Herniation pits of the femoral neck: appearance at MR imaging. Radiology 1989;172:231–4. Crossref, Medline, ISI, Google Scholar21 Pitt MJ, Graham AR, Shipman JH, Birkby W. Herniation pit of the femoral neck. AJR Am J Roentgenol 1982;138:1115–21. Crossref, Medline, ISI, Google Scholar22 Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg [Br] 2001;83-B:1119–24. Link, Google Scholar23 Murphy S, Tannast M, Kim Y, Buly R, Millis MD. Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clin Orthop 2004;429:178–81. Crossref, ISI, Google Scholar24 Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Techniques in Orthopaedics 2005;20:56–62. Crossref, Google Scholar25 Mardones RM, Gonzalez C, Chen Q, et al. Surgical treatment of femoroacetabular impingement: evaluation of the effect of size of the resection. J Bone Joint Surg [Am] 2005;87-A:273–9. Google Scholar26 Tonnis D, Hienecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg [Am] 1999;81-A:1747–70. Crossref, Google Scholar27 Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion: treatment with peracetabular osteotomy. J Bone Joint Surg [Am] 2003;85-A:278–86. Crossref, Medline, ISI, Google Scholar28 Dorfmann H, Boyer T. Arthroscopy of the hip: 12 years of experience. Arthroscopy 1999;15:67–72. Medline, ISI, Google Scholar29 Dienst M, Godde S, Seil R, Hammer D, Kohn D. Hip arthroscopy without traction: in vivo anatomy of the peripheral hip joint cavity. Arthroscopy 2001;17:924–31. Crossref, Medline, ISI, Google Scholar30 Ilizaliturri VM, Mangino G, Valero F, Camacho-Galindo J. Hip arthroscopy of the central and peripheral compartments by the lateral approach. Tech Orthop 2005;20:32–6. Crossref, Google Scholar31 Byrd JW. Hip arthroscopy: the supine position. Instr Course Lect 2003;52:721–30. Medline, Google Scholar32 Byrd JW. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275–80. Crossref, Medline, ISI, Google Scholar33 Byrd JW, Thomas MD. Hip arthroscopy, the supine approach: technique and anatomy of the intraarticular and peripheral compartments. Tech Orthop 2005;20:17–31. Crossref, Google Scholar34 Santori N, Villar RN. Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy 2000;16:11–15. Google Scholar35 Schenker ML, RobRoy M, Weiland D, Philippon MJ. Current trends in hip arthroscopy: a review of injury diagnosis, techniques, and outcome scoring. Curr Opinion Orthop 2005;16:89–94. Google Scholar36 surgical technique and to chondral Clin Orthop Crossref, ISI, Google The and treatment of labral and chondral Instr Course Lect Medline, Google a Hip of for Femoroacetabular and Acetabular Labral Clinical Journal of No. of around the hip and No. and of on and Hip Joint in Hip A of The of No. for Hip Arthroscopy for Femoroacetabular No. of findings of femoroacetabular impingement in a a Current Orthopaedic No. of a Hip for of an Acetabular Labral in a A Journal of and No. for Hip Arthroscopy in Femoroacetabular of a of the of Orthopaedic No. the for Hip A of the The Journal of No. in of and Clinical in of the of Orthopaedic No. of a hip on and pain in with femoroacetabular of and in No. and management of femoroacetabular impingement: A review of the and No. in the an of early hip A study in young of Orthopaedic and Trauma No. of around the Hip No. and Hip Arthroscopy for Femoroacetabular of Bone and Joint No. No. pincer femoroacetabular impingement. type is with more hip Orthopaedic No. and in with and without symptomatic femoroacetabular and of the and of the Hip and femoroacetabular of femoroacetabular impingement morphology in resonance imaging study with clinical of Hip in with on of Femoroacetabular of No. of on hip MRI in A clinical and imaging study of hip of and in No. to Hip in No. for Femoroacetabular and No. No. a a No. of femoroacetabular impingement: between clinical presentation and in symptomatic No. No. and for Arthroscopic Hip Acetabular outcome of arthroscopic treatment for femoroacetabular impingement. for a No. evaluation of bony impingement lesions after arthroscopic treatment for isolated femoroacetabular impingement using of Orthopaedic and Trauma No. the of for Femoroacetabular The Journal of Arthroscopic No. of impingement for hip osteoarthritis progression in a No. of arthroscopic for chondral of the hip: a of Orthopaedic and Trauma No. the of Surgical for Femoroacetabular The Journal of No. to The Journal of No. impingement: is Knee No. and of Acetabular No. Specific of the Hip of in of Femoroacetabular No. with femoroacetabular impingement occur with at all in a No. of the on a MR No. to in Hip Arthroscopy and The Journal of Arthroscopic No. of Osteoarthritis a Slipped of No. for Femoroacetabular A of the No. of the normal proximal human in of cam hip of the of Part Journal of in No. relationship between acetabular rim morphology and the of femoral cam D. J. The Bone Joint No. of the acetabular a of femoroacetabular British Journal of No. of for Femoroacetabular A between the and of the of No. in hip arthroscopy: surgical clinical No. of femoroacetabular impingement in undergoing total hip for Clinical No. Arthroscopic and of Femoroacetabular The Orthopaedic No. previous hip arthroscopy the clinical result of total hip of Orthopaedic and Trauma No. hip Current in No. to hip Part and and No. and Acetabular in Hip The Journal of No. a Anterior and Arthroscopic and No. Clinical No. concepts in the and management of femoroacetabular No. of Surgical Hip Dislocation and Hip Arthroscopy for of in Femoroacetabular The Journal of No. of Femoroacetabular Hip The Journal of No. for The Arthroscopic of Femoroacetabular on and The Journal of Arthroscopic No. conditions of the and No. dislocation of the hip and the management of femoroacetabular impingement: results of the Journal of No. of Orthopaedic No. examination of the between of femoroacetabular impingement in and the development of osteoarthritis of the N. The Journal of Bone and Joint Surgery. British No. Arthroscopy Surgical Hip The Journal of Arthroscopic No. femoral for cam femoroacetabular impingement in patients over years of J. The Journal of Bone and Joint Surgery. British No. impingement: a review of and Current in No. of the and Arthroscopic for Femoroacetabular The Journal of Arthroscopic No. of and in Hip Techniques in No. and in primary osteoarthritis of the hip with good and femoral of Orthopaedic and Trauma No. and of Hip of and in No. concepts in the management of hip pain in the young Journal of Clinical No. plain on radiographs in the assessment of femoroacetabular A. T. R. The Journal of Bone and Joint Surgery. British No. of Hip Arthroscopy in A of The Journal of Arthroscopic No. results after anterior approach for femoroacetabular impingement in early degenerative No. findings of femoroacetabular impingement syndrome: on No. and of the Hip and of hip arthroscopy for treatment of femoroacetabular impingement: a Orthopaedic No. of femoroacetabular impingement in patients with osteoarthritis of the No. impingement by an of the No. femoroacetabular No. the of in of No. of and in Osteoarthritis and for of No. FAI No. and of with Femoroacetabular before and after Arthroscopic The Journal of No. of Arthroscopic Femoroacetabular A Orthopaedics No. of FAI on Hip and Orthopaedics No. treatment of femoroacetabular Journal of No. with for an of the No. outcome of hip arthroscopy for femoroacetabular impingement J. R. N. The Journal of Bone and Joint Surgery. British No. of No. management of femoro-acetabular No. treatment of hip impingement by of the anterior inferior K. K. T. The Journal of Bone and Joint Surgery. British No. No. femoro-acetabular impingement. in young patients with hip No. in Femoroacetabular and Early Clinical The Journal of Arthroscopic No. anterior hip pain in young Current of No. of femoroacetabular impingement in slipped capital femoral epiphysis A R. W. The Journal of Bone and Joint Surgery. British No. Arthroscopy Surgical Hip Dislocation for Femoroacetabular The Journal of Arthroscopic No. dysplasia and the acetabular labrum A. R. N. The Journal of Bone and Joint Surgery. British No. for of the femoral head in cam K. The Journal of Bone and Joint Surgery. British No. arthroscopic management of femoroacetabular Knee No. treatment of femoroacetabular impingement to hip J. J. The Journal of Bone and Joint Surgery. British No. of arthroscopic acetabular labral debridement by femoral A W. The Journal of Bone and Joint Surgery. British No. of Femoroacetabular on of Hip Arthroscopy in with Early Orthopaedics in arthroscopic indications and Opinion in No. surgery of the hip R. N. The Journal of Bone and Joint Surgery. British No. in No. of of the hip in the young A. J. R. A. The Journal of Bone and Joint Surgery. British No. No. 1 87-B, No. 11 1 in 1 The British of Bone and Joint

If you are a brain injury professional who cannot read an article without knowing what the Glasgow Coma Scale (GCS) scores are for the sample studied, then this issue of the Journal of Head Trauma Rehabilitation may be a source of some consternation. The articles presented here all address methodologies employed to screen for traumatic brain injury (TBI) in various populations. Whether the purpose for identifying cases is to determine prevalence, focus additional services, or compare those with and without TBI, unfortunately, the existence, let alone availability, of a GCS score is a luxury that none of these authors enjoyed. Instead the reader will find that new, and previously untested, methodologies were employed as part of scientific approaches that may seem quite foreign. Why is this? The research literature on TBI is dominated by cohorts for which a diagnosis of TBI (or its absence) was determined at the time that medical attention was given. Whether samples are collected prospectively or retrospectively from a given point in the system of care (eg, emergency department admissions, patients treated in rehabilitation), the standard for description relies on indicators reflecting the extent of altered consciousness as observed by professionals who treated the acute injury (eg, first GCS in the emergency department, time to follow commands during acute hospitalization). Even studies from later in the process of treatment identify a sentinel occurrence of a TBI (eg, 6 months after severe TBI), and whenever possible report the altered consciousness observed at the time (eg, with 5 days of posttraumatic amnesia). Even the epidemiological data in our field are dominated by reports of incident cases, most commonly identified by the International Classification of Diseases, Ninth Revision (ICD-9) code given at the time of treatment. When the methodology shifts to identifying TBI in cohorts defined not by having been treated, but by some other criteria (eg, schoolchildren with behavioral problems, nursing home residents, prisoners, clients treated for substance abuse disorders, or soldiers returning from combat), then the ways of detecting and categorizing TBI to which we are so accustomed are no longer available. For many readers, the first reaction will be, “why not just collect information about past TBI's from previous medical records.” This is a logical approach and, if it were only impractical, someone would have done it. What is impractical, of course, is to attempt to find all of a person's prior treatments and then gain access to those medical records. Perhaps at some time in the future we will carry our medical records in a computer chip imbedded in our arm, but for now there is no way of determining a person's prior treatments without asking him or her to identify them. Putting aside the issue of self-report for the moment, the ability to actually obtain a lifetime's worth of medical records for injuries treated in physicians' offices, emergency departments, or hospitals is a daunting task without adding those injuries attended to only by a school nurse, athletic trainer, or emergency medical technician in the field. But obtaining all these medical records is only what makes the task impractical. What makes it impossible to use medical records to study a past history of TBI is the significant proportion of these injuries that receive no medical attention at all. Articles in this issue report that 61% of head injuries among prisoners were untreated1; similarly, 30% of TBIs experienced by persons with comorbid substance use disorders did not receive medical attention.2 A recent study reported that 42% of persons responding to a Web-based survey had experienced TBI without any medical attention.3 In other projects we have found 25% of adolescents in treatment for substance use disorders report prior TBI with loss of consciousness for which they received no medical attention of any kind; and 41% of TBIs reported by prisoners received no medical care (J.D.C. and J.A.B., written communication, September 2007). Quite clearly, if not treated there will not be a medical record to obtain. The second thought that often comes to mind when faced with the dilemma of identifying past TBI is to conduct testing. However, there is no biomarker for TBI. Techniques like computed tomography (CT) scans, magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), positron emission tomography (PET) scanning, or neuropsychological assessment can be used to detect acute TBI of sufficient severity, or chronic TBI of greater severity, but none of these techniques are sensitive to all TBI, especially not all TBI that may have occurred over a person's lifetime. The validity of our customary assessment techniques is due to their positive predictive value (an abnormal finding is highly likely to be an incident case) but not their negative predictive value (a normal finding means no TBI ever occurred). Very mild (transient confusion without loss of consciousness) or very old (a TBI experienced in childhood) injuries are the most likely to be missed. Further, despite exciting work being conducted using serology, we are still without a definitive biomarker of TBI. Thus, once again, to establish prevalence of TBI in a population (or eventually, the general population), or conduct research comparing those members of a cohort with and without TBI, requires approaches to case identification different from those used in research on incidence or studies of samples collected from treatment settings. As stated explicitly in 2 articles in this issue and implicit in others, the gold standard for determining prior TBI is self-report as determined by a structured or in-depth interview. While this statement may seem radical, it indeed reflects the standard of clinical care, if not research. When we look back before the sentinel TBI that has lead to a current episode of treatment, we use a clinical interview of patients or their proxies to determine if there was a prior history of TBI. Research reports often cite prior TBI as an exclusionary criterion; however, after editing this issue and conducting our own research on methods of eliciting prior history, we find these claims far more suspect than when we were naïve about the challenges of eliciting self-report. Indeed, not all self-report was created equal. One or 2 items in a self-administered scale or structured telephone survey will miss all but the most recent or most severe TBIs. In public health research, the tendency to forget past injuries is called telescoping.4,5 Diamond et al in this issue report that a 1-item, self-administered screener used during admission to prison detected only 19% of the TBIs identified via structured interview.1 Self-report also varies by the extent to which the respondent must self-diagnose whether the injury occurred. Whether “head injury” or “traumatic brain injury,” “lost consciousness” or “knocked out,” each of these terms requires a minimum amount of knowledge on the part of the respondent; and, quite likely, more than a minimum if we expect their response to correspond with our presumptions about their responses. There is no question that self-report leaves much to be desired; however, a face-to-face interview conducted by an informed professional is indeed the gold standard for determining lifetime history of TBI. The studies in the current volume represent a range of approaches to screening and identification of TBI. Karon et al6 and Gabella et al7 each tackled the difficult question of how to determine the prevalence of TBI among nursing home residents using the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set. While CMS estimated the nationwide prevalence of TBI among nursing home residents to be 0.8%,8 the studies in this volume estimate the prevalence to be closer to 2%.6,7 These articles carefully document the methodology used to arrive at what appears to be a more likely estimate of the rate among nursing home residents. Yet, both also express the strong likelihood that 2% is an underestimation of the lifetime prevalence in this population. The other 5 articles in this volume describe self-report procedures used to estimate prevalence of TBI in a variety of special populations. Walker et al9 and Corrigan and Bogner2 studied persons with substance use disorders. Walket et al's brief screener was incorporated into a statewide assessment system for all clients entering publicly funded services in Kentucky. Corrigan and Bogner used a sample of clients in treatment for both TBI and substance use disorders to test the reliability and predictive validity of their Ohio State University TBI Identification Method. Though the populations sampled are similar, the applications for which the screening instruments were designed would make each impractical in the context of the other's use. Dettmer et al10 describe a method used for identification of students in primary and secondary education who may require additional supports but have been overlooked because of brain injuries being invisible to the educator. They have the advantage of tapping both parent and educator observations; however, the significant challenges of identification are well described by these authors. Diamond et al1 describe the reliability and predictive validity of a screening instrument validated for use among prisoners; and Schwab11 describes the concurrent validity of a brief screener designed to identify soldiers needing further assessment following deployment in a theatre of war. While perusing the studies in this issue, the reader will encounter recurring themes about the challenges of screening and identifying TBI including the following: definitions of terms; whether data are extracted from records or self-report; whether self-report is self-administered or elicited by means of a structured interview; the inadequacy of medical records for determining prevalence of TBI; the challenge of untreated TBI; how to stimulate memory for remote injuries; how to link neurological symptoms to TBI versus other causes; the limits of self-report due to unawareness, poor recall, or stigma; and how to treat episodes of multiple mild TBI for which individual injuries cannot be distinguished by the respondent (eg, those arising from a career in boxing or protracted domestic violence). Almost all the authors faced these issues and made trade-offs in the way they were addressed. The reader is asked to judge the adequacy of decisions made. However, when taken as a whole, it appears to us that this issue of the Journal of Head Trauma Rehabilitation takes a giant leap in bringing scientific scrutiny to an endeavor that has previously been accepted for its face validity alone. As you read this issue, do not lose sight of the fact that many, many times each and every day, both clinicians and researchers attempt to determine an individual's lifetime history of TBI. This volume of the Journal of Head Trauma Rehabilitation sheds light on an issue we have taken for granted, with problems we have conveniently overlooked. Screening and identification of prior TBI has been a bit too much like making sausage—it is time to send the inspectors into the packing plant. John D. Corrigan, PhD Jennifer Bogner, PhD Issue Editors

The Journal of Bone and Joint Surgery. British volumeVol. 36-B, No. 3 Clinical Reviews and StudiesFree AccessAPPROACH TO THE HIPA Suggested Improvement on Kocher's MethodBryan McFarland, Geoffrey OsborneBryan McFarlandSearch for more papers by this author, Geoffrey OsborneSearch for more papers by this authorPublished Online:1 Aug 1954https://doi.org/10.1302/0301-620X.36B3.364AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byAnterolateral minimally invasive hip approach offered faster rehabilitation with lower complication rates compared to the minimally invasive posterior hip approach—a University clinic case control study of 120 cases2 January 2021 | Archives of Orthopaedic and Trauma Surgery, Vol. 142, No. 5The Idea of “Minimally Invasive Solution” Total Hip Arthroplasty: History and Perspective Behind the Modernization of Surgery Through the Watson-Jones Muscle Interval27 July 2022Lateraler transglutealer Zugang – Goldstandard oder aus der Mode gekommen?3 February 2021 | Orthopädie und Unfallchirurgie up2date, Vol. 16, No. 01Hip Arthroplasty18 December 2020Approaches for Total Hip Arthroplasty21 November 2021Supercapsular Percutaneously Assisted total hip arthroplasty versus lateral approach in Total Hip Replacement. A prospective comparative studyJournal of Orthopaedics, Vol. 21Surgical Approaches for Primary Total Hip Arthroplasty from Charnley to Now1 January 2020 | JBJS Reviews, Vol. 8, No. 1Muscle Damage in Different Approaches in Total Hip Arthroplasty According to Serum MarkersThe Open Orthopaedics Journal, Vol. 13, No. 1Anatomy and Physiology of the Pediatric Hip29 June 2019Surgical approaches for primary total hip replacementOrthopaedics and Trauma, Vol. 32, No. 1Nonunion of greater trochanter following total hip arthroplasty: Treated by an articulated hook plate and bone graftingIndian Journal of Orthopaedics, Vol. 51, No. 3Surgical approaches for total hip arthroplastyIndian Journal of Orthopaedics, Vol. 51, No. 4Abductor Muscle Function and Trochanteric Tenderness After Hemiarthroplasty for Femoral Neck FractureJournal of Orthopaedic Trauma, Vol. 30, No. 6Exposure of the Hip Joint12 March 2016Surgical approaches to the hip jointOrthopaedics and Trauma, Vol. 29, No. 6Revision total hip arthroplasty exposure considerations: Which way in?Seminars in Arthroplasty, Vol. 26, No. 3A Modified Anterolateral, Less Invasive Approach to the Hip: Surgical Technique and Preliminary Results of First 103 Cases29 November 2013Hip Dislocation and Femoral Head Fractures22 April 2014Exposure of the Hip - Trochanteric Osteotomy, Re-Attachment and Results22 April 2014Hip: Type of Prosthesis and Implantation TechniqueA modified direct lateral approach for neck-preserving total hip arthroplasty: tips and technical notes8 March 2013 | Journal of Orthopaedics and Traumatology, Vol. 14, No. 2Surgical Techniques and ApproachesPrimary total hip arthroplasty23 July 2013The Rottinger approach for total hip arthroplasty: technique and review of the literature9 August 2011 | Current Reviews in Musculoskeletal Medicine, Vol. 4, No. 3Repair of Gluteus Medius Muscle Avulsion following Transgluteal Hip Replacement6 June 2011 | HIP International, Vol. 21, No. 3Surgical approaches for total hip arthroplastyOrthopaedics and Trauma, Vol. 24, No. 6Late Repair of Abductor Avulsion After the Transgluteal Approach for Hip ArthroplastyThe Journal of Arthroplasty, Vol. 25, No. 3Hip Abductor Strengths After Total Hip Arthroplasty Via the Lateral and Posterolateral ApproachesThe Journal of Arthroplasty, Vol. 25, No. 1Two-stage revision arthroplasty of the hip for infection using an interim articulated Prostalac hip spacerA 10- TO 15-YEAR FOLLOW-UP STUDYG. S. Biring, T. Kostamo, D. S. Garbuz, B. A. Masri, C. P. Duncan1 November 2009 | The Journal of Bone and Joint Surgery. British volume, Vol. 91-B, No. 11Results of Surgical Repair of Abductor Avulsion After Primary Total Hip ArthroplastyThe Journal of Arthroplasty, Vol. 23, No. 5The safe distance for the superior gluteal nerve in direct lateral approach to the hip and its relation with the femoral length: a cadaver study9 October 2007 | Archives of Orthopaedic and Trauma Surgery, Vol. 128, No. 7Effects of the Lateral Approach on Blood Flow of the Gluteus Medius and Abductor Function in Total Hip ArthroplastyOrthopedics, Vol. 31, No. 6Objective functional assessment of total hip arthroplasty following two common surgical approaches: The posterior and direct lateral approaches10 September 2008 | Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, Vol. 222, No. 6Surgical Techniques and ApproachesDirect Lateral ExposureLong-term survival of a cemented titanium-aluminium-vanadium alloy straight-stem femoral componentS. Kovac, R. Trebse, I. Milosev, V. Pavlovcic, V. Pisot1 December 2006 | The Journal of Bone and Joint Surgery. British volume, Vol. 88-B, No. 12Anterior or Posterior: Does the Surgical Approach to the Hip Influence the Quality of the Femoral Cement Mantle?24 January 2018 | HIP International, Vol. 16, No. 2Poor results from the isoelastic total hip replacement8 July 2009 | Acta Orthopaedica, Vol. 76, No. 2Mini-incision Anterior Approach Does Not Increase Dislocation RateClinical Orthopaedics and Related Research, Vol. 426An Extensile Posterior Exposure for Primary and Revision Hip ArthroplastyVariations in the anterolateral approach to the hip24 January 2018 | HIP International, Vol. 13, No. 4Surgical Approach, Abductor Function, and Total Hip Arthroplasty DislocationClinical Orthopaedics and Related Research, Vol. 405Early dislocation after total hip arthroplastyThe Journal of Arthroplasty, Vol. 17, No. 8A Proximal Referencing System for the Charnley Low Friction Arthroplasty26 January 2018 | HIP International, Vol. 12, No. 3A Modified Direct Lateral Approach in Total Hip Arthroplasty4 December 2016 | Journal of Orthopaedic Surgery, Vol. 10, No. 1Instability in Primary Total Hip Arthroplasty With the Direct Lateral ApproachClinical Orthopaedics and Related Research, Vol. 393Intraoperative electromyography of the superior gluteal nerve during lateral approach to the hip for arthroplastyThe Journal of Arthroplasty, Vol. 15, No. 7The Direct Lateral and Vastus Slide ApproachThe Anterolateral Surgical ApproachConversion of Girdlestone Arthroplasty to Total Hip ReplacementA modified direct lateral approach in total hip arthroplasty A comprehensive reviewThe Journal of Arthroplasty, Vol. 13, No. 7Surgical Approaches in Revision Hip ReplacementJournal of the American Academy of Orthopaedic Surgeons, Vol. 6, No. 2Update on Nerve Palsy Associated With Total Hip ReplacementClinical Orthopaedics and Related Research, Vol. 344Anatomic basis of the transgluteal approach to the hip-joint by anterior hemimyotomy of the gluteus mediusSurgical and Radiologic Anatomy, Vol. 19, No. 2An anterolateral approach to the hip joint8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 68, No. 5Nerve injury after hip arthroplasty: 5/600 cases after uncemented hip replacement, anterolateral approach versus direct lateral approach8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 68, No. 6A new classification for heterotopic ossifications in total hip arthroplasty considering the surgical approachArchives of Orthopaedic and Trauma Surgery, Vol. 115, No. 6Muscular Activity and the Biomechanics of the Hip10 May 2019 | HIP International, Vol. 6, No. 3A modified direct lateral approach for primary and revision total hip arthroplastyThe Journal of Arthroplasty, Vol. 11, No. 3Significance of the Trendelenburg test in total hip arthroplastyThe Journal of Arthroplasty, Vol. 11, No. 2A clinical and radiographic study of the “safe area” using the direct lateral approach for total hip arthroplastyThe Journal of Arthroplasty, Vol. 9, No. 5The surgical anatomy of the superior gluteal nerve and anatomical radiologic bases of the direct lateral approach to the hipSurgical and Radiologic Anatomy, Vol. 16, No. 3Heterotopic ossification in total hip arthroplastyThe Journal of Arthroplasty, Vol. 9, No. 2Muscle strength following total hip arthroplastyThe Journal of Arthroplasty, Vol. 8, No. 6The transgluteal approaches to the hipArchives of Orthopaedic and Trauma Surgery, Vol. 111, No. 4Exposure of the hip using a modified anterolateral approachThe Journal of Arthroplasty, Vol. 6, No. 2Integrity of the gluteus medius after the transgluteal approach in total hip arthroplastyThe Journal of Arthroplasty, Vol. 5, No. 1Clinical experience with a triradiate exposure of the hip for difficult total hip arthroplastyThe Journal of Arthroplasty, Vol. 3, No. 3Comparison of functional outcome of total hip arthroplasties involving four surgical approachesThe Journal of Arthroplasty, Vol. 3, No. 3Anatomic basis of the transgluteal approach to the hipSurgical and Radiologic Anatomy, Vol. 9, No. 1The Direct Lateral Approach to the Hip for Arthroplasty: Advantages and ComplicationsOrthopedics, Vol. 10, No. 2The history of surgical access for hip replacementCurrent Orthopaedics, Vol. 1, No. 1Trans-gluteal approach for hemiarthroplasty of the hipArchives of Orthopaedic and Traumatic Surgery, Vol. 104, No. 2Surgical Approaches to the HipLong-Term Results of Rotator Cuff RepairThe Transgluteal Approach to the Hip JointArchives of Orthopaedic and Traumatic Surgery, Vol. 95, No. 1-2The transacromial approach to the shoulder for ruptures of the rotator cuffInternational Orthopaedics, Vol. 1, No. 2Para-Articular Ossification Following Hip Replacement: 70 Arthroplasties AD Modum Moore Using McFarland's Approach8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 48, No. 4The Surgical Approach for Total Hip ReplacementSurgical Clinics of North America, Vol. 53, No. 2Surgical ApproachesAn Exposition of Uncertain Reasoning Based AnalysisLate Complications of the Use of Endoprosthetic Devices in Surgery of the Hip JointSurgical Clinics of North America, Vol. 41, No. 6INVETERATE DISLOCATION OF THE HIPThe Lancet, Vol. 277, No. 7177Erfahrungen mit Kunstharz- und Cupplastiken am H�ftgelenkArchiv f�r Orthop�dische und Unfall-Chirurgie, Vol. 50, No. 5 Vol. 36-B, No. 3 Metrics History Published online 1 August 1954 Published in print 1 August 1954 InformationCopyright © 1954, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

THE National Academy of Sciences (NAS) was created by Congress and President Abraham Lincoln in 1863 to ensure that government decisions were informed by the best possible scientific evidence, and its scope was subsequently expanded by presidents Wilson, Eisenhower, and G.H.W. Bush. In 1970, the Institute of Medicine (IOM) was created as a component of NAS to provide scientific insight in matters of biomedical science, medicine, and health. Like the rest of NAS, IOM brings together committees of experts who serve pro bono to address important national issues: The Institute provides a vital service by working outside the framework of government to ensure scientifically informed analysis and independent guidance.... The Institute provides unbiased, evidence-based, and authoritative information and advice concerning health and science policy to policymakers, professionals, leaders in every sector of society, and the public at large. (www.iom.edu. Accessed June 1, 2009) In 2008, IOM published 47 separate reports, on subjects ranging from the state of health indicators in the United States to global climate change and extreme weather events to intermittent preventive therapy for malaria in infants. In 1998, in response to the growing concerns of the ill Gulf War veterans, Congress passed the Persian Gulf War Veterans Act and the Veterans Programs Enhancement Act. These laws directed the Veterans Administration to enter into a contract with NAS to review and evaluate the scientific and medical literature regarding associations between illness and exposure to toxic agents, environmental or wartime hazards, and preventive medicines or vaccines associated with Gulf War service, and to consider the NAS conclusions when deciding about the compensation. Responsibility for implementation was assigned to the IOM, and to date 7 volumes have been published on the basis of the work of IOM committees.1–7 The most recent was in response to a Veterans Administration's request inquiring whether traumatic brain injury (TBI) has long-term health effects.7 This topical issue of the Journal of Head Trauma Rehabilitation (JHTR) is an outgrowth of that work. The charge to the IOM's Committee on Gulf War and Health: Brain Injury in Veterans and Long-Term Health Outcomes was to examine the strength of the evidence of an association between TBI and potential long-term health effects. To implement its charge, the committee conducted a review of the scientific literature, including all relevant studies of human TBI in any population (civilian or military) caused by any mechanism (eg, motor vehicle crashes and falls). The committee sought to answer whether sustaining a TBI is associated with a specific health outcome. The full report of the committee's findings was published by the National Academies Press in 2009: Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury.7 The current JHTR topical issue—Long-Term Consequences of Traumatic Brain Injury—includes the results of the IOM committee's systematic reviews addressing cognitive,8 neurological,9 psychiatric,10 social,11 and other medical consequences12 of TBI. An introductory article13 describes the search process and criteria used to identify primary and secondary research studies that served as the basis for the committee's determination of whether an association exists between the types and severity of TBI and the conditions studied. Tabular summaries of the primary studies are available as Supplemental Digital Content. Given the committee's findings have been reported, why is JHTR publishing this issue? It was our hope to accomplish 2 goals: (1) bring this important body of work into the knowledge base of researchers and clinicians in the field of brain injury rehabilitation and (2) provide those scientists who constituted the committee with the opportunity to discuss the implications of the findings for the rehabilitation of persons with TBI. We leave it to the readers to determine our success in attaining our goals; however, several “higher order” observations are apropos. Most rehabilitation professionals would not be surprised by the conclusions that moderate to severe TBI is associated with later seizures, cognitive deficits, depression, aggression, unemployment, or social isolation. However, this systematic review of the literature also indicated that premature death, progressive dementia, Parkinson's disease, and endocrine dysfunction, particularly hypopituitarism, are also associated with TBI, particularly moderate to severe TBI. These conditions depart from the commonly cited long-term cognitive, behavioral, and social problems and suggest a chronic health condition that has a more physiological impact on the organism. These results lend support to the contention that TBI may not only be a long-term psychosocial problem but a chronic health condition as well. More important, this list may suggest potential new avenues for disease-management approaches to limit long-term consequences. Another higher-order issue deserving comment is the relationship between type or severity of TBI and observed associations. Two of the 3 conclusions made with the highest level of certainty-–definitive evidence of a causal relationship-–were consequences of penetrating TBI. It was concluded that both unprovoked seizures and premature mortality are caused by penetrating TBI. Decline in cognitive functions associated with the region and volume of tissue loss and long-term unemployment were almost equally certain to be a consequence of penetrating injuries. Clearly, there are significant consequences to be expected for persons who survive these injuries. For nonpenetrating TBI, the degree of certainty regarding an association was very much a function of severity. With 3 notable exceptions, most conclusions for which sufficient evidence of an association was present were limited to moderate or severe, but not mild, TBI. For cognitive deficits, only severe TBI was listed as having sufficient evidence; however, the committee observed that inconsistencies in the definition of moderate TBI were largely to blame for the weak evidence. The 3 exceptions were depression, aggressive behaviors, and postconcussive symptoms-–for each, sufficient evidence was found to conclude that an association exists between any TBI (ie, mild, moderate, severe, or penetrating) and these conditions. In addition to the above 3 long-term health consequences definitely associated with mild TBI, there was suggestive evidence for associations between mild TBI with loss of consciousness and unprovoked seizures, ocular or visuomotor deterioration, progressive dementia, parkinsonism, and post-traumatic stress disorder (the last was limited to Gulf War military populations). These results could be cited by proponents on both sides of the recent controversy about whether mild TBI is a condition distinct from moderate and severe TBI.14 Finding different levels of certainty should not be mistaken for evidence of different conditions. The nature, extent, and sensitivity of the available research can also be the source of this discrepancy. Indeed, the committee did not find sufficient evidence to conclude that there was no association between TBI and any of the examined health conditions. On the other side of the controversy, either definite or suggestive evidence of an association between mild TBI, particularly that involving loss of consciousness, was observed for a number of health consequences. First, it seems very plausible that severity is not the only mediating factor between nonpenetrating TBI and long-term health consequences. To the extent severity does mediate long-term consequences, it seems more intuitive that it has a gradient influence rather than there being a distinct cut-point below which long-term consequences are less likely and above which they are more likely. However, if there is such a cut-point, it also seems likely that we will need an indicator that is more sensitive than behavioral observations of obtunded arousal (ie, Glasgow Coma Scale, length of posttraumatic amnesia, or length of loss of consciousness) to measure it. Interested parties on both sides of the mild and/or moderate/severe controversy should be cheering for a definitive breakthrough in research on biomarkers of TBI. We hope the readers find this topical issue interesting and informative. While the approach to systematic review used by the IOM is somewhat different than the now-familiar Cochrane Collaboration's approach, there is no less rigor that goes into the conclusions drawn. And, indeed, the IOM process is quite explicit about the criteria used to reach conclusions about presence of a causal relationship or strength of association (see Ishibe et al13 in this issue.) While some conclusions that resulted are “old news,” the IOM process has placed some new issues on the table for long-term management of the consequences of TBI. George W. Rutherford, MD Institute for Global Health, University of California, San Francisco, Issue Editor John D. Corrigan, PhD, ABPP Editor-in-Chief, Journal of Head Trauma Rehabilitation

Prediction models are developed to aid health care providers in estimating the probability or risk that a specific disease or condition is present (diagnostic models) or that a specific event will occur in the future (prognostic models), to inform their decision making. However, the overwhelming evidence shows that the quality of reporting of prediction model studies is poor. Only with full and clear reporting of information on all aspects of a prediction model can risk of bias and potential usefulness of prediction models be adequately assessed. The Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) Initiative developed a set of recommendations for the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. This article describes how the TRIPOD Statement was developed. An extensive list of items based on a review of the literature was created, which was reduced after a Web based survey and revised during a three day meeting in June 2011 with methodologists, health care professionals, and journal editors. The list was refined during several meetings of the steering group and in e-mail discussions with the wider group of TRIPOD contributors. The resulting TRIPOD Statement is a checklist of 22 items, deemed essential for transparent reporting of a prediction model study. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. The TRIPOD Statement is best used in conjunction with the TRIPOD explanation and elaboration document. To aid the editorial process and readers of prediction model studies, it is recommended that authors include a completed checklist in their submission (also available at www.tripod-statement.org). To encourage dissemination of the TRIPOD Statement, this article is freely accessible on the <i>Annals of Internal Medicine</i> Web site (www.annals.org) and will be also published in <i>BJOG</i>, <i>British Journal of Cancer</i>, <i>British Journal of Surgery</i>, <i>BMC Medicine</i>, <i>The BMJ</i>, <i>Circulation</i>, <i>Diabetic Medicine</i>, <i>European Journal of Clinical Investigation</i>, <i>European Urology</i>, and <i>Journal of Clinical Epidemiology</i>. The authors jointly hold the copyright of this article. An accompanying explanation and elaboration article is freely available only on www.annals.org; <i>Annals of Internal Medicine</i> holds copyright for that article.

TRAUMATIC BRAIN INJURY can often be associated with long-lasting symptoms and effects on function in a wide variety of areas. Expertise in the assessment and management of chronic physical, cognitive, and behavioral complaints is limited in many geographic areas, especially in rural America. Even in urban and suburban areas, the ability to fund treatment and education may be limited over the long course of recovery from and living with a chronic disorder. However, alternatives to face-to-face visits and therapy may be found through the blossoming of communication technologies. Few are without access to good reliable telephone services these days and, increasingly, Internet access is available through cable and wireless services. Audio and visual contact is possible with individuals and groups through various means. Facebook, Wikis, and Twitter, all new and innovative means of communication, are potentially available to extend the reach of the healthcare provider. Reaching out electronically to provide treatment and education to patients and caregivers is the focus of this issue of The Journal of Head Trauma Rehabilitation. Dr Bombardier and colleagues report on the results of a telephone-based counseling intervention aimed at educating and improving problem-solving skills of persons with moderate to severe traumatic brain injury with a range of depressive symptoms. Dr Wade and her group present their findings on using Web-based education and therapy to improve outcomes among children, adolescents, and their families. Finally, focusing on caregiver support and education, Dr Sander and her fellow investigators describe the use of videoconferencing technology to provide access to those living at a distance from the brain injury rehabilitation site. Many pilot research and clinical uses of Web-based communication technology can be found, particularly in the military (eg, www.afterdeployment.org) and veterans healthcare worlds. Little is currently known about how and who accesses these resources, how effective they are in terms of education and outcome, or how these electronic resources compare with more traditional avenues of education and treatment. Experience gained in other fields of healthcare will need to be evaluated in light of the special cognitive challenges our patients bring to the process, for both education and therapy. Definitions and measures of “dosing” for interventions delivered by telecommunication methods will require further explication. With respect to currently available funding, only face-to-face education and treatment are generally covered by insurers and healthcare intermediaries, funded by government. As these techniques are researched and further developed, the means of financing electronically mediated interventions will need to be resolved. We could not present these papers without stretching our own avenues of education and dissemination as well. We will be presenting a Webinar on this JHTR Telerehabilitation issue at 3 PM ET on August 6, 2009. Registration for the Webinar, part of the Mitch Rosenthal Memorial Lecture series, will be available in the bookstore of the Brain Injury Association of America in early July. The path is www.biausa.org. Click on Bookstore, and then click on Strauss and Rosenthal Lecture Series to register. More information can be obtained by contacting Marianna Abashian at [email protected]. Kathleen R. Bell, MD Associate Professor, Rehabilitation Medicine, University of Washington, Seattle (Bell) Tessa Hart, PhD Institute Scientist, Moss Rehabilitation Research Institute, Research Associate Professor, Jefferson Medical College, Philadelphia, Pennsylvania (Hart)

Using the Scopus dataset (1996-2007) a grand matrix of aggregated journal-journal citations was constructed. This matrix can be compared in terms of the network structures with the matrix contained in the Journal Citation Reports (JCR) of the Institute of Scientific Information (ISI). Since the Scopus database contains a larger number of journals and covers also the humanities, one would expect richer maps. However, the matrix is in this case sparser than in the case of the ISI data. This is due to (i) the larger number of journals covered by Scopus and (ii) the historical record of citations older than ten years contained in the ISI database. When the data is highly structured, as in the case of large journals, the maps are comparable, although one may have to vary a threshold (because of the differences in densities). In the case of interdisciplinary journals and journals in the social sciences and humanities, the new database does not add a lot to what is possible with the ISI databases.

Using "Analyze Results" at the Web of Science, one can directly generate overlays onto global journal maps of science. The maps are based on the 10,000+ journals contained in the Journal Citation Reports (JCR) of the Science and Social Science Citation Indices (2011). The disciplinary diversity of the retrieval is measured in terms of Rao-Stirling's "quadratic entropy." Since this indicator of interdisciplinarity is normalized between zero and one, the interdisciplinarity can be compared among document sets and across years, cited or citing. The colors used for the overlays are based on Blondel et al.'s (2008) community-finding algorithms operating on the relations journals included in JCRs. The results can be exported from VOSViewer with different options such as proportional labels, heat maps, or cluster density maps. The maps can also be web-started and/or animated (e.g., using PowerPoint). The "citing" dimension of the aggregated journal-journal citation matrix was found to provide a more comprehensive description than the matrix based on the cited archive. The relations between local and global maps and their different functions in studying the sciences in terms of journal lit

We compare the network of aggregated journal-journal citation relations provided by the Journal Citation Reports (JCR) 2012 of the Science and Social Science Citation Indexes (SCI and SSCI) with similar data based on Scopus 2012. First, global maps were developed for the two sets separately; sets of documents can then be compared using overlays to both maps. Using fuzzy-string matching and ISSN numbers, we were able to match 10,524 journal names between the two sets; that is, 96.4% of the 10,936 journals contained in JCR or 51.2% of the 20,554 journals covered by Scopus. Network analysis was then pursued on the set of journals shared between the two databases and the two sets of unique journals. Citations among the shared journals are more comprehensively covered in JCR than Scopus, so the network in JCR is denser and more connected than in Scopus. The ranking of shared journals in terms of indegree (that is, numbers of citing journals) or total citations is similar in both databases overall (Spearman's \r{ho} &gt; 0.97), but some individual journals rank very differently. Journals that are unique to Scopus seem to be less important--they are citing shared journals rather than bein

The diagnosis of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT) is fraught with controversy due to critical statistical deficiencies in the data underpinning these diagnoses. This paper examines the reliability and scientific foundation of SBS/AHT through a statistical lens, highlighting the lack of independently verified ground truth, contextual biases, data circularity, and diagnostic heterogeneity. These issues render current methodologies inadequate and complicate evaluations of diagnostic accuracy, particularly when legal determinations are integrated into medical assessments. Without empirical evidence validating the specificity of symptoms like subdural hematoma, retinal hemorrhage, and brain swelling, the diagnosis remains untested and its foundational validity unproven. We recommend that physicians focus on reporting observed clinical signs and avoid making determinations of abuse, which should remain within the legal domain. Addressing these challenges requires comprehensive, high-quality data collection encompassing contextual, medical, and legal information to evaluate the accuracy, repeatability, and reproducibility of SBS/AHT diagnoses. These efforts are essential

An exploratory, descriptive analysis is presented of the national orientation of scientific, scholarly journals as reflected in the affiliations of publishing or citing authors. It calculates for journals covered in Scopus an Index of National Orientation (INO), and analyses the distribution of INO values across disciplines and countries, and the correlation between INO values and journal impact factors. The study did not find solid evidence that journal impact factors are good measures of journal internationality in terms of the geographical distribution of publishing or citing authors, as the relationship between a journal's national orientation and its citation impact is found to be inverse U-shaped. In addition, journals publishing in English are not necessarily internationally oriented in terms of the affiliations of publishing or citing authors; in social sciences and humanities also USA has their nationally oriented literatures. The paper examines the extent to which nationally oriented journals entering Scopus in earlier years, have become in recent years more international. It is found that in the study set about 40 per cent of such journals does reveal traces of internati

Using three years of the Journal Citation Reports (2011, 2012, and 2013), indicators of transitions in 2012 (between 2011 and 2013) are studied using methodologies based on entropy statistics. Changes can be indicated at the level of journals using the margin totals of entropy production along the row or column vectors, but also at the level of links among journals by importing the transition matrices into network analysis and visualization programs (and using community-finding algorithms). Seventy-four journals are flagged in terms of discontinuous changes in their citations; but 3,114 journals are involved in "hot" links. Most of these links are embedded in a main component; 78 clusters (containing 172 journals) are flagged as potential "hot spots" emerging at the network level. An additional finding is that PLoS ONE introduced a new communication dynamics into the database. The limitations of the methodology are elaborated using an example. The results of the study indicate where developments in the citation dynamics can be considered as significantly unexpected. This can be used as heuristic information; but what a "hot spot" in terms of the entropy statistics of aggregated cit

Some transformer attention heads appear to function as membership testers, dedicating themselves to answering the question "has this token appeared before in the context?" We identify these heads across four language models (GPT-2 small, medium, and large; Pythia-160M) and show that they form a spectrum of membership-testing strategies. Two heads (L0H1 and L0H5 in GPT-2 small) function as high-precision membership filters with false positive rates of 0-4\% even at 180 unique context tokens -- well above the $d_\text{head} = 64$ bit capacity of a classical Bloom filter. A third head (L1H11) shows the classic Bloom filter capacity curve: its false positive rate follows the theoretical formula $p \approx (1 - e^{-kn/m})^k$ with $R^2 = 1.0$ and fitted capacity $m \approx 5$ bits, saturating by $n \approx 20$ unique tokens. A fourth head initially identified as a Bloom filter (L3H0) was reclassified as a general prefix-attention head after confound controls revealed its apparent capacity curve was a sequence-length artifact. Together, the three genuine membership-testing heads form a multi-resolution system concentrated in early layers (0-1), taxonomically distinct from induction and pr

One of the most frequent and severe aftermaths of a stroke is the loss of upper limb functionality. Therapy started in the sub-acute phase proved more effective, mainly when the patient participates actively. Recently, a novel set of rehabilitation and support robotic devices, known as supernumerary robotic limbs, have been introduced. This work investigates how a surface electromyography (sEMG) based control strategy would improve their usability in rehabilitation, limited so far by input interfaces requiring to subjects some level of residual mobility. After briefly introducing the phenomena hindering post-stroke sEMG and its use to control robotic hands, we describe a framework to acquire and interpret muscle signals of the forearm extensors. We applied it to drive a supernumerary robotic limb, the SoftHand-X, to provide Task-Specific Training (TST) in patients with sub-acute stroke. We propose and describe two algorithms to control the opening and closing of the robotic hand, with different levels of user agency and therapist control. We experimentally tested the feasibility of the proposed approach on four patients, followed by a therapist, to check their ability to operate th

Io is the most volcanically active body in the Solar System. This volcanic activity results in the ejection of material into Io's atmosphere, which may then escape from the atmosphere to form various structures in the jovian magnetosphere, including the plasma torus and clouds of neutral particles. The physical processes involved in the escape of particles - for example, how the volcanoes of Io provide material to the plasma torus - are not yet fully understood. In particular, it is not clear to what extent the sodium jet, one of the sodium neutral clouds related to Io, is a proxy of processes that populate the various reservoirs of plasma in Jupiter's magnetosphere. Here, we report on observations carried out over 17 nights in 2014-2015, 30 nights in 2021, and 23 nights in 2022-2023 with the TRAPPIST telescopes, in which particular attention was paid to the sodium jet and the quantification of their physical properties (length, brightness). It was found that these properties can vary greatly from one jet to another and independently of the position of Io in its orbit. No clear link was found between the presence of jets and global brightening of the plasma torus and extended sodiu

Patients with neurological conditions require rehabilitation to restore their motor, visual, and cognitive abilities. To meet the shortage of therapists and reduce their workload, a robotic rehabilitation platform involving the clinical trail making test is proposed. Therapists can create custom trails for each patient and the patient can trace the trails using a robotic device. The platform can track the performance of the patient and use these data to provide dynamic assistance through the robot to the patient interface. Therefore, the proposed platform not only functions as an evaluation platform, but also trains the patient in recovery. The developed platform has been validated at a rehabilitation center, with therapists and patients operating the device. It was found that patients performed poorly while using the platform compared to healthy subjects and that the assistance provided also improved performance amongst patients. Statistical analysis demonstrated that the speed of the patients was significantly enhanced with the robotic assistance. Further, neural networks are trained to classify between patients and healthy subjects and to forecast their movements using the data

BACKGROUND: Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest. METHODS: The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility. RESULTS: The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events. CONCLUSIONS: Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.

Rankings of scholarly journals based on citation data are often met with skepticism by the scientific community. Part of the skepticism is due to disparity between the common perception of journals' prestige and their ranking based on citation counts. A more serious concern is the inappropriate use of journal rankings to evaluate the scientific influence of authors. This paper focuses on analysis of the table of cross-citations among a selection of Statistics journals. Data are collected from the Web of Science database published by Thomson Reuters. Our results suggest that modelling the exchange of citations between journals is useful to highlight the most prestigious journals, but also that journal citation data are characterized by considerable heterogeneity, which needs to be properly summarized. Inferential conclusions require care in order to avoid potential over-interpretation of insignificant differences between journal ratings. Comparison with published ratings of institutions from the UK's Research Assessment Exercise shows strong correlation at aggregate level between assessed research quality and journal citation `export scores' within the discipline of Statistics.

A number of journal classification systems have been developed in bibliometrics since the launch of the Citation Indices by the Institute of Scientific Information (ISI) in the 1960s. These systems are used to normalize citation counts with respect to field-specific citation patterns. The best known system is the so-called "Web-of-Science Subject Categories" (WCs). In other systems papers are classified by algorithmic solutions. Using the Journal Citation Reports 2014 of the Science Citation Index and the Social Science Citation Index (n of journals = 11,149), we examine options for developing a new system based on journal classifications into subject categories using aggregated journal-journal citation data. Combining routines in VOSviewer and Pajek, a tree-like classification is developed. At each level one can generate a map of science for all the journals subsumed under a category. Nine major fields are distinguished at the top level. Further decomposition of the social sciences is pursued for the sake of example with a focus on journals in information science (LIS) and science studies (STS). The new classification system improves on alternative options by avoiding the problem