text:
Nehalem tower servers: Dell, Fujitsu, HP square off
Three new servers based on Intel's latest Xeon CPU combine huge performance gains with excellent management tools; the choice comes down to expandability and price
I have to admit that I get a little excited whenever a new generation of scorch-your-eyebrows-off CPUs hits the server market. So when I got a chance to check out the newest Intel Nehalem Xeon systems, I made sure my insurance policy was up to date and relocated any breakables to another room.
Intel's newest server processors represent a major architectural change from earlier Xeon generations. One big improvement over previous-generation Xeons is the addition of an onboard memory controller and Non-Uniform Memory Access (NUMA). Taking a cue from AMD, Intel added NUMA to Nehalem to help eliminate cache starvation by tying banks of RAM to each processor.
[ Learn why Intel's Nehalem Xeon processor simply sizzles. Read the InfoWorld Test Center reviews of Nehalem-based Sun Fire servers, Nehalem-based Dell, HP, and Lenovo workstations and the Nehalem-based Apple Xserve and Mac Pro. ]
Intel also redesigned the I/O system between CPU and peripherals, doing away with the front-side bus bottleneck and replacing it with a high-speed pathway called QPI (Quick Path Interconnect). QPI can transfer data to local peripherals as fast as 25.6GBps, nearly double the performance of a 1,600MHz front-side bus system.
Other improvements include the reintegration of Hyper-Threading, the elimination of the Northbridge controller (PCI Express and Direct Media Interface are now in the CPU), and support for DDR3 memory.
Enter the dragon
I was able to secure three tower servers based on Intel's latest Xeon offering from Dell, Fujitsu, and Hewlett-Packard, and from the moment I fired each one up for the first time, I knew these servers were something special. The best part was watching Windows Server 2008 (my requested operating system) boot up in about 52 seconds -- simply fantastic.
In order to make this an apples-to-apples comparison, I requested a similar configuration from all three server vendors. (IBM was also invited, but did not provide a system.) Each server came with two Xeon X5550 2.66GHz CPUs, 24GB of 1,333MHz DDR3 RAM, and Windows Server 2008 Standard Edition (64-bit). I asked each vendor to supply hard drives in a RAID 5 configuration but left the size and type of drives up to each vendor. Dual Gigabit Ethernet and multiple USB 2.0 ports were standard on each system.
To get a feel for each platform's performance, I ran the SPECjbb2005 Java server benchmark and the STREAM memory benchmark tools on each system. The SPECjbb2005 test is a Java virtual machine stress test that emulates a three-tier client/server order and inventory system. During the test, a number of virtual warehouses is created (two warehouses per processor core), with each warehouse handling order entry, payment, status, delivery, and reporting transactions. Additionally, SPECjbb2005 also measures the performance of the CPUs, caches, memory, and the scalability of shared memory.
Rock around the clock
Using SPECjbb2005, I was able to make all 16 cores (8 Hyper-Threaded cores) busy, achieving near 100 percent utilization at the end of the test run. The test suite increased the workload by one until it reached the maximum of 32 virtual warehouses (2 warehouses per core). At the end of the test run, SPECjbb2005 generates a score in bops (business operations per second, and SPECjbb2005's unit of measure) for each warehouse simulation. Bops represent the overall throughput achieved by all the warehouses in a test run; a higher bops value indicates better overall performance.
|InfoWorld Scorecard
Expandability (20.0%)
Power usage (10.0%)
Performance (40.0%)
Value (10.0%)
Management (20.0%)
Overall Score (100%)
|Dell PowerEdge T610
|Fujitsu Primergy TX300
|HP ProLiant ML350
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This pirate lollipop mold has 3 designs and 3 cavities. Easy to use, easy to clean, and comes with complete instructions. Perfect for parties, candies, cakes, and more. These molds are easy to use and create picture perfect designs every time you use them. The molds can be used to create custom suckers or bite sized candy treats. Just pour in the mold, wait for it to set, and you have tasty lollipops in any color scheme you could want. The suckers are bite sized and have great detail. Includes 1 mold tray.
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text: Hi GatorCountry, I'm scheduled for a job interview tomorrow with UPS in Louisville. I have previously gotten the job before, but it was a seasonal job so I didn't accept it. However, all applications are thrown out at the start of the year so it will be as though I have never been for an interview before. I have been through the application and interview process several times having worked three jobs before (I'm 19) and interviewing for several more. I'm not one to get nervous and I seem to have done fairly well in job interviews in the past, as I've been hired on the spot for several other jobs. However, I'm a bit anxious because this job could do a lot for my future. If I land the position, I could get my school tuition completely paid for at the University of Louisville and get tons of benefits with UPS. So, I'm asking those with experience, what are some tips you guys have to conduct a successful interview? I know most of the basics, like eye contact, dressing nice and being polite - but are there any steps I should take to set me over the top? Thank you all!


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The Big Bang Theory Review: Solving the World's Energy Crisis with Potatoesby Carla Day at . Comments
Sheldon has the tendency to go cuckoo over the craziest things, but that's why we all love him, right?
In "The Proton Resurgence," Sheldon was ecstatic to find out that the host of his favorite childhood science show was available to do parties. And, what did he do? Of course, he hired Professor Proton to come over and do a party for him, Leonard and Penny. The premise was ridiculous, but it ended up being quite funny.
Given Sheldon's excitement over meeting Professor Proton, Amy should have been there. Wouldn't he have wanted to share this moment with his girlfriend? There wasn't even a comment to explain her absence. Given their relationship, that was an oversight, but as far as the jokes went, it worked better without her.
The character, Sheldon, is all over the place on The Big Bang Theory. In order to enjoy the show, I've come to just accept whatever craziness comes out of him whether it really makes sense or not. In this case, his excitement over Professor Proton wasn't the issue, it was the naivete that came with it. The same was true with Penny in this episode just in a different way.
Penny's ignorance of science was bright as the Las Vegas Strip. She definitely came across as dumb, but it was actually quite adorable at the same time. Though, how did that egg thing work? And, I only know about the potato clock because I did it in elementary school. If I hadn't learned that in school, I would have probably thought the same thing as Penny.
Her exchanges were the highlight.
Professor Proton: I power a clock with a potato.
Penny: Shut up! You can do that? I mean ... wouldn't that solve the world's energy crisis?
Professor Proton: No. | permalink
Penny: If you don't mind me asking, uh, the potato clock -- how does it work? Is it a trick clock or a trick potato?
Professor Proton [to Leonard]: What do you two talk about? | permalink
Professor Proton: I'm having trouble with my pacemaker.
Leonard: I'll call for help.
Penny: Any chance we could plug it into the potato?
Professor Proton: No. | permalink
Arthur went from impressed that Leonard was with Penny to flabbergasted by her comments. Though, she was the only reason that he stayed as long as he did. So, that's saying something.
It was sad to see that Arthur was disappointed in his life's direction after the show. He was a real scientist, but was trapped by his past. Even after Sheldon and Leonard shared that he was responsible for their love of science, it didn't seem to be enough. He was a broken man. If "Soft Kitty" couldn't cheer him up, nothing could. Though he did seem to warm up to Sheldon after he called him "Father."
It's too bad we didn't get to see Professor Proton, Jr at work. After the disastrous science presentation they did for the school girls, I'd be afraid what he would say at the party. Though, he does have the puppet to help.
The Professor Proton bit was definitely the better part of the episode. And, Bob Newhart was awesome as Professor Proton. There were some cute moments with Raj and Cinnamon. Howard and Bernie's conversation about having kids was also good, but that storyline fell mostly flat.
There were a ton hilarious lines throughout the episode. Check them out in our The Big Bang Theory quotes section.
Did you find Penny's potato comments to be the funniest part too? What was your favorite joke or quote? Can you see Howard and Bernie becoming parents any time soon? Did you miss Amy?
Carla Day is a staff writer for TV Fanatic. Follow her on Twitter and on Google+.Tags: The Big Bang Theory, Reviews
I like Amy's character but in this episode, I think it would have detracted from the humor. Bob Newhart's best feature is his almost deadpan reaction to others around him. Amy would have buffered his reactions to Penny which I thought were priceless, because the writers would have felt compelled to have Amy comment on Penny's naivety. And anyway, Amy's humor is mostly deadpan, too, so two people doing it wouldn't have been as funny. Great show, I love Newhart. His two old shows still crack me up, especially the totally classic ending to his last. The best part of the Howard, Bernadette, Raj line was moving the couple closer to having children. This was definitely a step forward for Bernie.
Poor Amy! I didn't miss her either. Great to see Bob Newhart on TV again,he's one of my all-time favorites. I feel a bit like Penny, because I don't know how a potato clock works either. But I would like to add to "Scientest too's" explanation of how the egg gets sucked into the bottle, that it's a hard-boiled egg...with the shell removed.
The episode just make more implausible the relationship between Leonard and Penny.
And I think that 24 min for 8 characters is very short, why not be a sitcom of a full hour???
I didn't notice Amy's absence either until reading it here -- and didn't miss her!
Bob Newhart towered over this episode. His timing was impeccable 40 years ago and has gotten even better with age. The cast worked very well with him. Instant classic TV.
I LOVED this episode! I love Bob Newhart and he was awesome and hysterical. I loved the parts with Penny, I literally laughed out loud and couldn't stop. Did miss Amy, but I think it would've been different had she been there. And I loved Bernadette and Howard trying to find the dog. Great episode
Watching this last night with my husband, I said I thought the role of Professor Proton was written specifically FOR Bob Newhart. He was hilarious in that very specific Newhart way. I mentioned that he didn't even get into show business until he was in his early 30s and my husband said, "What was he before -- an accountant?" I'm pretty sure the answer is YES. Agree with Sue Ann, there is never enough Newhart in the world.
love this one all lot the best part was bob newhart him self and no amy!!!!!!!!!!!!!!! sorry did not miss at all there was just to much amy this season it was nict to have an break from her. i am glad we got to learn what rajs puppy name is.
I could have watched Bob Newhart do any routine he chose. The cast of the big bang theory is great, but Newhart is fabulous.
This was fun, Professor Proton with his stunned expressions was hilarious ;) I didn't care about the dog storyline, it felt forced - they should've just put everyone together instead of trying to come up with something else for them to do. I didn't even realize Amy wasn't in the ep until I read it here, I guess that's why I liked it so much... I'm a scientist, and I didn't know the potato thing. But I do know that you can create electricity with lemons ;) Btw, since you asked: The egg gets sucked into the bottle because the fire in it creates a pressure difference.


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Gear Question
Have anyone tried to carry skis on this...
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Have anyone tried to carry skis on this backpack? And is this backpack suitable for people on 1.90 meters or taller?
Brian B.
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I'm not sure about the skis, but I am 1.95 meters (Norwegian/American) and the Arc'Teryx "Long" or "Tall" sizes fit my torso extremely well.
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The specifications indicates that there is no dedicated ski carry system. but I'm sure it wouldn't be too difficult to use the side compression straps or axe loops to carry the skis.
View More Details on Arc'teryx Naos 45 Backpack - 2500-2870cu in


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Print Options
California Shrimp Tacos with Corn Salsa Recipe
After trying fish tacos, I fell in love. I wanted to recreate them at home and though Why not use shrimp? It's an affordable healthy way to feed my seafood-loving family. —Kayla Peters, Cecilia, Kentucky
TOTAL TIME: Prep/Total Time: 25 min. YIELD:4 servings
- 1 can (11 ounces) Mexicorn, drained
- 3/4 cup chopped seeded tomatoes
- 1/2 cup black beans, rinsed and drained
- 1/4 cup minced fresh cilantro
- 3 garlic cloves, minced
- 1/4 teaspoon pepper
- 1/2 cup guacamole
- 3 tablespoons reduced-fat ranch salad dressing
- 16 uncooked large shrimp, peeled and deveined
- 3 teaspoons chili powder
- 1/2 teaspoon Cajun seasoning
- 8 taco shells, warmed
- 1. In a small bowl, combine the first six ingredients. In another small bowl, combine guacamole and salad dressing.
- 2. In a large bowl, toss shrimp with chili powder and Cajun seasoning. In a large nonstick skillet coated with cooking spray, saute shrimp until pink, about 5 minutes.
- 3. Place two shrimp in each taco shell. Top with 1/3 cup corn salsa; drizzle with 1 tablespoon guacamole mixture. Yield: 4 servings.
Nutritional Facts
2 tacos equals 342 calories, 14 g fat (3 g saturated fat), 83 mg cholesterol, 1,007 mg sodium, 40 g carbohydrate, 7 g fiber, 17 g protein.
Wine Pairings
Light-Bodied White Wine
Enjoy this recipe with a light-bodied white wine such as Sauvignon Blanc or Pinot Grigio.
© 2014 RDA Enthusiast Brands, LLC


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I love Font, everyone should go!
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User Profileregistered 12/Dec/11
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I Climb...
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Favourite Climbs
Haute Cuisine is a 7a i worked all last summer and got 2 days before i left for my ski season
such a cool climb.
Le Petit Toit is a super low boulder in Font. The first time i went there i saw it and i still havent completed it
this year!
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After nine years, 1,447 episodes and several well-deserved Emmy Awards, America's favorite faux news pundit signed off one last time with a promise that "We'll Meet Again."
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The unrest inspired by the killing of Michael Brown in Ferguson, Mo., and a grand jury's decision not to indict former Officer Darren Wilson in his death have nothing to do with race. Or so Fox News would have you believe.
The "Citizenfour" documentary filmmaker stopped by "The Daily Show" on Monday for a captivating interview in which she discussed how Edward Snowden first got in touch with her and what the repercussions of the whistle-blower's courageous acts have been.
It appears that pointing is now a serious offense in the state of Minnesota.
Jon Stewart gets in his last few swipes at the GOP before the midterm elections.
Who knew immigrating to America came with free computers and health care?
The Texas gubernatorial hopeful, who rose to fame after her nearly 13-hour filibuster in the Senate of the Lone Star State, stopped by "The Daily Show" to share her views on conservatism in Texas and her ideas on the lopsidedness of voter ID laws.
Despite countless speeches by Democratic leaders denouncing the evils of money in politics, their party sure knows how to raise and spend boatloads of campaign dollars. "And then of course there are ... the emails," a horror-stricken Jon Stewart says on Monday night's "Democalypse" segment of "The Daily Show."
Oh right, because Congress pretty much does diddly squat these days. Watch Jon Stewart make a jaw-dropping discovery as to why our elected officials refuse to publicly discuss what the "Daily Show" host calls one of the most "crucial issues of our time."
Using a cup of water and bowl of ice, the "Daily Show" host tries to show an exceptionally stubborn House representative why his metaphor about climate change is faulty.
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Al-Qaida has a thing or two to learn from ISIS about social media. Meanwhile, the efforts to squash ISIS have created some strange bedfellows. Luckily, Jon Stewart has returned from promoting his film "Rosewater" at festivals and has gotten back on "network anchor war footing" to tell us all about the new plagiarist terrorists in town.
Much to the "Daily Show" host's dismay, New York Sen. Kirsten Gillibrand recently revealed she'd been on the receiving end of several misogynistic comments from her colleagues in the legislative branch of the U.S. government.
"Do you not understand that life in this country is inherently different for white people and black people?" the "Daily Show" host asks of Fox News' pundits on the show's first day back from a summer break.
Though poking fun at right wingers is amusing, a Salon writer argues that it gets Democrats off the hook; Israeli media are "waking up" to the devastation in Gaza and to international criticism; meanwhile, an IBM chip has been developed that works similarly to human brains. These discoveries and more after the jump.
"You could salvage this entire fucking thing with a mediocre Scrabble hand," the "Daily Show" host shouts in exasperation.
With analysts estimating that the news network, often the butt of "Daily Show" jokes, could be worth $10 billion, Jon Stewart has launched a parody campaign to crowdsource the funds.
Watch as Jon Stewart gets hollered at by the rest of the "Daily Show" crew whenever he tries to talk about what's going on in Israel.
Obviously, the thing to do with the hundreds of children fleeing crippling poverty and violence is "shout at them in a language they don't understand," the "Daily Show" host explains.
Missing your (somewhat) daily dose of late-night satire while Jon Stewart and Stephen Colbert are on summer break? Fear not; we've rounded up some great clips from each show about the 4th of July.
Jon Stewart, accompanied by correspondents Jessica Williams and Jordan Klepper, explains how American universities are practically "incentiviz[ing] sexual assault" these days with inaction and leniency toward attackers.
The one thing everyone wants to know about 2016 Democratic front-runners Hillary Clinton and Joe Biden isn't what their stance is on any crucial issue, but rather which one is more "dead broke" than the other. Or at least that's what the two seem to think judging by their ridiculous comments about poverty.
Why don't we just accept the senseless killings that most developed countries don't experience as an inevitable fact of American life and stop trying to fix them?
Why does no one seem to care that a very important midterm election is mere months away?
The "Daily Show" veteran's new Sunday night show "Last Week Tonight" was only two episodes into its first season on HBO when the comedian was forced to tackle a doozy.
Conflation, conflation, conflation.
The Massachusetts senator went on "The Daily Show" on Tuesday night to talk about "A Fighting Chance," her new book, but ended up explaining all the things that are terribly wrong with our country these days.
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Clearly restoring "the glory" of male erections is a more pressing health matter than providing contraceptives for women.
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The hours and hours of U.S. cable television speculation about the fate of the missing Malaysian Air flight during the past seven days are a "Daily Show" parody waiting to happen.
According to "Fox Business" commentator Todd Wilemon, the U.S. will slowly slip into Third World status thanks to the Affordable Care Act, so "Daily Show" correspondent Aasif Mandvi set out to see what will happen to the "best health care system in the world."
The "Daily Show" host explains how the true difference between administrations is "not necessarily what they do but what they say to get to do it."
Despite Nancy Pelosi, minority leader of the House of Representatives, personally telling the "Daily Show" host that only Republicans are swayed by money, Stewart has a few examples in the shape of ambassador nominees that prove otherwise.
The comedian opened the 7th annual Crunchies Awards on Monday night with several eloquent jabs at the "nerds" who he claims have been changed by success and money.
"The Daily Show" is back from its holiday break and as funny as ever with this segment about Catholic nuns battling with the Obama administration about the contraception mandate in the Affordable Care Act. Watch as Jon Stewart's rage tumor grows back to its usual size as he grapples with sweet, musical nuns and birth control.
"The Daily Show's" segment on Fox News' Christmas paranoia doesn't get better than this clip where Jon Stewart takes down both Gretchen Carlson and Megyn Kelly for their absurd statements about nativity scenes and Santa. Whether or not you're celebrating the holiday, take some time to make it jollier with some Stewart inspired laughter.
Some are calling it a "Christmas miracle," but most can see the agreement reached by congressional negotiators after four years of living in a budget-less country is much ado about nothing. Except senior political correspondent John Oliver, who argues that the bipartisan budget is comparable to the Civil Rights Act.
"The Daily Show's" Jason Jones discusses the "art" of gerrymandering with redistricting consultant Kimball Brace, a man who won't stop drawing ludicrous new districts even after he's run the country into the ground. The only thing left to do is honor this artist with a gallery exhibit that shows how he uses color to change the face of American politics.
Wednesday's "The Daily Show" must have had Wall Street banksters reeling, and with good cause. The late night show host offered his audience a litany of infractions corporations, namely banks, have committed and then used their seeming immunity to actual punishment as proof they are not human.
As the secretary of health and human services, Kathleen Sebelius finds herself a mild-mannered Kansan in the center of one of the most vitriolic political battles in modern American history.
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News Brief
Britain pledged to give the Palestinian Authority $500 million in aid if it makes peace with Israel. Douglas Alexander, the British secretary of state for international development, said Monday that his government would pledge $500 million over three years if positive results come out of the Annapolis conference. Alexander met with P.A. President Mahmoud Abbas… More ▸


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Sister Wives Cast: Through the Years
Kody Brown and the cast of Sister Wives, in promotional photos through the years.
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First appt with midwife & weight Q
Find a Conversation
|Mon, 11-17-2008 - 8:17pm
Today was my first appt with the midwives that operate with my dr's practice...the dr gave the midwives such high praise, and I had a midwife deliver my second daughter 20 years go...I decide to give them a try (my dr's practice will allow me to see either the drs or the midwives and change my mind up until the delivery time). I am so glad that I did....i was very pleased with the midwife's attitude and the level of interest she took...I have developed hypothyroidism (or it finally showed up in the bloodwork
|Sun, 11-23-2008 - 1:35pm
Thanks Michelle! I guess that is a good way to look at it...I too had gained 35+ lbs with each of my past pregs but I am started out 20lbs heavier this time around (and 20 years later!)....I was hoping perhaps I would gain less. At least I am back to exercising, I hopped on the treadmill about 2 weeks ago and try to get 15-20min daily. Hoping that makes a difference...
Yes, I think I found a good practice overall...


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Before and After: A DIY Colorful Vintage Kitchen Makeover
See how one blogger gave her plain kitchen a bright and colorful makeover.
After: Cabinets and Island
"I painted some old counter stools we had with chalk paint, and reupholstered the seats with fabric that matched the drapes. The flooring is an inexpensive laminate from Lowe's (Allen + Roth Provence Oak) that we installed throughout the house before the cupboard installation."


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Madrid Tapas and Wine-Tasting Tour
Read what other Viator.com travelers think about the Madrid Tapas and Wine-Tasting Tour. What they loved, what they liked and what they think could be improved, it's all here to help you make the most of your next trip.
Click here for tour details, schedule and pricing
Great tour. Visited several great places which we never had dared to enjoy. Tour leader was very engaging and provided historical and cultural perspectives.
We had a great time tasting wine and tapas we would never have ordered ourselves!!! We would definitely recommend this tour!
Debby T
have booked tours in many cities across europe and this hands down was the best..ishmael was our guide and he was fabulous! we had a small group, just 3 couples which allowed a personalized tour. we all had great fun. the wine selections and tapas selections he made were right on..i admit i hesitated because of the price but it is so so worth it..
Ishmael was a super tour guide. He took us to great places and we got to sample amazing food and great Soanish wine. I did this tour a few years ago and was so glad to do it again. Different bars except one. It was nice the rain kept away huge crowds. Excellent time!
This tour was a highlight of my trip to Madrid. The guide was very knowledgeable. The food and wine was fabulous. Highly recommended for any trip to Madrid
Loved every minute of this. Ishmael was an excellent guide. Very passionate about the food and wine. Would highly recommend this tour. Great group of people and one of the best nights we had in Madrid. Ishmael was very accommodating and even managed to get my Fiance to eat shrimp!!! Went to tapas bars that we never would have stumbled upon. Would love to contact Ishmael directly to say thanks again.
Despite there only being 3 people booked on the tour we had an amazing night. The tour guide Ismael was the perfect host, very knowledgeable about the food and wine and he took our dietary requirements into account when choosing which Tapas bar to visit. Definitely worth doing. Thank you.
Great tour, great fun. Ismail, our guide, was very good and took us to some great spots we would have never found on our own. He knows his wine, too, and gave us a good primer on vino espagna. This is also a great way to meet fellow visitors.
Great time. Guide made the evening a fun experience for everyone in the group.
Shaun K
We went to several Tapas tours in other cities in Spain - THIS is the ONLY authentic one. Madrid is where Tapas started, and before we did the tour (on our last day) we were paying for Tapas. Our guide showed us the 'real tapas' culture - if only we knew before we left. A must book if you are in Madrid.
The Tapas and Wine Tasting tour was excellent. Our guide Ismael was extremely informative and knew what he was talking about with regard to Spanish wine. The Tapas bars/restaurants he took us to provided us with very tasty food, much more preferable than the many restaurants dotting the streets of Madrid. The staff were all courteous and friendly wherever we were taken. Not only did Ismael inform us about the food we were eating and it's origins but he supplied us with history of the restaurants and the places in Madrid that we walked through. There were four restaurants listed on the tour but we were taken to a fifth after being asked if we would like to go, a bonus.
I would recommend this tour to anybody who wants to explore Madrid and get to know the local cuisine and wines, but do it early on in your stay so that you can choose good eating places during your stay
Fantastic night. Could not fault it. Our small group of five had a great night and visited places we would not have normally gone to.We would say to people visiting Madrid to do this tour and because we were staying in the area where the tour was conducted made it even better.
I'd give this tour 6 stars if that were an option. On our recent trip to Europe, we booked small group tours in Portugal, Italy and Spain, and this tour was one of the very best. Friends had told us that there wasn't much to see in Madrid, but after taking this tour, I heartily disagree with them on this point.
Tour guide Ismael was warm and friendly and he had a great rapport with the proprietors at all of our tour stops. The food and wine were outstanding, and there was plenty of both. We didn't need to eat dinner after this tour. The eateries on this tour were fun and unique to Madrid. Definitely felt like an "insiders" experience.
Ismail was our guide for the evening, the instructions on the meeting place are clear and it is easy to find. His knowledge was first class and his choice of restaurants and wines was of equal quality. There is no way the wine and food we sampled on this tour would have been possible if we did not have him as a guide. Where would you select shark from a menu to eat! (It was lovely by the way). He took us to hidden gems that we would not have entered without local knowledge and also gave us an excellent insight into Spanish culture. There was the correct balance between food, wine and learning about the heritage of the restaurants we went to and the history of Madrid as a City. If you are even considering this do not hesitate, DO IT. It will be one of the best nights you will spend in Madrid and the value for money is excellent. The food was top quality and the hospitality was as well and you will pick up valuable tips that will set you up well for the rest of your Madrid stay………………..
This was awesome! It was only the two of us and new single woman, plus the guide. I think he stopped at 8 places and they were just great. We love the food, the information, and the company.


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Distraction Osteogenesis is a procedure for lengthening a bone. The Ilizarov External Fixator is an apparatus employed in the distraction osteogenesis procedure. The prospects for a successful clinical outcome of the procedure are enhanced by modifying the Ilizarov apparatus to obtain measurements of loads generated during the procedure. An apparatus and method for the clinical use of load measurements taken during the distraction osteogenesis procedure are disclosed. An alternative method is disclosed for converting load measurements to stress data in order to enhance the clinical outcome of the procedure. Additionally, the method may be employed to assess completion of the healing process.
1. A method for the clinical use of load measurements taken during distraction osteogenesis in which an external fixator having moment-free distraction means coupled to cannulated load cells is employed to distract a corticotomy site, comprising the steps of:
(a) performing a corticotomy at a selected corticotomy site;
(b) surgically affixing an external fixator having upper and lower fixator rings across said corticotomy site employing transosseous wires;
(c) coupling, to distractor rod assemblies, canulated load cells producing analog electrical signals proportional to a load impressed on said load cells;
(d) using moment-free connections, attaching at least three distraction rod assemblies to said upper and lower fixator rings;
(e) periodically distracting said corticotomy site;
(f) processing said electrical signals to derive said load across said corticotomy site;
(g) adjusting the rate of distraction of said corticotomy site to maintain said load across said corticotomy site within a load range sufficiently high to avoid premature consolidation of said corticotomy site and sufficiently low to avoid nonunion of said corticotomy site.
2. The method of claim 1 wherein said load range is from approximately 20 Newtons early in distraction to approximately 500 Newtons late in distraction.
3. The method of claim 1 comprising the additional steps of measuring the cross-sectional area of said corticotomy site, calculating the stress across said corticotomy site, and adjusting the rate of distraction of said corticotomy site to maintain said stress across said corticotomy site within a stress range sufficiently high to avoid premature consolidation of said corticotomy site and sufficiently low to avoid nonunion of said corticotomy site.
4. The method of claim 3 wherein said stress range is from approximately 27 Newtons per square centimeter to approximately 100 Newtons per square centimeter.
5. The method of claim 3 wherein said stress range is from approximately 45 Newtons per square centimeter to approximately 50 Newtons per square centimeter by approximately week three of distraction.
6. The method of claim 1, comprising the additional steps of:
(a) after the required amount of limb lengthening is achieved, periodically placing an external load on the corticotomy site;
(b) measuring the load across the corticotomy site to test for bony consolidation; and
(c) removing the external fixator when the degree of bony consolidation indicates completion of healing.
The present invention relates to orthopedic instrumentation including external fixation devices and in particular to a method and apparatus for the clinical use of load measurements taken during distraction osteogenesis.
Distraction osteogenesis is a technique for lengthening a bone so as to minimize differences in the lengths of a patient's limbs or for similar purposes. Professor G. A. Ilizarov developed a technique for bone lengthening using the technique of distraction osteogenesis which employs an external fixator attached to the patient's bone by tensioned small diameter wires. The Ilizarov technique may be used for various orthopedic purposes other than bone distraction. A description of the Ilizarov technique may be found in U.S. Pat. No. 4,615,338 issued to Ilizarov, et al. on Oct. 7, 1986 for "Automatic Compression-Distraction Apparatus", incorporated herein by reference.
Typically the Ilizarov apparatus employs two or more fixator rings which may be either complete or partial rings. Transosseous wires and/or pins are fixed to the fixator rings at each of their ends by means of wire fixation bolts after being passed through holes drilled in the patient's bone and through the soft tissue of the limb. In the basic form of the Ilizarov apparatus, distraction rod assemblies are attached to the fixator rings. The distraction rod assemblies comprise threaded rods and telescopic rods into which the threaded rods are received. The distraction rod assemblies may be fastened to the fixator rings using nuts or knobs which may be turned to gradually lengthen the distraction rod assemblies so as to force the fixator rings further apart.
For distraction osteogenesis of a leg bone the Ilizarov apparatus is used in the following manner. A site is selected on the bone to be lengthened. The external fixator rings are attached to the patient's leg on either side of the selected site by means of the transosseous wires which are passed through the soft tissue and bone of the patient's limb. The transosseous wires are attached at their opposite ends to the respective fixator rings. A corticotomy is performed through a small incision in the patient's limb. The patient's bone is separated at the selected site while preserving the blood supply within the interior of the bone and with minimal damage to the soft tissue in the vicinity of the severed bone. Following surgery, nuts on the distraction rods may be tightened to force the fixator rings apart and thereby applying tension to the tissues in the biological zone between the bony surfaces at the corticotomy site. Bony regeneration at the surface of the severed bone begins to occur as the process of distraction continues. The typical rate of distraction is approximately 1 mm per day until the necessary length of regenerated bone is achieved. Afterwards the external fixator is kept in place until the newly generated bone has stabilized.
While distraction osteogenesis is typically performed by manual adjustment of the rate of distraction, systems have been suggested for automatic distraction. U.S. Pat. No. 5,180,380 issued to Pursley, et al. on Jan. 19, 1993 for "Automatic Compression-Distraction-Torsion Method and Apparatus" discloses a system which includes at least one motor for incrementally adjusting the distraction rods.
U.S. Pat. No. 5,108,394 issued to Kurokawa, et al. on Apr. 28, 1992 for "Bone Fixing Device" discloses a bone fixing device comprising a single rod member and an axial actuator. Kurokawa furthermore discloses a load cell for detecting what is described as a repulsive force from the bone.
Various attempts have been made to understand the biomechanical forces involved in the distraction osteogenesis procedure. However, the studies to date have simply focused on the nature of the loads generated during the distraction process without attempting to apply that information in a clinical setting to improve the clinical outcome. Prior to the development of the method and apparatus of the present invention, distraction has been carried out at a fixed rate regardless of the loads generated in the patient during the process. It has been discovered that a knowledge of the loads generated by the distraction procedure across the active biological zone of the corticotomy site may be used to adjust the rate of distraction to avoid unsuccessful clinical outcomes. An unsuccessful clinical outcome could include either premature consolidation of the biological bridge between the surfaces of the severed bone or nonunion which is a result of a disruption of the biological bridge. In addition, the information derived from the measurement of loads at the corticotomy site may be used to test the degree of bony consolidation at the corticotomy site and thus to determine when healing has progressed to the point that the fixator may be removed from the patient.
Furthermore, prior to the development of the method and apparatus of the present invention, no consideration has been given to the variation in cross-sectional area of the bone in various patients. As a result there has been no recognition of the variation in stress or load per unit area in various patients in which the loads alone would appear to be otherwise similar. The method and apparatus of the present invention recognizes that an improved clinical outcome may be obtained by converting measured load information into stress values by comparing the measured loads to the measured cross-sectional area of the corticotomy site. The use of such derived stress information may then be applied to adjust the rate of distraction so as to avoid unsuccessful clinical outcomes.
Other objects, advantages and features of the present invention will be more fully understood when considered in conjunction with the following detailed description of the preferred embodiments together with the drawings.
FIG. 1 is a plan view of an external fixator showing the loads generated during distraction.
FIG. 2 is an elevation view of the distraction rod assembly of the present invention.
FIG. 3 is a perspective view of an external fixator employing the load measurement distraction rods of the present invention.
FIG. 4 is a schematic of the data processing apparatus associated with the present invention.
FIG. 5A is a graph of distraction loads versus week of distraction for metaphyseal versus diaphyseal sites.
FIG. 5B is a graph illustrating clinical outcome in terms of distraction load.
Limb lengthening requires the stretching of soft tissues such as muscle, fascia and skin. Distraction osteogenesis necessarily creates a biological interface between the cut bone surfaces which adds further resistance to the stretching. The mechanical environment for distraction osteogenesis seems to play an important role in successful bone formation and bridging.
External fixators provide a convenient vehicle to monitor the reactive forces during limb lengthening. These forces may indicate pathological conditions that would allow one to alter the treatment regimen such as the rate of stretching in order to avoid clinical damage.
Bone lengthening using the technique of distraction osteogenesis depends upon: preservation of the blood supply to each bony surface by a low-energy corticotomy, slow and gradual distraction of the resultant biological bridge and stable fixation to avoid complete disruption of the microstructures within the osteogenic zone. As the generator of distraction osteogenesis, the fixator must be able to withstand superimposed forces from sources such as soft tissue resistance to stretching or loads from weightbearing.
The Ilizarov external fixator commonly used in bone lengthening procedures is mechanically unique compared to other external fixators. With circumferential load cells, the circular external fixator can directly measure the axial load during lengthening.
There are several published studies concerning loads generated during limb lengthening procedures. White and Kenwright ("The Timing of Distraction of an Osteotomy," J. Bone Joint Surg., 1990) measured rabbit tibia distraction forces in a uniplanar bilateral external fixator during a 10% lengthening that utilized a diaphyseal osteotomy. The maximum load was 45 Newtons when distraction was started immediately after surgery and 95 Newtons when delayed for seven days. Leong and his coworkers were the first to measure distraction loads in-vivo during a human limb lengthening procedure using a bilateral external fixator. ("Viscoelastic Behavior of Tissue in Leg Lengthening by Distraction, "Clin Orthop., 1979) Distraction loads were measured in three patients undergoing tibial lengthenings of 38 mm, 37 mm and 39 mm; the maximum measured loads in these cases were 236 Newtons, 163 Newtons, and 183 Newtons respectively. Wolfson measured in-vivo distraction loads in the tibia of an 11-year old female patient undergoing 30 mm lengthening using the Ilizarov method with a metaphyseal corticotomy distracted 0.25 mm four times daily for fifty days. ("Force and Stiffness Changes during Ilizarov Leg Lengthening," Clin. Orthop., 1990). The maximum load was 245 Newtons at forty-four days after surgery. The axial stiffness of the distracted limb was reported to increase throughout the procedure and this was attributed to either soft tissue viscoelasticity or mineralization of the distraction gap tissue. Verkerke instrumented a Wagner fixator used for femoral lengthenings in two patients. ("Design of a Load Cell for the Wagner Distractor," Proc. Instn. Mech Engrs, Part H: Journal of Engineering in Medicine, 1989). The maximum loads measured were 270 Newtons after a 60 mm lengthening, and 400 Newtons after a 28 mm lengthening.
Steen studied forces and bone motions during lengthening of the ovine tibia and compared diaphyseal and metaphyseal osteotomy sites. ("Biomechanical Factors in the Metaphyseal- and Diaphyseal-Lengthening Osteotomy: An Experimental and Theoretic Analysis in the Ovine Tibia," Clin Orthop., 1990) Loads were estimated indirectly from computed tomography scans and load factors derived from electromyographic studies. The calculated compression load was estimated to be 210% higher at the metaphyseal osteotomy compared to the diaphyseal site. A numerical model was also used and it predicted a residual passive tissue tension of 431 Newtons after a lengthening of 26 mm.
Although the above studies involve different fixators, bones and distraction techniques, they are based on the same general biomechanical principle shown in FIG. 1. A bone 20 has been severed by a corticotomy or similar procedure. On either side of the corticotomy site 22 transosseous wires 21 have been inserted through the bone 20 and affixed to upper and lower fixator rings 11, 13 respectively. The fixator rings 11, 13 are held apart by threaded rods 10 which are threaded to receive nuts 12. The nuts 12 may be employed to force the fixator rings 11 apart. The result is an applied axial tension in the bone 20 and corresponding compressive forces in the threaded rods 10. The sum of the axial compressive loads in the threaded rods 10 is equal to the total tissue tension in the limb. A large percentage of the distraction load is generated by the tissue in the osteogenic zone. Therefore the distraction load may also provide indirect information about the biological status of the tissue under distraction. The apparatus of FIG. 1 is a generalized version of the prior art which is modified in the present invention as shown in FIGS. 2-4.
Loads measured from external fixators have been used to guide clinical decisions during fracture healing. Leong proposed that the forces created during limb lengthening relate directly to distraction rate and length. Verkerke theorized that forces created by limb lengthening are due to resistance in distracted soft tissues and soft tissue injury might be avoided by limiting force generation. In a series of patients undergoing limb lengthening, Kenwright attempted to avoid physeal fracture by using measured fixator loads to control distraction.
The present invention is based on the discovery that a relationship exists between distraction load or stress and clinical outcome; i.e., union versus non-union or premature consolidation.
In order to determine distraction loads for the purposes of the present invention, an instrumentation system was developed that could measure distraction loads in an Ilizarov fixator. The system was used experimentally to measure loads in canine subjects undergoing tibial lengthening. The clinical outcome of the lengthening was determined from radiographs and the load data was examined for prognostic value.
The strain gauge based instrumentation system was developed to meet several design criteria. Loads were measured in the distraction rods since the sum of the rod compressive forces would equal the total tensile force in the distracted limb. Eccentric loads that would cause bending moments in the distraction rods and inaccurate load readings had to be eliminated by moment-free connections. The load measuring apparatus had to be small enough to clear the soft tissues when mounted on the fixator.
In order to use commercially available transducers, hardware was designed to allow the transducers to be fitted to the Ilizarov fixator.
The load cell distraction assembly 50 is described with reference to FIG. 2. To allow the incorporation of load cells 30, mounts 32, 35 are designed to affix to telescopic distraction rod assemblies 31. The telescopic distraction rod assemblies 31, which replace the simple threaded rod 10 of FIG. 1, comprise a threaded distraction rod 33 threadedly received in a telescoping rod 34. A separate alignment rod 36 is attached to the lower fixator ring 13 and is employed to facilitate assembly of the load cell 30, the lower mount 35 and the lower coupled hemispherical washers 37. The mounts 32, 35 are designed to insure axial loading of the load cells 30 during distraction. The mounts 32, 35 are made of 440C stainless steel and therefore may be used in a sterile environment. The load cells 30 require hardened mating surfaces, so the mounts 32, 35 are heat treated to a hardness of 60 Rockwell C. An upper mount 32 is rigidly affixed to the telescoping rod 34. A lower mount 35 is assembled to the distraction rod assemblies 31 as will be described more fully below.
A prefabricated load cell 30 is used that not only meets the above design criteria but also fits over the alignment rod 36 with minor modifications. The 900 Newton capacity cannulated load cell 33 is mounted in hardened steel mounts 32, 35. The load cell 30 has a hollow annulus which permits the alignment rod 36 to be passed through it.
It has been found that a suitable load cell 30 is the AL Design, Inc. Model ALD-W-5 compact, temperature compensated load transducer designed to approximate the configuration of regular bolt washers. Each load cell 30 has a full Wheatstone Bridge circuit with the strain sensitive elements attached to a load column resulting in a linear output signal which is a function of load. Each load cell 30 has a capacity of 200 pounds force (890 Newtons) and a nominal sensitivity of 2.0 millivolts per volt of excitation at 200 pounds force. Since the actual sensitivity of each load cell 30 is slightly different from the nominal value, each is matched to a signal conditioner 40 with the appropriate gain to produce 5 volts DC output at full load as will be described more fully below.
The load cell 30 is seated between mounts 32, 35 in line with the distraction rod 33 and alignment rod 36. The mounts 32, 35 are then connected to upper and lower coupled hemispherical washers 37, 38 (conical washers, Smith and Nephew Richards, Memphis, Tenn.) to eliminate bending loads. The pure axial load is transmitted from the upper fixator ring 11 to upper hemispherical washers 38 to the distraction rod 33 and telescoping rod 34, through the upper mount 32 to the load cell 30 across the lower mount 35 to the lower hemispherical washers 37 and finally into the lower fixator ring 13.
The load measuring system for each external fixator consists of three identical load cell distraction assemblies 50 as shown in FIG. 3. Referring to FIG. 4, the load cell 30 in each load cell distraction assembly 50 is driven by a transducer signal conditioner 40 modified for a zeroing offset adjustment. A suitable device is Analog Devices Model 1B32AN Bridge Transducer Signal Conditioner. These devices offer programmable gain and excitation, a common mode rejection ratio of 150 dB (60 Hz G=1000), remote sensing of excitation, and a 4 Hz, 3-pole low pass filter with a 60 dB per decade roll off. The filter reduces line noise and improves the signal to noise ratio. Because the forces within the system are slowly varying, the narrow bandwidth of the 1B32AN poses no problems. Since the mounting card for the 1B32AN does not offer outboarding of the offset adjustments (zero suppression) for the amplifier, the mounting cards may be modified to allow offset adjustments to be made from the front panel of the instrument.
Because of the difference in sensitivity of each load cell 30, each should be matched to a signal conditioner 40. The gain of each signal conditioner 40 is set to produce a signal ranging from 0 to 5 volts for a full scale measurand (890 and 2224 Newtons force). The signals are multiplexed to a high speed analog to digital converter (ADC) 42 through a multiplexer 41.
In order to record the output of all the load cells 30 in a reasonable period of time and to make data collection less rigorous, the outputs of the load cell 30, after conditioning, are connected via a 16 channel multiplexer 41 to a high speed ADC 42 operating in one of the I/O slots of an IBM compatible computer 43. An acceptable 12-bit ADC 42 is a Daisi Model DAI-120 Data Acquisition Module. The DAI-120 has a 50 k-Hz sampling rate, 125 ns aperture time and a 12 μs settling time. This module allows for any of 16 analog input signals to be independently selected by the user.
The software developed for this system is a menu driven, interactive program developed specifically for the present invention. The software consists of several menus which guide the user through the testing procedure. Error trapping is incorporated to check the validity of the user's response. As an aid in record keeping, each data file is tagged with a header file which contains information about the test. The user is prompted to answer a group of questions pertaining to the test with a default value listed with each question. These header files are also used to acquire the information needed to gather data and are stored as a random access data files. Since the values returned from the analog to digital converter 42 are proportional to the output of the load cells 30, these values must be converted to values that are dimensionally the same as the measurand. This conversion is performed prior to the data being stored or displayed. Forces are given in Newtons and the displacements in millimeters. Since the monitored parameters within the system fluctuate slowly and each test may exceed two hours in length, a data accumulation rate of one sample every ten seconds is selected. This permits an adequate number of samples to be accumulated allowing representative plots of the data to be generated.
To assist in setting up the test equipment, real-time signal output from the load cells 30 may be displayed on the computer monitor. This allows offset voltages to be removed from the system prior to data accumulation. Output signals from the load cells 30 are also continuously displayed while data is being accumulated.
After creating the header file the user is directed to the data acquisition section of the program. In this section the user is first allowed to zero the system, and then asked to input the length of time over which data is to be accumulated. At this point, control is passed to the computer. The ADC channels which the user selected when setting up the header file are read and the data stored and displayed for the desired time interval. At any time data acquisition may be halted without loss of data. The data is stored to an array and then written to a disk file.
Other options provided within the software are subroutines for printing out data and header files, plotting data on the screen and dumping screens to the printer. These options have a convenient means of evaluating the data.
The washer type load cell 30 is designed around strain gauges bonded to a central aluminum ring. Load is transmitted to the ring element by mechanical bearing on this thin edge which is 0.35 mm thick and 10.8 mm in outside diameter. This mechanical connection is exquisitely sensitive to slight flatness imperfections in the bearing surfaces. To eliminate variability in readings due to this characteristic, the assemblies 50 are tested individually with dead weights to determine the optimal alignment of the hemispherical washers 37, 38, load cell 30 and mounts 32, 35. This alignment is then used in all further testing.
The assemblies 50 were tested in a testing jig to model an Ilizarov type configuration. A 120 mm diameter Ilizarov ring (Part Number 101202, Richards Smith Nephew, Memphis) was connected with three load cell distraction assemblies 50 to a 12 mm aluminum plate drilled to match the ring pattern. A single fixed rod was bolted to the plate and passed through the upper ring to provide mechanical stability. An aluminum platen bolted to a 25 mm aluminum rod was connected to the proximal ring with tensioned 1.8 mm smooth wires (Part Number 102100, Richards Smith Nephew, Memphis). Loads were applied to the platen with an Instron testing machine. Load magnitude and location were varied to stimulate different axial loads and bending moments. The system error was found to be less than 10% of the applied load.
A group of mature hounds undergoing tibial lengthening by the Ilizarov technique were used for a source of load readings. This group consisted of twenty-one dogs with either metaphyseal or diaphyseal corticotomies and varying latency periods between surgery and the start of distraction. The Ilizarov external fixator had been surgically applied with a 260� upper ring 11 and a full lower ring 13. Two 1.8 mm transosseous wires 21 were tensioned and bolted to each ring 11, 13. Three distraction rods 10 were evenly distributed between the rings 11, 13. All subjects were distracted a total of 28 mm (about 15% increase over baseline) at the rate of one mm/day by two 0.5 mm distractions in the morning and evening.
At one week intervals during the four week distraction phase the subjects were sedated and positioned supine on a holding frame. The external fixator was suspended so the tibia was horizontal to eliminate gravity loads. A dial caliper (Mitutoyo #505-635-50, Japan) was used to measure the baseline ring separation at the three distraction rod 10 locations. The load cell distraction assemblies 50 were installed and the load transferred from the distraction rods 10 to the load cell distraction assembly 50 by loosening the nuts 12 on the distraction rods 10 which were left loosely in place to provide translational control between the rings 11, 13. Load measurements were recorded for one minute before distracting each rod 0.5 mm. Loads were then measured for an additional nine minutes. After the monitoring period the load cell distraction assemblies 50 were removed and the rings 11, 13 reset to the proper position.
It is typical of distraction osteogenesis that loads show an instantaneous increase upon distraction followed by a gradual decline in load as stressed tissues relax. There is also an overall general increase in load over time as limb lengthening progresses. Once distraction is completed and bony consolidation begins, loads measured in the distraction apparatus decrease as more of the load is borne by the increasingly stiff bony tissue of the limb.
Each subject was studied with a Siemens Somaton DR3 CT scanner prior to surgery and at the end of distraction. A scout view and serial 4 mm axial slices along the tibia were obtained. The baseline tibia length was measured from the scout view. The cross-sectional area of the osteogenic zone at the end of distraction was computed at the scanner console by outlining a freehand region of interest around the new bone. The axial images were later processed to obtain the area of soft tissue at the osteogenic zone using a video image processing computer program (Image Analyst, Automatix, Billeerica, Mass.) running on a Macintosh IIx system.
Plain radiographs in the A-P and lateral projections were obtained at weekly intervals during distraction, at fixator removal, and prior to sacrifice. An aluminum stepwedge was used for density control.
The radiographs were examined during the distraction phase for signs of premature fusion of the osteogenic zone. These signs included radiodense bridging of the corticotomy site 22 and excessive deflection of the transosseous pins 21. The clinical outcome of the lengthening procedure was determined from examination of the last radiograph prior to sacrifice. Observer bias was prevented by using an investigator to analyze the radiographs who was unaware of the load measurement results. An outcome was judged to be a nonunion if there was a continuous radiolucency in the osteogenic area. An outcome of malunion was assigned if angular deformity (>5 degrees) existed without signs of a nonunion.
The variables for each subject were baseline tibia length, osteogenic zone area, soft tissue area at the osteogenic zone, latency from surgery to start of distraction, and distraction loads at weekly intervals. This data was grouped by both osteotomy site and outcome then analyzed using the BMDP statistics package (BMDP Statistical Software, Inc., Los Angeles, Calif. 90025). The BMDP programs used were 3D (T - Tests), 1R (Linear Regression by Groups), and 5V (Unbalanced Repeated Measures Models with Structured Covariance Matrices).
Six dogs had premature fusions early during the distraction phase. These were easily discernable on the plain radiographs. Loads were measured in these subjects within the safety limits of the load cells 30 so as not to overload the gauges and endanger the instrumentation system.
Fifteen dogs completed the distraction load measurement phase of the study. One animal died of lymphosarcoma (unrelated to the experimental protocol) prior to scheduled sacrifice. Fourteen dogs completed the entire protocol to final bone healing for outcome assessment. The clinical outcomes of these fourteen dogs were assessed radiographically prior to sacrifice at day 119 after surgery. There were eleven unions and three nonunions at the completion of the study. Two of the unions developed angular deformity that was felt to be secondary to premature removal of the fixator. These results are summarized in Table 1.
TABLE 1______________________________________Subject Groupings and Outcomes Outcome Pre-Corticotomy Latency Non- Union with Normal matureSite (Days) union Deformity Union Fusion______________________________________Metaphyseal 0 2 7 1 1 14 2 21 3Diaphyseal 0 3 7 1 1 14 1 1 1 21 1 1 1______________________________________
No significant difference was found by t-test in the baseline tibia length when grouped by corticotomy site (p=0.6424). There was a significant difference between osteogenic cross-sectional areas (p=0.0138) as calculated by CT scans; the mean (and standard deviation) of the metaphyseal sites were 3.31 cm2 (0.57) and of the diaphyseal sites were 2.34 cm2 (0.43).
The mean (and standard deviation) of the weekly load measurements are shown in FIG. 5A grouped by corticotomy site. Diaphyseal (n=40) and metaphyseal (n=20) observations from 15 subjects were divided evenly over the four observation periods. The mean load at the end of distraction was 155 Newtons for metaphyseal (n=5) and 111 Newtons for the diaphyseal (n=10) sites respectively.
Load based on the time from surgery was highly significant (p<0.0001). The effect of corticotomy site was also significant (p=0.0207). The interaction of time and corticotomy site was suggestive, but not quite significant (p=0.056).
A linear regression by groups was performed on the distraction loads vs. time and is shown in Table 2. For all data as a single group, R2 =0.55 (p<0.0001). An analysis of variance of regression coefficients over groups was highly significant (p=0.00161) indicating the slopes of the regression lines between metaphyseal and diaphyseal sites are statistically different for measured loads over time. The individual distraction loads were then divided by the respective cross-sectional area of the osteogenic zone in each subject. The resulting quantity was called the "osteogenic zone stress"; the regression analysis on this data is also in Table 2. For all data as a single group, R2 =0.50 (p<0.0001). An analysis of variance of regression coefficients over groups was not significant (p=0.87) indicating there was no statistical difference in the slopes of the regression lines for calculated stress.
This procedure was repeated using the cross-sectional area of all soft tissue in the osteogenic zone to calculate the "soft tissue stress". R2 =0.42 (p<0.0001) for all data as a group, and analysis of variance of the regression coefficients between groups was still significant (p=0.0005).
There was a significant difference in the baseline tibia length (p=0.0292) when grouped by outcome. The mean lengths and standard deviations were 175 mm (5.24) and 185 mm (9.70) for the unions and nonunions respectively. Furthermore, the three nonunions had osteotomies at the diaphyseal site. There were no significant differences in latency, osteogenic zone area, or soft tissue area. A linear regression of the load readings demonstrated a significant difference in the slopes (p<0.023) as shown in Table 2. The mean (and standard deviation) of the weekly load measurements are shown in FIG. 5B grouped by outcome. When compared by t-test there was a significant difference in loads at the end of the third week (p=0.044). There was a suggestive change at the end of the second week (p=0.056). No significant difference was found in the other weekly measurements.
TABLE 2__________________________________________________________________________Linear Regression Statistical Analysis p, differenceCalculation in regressionMethod Group R2 p < Slope Intercept lines__________________________________________________________________________Loads Only Metaphyseal 0.65 0.0001 5.69 -1.19 0.0016 Diaphyseal 0.58 0.0001 3.80 5.43Loads/Osteogenic Metaphyseal 0.61 0.0001 1.78 -1.06 0.8731Zone Area Diaphyseal 0.46 0.0001 1.74 1.78Loads/Soft Metaphyseal 0.62 0.0001 0.18 -0.10 0.0005Tissue Area Diaphyseal 0.48 0.0001 0.28 0.45Loads Only Nonunion 0.56 0.0047 2.42 13.96 0.0028 Normal 0.63 0.0001 4.79 -0.15 Union__________________________________________________________________________
This study shows that distraction loads increase with time during the actual lengthening. No appreciable decay in load was seen between the weekly measurements. Empirically, elastic tissue resistance is the most likely cause of the force increase.
This study statistically supports earlier case reports that suggest distraction loads vary with corticotomy site (metaphyseal vs. diaphyseal). We hypothesized that this load is directly related to distraction of the collagenous bridge central to the osteogenic interzone. This was supported statistically when the measured loads were converted to stress by dividing the osteogenic zone area into the load. When metaphyseal stresses were compared to diaphyseal stresses by linear regression, there was no longer a significant difference between groups and the regression lines for the two groups were essentially parallel and collinear. When the loads were normalized by the soft tissue area, a significant difference between the metaphyseal and diaphyseal groups remained, consistent with the hypothesis that a large portion of the distraction load is generated in the fibrous interzone.
This study suggests that distraction loads measured during the actual limb lengthening are useful in predicting the clinical outcome of the procedure. The nonunion group (n=3) had statistically significant lower loads at the end of week three than the normal group (n=11).
The significant difference in tibia length between outcome groups could be due to chance since multiple statistical comparisons were performed on a small group of subjects. If nonunions are less resistant to distraction (lower loads), these tibiae would stretch further for a given fixator distraction, which could account for the increased tibial length, a mean of 10 mm at the end of distraction. Low load measurements during the distraction phase may indicate low axial stiffness which may lead to mechanical instability and larger movements in the osteogenic zone. Larger distraction increments or macromotion could disrupt normal tissue differentiation and result in a nonunion. Alternatively, inadequate collagenous bridging may be less resistant to distraction loads. Nonunions stem from fibrocartilage and necrotic, loose connective tissue, both of which contain less collagen and are therefore less stiff and result in lower loads early in the distraction phase. A high early load in the distraction phase is a sign of premature consolidation. Normal load increments indicate appropriate collagen bridging across the fibrous interzone.
Direct axial loads were measured weekly during a 15% left tibial lengthening in 21 skeletally mature dogs using three in-line load cells mounted between the rings of an Ilizarov external fixator. The loads all increased linearly over time to a maximum at the end of distraction (week 4). The metaphyseal lengthening site (mean 155 Newtons) generated significantly higher loads than diaphyseal sites (mean 111 Newtons). Stress was calculated by dividing measured load by the CT measured cross-sectional area of each distraction osteogenesis site; the metaphyseal and diaphyseal groups demonstrated equal stress at each time point with a maximum of 47 Newtons/cm2 at the end of distraction. Six premature consolidations occurred that demonstrated loads significantly greater than 200 Newtons by week 2 of distraction. Three nonunions occurred which had significantly lower loads measured by week 3 of distraction (mean 60 Newtons or 26 Newtons/cm2). It is well known in the art that, with adjustments for the greater cross-sectional area of human bones, experimental data on canines is directly transferable to human patients.
The apparatus of the present invention may be used to measure moment free axial loads in the bones of patients undergoing the distraction osteogenesis procedure using an Ilizarov external fixator. By measuring actual loads generated during the distraction procedure, the method of the present invention may be employed to improve the clinical outcome of the procedure. By avoiding loads on the biological zone of the corticotomy site that are neither too high nor too low, it is possible to avoid nonunion or premature consolidations. For human patients a load range from approximately 20 Newtons early in distraction to approximately 500 Newtons late in distraction is desirable.
Furthermore, the effectiveness of the method of the present invention may be improved by employing a variation on the method in which measurements of the cross sectional area of the corticotomy site may be used to calculate the stress at the corticotomy site rather than the total load at the corticotomy site. It is therefore possible to effect a normalization which reflects the variation in the cross sectional area of the corticotomy site in various patients. A stress range from approximately 27 Newtons per square centimeter to approximately 100 Newtons per square centimeter is desirable while a stress range from approximately 45 Newtons per square centimeter to approximately 50 Newtons per square centimeter appears to be optimal by approximately three weeks of distraction.
Further, the apparatus and method of the present invention may be employed in the end stages of the distraction procedure to assess the end of healing. After the desired degree of limb lengthening is achieved, the corticotomy site will not have completed bony consolidation. The degree of bony consolidation is assessed by loading the patient's limb; for example, by having the patient stand on the leg on which the distraction has been performed. Loads are measured across the corticotomy site. As the degree of bony consolidation progresses, the consolidated bony tissue is able to carry proportionally more of the load on the limb. When essentially all of the load is carried by the limb and not by the fixator, bony consolidation, and therefor healing, is complete and the fixator may be removed.
Although the apparatus and method of the present invention are described with respect to certain preferred embodiments, one skilled in the art would recognize that other variations are possible without departing from the scope of the invention as set forth in the appended claims.
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26th Chaos Communication Congress in Berlin
Under a banner of "Here be dragons," an inscription found on old navigational charts, the Chaos Computer Club held its annual conference for the 26th time.
Guarded by a watchful dragon, the Chaos Computer Club (CCC) welcomed some 4,000 visitors to Berlin's Congress Center at Alexanderplatz. Despite having to wait in line, visitors were able to experience around 80 talks.
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Find the Adjectives
Hit a home run with your child while learning about adjectives. You can share your favorite baseball experience and give your child a fun grammar lesson all in one at-bat.
Topics: Spring, Second Grade, Grammar
Updated on Jul 29, 2013
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Saints bounty scandal is worse than Spygate for the example it se...Gregg Easterbrook
TMQ says the Saints scandal threatens the NFL's integrity.Story | Conversation | March 06, 2012
The Flem File uncovers some of the worst testicle injuries in spo...David Fleming
Flem File has the balls to write about testicle injuries.Story | Conversation | October 05, 2011
Kurt Snibbe's Page 2 cartoon caption contest winnerKurt Snibbe
Earlier today, we posted a blank cartoon and readers offered their captions. Our favorite was by user thehunter000. Thanks for participating. Check back tomorrow for another cartoon....Blog | Conversation | September 22, 2011
Kurt Snibbe's Page 2 cartoon caption contestKurt Snibbe
Take a shot at writing a cartoon caption. Page 2 cartoonist Kurt Snibbe will offer up a blank cartoon each weekday morning, and he will fill in the blank with our favorite reader submission at the end of the business day. So please, by all means, sh...Blog | Conversation | September 22, 2011
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Virginia Tech helmet study provides much-needed information.Story | Conversation | July 19, 2011
Remembering highlights of Kyrie Irving era at Duke, which was all...Dave Wilson
Kyrie Irving, college basketball hardly knew you. The heralded freshman point guard declared for the NBA draft on Wednesday and plans to hire an agent, after playing in only 11 games for the Blue Devils, missing much of the season with an injured big...Blog | Conversation | April 07, 2011
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With apologies to author Richard Connell -- oh, and also Ice-T and Gary Busey in "Surviving the Game" -- the world's most dangerous game isn't man hunting man for perverse sport. It's man elbowing, kneeing and tripping man -- or just plain landing f...Blog | Conversation | April 01, 2011
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Winnipeg Free Press - PRINT EDITION
Why Republicans can blackmail
A salient feature of American "exceptionalism" is the belief that the United States can never be ordinary. If it is not the best, then it must be the worst. If it is not destined to dominate the world forever, then it is doomed to decline and decay.
This kind of thinking explains why much of the commentary in the United States about the recent "shutdown" of the U.S. government, and also about the impending default on the national debt (due on Oct. 17), has started at hysterical and quickly geared up to apocalyptic. We Americans have lost the mandate of Heaven, and it will soon be raining frogs and blood.
So everybody take your tranquilizer of choice (mine's a double scotch), and let's consider what is actually going on here. The United States is the world's oldest democratic country, with an 18th-century constitution that is bound to be an awkward fit for 21st-century politics. But that hasn't stopped the United States from becoming the world's biggest economy and its greatest power. Has something now gone fundamentally wrong?
The problem lies in Congress, specifically in the House of Representatives, where the Republican majority is refusing to pass the budget, and threatening not to raise the official debt ceiling either, unless U.S. President Barack Obama postpones the implementation of his bill extending medical care to all Americans.
The Affordable Care Act was passed by both houses of Congress and signed into law by Obama almost four years ago. Last year it passed scrutiny by the Supreme Court, and was subsequently welcomed by a majority of the voters in the presidential election, so Obama is understandably refusing to yield to blackmail. But the House Republicans seem mysteriously unworried by the fact the public blames them for the impending train wreck. Why?
Because 80 per cent of the Republicans in the House of Representatives don't have to worry about what the general public thinks. They represent Congressional districts that have been so shamelessly gerrymandered by state legislatures that it is almost impossible for anybody who is a Republican to lose an election there. National public opinion is no threat to them, whereas the views of their extremist Tea Party colleagues are a potentially lethal danger.
You can't gerrymander the Senate; every senator's "district" is the entire state he or she represents. State legislatures controlled by the Democrats also gerrymander congressional districts to create safe seats for their own party, but there is no organized extremist group in the Democratic Party that will try to destroy elected members of their own party who do not toe the ideological line. Whereas in the Republican Party, there is.
Republicans seeking reelection to the House of Representatives may not have to worry about their Democratic opponents, but they certainly have to fear the Tea Party. If it decides to mount a challenge to an incumbent in the Republican primary elections, the far-right challenger will be lavishly funded by the Tea Party's wealthy supporters, and that may mark the end of the incumbent's political career.
So the Republicans in the House of Representatives, even those generally open to compromise, are keeping their heads down for fear of angering the Tea Party. That means it is possible (though not probable) that the Oct. 17 deadline will be missed, and the U.S. government will be forced to default on its debt. How bad would that be?
Very bad, according to a U.S. Treasury spokesperson. "Credit markets could freeze, the value of the dollar could plummet, U.S. interest rates could skyrocket, the negative spillovers could reverberate around the world." And it might rain frogs and blood.
Or maybe not. There would certainly be turmoil in the markets: many people would lose money, and some would gain. But it would not be a repeat of the crash of 2009, when it was suddenly understood that huge amounts of the mortgage debt held by banks could never be repaid. The U.S. government can still pay its debts; it just has to get Congress's permission first. And the markets, while prone to panic, are not completely stupid.
Nor is the U.S. Constitution fundamentally broken. It always requires a fair degree of compromise between the various branches of the government in order to work smoothly, and at most times in history that cooperation has been forthcoming. The current paralysis is due mainly to the gerrymandering of Congressional districts that makes members of the House of Representatives less afraid of public opinion than of the views of their own party's hardliners.
It wouldn't hurt to put some controls on election spending as well, so that rich ideologues had less influence over the political process. But that is merely desirable; ending the gerrymandering is absolutely essential. It will take time, but this is a problem that can be fixed. And in the meantime, the U.S. government is not really going broke.
Gwynne Dyer is an independent journalist whose articles are published in 45 countries.
Republished from the Winnipeg Free Press print edition October 8, 2013 A6
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Enjoy dining in the contemporary-styled restaurant. The menu offers a selection of starters, flame grilled steaks, lamb and chicken plus fresh line fish of the day. Salads, 200 gram beef burgers and a range of home made desserts.
The 75-seater Black Sheep Diner and adjacent Satellite Bar are fast becoming a regular spot for our members and their guests.
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Black Sheep Diner December Special
Visit the Black Sheep Diner and enjoy a delicious 200g Steak and 400g Ribs served with your choice of Vegetables or Chips. Every Wednesday, for only R 175 per person.
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- Local businesses have generated 65% of the country's net new jobs over the past 17 years — US Small Business Administration
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