Norman Otsuka - Academia.edu (original) (raw)
Papers by Norman Otsuka
Orthopedics, 2001
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Journal of surgical orthopaedic advances, 2021
Physical examination education begins early for medical learners. A hindrance to physical exam co... more Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confidence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accuratel...
Bulletin of the Hospital for Joint Disease, 2019
BACKGROUND Supracondylar humerus fractures account for two thirds of all hospitalizations for elb... more BACKGROUND Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthop...
Orthopedics, 2001
The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffn... more The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffness of trabecular bone in intact canine femoral head specimens was investigated. Twenty-four skeletally mature dogs were divided into two groups. Twelve paired fresh femora were tested and 12 paired femora were tested after freezing at -20° C. The intact femoral head specimens were subjected to a load of physiologic magnitude, and then the stiffness of the underlying trabecular bone was determined in intact femora, in drilled femora with a disrupted intraosseous fluid compartment, and subsequently after refilling the compartment with fluid. Drilling of the femoral head and disrupting its bony fluid compartment resulted in a 40% decrease in stiffness (P<.001). This effect was seen only with fresh specimens and not frozen specimens. Refilling the bony compartment with fluid restored the stiffness of the fresh femoral head. These results demonstrate the mechanical properties of trabecula...
Orthopedics, 1999
The charts of 21 patients (22 knees) with significant radiographic changes of the patella after t... more The charts of 21 patients (22 knees) with significant radiographic changes of the patella after total knee arthroplasty were reviewed. The average patient age was 73 years, and average follow-up after arthroplasty was 7.3 years. Lateral release, fat pad excision, quadriceps tendon release, and previous surgery were implicated in the etiology of fracture of the patella. Five cases had type 1 pattern (sclerosis, fragmentation, and no fracture), 5 cases had type 2 pattern (undisplaced fracture and fragmentation), and 12 cases had type 3 pattern (displaced fracture and fragmentation). Type 1 and 2 patterns required no surgical treatment and were rated good to excellent according to the Hospital for Special Surgery Disability Score Sheet. Patients with a type 3 pattern who did not undergo surgery were rated poor to fair, while patients with a type 3 pattern who underwent surgical treatment (patellectomy, removal of the patellar component, or excision arthroplasty for infection) were rated good. Patellectomy is the treatment of choice for patients with displaced fractures of the patella. A classification system for the pattern of patellar changes is proposed.
Journal of Pediatric Orthopaedics, 2018
Purpose: The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatri... more Purpose: The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. Methods: A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the product...
Pediatrics In Review, 2018
Practice Gaps 1. The differential diagnosis for a limping child or adolescent with hip or knee pa... more Practice Gaps 1. The differential diagnosis for a limping child or adolescent with hip or knee pain is broad. Delayed or missed diagnoses of slipped capital femoral epiphysis and Legg-Calvé-Perthes disease have significant morbidity. Clinicians should understand when to suspect these disorders based on history, examination, and early imaging findings to allow for timely referral to a specialist. 2. Clinicians should also have a basic understanding of the treatment options and prognosis of these disorders to counsel patients and their families before and during treatment by a specialist. Objectives After completing this article, readers should be able to: 1. Identify the general anatomy relevant to slipped capital femoral epiphysis (SCFE) and Legg-Calvé-Perthes disease (LCPD) pathology. 2. Recognize the symptoms and physical examination findings of SCFE and LCPD. 3. Know the basic laboratory values and imaging to order to evaluate for SCFE and LCPD when referring to a specialist. 4. Differentiate straightforward presentations of SCFE and LCPD. 5. Understand broad treatment categories and the prognoses of SCFE and LCPD. 6. Realize the importance of timely referral to a specialist for SCFE and LCPD.
Foot & Ankle International, 2000
Neglected congenital clubfoot in adults has been described in literature, but is not common to se... more Neglected congenital clubfoot in adults has been described in literature, but is not common to see adult patients with this orthopaedic disorder in developed countries with 30 years of follow-up. We report an asymptomatic case of neglected congenital clubfoot in an adult, who is incidentally seeking treatment for her 18-month-old son with congenital clubfoot. Although the cosmetic appearance is unacceptable, this mother remarkably has no functional limitations and for this reason she refuses any surgical treatment for her foot. To our knowledge, this is the first report of an untreated congenital clubfoot with 30 years follow-up.
Foot & Ankle International, 2000
A 14-month-old female with bilateral clubfeet was initially treated by serial casting and percuta... more A 14-month-old female with bilateral clubfeet was initially treated by serial casting and percutaneous tenotomy of the Achilles tendon, bilaterally. Both clubfeet subsequently underwent surgical treatment with a posteromedial release through a Cincinnati incision. At surgery on one clubfoot, an accessory Soleus muscle was found anterior to the Achilles tendon with a distinct insertion on the upper surface of calcaneus, anterior and medial to the insertion of Achilles tendon. This accessory Soleus muscle may have been the cause of resistance to correction in this congenital clubfoot.
Foot & Ankle International, 2004
1. Foot Ankle Int. 2004 Sep;25(9):630-1. Osteochondromas of the talus presenting as intraarticula... more 1. Foot Ankle Int. 2004 Sep;25(9):630-1. Osteochondromas of the talus presenting as intraarticular loose bodies: report of two cases. Jackson KR, Gurbani B, Otsuka NY. Shriners Hospital for Children, 3160 Geneva Street, Los Angeles, CA 90020, USA. ...
Foot and Ankle Clinics, 2015
Calcaneonavicular coalitions are an important cause of adolescent foot pain and deformity. The co... more Calcaneonavicular coalitions are an important cause of adolescent foot pain and deformity. The congenital condition is characterized by an aberrant osseous, cartilaginous, or fibrinous union of the calcaneal and navicular bones. Calcaneonavicular coalitions are the most common form of tarsal coalitions identified within epidemiologic studies. A thorough understanding of this clinically significant entity is important for restoring joint motion and preventing long-term disability.
Journal of Pediatric Orthopaedics B, 2010
Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiol... more Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiology of the condition has been attributed to various deformities in the forefoot, ranging from the first metatarsophalangeal joint, the morphology of the distal metatarsal, and the intermetatarsal angle (IMA). There have been very few studies evaluating the first metarsocuneiform (MTC) joint, and the results available vary. The purpose of this study is to more critically evaluate the MTC joint with novel angular measurements as a contributor to JHV. A cohort of 46 feet from 29 patients (average age 14.2 years) with hallux valgus as defined as IMA of greater than 10 degrees were evaluated. The hallux valgus angle, IMA, base of first metatarsal to articular surface of medial cuneiform angle, first metatarsal to cuneiform (1MCA), second metatarsal to cuneiform (2MCA), intrinsic medial cuneiform obliquity angle (COA), distal metatarsal articular angle, and ratio of first cuneiform to second cuneiform length were measured. The same was done for an age-matched control group of 36 normal feet from 25 patients (average age 13.2 years). The two groups were statistically compared. There were several statistically significant differences between the study and control groups. Naturally, the hallux valgus angle and IMA were statistically greater by definition. In addition, the distal metatarsal articular angle and 1MCA were significantly larger in the study group. The magnitude of the 2MCA was found to positively correlate with the magnitude of the IMA. The COA angle was not found to be statistically different. In conclusion, the role of the MTC joint in JHV has been evaluated earlier with varying results. The objective of this study is to critically evaluate the MTC joint with novel angular measurements to delineate its contribution to JHV. One such novel measurement is the 1MCA. The statistically significant increase in 1MCA suggests that a property intrinsic to the articulation between the medial cuneiform and the first metatarsal may be involved in JHV. Another angle, the 2MCA was found to positively correlated with increased IMA, further implicating the MTC joint as a contributor to increased IMA and thus, JHV. Third, the COA was used to define the intrinsic obliquity of the medial cuneiform articular angle. This angle was not found to be statistically different between the study and control groups, suggesting that the morphology of the cuneiform is not involved in JHV.
Journal of Pediatric Orthopaedics B, 2011
Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with ... more Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.
Journal of Pediatric Orthopaedics B, 2003
We introduce a novel orthosis used with serial manipulations for the treatment of 14 congenital c... more We introduce a novel orthosis used with serial manipulations for the treatment of 14 congenital clubfeet (six boys and three girls). The average age at the time of initial treatment was 3.5 months (range, 2-6 months). The average length of treatment was 4.9 months (range, 3-7 months). All patients traveled at least 480 kilometres for their clinic visits. According to the clubfoot classification of Dimeglio et al., 12 clubfeet (85%) were severe and two clubfeet (15%) were moderate. At the end of treatment, all clubfeet were improved by at least one level of grading. Although all clubfeet went on to operative treatment, the initial non-operative treatment did improve the clubfeet. We propose the use of our technique for the non-operative treatment of patients presenting beyond the newborn period with clubfoot, who are restricted in traveling over long distances.
Journal of Pediatric Orthopaedics B, 2006
Here we report the first documented case of rice body formation within the biceps tenosynovium in... more Here we report the first documented case of rice body formation within the biceps tenosynovium in a patient with juvenile rheumatoid arthritis. We discuss the pathophysiology and the clinical and radiographic findings and correlate these to prior case studies. Lastly, we suggest that limited awareness is a barrier in achieving a timely diagnosis and appropriate management.
Journal of Pediatric Orthopaedics, 2002
Tibial osteotomies in children have been associated with a number of complications. A retrospecti... more Tibial osteotomies in children have been associated with a number of complications. A retrospective review of 116 children who had 129 tibial osteotomies was performed to assess these complications at our institution. Results showed that there were 35 cases of wound problems, 6 cases of recurrence/reoperation, 5 cases of delayed union, 2 cases with transient peroneal nerve palsy, 1 case of nonunion, and 1 case of mal-union. Patients having certain comorbidities had a higher frequency of complications. There were no significant differences between the location of the tibial osteotomy (proximal or distal) and the incidence of complication. External fixation was associated with a lower incidence of complications than the use of pins and casting. Although our results demonstrate an overall low complication rate, there is a significant association between complications and comorbid conditions. This highlights the need to recognize comorbidities preoperatively and the potential of increased postoperative complications.
Journal of Pediatric Orthopaedics, 2003
Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief tha... more Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients (<11 years) and a group of more skeletally mature patients (>11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.
Journal of Pediatric Orthopaedics, 2006
scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Ac... more scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Achilles tendon and the distal extension of the rearfoot. Results.-Prevalence of flexible flat foot in the group of 3-to 6-year-old children was 44%. Prevalence of pathological flat foot was <1%. Ten percent of the children were wearing arch supports. The prevalence of flat foot decreases significantly with age: in the group of 3-year-old children 54% showed a flat foot, whereas in the group of 6-year-old children only 24% had a flat foot. Average rearfoot angle was 5.5°of valgus. Boys had a significant greater tendency for flat foot than girls: the prevalence of flat foot in boys was 52% and 36% in girls. Thirteen percent of the children were overweight or obese. Significant differences in prevalence of flat foot between overweight, obese, and normal-weight children were observed. Conclusions.-This study is the first to use a three-dimensional laser surface scanner to measure the rearfoot valgus in preschool-aged children. The data demonstrate that the prevalence of flat foot is influenced by 3 factors: age, gender, and weight. In overweight children and in boys, a highly significant prevalence of flat foot was observed; in addition, a retarded development of the medial arch in the boys was discovered. At the time of the study, >90% of the treatments were unnecessary.
Journal of Pediatric Orthopaedics, 2003
Patients with myelodysplasia have increased wound dehiscence and ulcer formation compared with th... more Patients with myelodysplasia have increased wound dehiscence and ulcer formation compared with the normal population. While neurologic deficits and resultant muscle imbalance are the presumed etiologies for these complications, no study has investigated the role of peripheral circulation in myelodysplasia. Eighty-two patients (ages 2-20) were prospectively recruited for this study, consisting of 41 patients with myelodysplasia and 41 age-matched controls. Peripheral circulation was quantified using systolic blood pressures in arms and legs (ankle-brachial index [ABI]) and transcutaneous pO 2 measurements (TcO 2) in a standardized location in the forefoot. Both groups had similar mean age. Patients with myelodysplasia had a lower ABI but similar TcO 2 compared with the control group. Among the patients with myelodysplasia, the ABI and TcO 2 did not vary according to the level of neurologic deficit or the patient's age. However, those with prior surgical procedures had significantly higher ABI and TcO 2 compared with those without prior surgery (P < 0.05). This study suggests that patients with myelodysplasia may have decreased peripheral circulation compared with normal controls. Vascular insufficiency may therefore contribute to increased wound healing complications and ulcer formation in these patients.
Journal of Pediatric Orthopaedics, 2007
Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cereb... more Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP. In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used. Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and parent-physical sections (25.0%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001).…
Orthopedics, 2001
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Journal of surgical orthopaedic advances, 2021
Physical examination education begins early for medical learners. A hindrance to physical exam co... more Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confidence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accuratel...
Bulletin of the Hospital for Joint Disease, 2019
BACKGROUND Supracondylar humerus fractures account for two thirds of all hospitalizations for elb... more BACKGROUND Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthop...
Orthopedics, 2001
The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffn... more The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffness of trabecular bone in intact canine femoral head specimens was investigated. Twenty-four skeletally mature dogs were divided into two groups. Twelve paired fresh femora were tested and 12 paired femora were tested after freezing at -20° C. The intact femoral head specimens were subjected to a load of physiologic magnitude, and then the stiffness of the underlying trabecular bone was determined in intact femora, in drilled femora with a disrupted intraosseous fluid compartment, and subsequently after refilling the compartment with fluid. Drilling of the femoral head and disrupting its bony fluid compartment resulted in a 40% decrease in stiffness (P<.001). This effect was seen only with fresh specimens and not frozen specimens. Refilling the bony compartment with fluid restored the stiffness of the fresh femoral head. These results demonstrate the mechanical properties of trabecula...
Orthopedics, 1999
The charts of 21 patients (22 knees) with significant radiographic changes of the patella after t... more The charts of 21 patients (22 knees) with significant radiographic changes of the patella after total knee arthroplasty were reviewed. The average patient age was 73 years, and average follow-up after arthroplasty was 7.3 years. Lateral release, fat pad excision, quadriceps tendon release, and previous surgery were implicated in the etiology of fracture of the patella. Five cases had type 1 pattern (sclerosis, fragmentation, and no fracture), 5 cases had type 2 pattern (undisplaced fracture and fragmentation), and 12 cases had type 3 pattern (displaced fracture and fragmentation). Type 1 and 2 patterns required no surgical treatment and were rated good to excellent according to the Hospital for Special Surgery Disability Score Sheet. Patients with a type 3 pattern who did not undergo surgery were rated poor to fair, while patients with a type 3 pattern who underwent surgical treatment (patellectomy, removal of the patellar component, or excision arthroplasty for infection) were rated good. Patellectomy is the treatment of choice for patients with displaced fractures of the patella. A classification system for the pattern of patellar changes is proposed.
Journal of Pediatric Orthopaedics, 2018
Purpose: The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatri... more Purpose: The American Academy of Orthopaedic Surgeons (AAOS) and the American Academy of Pediatrics (AAP) both advocate for childhood injury prevention by publishing recommendations to orthopaedic surgeons, pediatricians, and the public. Popular topics of advocacy campaigns have included trampolines, all-terrain vehicles (ATVs), and lawnmowers. The purpose of this study was to investigate the temporal relationship between AAOS/AAP advocacy and pediatric orthopaedic injury rates, using these topics as examples. We hypothesized that pediatric orthopaedic injury rates decline in years, following related AAOS/AAP recommendations. Methods: A retrospective review of fractures associated with trampolines, lawnmowers, and ATVs among patients aged 2 to 18 years from 1991 to 2014 was performed using the National Electronic Injury Surveillance System (NEISS). Fracture rates and percent changes year-to-year were calculated. A timeline of AAOS and AAP advocacy statements published on the product...
Pediatrics In Review, 2018
Practice Gaps 1. The differential diagnosis for a limping child or adolescent with hip or knee pa... more Practice Gaps 1. The differential diagnosis for a limping child or adolescent with hip or knee pain is broad. Delayed or missed diagnoses of slipped capital femoral epiphysis and Legg-Calvé-Perthes disease have significant morbidity. Clinicians should understand when to suspect these disorders based on history, examination, and early imaging findings to allow for timely referral to a specialist. 2. Clinicians should also have a basic understanding of the treatment options and prognosis of these disorders to counsel patients and their families before and during treatment by a specialist. Objectives After completing this article, readers should be able to: 1. Identify the general anatomy relevant to slipped capital femoral epiphysis (SCFE) and Legg-Calvé-Perthes disease (LCPD) pathology. 2. Recognize the symptoms and physical examination findings of SCFE and LCPD. 3. Know the basic laboratory values and imaging to order to evaluate for SCFE and LCPD when referring to a specialist. 4. Differentiate straightforward presentations of SCFE and LCPD. 5. Understand broad treatment categories and the prognoses of SCFE and LCPD. 6. Realize the importance of timely referral to a specialist for SCFE and LCPD.
Foot & Ankle International, 2000
Neglected congenital clubfoot in adults has been described in literature, but is not common to se... more Neglected congenital clubfoot in adults has been described in literature, but is not common to see adult patients with this orthopaedic disorder in developed countries with 30 years of follow-up. We report an asymptomatic case of neglected congenital clubfoot in an adult, who is incidentally seeking treatment for her 18-month-old son with congenital clubfoot. Although the cosmetic appearance is unacceptable, this mother remarkably has no functional limitations and for this reason she refuses any surgical treatment for her foot. To our knowledge, this is the first report of an untreated congenital clubfoot with 30 years follow-up.
Foot & Ankle International, 2000
A 14-month-old female with bilateral clubfeet was initially treated by serial casting and percuta... more A 14-month-old female with bilateral clubfeet was initially treated by serial casting and percutaneous tenotomy of the Achilles tendon, bilaterally. Both clubfeet subsequently underwent surgical treatment with a posteromedial release through a Cincinnati incision. At surgery on one clubfoot, an accessory Soleus muscle was found anterior to the Achilles tendon with a distinct insertion on the upper surface of calcaneus, anterior and medial to the insertion of Achilles tendon. This accessory Soleus muscle may have been the cause of resistance to correction in this congenital clubfoot.
Foot & Ankle International, 2004
1. Foot Ankle Int. 2004 Sep;25(9):630-1. Osteochondromas of the talus presenting as intraarticula... more 1. Foot Ankle Int. 2004 Sep;25(9):630-1. Osteochondromas of the talus presenting as intraarticular loose bodies: report of two cases. Jackson KR, Gurbani B, Otsuka NY. Shriners Hospital for Children, 3160 Geneva Street, Los Angeles, CA 90020, USA. ...
Foot and Ankle Clinics, 2015
Calcaneonavicular coalitions are an important cause of adolescent foot pain and deformity. The co... more Calcaneonavicular coalitions are an important cause of adolescent foot pain and deformity. The congenital condition is characterized by an aberrant osseous, cartilaginous, or fibrinous union of the calcaneal and navicular bones. Calcaneonavicular coalitions are the most common form of tarsal coalitions identified within epidemiologic studies. A thorough understanding of this clinically significant entity is important for restoring joint motion and preventing long-term disability.
Journal of Pediatric Orthopaedics B, 2010
Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiol... more Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiology of the condition has been attributed to various deformities in the forefoot, ranging from the first metatarsophalangeal joint, the morphology of the distal metatarsal, and the intermetatarsal angle (IMA). There have been very few studies evaluating the first metarsocuneiform (MTC) joint, and the results available vary. The purpose of this study is to more critically evaluate the MTC joint with novel angular measurements as a contributor to JHV. A cohort of 46 feet from 29 patients (average age 14.2 years) with hallux valgus as defined as IMA of greater than 10 degrees were evaluated. The hallux valgus angle, IMA, base of first metatarsal to articular surface of medial cuneiform angle, first metatarsal to cuneiform (1MCA), second metatarsal to cuneiform (2MCA), intrinsic medial cuneiform obliquity angle (COA), distal metatarsal articular angle, and ratio of first cuneiform to second cuneiform length were measured. The same was done for an age-matched control group of 36 normal feet from 25 patients (average age 13.2 years). The two groups were statistically compared. There were several statistically significant differences between the study and control groups. Naturally, the hallux valgus angle and IMA were statistically greater by definition. In addition, the distal metatarsal articular angle and 1MCA were significantly larger in the study group. The magnitude of the 2MCA was found to positively correlate with the magnitude of the IMA. The COA angle was not found to be statistically different. In conclusion, the role of the MTC joint in JHV has been evaluated earlier with varying results. The objective of this study is to critically evaluate the MTC joint with novel angular measurements to delineate its contribution to JHV. One such novel measurement is the 1MCA. The statistically significant increase in 1MCA suggests that a property intrinsic to the articulation between the medial cuneiform and the first metatarsal may be involved in JHV. Another angle, the 2MCA was found to positively correlated with increased IMA, further implicating the MTC joint as a contributor to increased IMA and thus, JHV. Third, the COA was used to define the intrinsic obliquity of the medial cuneiform articular angle. This angle was not found to be statistically different between the study and control groups, suggesting that the morphology of the cuneiform is not involved in JHV.
Journal of Pediatric Orthopaedics B, 2011
Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with ... more Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.
Journal of Pediatric Orthopaedics B, 2003
We introduce a novel orthosis used with serial manipulations for the treatment of 14 congenital c... more We introduce a novel orthosis used with serial manipulations for the treatment of 14 congenital clubfeet (six boys and three girls). The average age at the time of initial treatment was 3.5 months (range, 2-6 months). The average length of treatment was 4.9 months (range, 3-7 months). All patients traveled at least 480 kilometres for their clinic visits. According to the clubfoot classification of Dimeglio et al., 12 clubfeet (85%) were severe and two clubfeet (15%) were moderate. At the end of treatment, all clubfeet were improved by at least one level of grading. Although all clubfeet went on to operative treatment, the initial non-operative treatment did improve the clubfeet. We propose the use of our technique for the non-operative treatment of patients presenting beyond the newborn period with clubfoot, who are restricted in traveling over long distances.
Journal of Pediatric Orthopaedics B, 2006
Here we report the first documented case of rice body formation within the biceps tenosynovium in... more Here we report the first documented case of rice body formation within the biceps tenosynovium in a patient with juvenile rheumatoid arthritis. We discuss the pathophysiology and the clinical and radiographic findings and correlate these to prior case studies. Lastly, we suggest that limited awareness is a barrier in achieving a timely diagnosis and appropriate management.
Journal of Pediatric Orthopaedics, 2002
Tibial osteotomies in children have been associated with a number of complications. A retrospecti... more Tibial osteotomies in children have been associated with a number of complications. A retrospective review of 116 children who had 129 tibial osteotomies was performed to assess these complications at our institution. Results showed that there were 35 cases of wound problems, 6 cases of recurrence/reoperation, 5 cases of delayed union, 2 cases with transient peroneal nerve palsy, 1 case of nonunion, and 1 case of mal-union. Patients having certain comorbidities had a higher frequency of complications. There were no significant differences between the location of the tibial osteotomy (proximal or distal) and the incidence of complication. External fixation was associated with a lower incidence of complications than the use of pins and casting. Although our results demonstrate an overall low complication rate, there is a significant association between complications and comorbid conditions. This highlights the need to recognize comorbidities preoperatively and the potential of increased postoperative complications.
Journal of Pediatric Orthopaedics, 2003
Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief tha... more Many authors delay triple arthrodesis in skeletally immature patients secondary to the belief that such a surgery would cause excessive shortening in a foot that is often already short. In the current study, foot growth rates were compared between a group of skeletally immature patients (<11 years) and a group of more skeletally mature patients (>11 years) after triple arthrodesis. The average age at surgery in the skeletally immature group was 9.8 years, with a mean follow-up of 3.4 years, and the average age at surgery in the more skeletally mature group was 13.6 years, with a mean follow-up of 2.5 years. No statistically significant differences in length or height growth rates after triple arthrodesis were found between the two groups. The incidence of pseudoarthrosis and residual deformity in both groups was comparable with other studies in the literature. This study does not support the belief that triple arthrodesis to correct hindfoot deformity, instability, or relief of pain should be restricted to the older child.
Journal of Pediatric Orthopaedics, 2006
scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Ac... more scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Achilles tendon and the distal extension of the rearfoot. Results.-Prevalence of flexible flat foot in the group of 3-to 6-year-old children was 44%. Prevalence of pathological flat foot was <1%. Ten percent of the children were wearing arch supports. The prevalence of flat foot decreases significantly with age: in the group of 3-year-old children 54% showed a flat foot, whereas in the group of 6-year-old children only 24% had a flat foot. Average rearfoot angle was 5.5°of valgus. Boys had a significant greater tendency for flat foot than girls: the prevalence of flat foot in boys was 52% and 36% in girls. Thirteen percent of the children were overweight or obese. Significant differences in prevalence of flat foot between overweight, obese, and normal-weight children were observed. Conclusions.-This study is the first to use a three-dimensional laser surface scanner to measure the rearfoot valgus in preschool-aged children. The data demonstrate that the prevalence of flat foot is influenced by 3 factors: age, gender, and weight. In overweight children and in boys, a highly significant prevalence of flat foot was observed; in addition, a retarded development of the medial arch in the boys was discovered. At the time of the study, >90% of the treatments were unnecessary.
Journal of Pediatric Orthopaedics, 2003
Patients with myelodysplasia have increased wound dehiscence and ulcer formation compared with th... more Patients with myelodysplasia have increased wound dehiscence and ulcer formation compared with the normal population. While neurologic deficits and resultant muscle imbalance are the presumed etiologies for these complications, no study has investigated the role of peripheral circulation in myelodysplasia. Eighty-two patients (ages 2-20) were prospectively recruited for this study, consisting of 41 patients with myelodysplasia and 41 age-matched controls. Peripheral circulation was quantified using systolic blood pressures in arms and legs (ankle-brachial index [ABI]) and transcutaneous pO 2 measurements (TcO 2) in a standardized location in the forefoot. Both groups had similar mean age. Patients with myelodysplasia had a lower ABI but similar TcO 2 compared with the control group. Among the patients with myelodysplasia, the ABI and TcO 2 did not vary according to the level of neurologic deficit or the patient's age. However, those with prior surgical procedures had significantly higher ABI and TcO 2 compared with those without prior surgery (P < 0.05). This study suggests that patients with myelodysplasia may have decreased peripheral circulation compared with normal controls. Vascular insufficiency may therefore contribute to increased wound healing complications and ulcer formation in these patients.
Journal of Pediatric Orthopaedics, 2007
Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cereb... more Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP. In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used. Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) and parent-physical sections (25.0%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001).…