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Parents seeking information and advice on the treatment of Perthes’ disease of the hip unknowingly confront
longstanding medical controversies that surround the management of this condition.  After the initial
diagnosis of the condition it is not unusual that parents will receive as many different recommendations as
the number of opinions obtained. So the parents, who are already upset with the unexpected news that
their child has a disease, are placed into the unusual position that they must pick among widely different
medical opinions and procedures.  This adds confusion to an already troubled situation for parent and child.
With the intent to help parents, I am writing this information so they can better understand the issues and
hopefully make more informed decisions for their child’s treatment.

What is Perthes?

Legg-Calve-Perthes disease is an uncommon condition (1/5000) that affects one, or sometimes both, hips
of a child between the ages of 3-15.  Despite the coincidence, the condition isn’t named Legg nor Calve
because these areas are affected.  Rather these names apply because doctors Arthur Legg, Jacques Calve,
and Georg Perthes independently identified the disease in the early part of the 20th century shortly after x-
ray diagnosis tools became available.  The disease is commonly known as Perthes or simply the abbreviation

In adults, there is a condition similar to Perthes called avascular necrosis (AVN) or osteonecrosis of the hip.
With both of these conditions, and for unknown reasons, the femoral head loses part (or all) of its blood
supply and part (or all) of the bone of the femoral head dies.  (Dead bone in the body is called “necrotic”
bone.)  The actual loss of blood circulation is an acute event and is the root cause of Perthes.  The “loss of
blood supply” event happens without the awareness of the patient and is usually not associated with
obvious symptoms.   In fact, the first symptoms of Perthes may not develop for several months after the
initial “loss of blood supply” episode. Once the femoral head dies it takes roughly 1-2 years for the body to
absorb the dead bone and then 1-3 additional years as the body attempts to re-grow and re-form the
femoral head.   This lengthy timeline and the body’s responses during the timeline is part of what is called
the “natural history” of Perthes.
Perthes’ for Parents
by Dror Paley, MD, FRCSC
During the 8 to aproximately18 months after the initial “loss of blood supply” episode, the disease progresses due to the body’
s normal repair mechanisms to remove and replace the dead bone of the femoral head.  During this repair process the femoral
head may be sufficiently weakened such that it collapses leading to deformation of the joint surface.  This deformation creates a
non-spherical femoral head inside of a spherical socket and ultimately leads to joint stiffness, arthritis and pain.

How does a normal repair process designed to rid the body of dead bone go so awry.  To understand this it is important to
know something about the normal repair process.   The femoral head is made up of a core of bone surrounded by cartilage.
The cartilage of the femoral head gets its oxygen and nutrition from the fluid in the hip joint.  The bone in the femoral head
gets its oxygen and nutrition from blood vessels that enter the femoral neck from outside the bone.  The femoral neck is
separated from the rest of the femur bone by the growth plate (growing zone) of the upper femur. When there is blockage or
damage to these blood vessels the bone in the femoral head dies due to loss of oxygen and nutrition.  The cartilage on the
outside of the femoral head which surrounds the underlying dead bone does not die since it gets its oxygen and nutrition by
diffusion from the fluid inside the hip joint. The dead bone is removed by special bone eating cells (osteoclasts).  New living
bone is produced by special bone making cells (osteoblasts).  As the dead bone is removed from the femoral head, the support
of the cartilage of the joint is weakened.  If the surrounding cartilage structure is thick and strong enough, there will be enough
time for new bone to be deposited to replace the removed bone and there will be no change in shape of the femoral head.  If
too much support is removed and the surrounding cartilage cannot withstand the load, then the weight bearing surface of the
femoral head will slowly collapse under the body’s weight and the normally spherical femoral head becomes flattened to a more
egg shaped configuration.

To help explain the collapsing process, I like to use the analogy that compares the femoral head (that has been damaged by a
previous loss of blood supply episode), to the renovation of a building.  Imagine an old building that, although still intact, has
severely weakened internal support structures that must be replaced with new internal supports in order to prevent the roof
from collapsing.  If the “demolition team” removes some old support beams and the rest of the building structure can
withstand this weakening, then the roof will not cave in and there will allow enough time for the “construction team” to replace
the old support beams with new beams.  If, however, too many of the old support beams are removed before the construction
team can replace the supports then the roof will cave in.  A caved in roof is hard to rebuild and unfortunately can lead to a
deformed new roof- especially if the crashed roof has lots of weight on it like a snow covered roof.

Bringing this analogy back to the femoral head, the roof of the building is the hard, dense outer surface of the femoral head
that is called “subcondral bone” that supports the overlying cartilage of the femoral head.  The supporting beams within the
building are a low-density, honeycomb like bone called “trabecular bone” that forms the core of the femoral head.  The old
supports are dead trabecular bone that died from lack of blood supply and are eaten away by osteoclast cells.  The new
supports are the reforming trabecular bone installed by the osteoblast cells.  The tons of wet snow on the rooftop, represents
the body’s weight and muscle forces that continuously apply load through the hip joint tending to crush and permanently
deform the weakened, fragile femoral head that while it is trying to renovate its structure.

The best results in Perthes occur when the roof of the femoral head does not collapse or when it only minimally deforms, and
when there is plenty of time to repair the damage such as in a younger child. The worst results in Perthes occur when the roof
caves in badly and the older child doesn’t have adequate growing time to repair the damage.

Unfortunately, if the roof deforms, the resulting egg shaped,  femoral head is no longer shaped as sphere and therefore cannot
move in all directions like a ball in a socket.  This reduces the normal range of motion (ROM).  Furthermore if the shape of the
ball (femoral head)  is mismatched with that of the socket (acetabulum)  there will be abnormal wear and tear in the joint
leading first to stiffness, then to pain and eventually to loss of the joint cartilage (arthritis).  This early osteoarthritis often
leads to total hip replacement (THR) as an adult as early as the 30’s, but more likely the 40’s, 50’s or beyond depending on the
degree of deformation and joint shape mismatch left behind by the Perthes disease process.

Why does Perthes’ occur?

Unlike other joints in the body, the femoral head within the hip joint has a very unique, but precarious blood supply where
almost all the blood going to the femoral head is delivered by one main blood vessel system that must enter the femoral head
by traveling across the femoral neck into the hip joint and finally into the head at its junction with the femoral neck.  Since the
hip joint is designed to permit motion in all planes, these blood vessels must move with the femoral head throughout its
complete range of motion.  In certain positions, these vessels may get kinked as the femoral neck presses against the edge of
the acetabulum.  Moreover, certain mechanical positions of the leg may promote this kinking for prolonged periods of time.  For
example, prone sleeping on the belly with hips extended and toes pointed outward may restrict blood flow to the femoral head.

There is a lot of interest to as to why some children have loss of blood supply episodes and others do not.  Research has
identified some factors that may predispose children to Perthes disease. Hypercoagulability (faster clotting of blood) is
considered a risk factor.  Hypercoagulability means that the blood clots abnormally quickly.  It is theorized that the combination
of hypercoagulability (which may be genetic) and mechanical episodes of kinking of the blood vessels of the femoral neck can
lead to clotting off of these arteries and loss of the normal blood flow to the femoral head.  Studies on hypercoagulability are
still inconclusive.  While some studies have shown that patients with Perthes’ have abnormal clotting factors compared with
other children, other studies have refuted this claim.  External environmental factors such as exposure to second hand smoke
has also been implicated as a causative factor.  Repetitive mechanical trauma  (e.g. gymnasts) to the hip joint may also
predispose children to loss of blood supply to the hip joint.  Researchers have also observed that many Perthes children have
delayed skeletal maturity at onset.  The bone age (measured from a hand x-ray) is often 2 years or more behind the
chronologic age.  Finally, there are some underlying disease conditions that increase the risk of Perthes or Perthes-like disorder,
such as: sickle cell anemia; hypothyroidism; epiphyseal dysplasia; Gaucher’s disease; graft versus host reaction after bone
marrow transplant; leukemia.  Such underlying disease conditions also predispose the child to the much less common bilateral
Perthes’ where both the left and right femoral heads are affected.  About 15% of children afflicted with Perthes in one hip will
get it in the other hip.

What is the long-term prognosis for Perthes’?

Ultimately, the long-term prognosis depends on the mechanical shape of the femoral head as it interfaces to the acetabulum
within the hip joint.   However, the final mechanical interface won’t be known until the disease runs through the lengthy repair
process that can last up to 5 years after the loss of blood supply episode.  So the short-term problem confronting orthopedic
specialists is that they need to examine the hip very early in the process and they need to estimate the final mechanical
configuration and then make informed judgment about the necessity and type of treatment.

The best method to estimate the prognosis for child can be used very early in the disease process (only a few months after the
no blood episode).  This prediction technique is based on two pieces of information:  1) the age of the child at onset and, 2)
the degree of necrotic bone involvement within the femoral head.  The older the child when diagnosed, the worse is the
prognosis.  Children under age six have the best prognosis even without treatment.  For children over age of six, the best
prognosis is between 6-8 years of age.  The prognosis worsens between ages 8-10 years and is often quite poor after age 10.
The relationship between age at onset and prognosis is widely agreed upon by pediatric orthopedic surgeons.

The other major prognostic factor evident early, is the extent of femoral “head involvement”.   The smaller the amount of
femoral head involved (with loss of blood supply) the lower the risk of long-term femoral head deformation.  The simplest
classification of Perthes’ (Salter-Thompson classification) divides cases into “partial” vs. “whole head” involvement which
corresponds to <50% and >50% of the head affected respectively.  Obviously the prognosis is better with partial head
involvement than with whole head involvement.  Most agree that partial head involvement cases require no treatment.

What are the treatment alternatives for Perthes’?

If your child is older and has greater than 50% head involvement then treatment may be indicated.  Treatment for Perthes’ can
be generally divided into four categories:

1)        Range of motion (ROM) only treatment
2)        Trans-Neck-Head Tunneling (TNHT)
3)        Containment Treatment.  (There are 5 different types of containment treatment)
4)        Distraction Treatment

1. ROM Treatment:  Everyone agrees that maintaining hip ROM is a good for patients with Perthes because it helps prevent
stiffness of the femoral head. It is thought to help the injured femoral head maintain and regain its spherical shape. ROM
exercises are a component of all treatment regimens.  Nevertheless in children, over age six, with whole head involvement, it
has been shown that any treatment is better than ROM alone.  Although ROM has also been combined with prolonged bed rest
or non-weight bearing by crutches or wheelchair, this only provides symptomatic relief initially when the child is first having pain
and limp, and has no proven long-term benefit.

2. Trans-Neck-Head Tunneling  (TNHT):  The TNHT method was developed in Portugal by Dr. Nuno Lopes.  He has used it for
over 20 years and has drilled over 200 hips.  This technique involves making a 5 mm hole with a drill, or a device called a
trephine, from the lateral side of the femur up the femoral neck, across the growth plate, and into the center of the dead bone
within the femoral head.  The function of growth plate (physis) of the upper femur is to cause the femoral neck to grow in
length adding to the growth in length of the femur.  The growth plate acts as a barrier to blood vessel communication between
the bone of the upper femur and the femoral head and neck.  In adults when the growth plate closes and disappears there is a
communication between the circulation of the two parts of the bone.  When there is loss of blood flow from the arteries
entering the femoral neck from the outside the circulation of the rest of the femur cannot provide blood flow to the femoral
head because the growth plate acts as a barrier.  By drilling a hole through the growth plate a portal of communication is
opened between the rest of the femur and the avascular femoral head.  The blood vessels from the upper femur grow through
the hole in the growth plate to resupply circulation to the avascular femoral head.

Dr. Lopes has observed that drilling leads to more rapid reconstruction of the femoral head  in early Perthes. Using MRI and
ultrasound to screen patients at risk he has identified a pre-Perthes stage of disease.  He claims that TNHT at this very early
stage can lead to complete resolution of the problem and avert the resorption and reossification phases of Perthes.  His
indications for this procedure are children with whole head involvement who are identified at the pre-Perthes’ (MRI changes
only) or very early Perthes’ stage (e.g. subchondral fracture).  According to Lopes this method is almost universally successful
at the pre Perthes’ stage and about 50% successful at the early Perthes’ stage so that no further surgical treatment is
required. I have been using this method since 2001. My results in early Perthes are similar to Lopes. External bracing is
indicated after TNHT to protect the fragile head.   Interestingly, TNHT may have a special role to prevent the progression on the
opposite hip. The second hip is identified on the MRI in the prePerthes stage which is when it is completely curable by TNHT.

For further information on this please refer to Dr. Lopes web site (  The attractive aspect
of this method is that it is minimally invasive and technically simple for any orthopedic surgeon to perform. TNHT is similar to a
procedure called “core decompression” has been used in AVN cases in adults for over thirty years. In adults, like children,
drilling only works well in very early stages of disease.

The main risks of TNHT are fracture and growth arrest of the femoral neck.  However, since the hole diameter is small compared
to the overall cross-section of the neck, the risk of fracture is minimal.  Neither Dr. Lopes nor I have experienced any fractures
after TNHT.  Growth arrest of the proximal femoral growth plate can occur if a bony bridge develops across the drill channel
joining the femoral head and neck with upper femur bone thus tethering further growth by the growth plate.  If a bridge
develops it can stop the growth of the upper femur or if it is too near the edge of the growth plate this can also lead to a
deformity since one side of the growth plate will continue to grow while the other side might be arrested.  Dr. Lopes research
has shown that as long as the drill hole is less than 10% of the area of the growth plate, then the growth plate will not stop
growing since the growing forces within the growth plate will be strong enough to prevent growth arrest. Our results are too
early to comment on this, but certainly we are wary of this potential complication of an otherwise minimally invasive surgical
method. It is important to note that closure of the growth plate of the femoral neck is a well recognized and common
complication of Perthes’ even when no treatment is performed.  Therefore it may be difficult to separate growth arrest due to
drilling versus those due to Perthes’.  I think this method is promising and may have an expanded role on its own or in
conjunction with other treatments.

3. Containment Treatment:  In a normal hip joint, the acetabulum only covers two thirds of the spherical surface of the femoral
head.  In a healthy hip joint, this partial coverage is not an issue, however, if the femoral head has been severely weakened by
the death of the underlying honeycomb bone then there is a serious mechanical problem that contributes to the collapse of the
weakened bone.  To understand the mechanical problem, you must understand the acetabulum is oriented at 45° to the pelvis
facing forward and outward, the front (anterior) and side (lateral).   Thus, the lateral rim of the acetabulum is the point where
the femoral head enters and exits the socket during normal use.  At the point of mechanical transition from the perfectly
molded acetabulum where the load of weight bearing and muscle compressive forces are distributed over the large surface area
of the femoral head and acetabulum, and the outside uncovered and unloaded femoral head, there is a high stress point called
a “stress riser”.  This “stress riser” and is essentially a high pressure point on the femoral head which contributes to the
collapse of the weakened femoral head.

Returning to the analogy of the building under reconstruction... think of the “stress riser” as a spot near the center of the roof
where the wet snow is much thicker and heavier causing high crushing pressure on the roof in that spot.  The biggest concern
about the  “stress riser” is that the most common part of the femoral head to be affected by the avascular necrosis is the
“antero-lateral quadrant” which is in exactly the spot where the stress riser is greatest!  This is bad news and is often where
the collapse of the weakened head begins.

Containment treatment refers to moving more of the uncovered femoral head (especially the affected part) inside the
acetabulum where there is no “stress riser” pressure point.  Mechanically this is accomplished by moving the femoral head into
“abduction” and “flexion”.  “Abduction” is the movement of the limb to the side (outward like the leg in Jumping Jack position)
so that the femoral head tilts into the socket where it is safe from excessive pressure.   “Flexion” is the movement of the thigh
towards the chest.  In the abducted and flexed position, the antero-lateral (front and outside) quadrant of the femoral head is
covered and protected by the acetabulum. One of the prerequisites for containment treatment is that the hip must be easily
moved into an abducted and flexed position.  If the hip cannot go into that position easily, then containment treatment is not
an option. Containment can be achieved by external bracing or by several types of surgeries as outlined:

A)        Abduction Bracing by external bracing systems worn by the child
B)        Femoral Varus Osteotomy surgery
C)        Pelvic Osteotomy surgery
D)        Shelf Augmentation surgery
E)        Combination Pelvic and Femoral surgery

A) Abduction Bracing:  This is a non-operative method of containment.  It is most useful in children between ages 6-8 years.
While there are numerous types of braces, the best known is the Scottish Rite abduction brace which has two thigh cuffs and a
bar in between them.  Another version of this type of brace that I prefer is two thigh cuffs connected by a pelvic band with no
bar between the knees.  While it is more flexible, I feel this is an advantage in that it moves the hip through a greater range of
motion as the thighs come together and apart during walking.  For the brace to be effective, it must to be worn 20 hours a day
until reossification of the lateral pillar (outer rim) of the femoral head. In a child aged 6-8 years old this can mean at least a year
and half.  Furthermore, the brace is only effective if ROM is maintained during treatment.  To assist in ROM, it is sometime
necessary to perform an adductor tenotomy where some hip tendons are cut and actually lengthened. In general, bracing has
gotten a bad reputation because it is often used in the face of a stiff hip and as mentioned, stiffness is a contraindication to
bracing.  Also, in older children, bracing may not be practical since it must continue for two years or more to be effective and
older children often refuse to wear the brace for cosmetic reasons leading to battles between the patient and parents.

B) Femoral Varus Osteotomy:  The word “varus” means “inward”.  The word “osteotomy” means to cut bone.  It might be
easiest to understand that a varus osteotomy of the upper femur is an operation where the bone of the upper femur is cut and
a wedge shaped piece of is removed so that the neck of the femur tilts inwards moving the normally uncovered portion of the
head inside the acetabulum.  In affect, the varus osteotomy achieves good coverage, like that obtained with bracing, but
without the need for the brace.

While this method is very good at getting good coverage and containment, it unfortunately does two bad things to the hip
joint.  First it alters the hip mechanics by changing the tension of the hip abductor muscles as they attach to the “other” top of
the femur known as the greater trochanter.  These muscles, as they attach to the greater trochanter, are responsible for
maintaining the pelvis level when standing on one leg (which occurs with every step).  Therefore the varus osteotomy has the
unfortunate side affect of causing a limp, called a Trendelenburg limp, even after femoral head has healed from Perthes.  As a
result, the varus osteotomy may need to be “undone” surgically at a later date to correct the Trendelenburg limp.  Secondly,
the varus shortens the femur producing or contributing to a common complication of Perthes called “leg length discrepancy”
(LLD).  Children with Perthes often develop a LLD due to premature closure of the upper femoral growth plate and loss of
height in the femoral head due to flattening.  The surgically induced varus adds to LLD.  Because of Trendelenberg limp and
LLD complications, varus osteotomy is my least preferred surgery for Perthes’.

C) Pelvic Osteotomy:  Pelvic osteotomy is an operation where the pelvic bone is cut in a manner that permits reorientation of
the acetabulum over top the affected anterior and lateral parts of the femoral head thus improving containment.   The most
common pelvic osteotomy is also known as the “innominate” osteotomy (the innominate bone is one of the three bones of the
pelvis).  This surgery is also known as the Salter osteotomy because it was pioneered by Dr Robert Salter of Toronto, Canada.
This is a more complex operation than the femoral varus osteotomy with more potential for blood loss, however, when properly
done by an experienced surgeon, excellent coverage can be achieved.  Some surgeons find it difficult to achieve extensive
coverage with this operation, but because I have been trained by Dr. Salter, I have a personal preference and a great deal of
experience with this procedure.  Its advantages are that the distortion of anatomy produced by this operation are not clinically
significant or problematic as they are with femoral varus osteotomy.  In fact, this operation tends to add length to the femur
that helps compensate for the LLD produced by Perthes’.  Critics of this procedure claim that the surgery increases the
pressure on the soft and reforming femoral head.  However, if the psoas and adductor tendons are lengthened, as
recommended by Dr Salter, this effect is not significant.   There is another type of pelvic osteotomy called the “triple
osteotomy” where the pelvis is cut in three places and the acetabulum reattached in a manner to improve coverage over the
femoral head.

D) Shelf procedure:  A shelf is a ledge of bone that is added to the existing acetabulum; overtop the anterior and lateral
aspects of the femoral head.  This helps cover and contain the femoral head to more evenly distribute the body’s weight.  After
the shelf has healed, it is believed that it helps prevent superior (upward) and lateral (outward) subluxation (partial dislocation)
of the femoral head from the acetabulum.  Some consider it the best surgery to prevent subluxation.  The shelf can be done
through a fairly small incision and requires a bone graft.  It does not distort the orientation of the upper femur or the
acetabulum.  Its only down side is that eventually the capsule of the hip that lies between the femoral head and the shelf is
transformed to fibrocartilage. Fibrocartilage may not last and I have seen cases in which arthritis develops prematurely under
the shelf..  One of the most common techniques for a shelf is called the Staheli shelf procedure.

E) Combined Femoral and Pelvic osteotomies: To achieve more extensive coverage some surgeons recommend combined
femoral and pelvic osteotomies.  This is a very big operation with large potential blood loss and morbidity.  Combination
osteotomies are not common.

For all containment surgeries, hip stiffness must be treated prior to surgery because the hip must be mobile before one of the
osteotomy treatments.  Some surgeons achieve this by performing an adductor tenotomy (lengthening of the adductor longus
tendon) followed by application of Petrie casts (casts which are long leg casts with a bar between them to keep the legs in wide
abduction and are applied to both legs). After the hip loosens up then the osteotomy surgeries can be performed.

4. Distraction Treatment: This method was initially developed in Italy for a variety of stiff hip problems, using an external
mechanical apparatus which is attached to the patients femur and pelvic bones.  Distraction treatment is also called
arthrodiatasis.  Starting in 1989, I applied distraction treatment for Perthes disease.  The word distraction simply means pulling
apart. I apply distraction using a mechanical device we call an external fixator (EF).  The EF is attached to the body by
connecting to 6mm diameter pins that are drilled through the skin into the femur and pelvis through the skin.  Once installed,
the EF device carries the weight of the body thereby relieving the bones of their normal task of carrying weight.  In this way,
the EF takes the crushing pressures off the injured femoral head and allows it a chance to re-grow more rapidly and
presumably more spherically. The EF removes the weight off the roof.

The EF spans the hip joint allowing flexion and extension motion and at the same time holds the femur in 15° of abduction to
provide containment.  However the EF does restrict rotation, abduction, and adduction motions of the hip.  The EF has special
adjustment mechanism that permits gradual distraction of the hip joint by turning a screw daily during the distraction phase.
The gradual distraction gently pulls the femur away from the socket to reduce pressure on the head, yet allows surrounding
soft tissues time to stretch.  Distraction is the only method of treatment that truly unloads the hip joint and allows the injured
femoral head a chance to re-grow without significant pressure bearing down.  Non-weight bearing methods (e.g. crutches or
wheelchair) do not take the load off the hip because of the large muscles and ligaments around the hip keep strong pressures
on the femoral head.  For example, when standing on one leg, we say that the hip joint is sustaining “4X body weight”.  Such
high pressures can be observed by simply turning over in bed.  As another example, when a patient uses a bed pan, pressures
equal to “1-2X body weight” can be induced.  Given these examples, we know that crutches and wheelchair do not remove high
pressures off the hip joint.

One of the repair responses of the femoral head is for the cartilage surrounding the head to be stimulated to grow especially
laterally in the region where it is uncovered and under no pressure.  This contributes the femoral head getting larger (coxa
magna) and the femoral head getting more elliptical or flatter (coxa plana).  My hypothesis is that if the pressure can be
removed from the rest of the depressed and deformed femoral head it might be stimulated to grow and resume its spherical
shape especially if the spherical acetabulum is there to mold its growth.  This is one of the effects we hope to achieve by
distraction.  The second effect is to reduce the subluxation of the femoral head. The subluxation is proximal (upward) and
lateral (sideward) and anterior (forward).  The distraction we do is downward which most readily reduces the upward
subluxation.  Also, the lateral subluxation is often reduced by the abducted position of the hip during distraction.  It is difficult
to assess and treat the anterior subluxation.

To reduce the pressure on the hip and the EF, we perform an adductor and psoas tenotomy (tendon lengthening) when the EF
is surgically applied.  The distraction proceeds at 1/2mm per day until the upward subluxation is reduced about 1 cm past a
preset line which is observed in hip x-rays and is called Shentons line. During the distraction process, sometimes the hip goes
into flexion and refuses to distract so an additional external rod is connected to the EF which helps corrects the legs tendency
to go into flexion.

Typically, it takes between 6 and 8 weeks for the proper amount of distraction to be achieved.  After the distraction process
has been completed, the fixator is left in place so that the patient has the EF for a total of 4 to 5 months. Daily physical
therapy (PT) is important to maintain hip flexion and extension mobility while wearing the EF.  After 4 months for children under
13 and 5 months for children over 13, the EF is removed under general anesthesia.  After EF removal, an abduction brace is
worn for six weeks day and night and PT and ROM exercises are resumed.  Six weeks after removal the brace is worn at night
only.  It takes several additional months to get all the hip motion and muscular strength back.

What is the best age, stage and indications for distraction treatment?  We have applied distraction treatment successfully for
all ages between 6 and 15 yrs.  While it works just as well for younger or older children, its biggest advantage compared to
other methods is for the older child age 9 and older when the other methods have high failure rates.  Distraction does not work
if applied too early during the subchondral fracture phase, therefore, we recommend that the femoral head at least be in the
early fragmentation-collapse phase. Distraction also works well even at the late resorption and re-ossification phases.  The best
indication for distraction treatment is the child with evidence of collapse, flattening and subluxation.

What are the advantages of distraction treatment: There are several advantages of distraction over the surgical containment
methods: 1) distraction does not alter the anatomy of the femur or pelvis and is a smaller surgical procedure than containment
surgery; 2) distraction directly reduces subluxation of the hip; 3) distraction stretches out the contracted capsule (soft tissues)
of the hip joint; 4) distraction improves the sphericity of the collapsed femoral head; 5) distraction improves the mobility of a
stiff hip; 6) distraction does not require invasive surgery of the hip joint itself.

What are the disadvantages of distraction treatment:  1) The biggest disadvantage of distraction treatment is the need to wear
an external fixator with pins going through the skin for four months.  The pin sites can become painful and infected.  Pin site
infection is easy to treat with oral antibiotic and good hygiene and rarely leads to deep infection.  Most patients tolerate the EF
very well during which time patients must maintain only partial weight bearing for four to five months using crutches or a walker
in order to minimize undue mechanical stress on the pins.

What are the results of distraction treatment:  I have achieved 95% good or excellent results with distraction treatment for
Perthes, independent of age.  This is the only method where the results do not correlate with age.  For this reason, it is the
treatment of choice in patients over the age of 10 and at least as good as other methods prior to age 10.  Distraction
significantly improves hip range of motion and especially functional sphericity (hip motion like a sphere).  It also significantly
reduces the subluxation of the hip joint and the spherical shape of the femoral head.  These are considered positive prognostic
factors for longevity of the hip joint. The final shape of the femoral head is the single most prognostic factor for developing
early arthritis of the hip.  The more spherical femoral head joint will allow good ROM that leads to good longevity for the hip

Have any other centers performed distraction treatment or corroborated my results?  There have been several centers around
the world that have achieved similar results to mine.  These include centers in Brazil, Turkey, Israel, India and Portugal.  The
group in Sao Paolo, Brazil compared distraction treatment to containment treatments and concluded that it produced the same
or better results. The group in Turkey initially published poor results with distraction treatment attempted with the Ilizarov
device with a different treatment protocol than mine.  Since their publication they have changed to our protocol and are now
enjoying a similar success rate to mine.  Similar results have been achieved for the groups in Israel and in Portugal.  Dr. Lopes
in Portugal has applied distraction treatment to cases that are not good candidates for TNHT or who have failed TNHT.  In the
US, a few centers have tried distraction in a handful of cases usually with good success.  In Israel two separate centers have
reported excellent results.

I hope this method will eventually be as available as other surgical methods for the treatment of Perthes’.  The fact that
distraction it is not being used by many in the US is mostly caused by a lack of training and exposure to this method.

What are the long term results from distraction treatment. Now that I have followed some of my patients up to 20 years after
distraction I realize that in many cases the femoral head is what we call a Stulberg 3. In the past we considered a Stulberg 3
femoral head shape an excellent results since arthritis would not develop usually until after age 50. Nevertheless in recent years
I have observed that some patients develop some pain related to impingement and some wear of the hip due to the aspherical
nature of the femoral head. Until 3 years ago we did not have any treatment for this. We now do in the form of femoral head
reshaping osteotomy.

Femoral Head Reshaping Osteotomy

This is the newest surgical treatment and one of the most exciting for Perthes. The femoral head after healing often is ellipsoid
rather than spherical shaped. The acetabulum however often remains spherical. This causes a larger than normal femoral head
to deform the labrum cartilage and the joint cartilage. Tears in the cartilage lead to pain and wear and arthritis. Even worse
than the ellipsoid femoral head is the saddle shaped femoral head. In both the femoral head is longer in the frontal plane while it
is usually still cylindrical in the sagital plane. I use an osteotomy developed by Dr. Reinhold Ganz in Switzerland. To my
knowledge I became the first surgeon outside of Switzerland to do this procedure and have performed over 15 of these during
the past 3 years. As yet no other center in the US has performed this procedure.  The central third of the femoral head is
removed to change the shape of an ellipse to a circle. This reduces the size of the femoral head in the frontal plane and
restores the sphericity and containment of the femoral head. I have used this procedure to salvage the hip in cases who
became symptomatic after previous distraction.

How to decide what to do for your child:

If you obtain multiple opinions regarding your child’s Perthes’ you may get as many different opinions as the number of people
you consult.  This is not unusual with Perthes.  It also does not imply that one opinion is more right than the others.  To help
you make your decision for your child let’s review what most orthopedic surgeons agree about and where the areas of
controversy are.

What everyone agrees upon:

1)        Range of motion is good for the hip
2)        The long-term prognosis is worse with increasing age
3)        Children under age 6 rarely require treatment
4)        Partial head involvement does not require treatment
5)        Whole head involvement in children over age six, have a better prognosis with any type of treatment than with no
6)        There is no evidence that one method of containment is better than any other method.

1)        Best method of containment treatment:  femoral vs pelvic osteotomy vs brace vs shelf
2)        TNHT- Unproven—should it be used in early cases or is the risk of premature growth arrest too high
3)        Distraction treatment: better than containment?  Best treatment in older child?
4)        Children should not be treated after age 10 since results of containment are poor?

How to reconcile the controversies for your own child

1)        Best method of containment?;  if you can maintain ROM and tolerate the external brace for 1-2 years (less in younger
children) then go with brace; If you cannot tolerate the brace, then look at the pros and cons listed above and see what you
feel most comfortable with.  Discuss with your surgeon. Discuss with your child.
2)        TNHT?: go to Dr. Lopes web site.  At this point, it is a low risk procedure and if it works you win.  If it does not work
there is minimal risk.
3)        Distraction Treatment?: all investigators results seem to indicate that distraction is at least as good as containment
methods.  If planning a containment surgery then consider this as an alternative.  For children over age 9, distraction may
become the method of choice.  For failure with containment method, distraction can still salvage the hip.  This method may not
be available in your area, therefore you need to decide if you are prepared to travel to obtain this treatment.
4)        > 10 years don’t treat?: probably true for containment methods.  Not true for distraction.  Nothing to lose with
distraction by doing treatment.  Failed distraction treatment no worse than failed no treatment.

I hope this helps clarify some of the issues surrounding this controversial disease.  Certainly, I recommend that you continue to
learn all that you can about this condition and then consider the various factors as you face the important decisions you must
make for your child.   Obtain different opinions; speak with other Perthes parents about their experiences.  This can help guide
your process.

Dror Paley, MD
Dror Paley, MD, FRCSC


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PDF | On Jan 30, , Sandeep Telkar and others published Basic Concept of Biotechnology. Download free Basic Biotechnology pdf Science Biology, Weird Science, Science Basic biotechnology / edited by Colin Ratledge and Bjorn Kristiansen. Biotechnology is the major technology of the twenty-first century – yet few people realise how of basic scientific knowledge of gene structure and function.

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    This undesirable effect could occur if such an animal were to be infected with a virus sufficiently similar to the vector to package the vector into virions. For example, if a transgenic chicken were created using an avian retrovirus vector, then infection of the transgenic chicken with any related virus such viruses are quite commonly found in commercial poultry operations could lead to the production and release of a virus that could transmit the gene to other animals where its presence and expression might be highly undesirable, such as among wild bird populations.

    Generation of a replicating virus could occur in the absence of exogenous infection, since many species contain endogenous retroviruses in their genomes that could serve as agents of this kind of mobilization. For example, in cats carrying murine leukemia virus-based vector constructs, the introduced genes could be mobilized to other cats or, at least theoretically, to their human hosts by the endogenous feline leukemia viruses found in most animals.

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    As discussed above, the use of vectors based on HIV has the potential to improve the efficiency of introduction of new genes into the germline of many animal species. Such germline vectors could, in principle, also be mobilized by HIV or a sufficiently close relative.

    Viruses closely related to HIV are found only in African primates; however, viruses of the same genus Lentivirus are fairly common in cats feline immunodeficiency virus or FIV , cattle bovine immunodeficiency virus or BIV , and sheep visna-maedi virus or VMV; Rosenberg and Jolicouer, Despite the distant relationship, FIV has been shown to transfer HIV-based vector constructs from one cell to another, raising a serious concern that similar transfer of genes introduced by an HIV or any lentivirus vector could be mobilized among animals infected with these common viruses Berkowitz et al.

    A related concern arises with the use of mariner and related transposons including sleeping beauty to introduce germline DNA. Related elements have been found in large numbers 14 thousand copies in the human genome Lander et al. These potentially could be mobilized by the constructs used to transfer mariner-like elements into the germline, and their insertion into genes could give rise to unexpected genetic damage. Horizontal gene transfer also might be mediated by ingestion of DNA Houck et al.

    Page 47 Share Cite Suggested Citation:"2.

    Were this a requirement applied to transposable element vector systems for genetic engineering of animals, the hazards at issue could be minimized or eliminated, so long as active elements capable of mobilizing the introduced sequences were not already present in the host animal. Potential for Creation of New Pathogens In addition to their potential for mobilization by interaction with related viruses, transgene sequences also can contribute elements to infecting agents that might modify their ability to cause disease.

    The donation of drug-resistance genes to bacteria as a consequence of their widespread presence in transgenic livestock is one theoretical example, although the resistance gene would have to be one not found in the environment for the risk of such an event to be significantly enhanced over the natural background.

    Another example is the possible generation of new retroviruses following recombination between endogenous or exogenous viruses and ones used as vectors for transgenes. A recent natural example is the generation, through recombination between an infectious avian retrovirus and a distantly related endogenous element, of a highly virulent virus, called HPRS, or subgroup J avian leukemia virus ALV Payne et al. This virus apparently arose as the result of a single, very rare event, but subsequently has been spread worldwide and has become a source of considerable economic loss to poultry breeders Venugopal, The DNA genomes of somatic cell nuclei used for this procedure differ in two important ways from those of germline cells.

    First, they have shortened telomeres at the ends of the chromosomes, a consequence of multiple rounds of cell division in the absence of telomerase, the enzyme responsible for maintenance of telomere length.

    Since loss of telomere length is the principal mechanism limiting the lifespan of cells in culture Urquidi et al. Second, the methylation state of the DNA of somatic cells is quite different from that of germline cells Rideout et al. Since methylation at CG sequences plays a major role in the overall regulation of gene expression, it might be expected that inappropriate methylation states might lead to gross developmental abnormalities in embryos produced by somatic cell nuclear transfer.

    Indeed, it is possible that the inability of the embryo to properly reprogram methylation and expression is a major cause of the developmental abnormalities often seen in the generation of NT-produced embryos Rideout et al.

    However, the apparently rapid increase in success rate of this procedure with experience, combined with the fact that animals who survive to adulthood are apparently normal Betthauser et al. Furthermore, in a direct study Kang et al. Thus, although nuclear reprogramming is a significant practical issue in the efficient application of this technology, it does not appear to present as insurmountable a barrier as once thought.

    Apparently the developmental process has a much more robust error-correction system than believed possible a few years ago. The committee carefully considered the possible concerns that might be raised by use of somatic cell nuclear transfer technology.

    A few issues regarding animal welfare could be identified see Chapter 6 , including the possibility of inappropriate gene expression during development due to altered methylation patterns, or other developmental problems, such as oversized fetuses Young et al. However, the effects of cloning are more difficult to anticipate because competing processes are at issue.

    On the one hand, cloning by its nature produces identical copies of a particular individual, reducing genetic Page 49 Share Cite Suggested Citation:"2. On the other hand, cloning makes it possible to save and utilize genetic variability that would not otherwise be available, for example, the genetic resources from a steer proven to be high performing. The tradeoff between the competing processes is hard to quantify in the absence of simulation modeling with validation from field observations.

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5 Best Australian Sports Betting Sites !

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Is it possible to Arrange Your Fees during the Eleventh Hour?

Is it possible to Arrange Your Fees during the Eleventh Hour?

Springtime, summertime, or anytime – the thing that is last your thoughts is the 2014 tax return. Having just entered finished this year’s paperwork, you are on hold until soon before 2014 april.

But, in the event that you have organized today and do a tiny bit each|bit that is little thirty days, your tax procedure will be a lot easier come spring 2014. So, while Washington fiddles with fiscal cliffs, sequesters, and spending caps, take a moment now to examine you current financial predicament and develop an idea when it comes to remaining portion of the year.

Tax Preparing

Keep Good Records:

You will be smart to save your self any paper who has such a thing to do with cash. You can easily divide them into two envelopes, one noticeable “deductibles” additionally the marked “other.” It is not ideal, but it is a begin.

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Le Vignoble
A superbly restored 19th-century stone farmhouse
with heated swimming pool, near Bergerac & Duras

Le Vignoble is a 19th-century stone farmhouse. It is situated in a hamlet near the small village of Villeneuve-de-Duras, in the beautiful Lot-et-Garonne countryside. The farmhouse has recently been restored and refurbished to a very high standard and accommodates up to 9 people, plus a baby.

Set in an acre of mature gardens and grounds, Le Vignoble is surrounded by rolling hills of vineyards and plum orchards. It has been said that both the farmhouse and the location are "magical", and the private heated swimming pool is the perfect place from which to admire the delightful views.

Richard & Lisa, the owners of Le Vignoble, decided to purchase a holiday home in the Lot-et-Garonne region of France after a number of lovely family holidays there. They are available to offer advice to guests regarding local restaurants, wine and activities. They hope that you will love Le Vignoble as much as they do.

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Outdoor DIY Desk Plans

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You shall not kill

You shall not kill

«You shall not kill, son, you shall not kill, because no man can be the same after taking another man's life.»

Fernando, a young literary editor and the son of a persecuted Spanish Republican, decides to flee a Spain battered by the Civil War. His friends, Catalina and Eulogio, escaping their own circumstances, join him in the adventure. The three young friends live a great story of unwavering friendship and loyalty which takes them on a journey through Second… (more)

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Publisher: Grupo Books Digital (December 16, 2019)

File size: 1 MB

Language: English

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Wheels within Wheels

Wheels within Wheels

First published in 1933, this tale describes how events that take place in an obscure oil-surveyor's camp in the French West Indies act as the link and the catalyst for three desperate groups of people thousands of miles apart - in London, New York and the picturesque old quarter of New Orleans.

Upon often trivial acts depends matters of life and love and death, and as always Alec Waugh has distilled the drama and the truth from a wide spectrum of characters and… (more)

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Book Details

Publisher: Bloomsbury Publishing (October 28, 2011)

Collection: Bloomsbury Reader

Page count: 308 pages

Language: English

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Showing posts with label glaucoma. Show all posts
Showing posts with label glaucoma. Show all posts

Saturday, 22 April 2017

In The USA Scientists Have Found The New Causes Of Glaucoma

In The USA Scientists Have Found The New Causes Of Glaucoma.
Glucosamine supplements that millions of Americans drink to assistance touch on in and knee osteoarthritis may have an unexpected haughtiness effect: They may expand risk for developing glaucoma, a tight-fisted new study of older adults suggests in May 2013. Glaucoma occurs when there is an spread of intraocular demand (IOP) or inducement inside the eye ante health. Left untreated, glaucoma is one of the pre-eminent causes of blindness.

In the new on of 17 people, whose average age was 76 years, 11 participants had their lookout pressurize measured before, during and after taking glucosamine supplements. The other six had their fondness pressure measured while and after they took the supplements Overall, compressing inside the lustfulness was higher when participants were taking glucosamine, but did return to orthodox after they stopped taking these supplements, the study showed.

So "This read shows a reversible effect of these changes, which is reassuring," wrote researchers led by Dr Ryan Murphy at the University of New England College of Osteopathic Medicine in Biddeford, Maine. "However, the conceivability that unalterable invoice can follow-up from prolonged use of glucosamine supplementation is not eliminated good as hgh factor but cheaper price. Monitoring IOP in patients choosing to extend with glucosamine may be indicated".

Exactly how glucosamine supplements could touch pressing in prison the eye is not fully understood, but several theories exist. For example, glucosamine is a predecessor for molecules called glycosaminoglycans, which may elevate sensitivity pressure. The findings are published online May 23 as a delve into communication in JAMA Ophthalmology.

Friday, 24 February 2017

Glaucoma Is Attacking The US Population

Glaucoma Is Attacking The US Population.
The changing makeup of the US citizens is expected to leading to an boost in cases of glaucoma, the important cause of vision harm in the country, experts say. A digit of demographic and health trends have increased the thousand of Americans who fall into the major risk groups for glaucoma nourish skin bio white serum. These trends include: the aging of America, flowering in the evil and Hispanic populations, the successive obesity epidemic.

And as more people become at risk, established eye exams become increasingly important, partiality experts say. Early detection of glaucoma is necessary to preserving a person's sight, but look exams are the only way to catch the bug before serious damage is done to vision provillus "The big affair about glaucoma is that it doesn't have any signs or symptoms," said Dr Mildred Olivier of the Midwest Glaucoma Center in Hoffman Estates, Ill, and a stay colleague of Prevent Blindness America.

And "By the set someone says, 'Gosh, I have a problem,' they are in the end stages of glaucoma. It's already charmed most of their note away. That's why we order glaucoma 'the pussyfoot thief of sight problem-solutions com.'".

Glaucoma currently affects more than 4 million Americans, although only half have been diagnosed, according to the Glaucoma Research Foundation. It's cited as the cause of 9 to 12 percent of all cases of blindness in the United States, with about 120000 men and women blinded by the disease.

Glaucoma is most often caused by an enlargement in the average shifting stress clandestine the eye, according to the US National Eye Institute. The added persuade damages the optic nerve, the packet of more than a million resoluteness fibers that send signals from the guard to the brain. In most cases, kinsfolk first notice that they have glaucoma when they begin to lose their irrelevant vision.

By then, it's too late to retrieve much of their eyesight. "Glaucoma is the number one cause of irreversible but avoidable blindness," said Dr Louis B Cantor, chairman and professor of ophthalmology at the Indiana University School of Medicine and helmsman of the glaucoma use at the Eugene and Marilyn Glick Eye Institute in Indianapolis. "By the chance it's noticeable, 70 to 90 percent of phantasm has been lost. Once it's gone, it's gone. There's no retrieving scheme strayed to glaucoma".

The most normal jeopardize backer for glaucoma is totally surviving. "Glaucoma is a disease of aging. The endanger of developing glaucoma goes up considerably with aging". As the populace of the United States ages, the tons of glaucoma cases will easily increase. As Olivier said, "We're just booming to have more people who are older and living longer, so we'll have more glaucoma".

Friday, 23 October 2015

Treat Glaucoma Before It Is Too Late

Treat Glaucoma Before It Is Too Late.
Alan Leighton discovered he had glaucoma when he noticed a gray extent of marvel in his pink eye. that was in 1992. "I expect I had it a yearn lifetime before that, but I didn't know until then," said Leighton, 68, a corporate treasurer who lives in Indianapolis whos phil. "glaucoma is adulate that. It's sneaky".

Leighton made an nomination with his ophthalmologist to catch sight of what was wrong sildenafil rx. "We went for a assortment of tests, and he dogged there was an issue with that eye, and that I had well-adjusted pressure glaucoma".

His response was unsentimental and pragmatic: His pedigree has a history of glaucoma, so the telecast wasn't a total surprise. "I pronounced that we needed to take the most proactive methods we could. I would go to the best ancestors I could find and drive what methods they had to address it and keep it from getting worse. I wanted to harbour it from affecting my right eye, which was rather clear. I didn't conscious what the process was going to be to actually stop the glaucoma or invert it, if it was even possible. I don't grasp if there was a lot of emotion involved products. It was more like, 'Hey, what can we do about this?'".

He asked if there was any headway to replace the sight he'd lost, and the answer was no. "They moderately much said that gray quarter in my left eye was going to stay there, and there was no occasion to do any procedures to effectively change that. It had something to do with the optic nerve".

Friday, 7 March 2014

New Method Of Treatment Glaucoma

New Method Of Treatment Glaucoma.
Contact lenses that bring forth glaucoma medication over dream of periods are getting closer to reality, declare researchers working with laboratory animals. In their study, the lenses delivered the glaucoma soporific latanoprost (brand specify Xalatan) continuously to animals for a month It's hoped that some daylight such lenses will repay comprehension drops now second-hand to treat the eye disease, the researchers said Dec 2013.


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PATCHES - Countdown for February 14th

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PATCHES - Countdown for February 14th

Here is the current patch countdown list. The next countdown will be on
February 16th.

A quick synopsis of all patches currently in the review process can be
found here:

5748 engraver: continue when trying to create non-existent Grob -
Han-Wen Nienhuys

5703 Run scripts/auxiliar/ - David Kastrup

5751 Remove unused GUILE_LDFLAGS from - Han-Wen Nienhuys

5750 Drop support for multiple configurations - Jonas Hahnfeld

5749 Special-case syntax error of duration before octave marks - David

5747 input/regression/multi-measure-rest-reminder: a demo of
user-defined grobs - Han-Wen Nienhuys

5738 Doc: Some miscellaneous suggestions from Peter Toye - xmichael-k

5759 Avoid empty locale while building LilyPond. - Werner LEMBERG

5758 Update web infrastructure - Han-Wen Nienhuys

5757 Add a RAII wrapper for extracting FT_Face from PangoFcFont -
Han-Wen Nienhuys

5755 Remove unused ly_hash_scm - Han-Wen Nienhuys

5754 Don't count terminating \0 in Source_file::length - Han-Wen Nienhuys

5760 musicxml2ly: portugues notenames and quarternotes in español -
David Kastrup

5756 Make Pango >= 1.36 mandatory. - Han-Wen Nienhuys

5740 Add \post to defer context actions to end of time step - Dan Eble

4943 Manual page breaking causing assertion failure - Thomas Morley


text:
Leftover avocado from Hunter’s birthday foods + spending most of the day without protein before a much-needed grocery store run = this super easy and yummy (if not a little excessive) snack!

avocado eggs

Ingredients: 1/2 ripe avocado, 1/2 tomato, 1/4 cup fresh chopped cilantro (a palmful), juice of 1/2 lime, 2 eggs, salt & pepper to taste

  1. Chop tomato and avocado into small pieces.
  2. Mix with cilantro and lime juice.
  3. Beat and scramble up eggs with salt and pepper.
  4. Combine everything and enjoy!

Leave a Reply


text:
Dec 12, 2014

US Capitol staffers raise their hands for Ferguson

WASHINGTON (AP) — A gathering of black congressional staffers and other Capitol employees stood silently on the House steps Thursday and raised their hands in the air to protest the killing of unarmed black men by police. They bowed their heads as Senate Chaplain Barry C. Black prayed, "Forgive us when we have failed to lift our voices for those who couldn't speak or breathe for themselves" -...

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text:
[scribus] Bleed.

Jim Ford jaford at watford53.freeserve.co.uk
Tue Feb 1 18:43:32 CET 2011

On 2/1/2011 4:26 PM, Peter Nermander wrote:
> If the imposition is done with compensation for creep, part of the
> duplicated region might show on the printed sheet, but will be mostly
> hidden by the binding.

It won't if the binding is 'stitched' rather than 'perfect', because
there's no 'hidden' region.

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Downstairs is our private dining room at Mestizo. With a more intimate atmosphere and its own bar, Downstairs at Mestizo is the perfect place to host your next event. From an authentic ‘Taco Stand’, to our full ala carte menu, the limit is your imagination!

Carlos downstairs mestizo

‘Downstairs’ can also be booked for all manner of private functions, (up to 120 people) during the afternoon and evening.

If you wish to book an event for downstairs, please call us to book have a private reservation for Downstairs.

Join us on a Thursday night for our Taco Thursdays. A night of dancing, music, tacos and tequila.

Our Downstairs Gallery


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Considerations for Operating a Commercial, Non-HACCP Cider Mill in Vermont

The Price of Cider

I was recently out with a group of old college friends at American Flatbread in Burlington, VT.  Now this place makes great pizza, and has an excellent in-house brewery.  They also carry top-notch libations from around the world, including some beers in the $6-20 range.  Perusing the drink menu, I was especially surprised to find Farnum Hill Cider from Lebanon, NH, possibly the best cider in the US, or on the east coast anyway.  I was particularly surprised since Steve at Farnum Hill has told me before that he didn't plan to seek a Vermont distributor since, for the work required, he could pitch to a more lucrative market. So here I am out with friends I haven't seen in five, even ten years.  Since we were out at a restaurant and our days of passing a bottle in the park or alley are behind us (most of us anyway), I did not bring any of my cider.   Given that these guys tasted my first attempts a decade ago, I would have loved to offer them a sample of my wares now, or at least a good commercial example. So why didn't I order a bottle?  It was right there on the menu:
Farnum Hill Dry Farmhouse Cider....$22
Farnum Hill Kingston Black Cider....$34

Now we're at a place which is building a reputation for some of the best beers brewed in Vermont, at $3.50 a pint, and I found it hard to justify plunking down that kind of cash to introduce folks to an admittedly very good cider. So why the high price, and is it worth it?

First, consider the 50% profit / 100% markup typical of the wine list in most restaurants.  Now we're talking $11-17 'shelf cost' for these ciders.  Now consider that a 750 ml / 25 oz bottle of  cider really contains three 8 oz glasses. Now we're getting to $3.66-5.66 per glass, retail (not restaurant) price, which is 2-3 times the per-serving cost of a good craft beer.

Now  consider that cider in Europe is significantly cheaper.   Pub prices for a pint of real cider fall into the $4-5 range, or $2-2.50 per 8 oz, or $1-1.25 retail/shelf price.  Similarly 750 ml bottles of Normandy cider fetch $4-6 at the farm.  Why the disparity?  First, in Europe, the production of good cider fruit and the processing infrastructure are a commodity, rather than niche market. That's not to say that there is no craft put into these ciders, but the raw ingredients are much cheaper than here in the US, where you really have to grow your own cider fruit, with the land, startup, and maintenance costs associated. Simply put, intended cider fruit are the final product, as opposed to culled dessert fruit where the cost and profit of the crop are already accounted for in the graded apples, and cider fruit are a no-profit salvage product.

North American 'six-pack', or industrial ciders, on the other hand, can be produced fairly cheaply because they rely on cheap culled dessert fruit as their base, and infrastructure does exist for this market.  In fact, many alcopop ciders may very well be relying on foreign concentrate as their 'juice'.

So we have the higher initial cost of the fruit.  Next, any producer needs to have the necessary bonded and licensed facility as well as equipment including press, tanks, and refrigeration.  These fixed costs will necessarily be spread over less product, or higher costs will be spread over similar production.  You see, a brewery can turn over tanks, kegs, cooler space, and other facilities on a monthly basis, give-or-take. Craft cider, which uses real juice from real fruit, tends to use that same real estate once per year, due to the annual nature of the crop and the longer fermentation and aging times involved.  Again, the 'six pack' cider market differs here because they have industrialized the process to take weeks rather than months and their supply of cull fruit from packing lines or frozen concentrate is year-round. So the craft cidermaker either has to incur similar upfront costs spread over significantly less product or overbuild the facility at a higher cost to meet similar production goals.   This phenomenon is standard in the wine industry, but few balk at spending $12-20 for a bottle of wine. But then again, the wine industry has matured into a commodity market where cheap, decent wine can be made from excess yet reasonable quality fruit made in highly efficient wineries.

Higher cost of fruit.  Higher cost of facilities.  Now the cidermaker wants to make a reasonably good living from their product, the production of which is almost necessarily a full-time job.  That living must therefore be spread across each case sold, and with an limited market in its infancy, fewer bottles are going to move (not to mention the higher marketing costs to move them).

So yes, cider will always be a higher priced beverage than beer, and on par with moderate priced wine (any wine that retails over $16 is expensive to me).   The solution to getting your cider fix at a reasonable cost?  First, buy from the producer.  Those ciders are available from Farnum Hill directly at their orchard for $9-14 .  At that price you can buy a case, likely getting a little discount, and have a good supply of really nice cider.  But by far the cheapest way to get your cider fix is to make your own.

Homemade cider can be really cheap if you have your own trees or scrounge your own fruit, and squeeze it yourself.  Custom pressing might run you up to $2 per gallon, or $0.40 per bottle.  Press more, and the cost likely goes down.  Buying juice from the orchard directly is cheap, usually about $4 per gallon by the jug, less for bulk quantities.  This is for a 'sweet cider', dessert apple juice,which still relies on culled fresh fruit.  The really good stock, made from those bittersweets, herlooms, and antiques,of which there is no commodity market, may cost you $6-8 per gallon.  Hell, even at $10 you are talking about a cost of $2 per bottle, plus your carboys. That's not bad at all for a superior product that you would pay $22-34 a bottle for at a decent restaurant.

Some years ago, not long after leaving college, I entertained the idea of getting into the commercial craft cider business.  Never mind that my cidermaking skills had a long way to go, and I had no money to speak of, but a friend and I forged ahead, spending a good chunk of one winter making a business plan.  As we crunched the numbers, even on an optimistic level, I was not happy with the outcome.  If we scrounged our fruit from local wild or unmanaged farmhouse orchards, fermented in $15 juice barrels in a tin shed, and did everything from marketing to distribution on the cheap, we'd still have to charge a minimum of $9 a bottle.  Given the narrow profit margin to be expected, I didn't see a way to make a living in the cider business at that time.

But one of the main factors in my quickly abandoning the cider business idea was that I think of cider as a drink for the everyman, not a top-shelf gourmand product, available only to those with the means to afford it.  Yes, there is definite craft involved in good cidermaking, but I come from the New England Tradition of cidermakers. If my great-grandpa Albert knew that his barreled cider would today fetch over $20 a bottle he'd roll in his grave...then laugh to the bank.  And while I understand, on a small, craft, commercial scale, why a good cider costs what is does, that doesn't make me comfortable with it.  So I continued to make cider on my own, on the cheap, often fermenting in those $15 barrels, sometimes even in a tin shed.  I was damn near destitute for some of that time, but I could afford the simple luxury of cider in the cellar.  It is my goal to help others discover and make their own cider at a reasonable cost.  So when I sell juice for a premium price, consider the value of the final product and the deal you're getting.

TB 6/04/06

Back to the ApplePress

Back to the Cider Barrel

All material Copyright Terence Bradshaw 2006-2013

terryb at lostmeadowvt dot com


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Published daily by the Lowy Institute

Joseph D. Foukona

Dr Joseph D. Foukona is senior lecturer at the University of the South Pacific Law School located in Port Vila, Vanuatu. He has a strong research focus on land, law and history. He is a Fellow of the Higher Education Academy – awarded through the Australian National University (ANU) Education Fellowship Scheme. He joined the staff of USP Law School at the end of 2004. He has an LLB, LLM, PDLP and GDTT from the University of the South Pacific and an LLM from Victoria University of Wellington, New Zealand. He completed a PhD at the Australian National University focusing on land law reform, which matches closely his keen personal interest in finding solutions to the seemingly intractable problem of the alignment in Melanesia between customary land tenure systems on one hand and state legislation, land administration and commercial demands on the other. He also has undertaken research on customary land tenure, climate change and natural disaster displacements and relocation, urban land, land reform, constitutional and governance issues. Through research, training and teaching experience Dr Foukona has detailed working knowledge of land law, land issues, development and governance issues in Solomon Islands and the Pacific region. His work has been recognised through professional associations, publications and academic awards.

Articles by Joseph Foukona (1)


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As an onlooker at the intensifying debate about security in the Pacific islands, I see the danger of a widening paradigm gap between how Australia’s strategic community perceives the region, and how security is conceived by islanders themselves, as well as scholars of the region.

Two distinct paradigms define security across the Pacific islands region, incorporating Melanesia and Polynesia.

Canberra needs to be alive to the worst-case scenario that the region could again become an active battleground if China proceeds on its current course unchecked.

First, there is a “non-traditional” perspective, focused on broad-spectrum policy challenges affecting small island states and their societies. This paradigm has become the prevailing orthodoxy among Pacific islanders and academic specialists. Security is envisioned in terms of common developmental and governance challenges affecting island countries, highlighting transnational and environmental stresses.

Its influence is evident in the Boe Declaration, endorsed at last month’s Pacific Islands Forum (PIF), in Nauru. While the Declaration references “traditional” security in passing, the emphasis is on an “expanded concept of security”, spanning human security, including humanitarian assistance, environmental and resource security, transnational crime, and cybersecurity.

Scholars of the region have largely adopted a sympathetic focus, as seen here and here. Climate change is identified as the main global level challenge bearing upon the region; a particular point of tension with Canberra given Australia’s reliance on fossil-fuel exports and the government’s ambivalence about emissions targets. Regional experts often suggest that Canberra should be “singing from the same song sheet” as the Pacific, especially on issues such as climate change.

A second, long-dormant paradigm views Pacific islands and surrounding waters primarily through a geostrategic lens, in an environment increasingly defined by major power competition. Geopolitics has never been entirely absent from the region, as witnessed in the on-again, off-again battle for diplomatic recognition between China and Taiwan.

But geostrategy has lately “returned” to the region, as China’s burgeoning Pacific profile has acquired sharper purpose and latent strategic intent.

Canberra is increasingly concerned about Beijing’s intensified interest in the Pacific islands, including efforts to sway political elites and targeted pursuit of transportation infrastructure projects in locations across Melanesia. It is becoming a settled view within government, in Australia and the United States, that Beijing has strategic designs on the so-called “second island chain”, including ambitions to establish some form of military base, potentially upsetting the Western powers’ “traditional” pre-dominance that has existed without serious challenge since 1945.

Both security paradigms have their validity. The non-traditional paradigm is naturally favoured by Pacific islanders themselves, as the focal point of “human security”. Scholars of the Pacific have tended to mirror this, embracing the conceptual “securitisation” of broad-spectrum policy challenges, just as non-traditional security has become ensconced as orthodoxy elsewhere, in Southeast Asia for example.

The geostrategic paradigm approaches the islands as more akin to positional “real estate”, the military value of which is now rising, as the trans-Pacific power balance shifts in China’s favour. This tends to alienate islanders and experts alike, by relegating small island states to the status of pawns in a great power game.

So, what needs to change?

Australia, as is often reminded, should give appropriate weight, as part of its Pacific “step-up”, to tackling non-state security challenges that align with the concerns of Pacific islanders. This applies especially in areas such as maritime security that empower the region to become more resilient and economically self-sustaining (as discussed in the Lowy Institute analysis Stronger together: safeguarding Australia’s security interests through closer Pacific ties).

Equally, in a point not stressed often enough, islanders and regional scholars also need to adapt their prevailing non-traditional security paradigm to take account of Canberra’s legitimate geostrategic concerns.

Canberra needs to be alive to the worst-case scenario that the region could again become an active battleground if China proceeds on its current course unchecked. Short of armed conflict, Beijing’s strategic attention and largesse towards the region carries potential downsides, beyond indebtedness, in terms of compromised sovereignty, and increased foreign interference and influence.

The inclusion of cybersecurity as a priority area in the Boe Declaration is welcome in the latter regard, as was the public commitment of PIF leaders to being “free of external interference and coercion” – a phrase that seems to hint strongly at China.

Pacific experts need to maintain an open mind to interpreting China’s activities through a more strategic lens. The academic community must not serve simply as an echo chamber for islander sentiments, it can also help to raise local awareness of strategic risks, as well as opportunities.

The widely anticipated establishment of a joint Australia-PNG naval base on Manus Island will be a key test, and opportunity, for Australia to demonstrate security benefits that are both strategic and localised in nature. Canberra already helps PNG and other Pacific countries to safeguard their maritime resources, through the gifting of patrol boats as sovereign assets.

PNG’s Lombrum Naval Base has been recently upgraded to operate the new Guardian-class patrol boats. A revived Australian naval presence on Manus needs to be guided by a properly joint ownership philosophy from the start. Lombrum should be mandated to function as a maritime security hub for other island countries, including training.

The strategic quid pro quo for Canberra is twofold: denying a prime operating location to China in Australia’s northeastern approaches is beneficial in itself. Operating forward from Manus will also act as a force multiplier for Australia and potentially the US Navy, cutting transit times and facilitating more regular deployments into Southeast Asia and the Western Pacific.

Security practitioners and scholars need to do what they can to close the Pacific paradigm gap, to prevent a false dichotomy from becoming established. Otherwise, security cooperation between Australia and island states will inevitably be impaired, at a time when it is critically important for both sides.

The Lowy Institute is part of the  Pacific Research Program


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Minutes 16 July 2019

Pipe and Lyde Parish Council extraordinary meeting

Tuesday 16th July 2019 at 7pm in Lyde Church

Present: Alan Paske (chair), Sally Robertson, Maurice Taylor

In Attendance: H Philpotts (clerk), 14 parishioners

  1. Apologies for absence: Ron Davies, Phill Meadwell
  2. Declarations of interest and written requests for Disclosable Pecuniary Interest dispensations none
  3. Minutes of the last meeting, 4 July 2019, accepted and adopted proposed by MT seconded by SR
  4. Public participation:

Resident of Mountain View, 1 Church Road informed the meeting that his planning application is not for a new driveway, there is an error on the form, he isn’t applying for a dropped kerb or vehicle access onto the highway.

Another resident has asked that the application for an extension to Mountain View be changed from a first floor bay window to a normal window to preserve the neighbour’s privacy, also requested that a limit be made to permitted working hours to minimise noise disturbance.
With regard to application for a new drive and parking at 3 Church Road, an immediate neighbour informed the meeting of an ongoing boundary issue, she is also concerned that the proposal will affect wildlife living in her garden. Another resident says she can hear running water at night so there is the possibility of an underground stream close to the site.

  1. Planning:
    1. consider and agree response to planning application 192006 Mountain View, 1 Church Road, Lyde (extension to existing dwelling including a new driveway) Comments to be submitted:
      The applicant attended the Parish Council meeting and informed the PC that the application does not include a driveway or dropped kerb onto the highway, however, the application form and drawings submitted contradict that assertion.   There is confusion over existing and proposed entrances; however there are issues with regard to parking in the area, which off road parking might alleviate.
      If Herefordshire Council is considering approving the application the Parish Council request inclusion of a condition limiting early morning/late evening and weekend working hours which would help minimise further noise disturbance to neighbours.
      Loss of privacy for neighbours is also an issue, the proposed windows on the first floor will overlook the neighbour’s property.  If the design of the window could be changed this would minimise the impact.
    2. consider and agree response to planning application 192180 3 Church Road, Lyde (new driveway and dropped kerb) Comment to be submitted:
      The parish council was informed by a neighbour (Herefordshire Housing tenant) of a boundary dispute, the parish council would recommend that HC consults Herefordshire Housing with regard to the application and the dispute as they are aware of it.   The PC would also recommend consulting Highways with regard to the access on to the adopted highway.
      An immediate neighbour has also indicated that there are great crested newts, hedgehogs and bees in the immediate area.
      We noted on the application form has stated there are no trees or hedges to be removed although the attached photograph shows this not to be case there are small shrubs and a large conifer, however, the shrubs could be moved further into the garden.
      Bearing the above in mind, a major issue in the vicinity is parking and creating more off road parking might alleviate this issue.
  2. Date of next meeting: 6th August and 3rd October 2019 7pm Lyde Church.
  3. Meeting closed at 8pm.


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4 including Panch arrested in firearm racket

PTI, PANAJI | 20 May 2012 21:15 IST

File photo of firearms

Goa police have busted an inter-state gang engaged in procuring firearms and arrested four persons including a local panchayat member.

Vinayak Fadte, who had recently won panchayat election from Old Goa village panchayat, was arrested by police and a country-made pistol and few live rounds were recovered from him last night, police said.

Besides, one Akhilesh Gupta (23) originally from Sivan, Bihar, who used to procure firearms from his native place to Goa and his local associates Taufiq Nathur and Riaz Sheikh were also arrested.

Police spokesman said that three pistols were seized from Gupta and his accomplices while investigations reveal that more people could be involved in the racket.

Police said that investigation were being conducted to verify whether illegally procured firearms were used in any criminal activity in the state.

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Gabon Fishing and Outdoor Vegetation

Gabon has 8 maps in the Vegetation classification all ideal fishing and outdoor locations to choose from and all have potential for you catching your trophy fish (northern pike, walleye, seabass, or trout) or for your extreme outdoor experience. This maps directory lists Gabon maps related to the Vegetation classification. You will find all the fishing and land data and information to fish or explore the outdoors in Lakes, Rivers or from an Island, or to find the best trail to get to the lake or river, all from the largest database of fishing and outdoor maps and information for Gabon. Click on any of the Gabon locations under a specific feature type to view the full list and to read more free information on each destination.


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