List of scoring systems [14].
\r\n\t
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Dr. Yu is a holder of 90 journal papers, with an h index of 21, is a member of A& WA (USA) and AAAR (USA), and is the holder of 24 registered patents.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"188972",title:"Prof.",name:"Mingzhou",middleName:null,surname:"Yu",slug:"mingzhou-yu",fullName:"Mingzhou Yu",profilePictureURL:"https://mts.intechopen.com/storage/users/188972/images/system/188972.jpg",biography:"Mingzhou Yu is now a Professor at China Jiliang University and a Guest Professor at Key Laboratory of Aerosol Chemistry and Physics, Chinese Academy of Science. He received his PhD degree from Zhejiang University in 2008 with the major fluid mechanism. During the time period between 2009 and 2012, he moved to Karlsruhe Institute of Technology, Germany, as a Alexander von Humboldt researcher where he worked with Prof. Gerhard Kasper and Dr. Martin Seipenbusch. Since 2013, he joined Prof. Junji Cao's research group as a guest Professor at Key Laboratory of Aerosol Chemistry and Physics, Chinese Academy of Science. During the time period between 2013 and 2016, he worked in The Hongkong Polytechnic University and Universidad Autónoma de Madrid, Spain, as a research associate or postdoc researcher. He is now leading a Aerosol Science and Technology Laboratory supported by Zhejiang Special Provincial Support in CJLU. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2270",title:"Fourier Transform",subtitle:"Materials Analysis",isOpenForSubmission:!1,hash:"5e094b066da527193e878e160b4772af",slug:"fourier-transform-materials-analysis",bookSignature:"Salih Mohammed Salih",coverURL:"https://cdn.intechopen.com/books/images_new/2270.jpg",editedByType:"Edited by",editors:[{id:"111691",title:"Dr.Ing.",name:"Salih",surname:"Salih",slug:"salih-salih",fullName:"Salih Salih"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"72867",title:"High Tibial Osteotomy",doi:"10.5772/intechopen.92887",slug:"high-tibial-osteotomy-1",body:'Cartilage degeneration of a particular compartment of the knee joint is usually the result of overloading of medial compartment which is associated with the malalignment of the lower extremity. In other words, cartilage degeneration is an inevitable result of lower extremity malalignment and it is associated with clinical symptoms including pain and gait difficulty. In addition to arthritis, rickets, Blount disease, or tibial plateau fractures are other reasons for lower limb deformity, but we will not further mention them here because they are irrelevant to this chapter. In order to prevent the progressive cartilage degeneration followed by amelioration of the symptoms, re-alignment osteotomies, which have the potential to unload the compartment while preserving the native joint, are generally applied. Considering the relative young age of these patients with unicompartmental arthrosis, in order to delay the arthroplasty, re-alignment osteotomies, while being technically challenging constitute the most important treatment modality by providing earlier return to high-level activities in contrast to arthroplasty. Osteotomies might also be applied with procedures including meniscal repairs, ligamentous reconstructions, or cartilage regenerating procedures, because of augmenting the success rates of these co-applied procedures. Indications for re-alignment osteotomies have been expanded recently as a result of high activity levels of the relatively older patients. Meanwhile, an optimization of the re-alignment osteotomies occurred as a result of the modified surgical instruments and techniques, leading to more reliable outcomes.
In young and active patients, it is important to preserve the medial compartment of the knee and provide adequate cartilage coverage to prevent a premature arthritis and to delay the arthroplasty as much as possible [1]. High tibial osteotomy (HTO) for varus deformity is one of the most common types of osteotomies for the re-alignment of the knee.
First HTO was performed by Jackson and Waugh in 1958, while they defined the technique as a ball and socket osteotomy inferior to anterior tibial tuberosity and at the middle third portion of the fibula [2]. Modifications of the original technique were reported with a success rate of 85% [3]. In 1965, Coventry reported his results regarding long-term outcomes, which was not very promising and made several publications in the following years [4]. The introduction of the blade plate for maintaining correction and allowing early motion was undertaken by Koshino. Opening wedge technique was later introduced by Hernigou and Debeyre with medial approach, where bone grafts and plates were used in order to have a stable fixation, while they recognized the importance of maintaining the sagittal slope while the coronal plane was being corrected [5, 6]. In the beginning of 1980, Maquet described the tibial dome osteotomy. The modern HTO is actually a variation of the Coventry osteotomy. HTO’s high popularity between 1960 and 1980, showed a slow decline afterwards as a result of many reported good outcomes of total-unicondylar knee arthroplasty that changed the surgeons’ preferences.
HTO is regaining popularity, especially in young and active patients with high expectations for physical activities and increased life expectancy, in order to preserve the native joint together with bone stock, cartilage covering and proprioception, which are compromised with unicompartmental knee arthroplasty, in addition to its allowance to relatively limited physical activities [1, 7, 8]. The currently used plates are providing very stable osteosynthesis by preserving the periosteal blood supply; while there are also new biomaterials and bone substitutes that prevent many complications related to iliac crest graft harvest [9, 10, 11]. Meanwhile, HTO became a more popular option for young and active patients as a result of the improvements regarding the surgical technique, fixation devices, and fewer complications accompanied with a meticulous patient selection [12, 13, 14, 15].
HTO, as a re-alignment osteotomy is applied to transfer the medially deviated mechanical axis to lateral toward the midline of the knee to unload the medial compartment and delay the process of osteoarthritis (OA) [11, 13, 14]. The first aim of HTO is to eliminate or reduce pain, by translating loads to the contralateral (femorotibial) compartment as a result of the deformity correction; while some studies has reported that the regenerative process was beginning after the accomplishment of re-alignment [16, 17, 18].
Careful pre-operative planning and strict indication criteria are paramount in order to have a successful outcome in the long term [1, 11].
Indications of HTO can be categorized as physical and radiological. Physical indications include:
Physical contraindications comprise:
Radiological indications include:
Controversial contraindications regarding the HTO procedure include:
HTO was recently suggested to be included in joint preservation surgery, to unload a cartilage restoration site (autologous chondrocyte implantation [ACI], osteochondral autograft or allograft, microfracture), and to correct the sagittal slope in cruciate ligament insufficiency [1, 8, 17]. When HTO is performed before medial compartment, arthritis has become severe and subchondral bone has been exposed, superior clinical and outcomes can be achieved [19, 20].
We would like to underline some important scenarios that should be meticulously assessed. Patients with anterior knee pain may get worse after the HTO procedure providing a coronal plane correction that can worsen their symptoms. Patients should be carefully explained, that the recovery from an HTO is time consuming and requiring commitment of the patient. Patients should be explained, that HTO procedure’s post-operative rehabilitation protocol typically requires a period of protected weight-bearing followed by extensive lower limb muscular training. Patients should understand that an average of 6 months is needed to have a total recovery to a pain-free state of full activity. It is also very important that, pre-operatively, patient expectations should be thoroughly discussed and managed appropriately.
Indications of HTO might differ according to the geographical region. Patients older than 60 of age are typically offered total or unicompartmental knee arthroplasty over an HTO in the United States, while outside the United States, HTO is frequently performed in older patients, who are fit and active, and are explained that they may not obtain total symptom relief [1, 8].
It should be noted that the ideal patient for the application of HTO is a relatively young, active, and non-smoking patient, for whom arthroplasty should be prevented or delayed. As described above, obesity was also reported as a contraindication in old patients, because of the increased stresses that the osteotomy site must support; while it is a relative indication in younger patients in whom arthroplasty is indicated [1, 8].
A large-scale population-based study looking at 2671 patients who had undergone an HTO before conversion to a TKA found that certain factors lowered HTO survival rates, including accompanied ligament injuries, prior meniscectomy, older age, and female sex were reported to lower the HTO survival rates in 2761 patients, who underwent HTO before conversion to total knee arthroplasty [21].
A thorough history and physical exam are paramount before proceeding with HTO. As a result of that, patients with a prior traumatic knee injury and patients with a new onset of medial compartment arthritis could be distinguished. Previous trauma may be associated with other concomitant ligamentous and cartilaginous injuries. In every patient, in order to meet the expectations, the levels of activity, and overall health should be precisely noted.
Physical exam starts with the observation of patient’s gait and stance, especially to assess varus thrust, accompanied with the presence of lateral collateral ligament insufficiency. Patients with varus deformity at the knee joint can be identified by observing them standing and walking. However, in cases of large body habitus, observation alone might not be very reliable. Examination of gait is critical regarding the decision with HTO. In patients with varus deformity at the knee joint, medial compartment is overloaded which creates an increased knee adduction moment, leading to increased stresses of the tensions of lateral ligamentous structures. In the presence of varus malalignment at knee joint, lateral ligamentous insufficiency may develop over time, and can even progress to varus recurvatum deformity associated with anterior cruciate ligament (ACL) insufficiency requiring ligament reconstruction in addition to HTO procedure [1, 11]. Joint instability including insufficiency of collateral and cruciate ligaments, any ankle deformity and limb length discrepancy should be considered for concomitant or staged surgery [22, 23].
A complete radiographic evaluation comprises the following X-rays:
A full-length, three-joint (bilateral hip to ankle on the same cassette) weight-bearing view in full extension with the feet in a neutral position to evaluate the alignment;
A 45° flexion posteroanterior view to evaluate any narrowing in the posterior femorotibial compartment;
A lateral view to measure patellar height and assess the patellofemoral joint (PFJ);
Stress views are mandatory when physical exam reveals ligamentous laxity,
The tibia bone varus angle (TBVA) is measured on AP radiograph and TBVA ˃ 5° is a good prognostic factor after osteotomy
A skyline view for detailed evaluation of the patellofemoral joint [1, 8, 11].
Indices regarding the pre-operative patellar height (Caton-Deschamps index, modified Insall-Salvati index, Blackburne-Peel index) should be calculated because both opening and closing wedge HTOs have had the potential to result in patella baja. Therefore, patients with pre-existing patella baja should be evaluated very carefully before performing the HTO procedure [24, 25].
To establish the posterior tibial slope baseline, a lateral radiograph should be obtained. Because of the anatomical-triangular shape of tibia, a medial opening wedge osteotomy comprises a bone cut from anteromedial to posterolateral aspect of the tibia. As the osteotomy site is opened, the tibial slope increases. For a lateral closing wedge osteotomy, the same principle can be used but in a reverse fashion. Considering this type of osteotomy, the bone cut is directed from anterolateral-to-posteromedial, decreasing the tibial slope [1, 23].
In knee joints with cruciate ligament deficiencies, tibial slope changes could directly affect the problem regarding the ligaments. Meanwhile, PCL insufficiency is accentuated by an increased tibial slope, while in an ACL-deficient knee as a result of the decreased tibial slope, the degree of instability is frequently progressed [1, 21, 24]. However, to improve the outcome of HTO procedure, tibial slope adjustments can be applied. To enhance stability in an ACL-deficient knee, tibial slope may be increased, whereas in PCL-deficient knees decreasing the slope can be helpful in establishing stability [1, 21, 24]. We recommend using magnetic resonance imaging (MRI) in order to evaluate the soft tissue problems, including meniscus tears, ligamentoıus injuries, osteochondral defects, or even for the detection of subchondral bone edema.
In 2004, ISAKOS (International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine) developed a protocol for the HTO [23]. As a result of that protocol, an ideal patient for HTO is defined by following criteria:
Malalignment < 15°
Metaphyseal varus (i.e., TBVA > 5°)
Full range of motion (ROM) of the knee joint
Normal, near-normal lateral, and patellofemoral compartments
No ligamentous instability
Non-smoker
Moderately active high-demand patient
Young (40–60 years of age)
BMI < 30 (in other words: obesity is a contraindication)
Isolated medial joint line tenderness
Some level of pain tolerance
HTO is contraindicated in patients with followings:
Severe OA of the medial compartment (Ahlback grade III or higher)
Tricompartmental OA
Patellofemoral OA
Age > 65
Knee ROM < 120°
Knee flexion contracture > 5°
Diagnosis of inflammatory arthritis
Heavy smokers
large area of exposed bone on tibial and femoral articular surface (>15 × 15 mm)
Good prognostic factors [26, 27, 28] regarding the HTO procedure can be summarized as the followings:
Ahlback grade 0 arthritis of medial plateau
Age < 50
Pre-operative TBVA > 5°
Post-operative obliquity of tibiofemoral joint line in a narrow range close to 0°
Anatomical valgus alignment of ≥8° at 5 weeks post-op
Excellent pre-operative Knee Society Score (KSS)
Poor prognostic factors [26, 27, 28] regarding the HTO procedure can be summarized as the followings:
Smoking
Obesity
Age > 56 years
Valgus alignment of ≤5° at 5 weeks post-op
Post-operative flexion < 120°
Cartilage defect at the medial tibial plateau was shown not to affect the clinical results of HTO procedure by Niemeyer et al. [14] in their study with minimum of 36-month follow-up of 69 patients after medial open wedge high tibial osteotomy (MOWHTO). They also concluded that partial thickness defect in lateral tibial plateau was well-tolerated.
Before starting with the decision-making process, some important terms regarding the alignment of the lower extremities should be explained [29, 30, 31, 32].
Normal values of the aforementioned axis are [29, 30, 31, 32]:
6° of valgus between the mechanical and anatomical axes
Weight-bearing line passing through the lateral 30–40% of the tibial plateau
60% of the total body weight force passes through the medial compartment.
These measurements are performed on the alignment view (Figure 1). As a result of that, the type, location, and most importantly the amount of corrective osteotomy is ascertained. The pre-operative mechanical axis deviation and the degree of medial compartment arthrosis determine the amount of correction needed. Unicompartmental OA was reported to yield clinical symptoms, when the lower extremity alignment was a more than 10° of normal range [33].
The main axes of the lower extremity. AC: mechanical axis of femur, BC: anatomical axis of femur, CD: anatomical and mechanical axis of tibia, and AD: weight-bearing axis.
If a decision to perform the HTO procedure is established, a medial opening wedge osteotomy or a lateral closing wedge osteotomy can be chosen purely based on the surgeon’s decision.
Lateral closing wedge osteotomy, which allow for immediate weight-bearing, possess lower rates of non-union/mal-union, and is theoretically associated with lower risks of increasing the posterior sagittal slope and leading to patella baja was widely used by Coventry in 1960s [34, 35]. However, an exposure violating the anterior compartment of the leg, loss of the present bone stock together with a narrow window for modification once the bone wedge is removed, a possible concomitant fibular osteotomy, and risks associated with peroneal nerve exposure are the disadvantages associated with lateral closing wedge osteotomy.
Recently, as a result of advancements regarding low-contact profile-plated and fixation techniques, bone grafting options and most importantly regarding the technical advantages of the exposure and approach, medial opening wedge osteotomy has gained popularity [10, 13, 14]. By performing the HTO from the medial side and avoiding the lateral side, certain risks associated with the anterior compartment dissection, peroneal nerve exploration and fibular osteotomies can be avoided [8, 13, 14]. HTO procedure, performed as medial opening wedge osteotomy, facilitates correction and allow for fine-tuning in both the coronal and the sagittal planes. However, the risk to increase the sagittal slope and historically higher rates of non-union are the associated disadvantages of this approach [36].
The degree of correction is established according to the location of the mechanical axis line through the knee joint [1, 8]. The reference point on the tibial plateau is set at 62.5% of its width as measured from the medial cortex for most cases of genu varum resulting from OA [1, 14, 32]. In order to unload the medial compartment, the mechanical axis is planned to pass lateral to the center of the knee, aiming the lateral compartment [1, 14, 32] (Figure 2). A careful pre-operative planning should be undertaken in order to avoid the overloading of the lateral compartment, especially in cases with mild degenerative changes within the lateral compartment [14, 21, 36]. In these cases, massive corrections, or subtle corrections with a concomitant cartilage transplant, the mechanical axis can be moved to the midline of the knee joint to prevent overloading of the lateral side [14, 21, 36].
Pre-operative planning for MOWHTO. (A) The white dashed line represents the weight-bearing axis, whereas the red circle represents the desired point where the weight-bearing axis is planned to pass post-operatively. (B) α, the correction angle, is the angle formed by the mechanical axes of femur and tibia that are aimed to be provided post-operatively. The osteotomy line (the red dashed line) is planned to be started about 4 cm distal to the medial joint line, aiming the tip of the head of fibula.
HTO procedure aims to reach a slight valgus axis to prevent any recurring of genu varum deformity. 3–5° of valgus in the mechanical axis or 8–10° of valgus in the anatomical axis are considered as the primary goals regarding correction after surgery [1, 5, 16, 34]. There is a fine balance between over- and under-correction; while slight varus correction can lead to recurrence of previous deformity, whereas overcorrection and over-deviation of the axis to the lateral compartment can cause cartilage degeneration at the lateral compartment, leading to lateral compartment OA [1, 5, 16, 34].
The weight-bearing line (WBL) should pass from 62% of the tibial plateau width when measured from the medial edge point of the medial tibial plateau [32, 37]. The point where WBL intersects the tibial plateau is called as the Fujisawa point [32, 37] (Figure 3). Fujisawa point is located slightly lateral to the lateral tibial spine and matches over the mechanical axis with 3–5° of valgus [32, 37]. A line is drawn from this point to the center of the ankle joint and another line from this point to the center of the ipsilateral femoral head is drawn to determine the amount of required correction [32, 37]. The angle measured between these two lines indicates the amount of required correction to re-align the knee joint [11, 32, 37]. The line for the osteotomy is drawn approximately 4 cm below the medial joint line toward the fibular head. This line has to be transferred to the apex of triangle that is created just during planning. The width of the triangle’s base corresponds to the amount of correction that is required during a medial open wedge osteotomy [11, 13, 14].
Picture defining Fujisawa point.
The correction angle for lateral closing wedge osteotomies is calculated using a similar technique. Perpendicular to the axis of tibia and approximately 2 cm below the joint line the first osteotomy line is drawn. Applying the 1° to 1-mm equivalence at the lateral cortex below the initial osteotomy, the second osteotomy line is drawn. The wedge that has been bordered by the two osteotomy lines should be removed. By performing lateral closing wedge osteotomies, the sagittal slope must be assessed repeatedly to avoid significant slope perturbations [5, 8, 12].
We usually start with arthroscopy to perform the debridement of the lateral compartment and to manage the concomitant pathologies regarding the menisci and chondral tissues before starting with the HTO, as recommended [38]. For the correction of genu varum deformity and re-alignment of the lower extremity, medial opening wedge, lateral closing wedge, and dome osteotomy can safely be applied. Our preference is the medial opening wedge osteotomy.
In the middle of the line drawn from the tibial tubercule to medial border of tibia, a 3–5 cm longitudinal skin incision is made carefully by beginning 1–2 cm inferior to the medial joint line and continuing caudally to the pes anserinus. After dividing the sartorial fascia, we usually distract the tendons of pes anserinus distally, but an inverted L-shaped flap can also be elevated. After subperiosteal dissection and sufficient exposure of the proximal-medial tibia and the joint line, the superficial medial collateral ligament (sMCL) fibers are elevated from their medial tibial attachment sides; otherwise, if the attachment of sMCL is left intact on the medial tibia, pressures of the medial compartment may inevitably increase as a result of the tensioning of sMCL fibers during the distraction phase of the osteotomy [1, 8]. Proximal to the tibial tubercule, patellar tendon should be identified and protected from the possible damage that might be caused by the blade of the saw by placing a broad retractor anteriorly. It is of high importance to conduct careful subperiosteal dissections in order to protect and secure the posterior neurovascular structures.
After the subperiosteal dissection and exposure of the entire proximal-medial portion of the tibia, a guide wire is inserted, starting proximal to the tibial tubercule and aiming toward the tip of the fibular head with an anteromedial to posterolateral trajectory. After the insertion of the first guide wire, it is optional to place another wire posteriorly to determine the osteotomy’s sagittal angle that can influence the amount of the sagittal slope. If a reduction of the posterior tibial slope is desired, the posterior guide wire should be placed more superiorly resulting in a flatter cut. If a rise of the sagittal slope is desired, then the posterior guidewire should be placed more inferiorly.
An oscillating saw is used to make the first cut of the osteotomy on the anteromedial cortex.
This cut is advanced with osteotomes until to a distance of 1–1.5 cm to the lateral cortex of the tibia, in order not to cause any fracture on the tibial plateau. In addition to that, it is also recommended, that the vertical distance from the tip of the osteotome to the lateral tibial plateau should be 1.25 times of the horizontal distance to the lateral tibial cortex, to minimize the risk of any fracture on the lateral tibial plateau. Hereby, the osteotomy is ended, followed by the opening of the osteotomized bone and very gentle and careful application of valgus force on the tibia. Osteotomy side is opened sequentially with calibrated wedges. As a result of that, a new mechanical axis has been reconstructed (Figure 4). The new mechanical axis is confirmed by either placing a cord of electrocautery or a long alignment rod from the center of the hip to the center of the ankle and confirming its distance from the knee joint under image intensifier. It was also suggested to add a concomitant tibial tuberosity osteotomy, if more than 12.5 mm correction is required, in order to avoid the potentially adverse effects of patella baja and increased pressure in patellofemoral compartment [8, 39].
Post-operative weight-bearing orthoroentgenogram of a patient after MOWHTO. β (7° in this case) is the angle formed by the anatomical axis of femur and the weight-bearing axis (white dashed line) or the mechanical and anatomical axes of tibia, where all three axes are overlapping each other in the tibia.
The advantages of the medial open wedge osteotomy can be summarized as:
the ability to provide biplanar correction and biplanar alignment (coronal and sagittal),
no limb shortening,
no bone loss,
no need for fibular osteotomy,
use of a single cut with no need to detach the muscles,
little risk of peroneal nerve injury,
ability to adjust the amount of correction during surgery,
easier conversion to arthroplasty.
The disadvantages of the medial open wedge osteotomy can be summarized as:
the need for bone graft,
the risk of delayed union or non-union.
Plate fixation was reported to be biomechanically superior as compared to external fixation [40, 41]. Plates without spacer wedges were shown to have higher rates of failure compared to those with wedges [11, 41]. Plate fixators (i.e., The TomoFix plate) are manufactured with the principles of the locking compression plate (LCP) concept; meanwhile offering the advantage of a rigid fixation, and providing early weight-bearing, and early start of motion while the normal pre-operative posterior tibial slope is maintained [13, 14, 42]. TomoFix plates (Synthes, West Chester, PA) and Puddu plates (Arthrex, Naples, FL) were detected to provide adequate biomechanical stability, whereas in case of lateral cortex fracture, TomoFix plates were detected to provide adequate stability without the need of any additional lateral fixation [8, 42]. The biomechanics of three spacer plates with different length was studied, while two were with locking bolts, and one was the TomoFix plate, which was shown to be superior at single load-to-failure and cyclical load-to-failure tests and also possessed the maximum residual stability after failure of the lateral cortex, in addition to least motion at the osteotomy gap [43, 44, 45].
After medial open wedge HTO procedure, healing was shown to start from the lateral hinge and advancing toward the medial aspect, while 3 months after the procedure, callus formation, and ossification was visible [8, 11, 13]. In our clinical practice, 6 months post-operatively more than 80% of the gap is filled with newly formed bone (Figure 5), and more than 80% of patients X-ray and CT scan, a consolidation is visible at the end of the first post-operative year.
Anteroposterior and lateral X-rays of the patient after 6 weeks (A and B) and 6 months (C and D) post-operatively.
To enhance stability and accelerate the healing, we like many other surgeons prefer to fill the gap of osteotomy with grafts or bone substitutes. Post-operative alignment and clinical outcome were reported to be comparable between beta-tricalcium phosphate (TCP) and hydroxyapatite (HAp), but TCP was noted to possess a significant superiority regarding osteoconductivity and bioabsorbability after 18 months [46]. After the TomoFix plate removal, it was observed, that TCP was completely absorbed and the newly forming bone was completely remodeled and incorporated into osteotomized tibia [47].
Autogenous iliac bone graft as the bone filler is widely used at the end of the HTO procedure. It is also considered as a reliable bone filler in patients who are at risk of non-/delayed union such as smokers, obese patients, and those with [48]. Results with autograft were reported to be superior with lower rates of total complications as compared to allograft and bone substitutes such as the calcium-phosphate ceramic spacer [49].
Lateral closing wedge osteotomy (LCWO) starts with an inverted L-shaped incision directed anterolaterally, while the vertical part is placed on the lateral edge of the tibial tubercule and the horizontal part is placed 1–1.5 cm distally to lateral knee joint line. This osteotomy requires peroneal nerve exposure and dissection, which is found on the anatomical area located the 2–3 cm distally to fibular proximal styloid process and crossing the neck of the fibula. The nerve should be carefully dissected and protected. After the dissection and protection of the peroneal nerve, the anterior compartment muscles are elevated subperiosteally from the anterolateral aspect of tibia while the incision is advanced distally. Patellar tendon should be protected while placing a retractor between the tendon and the anterior tibia. Following this step, the tibiofibular joint can be disrupted by using an osteotome, combined with the resection of the medial one-third of fibula or applying a fibular shaft osteotomy placed 10 cm distally to the fibular head. After that, we usually identify the joint by using two needles and placing the osteotomy guide parallel to the needles aiming 2–2.5 cm distal to the joint line. Following this step, the osteotomy guide is secured to the bone by using two smooth pins, over which the plate is also placed with high precision to the bone while directing it exactly parallel to the posterior slope of the tibial. Before starting to perform with the osteotomy by using an oscillating saw and osteotomes, posterior neurovascular structures, and patellar tendon should be ensured to be protected by the retractors. It is important to end the tip of the osteotome with a distance of 1 cm from the medial tibial cortex and 2–2.5 cm distal to the knee joint line (Figure 6). With the help of the osteotomy guide, the required amount of bone can be resected. This step is followed by the application of the plate over the previously placed pins that are replaced with screws. By using a large reduction clamp, the osteotomy is closed and compressed, followed by the insertion of the remaining screws.
Pre-operative planning for LCWHTO. α, the correction angle, is the angle formed by the mechanical axes of femur and tibia that are aimed to be provided post-operatively. The osteotomy lines are drawn as red dashed lines.
A dome osteotomy is usually indicated when a correction more than 20° are needed. The osteotomy is performed by applying an inverted U-shaped (dome shaped) osteotomy proximal to tibial tubercule. Especially in cases with accompanying patellofemoral disease, by staying proximal to tibial tubercule, distal tibia is shifted anteriorly, yielding to anterior translation of the tibial tubercule, which maintains the patellar height. After the placement of a jig, anteroposterior drill holes are applied in a half barrel shaped configuration while staying proximal to tibial tubercule. During dome osteotomy a partial resection of the fibular shaft might be necessary. Before starting with the osteotomy, the amount of correction should be certainly indicated on the jig and marked with Steinmann pins located in the proximal and distal fragments. Removal of the jig is followed by careful osteotomizing of the posterior cortex, while the pre-determined amount of correction is achieved by anteriorization of the distal fragment together with the tibial tubercule. Dome osteotomy is usually fixed by using an external fixator. Increased operative time, patient discomfort caused by the external fixator, possible risks of pin tract infections, need for frequent follow-up visits for the fine-tuning of external fixator or assessment of the wound side are the disadvantages of dome osteotomy. In our clinical practice, we do not apply the dome osteotomy frequently as a result of the aforementioned disadvantages, while we spare this procedure for patients requiring high degrees of bony correction.
A good surgical technique combined with rigid fixation together with meticulous patient selection and appropriate post-operative rehabilitation protocols are keys to long-term survival of HTO. Koshino et al. reported 93.2% as the 10-year survival rate for closed wedge osteotomy, related to some post operation factors including, valgus anatomical angle of 10°, no flexion contracture and concomitant patellofemoral decompression procedure if indicated [50]. In patients who underwent medial open wedge high tibial osteotomy a 10-year delay of arthroplasty in 63% of 73 patients [51], and in 85% of 203 patients was shown [52].
In a study of 54 patients with osteoarthritis limited to medial compartment, 24% rate of conversion to arthroplasty was reported after a median of 16.5 years with either medial opening or lateral closing wedge HTO, while no significant difference regarding the functional scores and survival rates was found between the two techniques [53].
It was reported, that authors showed that the lateral closing wedge osteotomy was related to higher number of conversion to total joint replacement, whereas the medial opening wedge HTO was related to higher incidence of complications [54].
Results of HTO were noted to be good within the first 10 years following the surgery; whereas, a worsening of the results was also shown after 15 years [55, 56].
HTO’s complication rate was reported between 7 and 55%. It should be remembered that HTO requires a long learning curve leading to decreased rates of complication [1, 7, 8].
With more experience and over the course of years, rates of complications were decreased to 8–15% [1].
It is a fact that medial opening wedge HTO became more popular that the other techniques, because of the successful outcomes. Complications including hardware failure, hardware irritation (up to 40%), loss of correction, non-union, lateral tibial plateau fractures, medial collateral ligament injuries were reported for opening wedge HTO [1, 8, 57]. In addition to that, lateral cortex violation was reports as an important factor for fixation failure, resulting in a minimum 4° of loss of correction in the final follow-up as compared to immediate post-operative X-rays [49]. In a study comprising 100 consecutive MOWHTO patients with an average follow-up of 4 years, allograft combined with plasma-rich platelets and/or DBM was associated with the risk of non-union [58]. Severe adverse events were reported to be seen more common as a result of HTO in patients with diabetes, active smoking, displaced lateral hinge fractures, and patients with no compliance [59].
HTO with and without articular cartilage procedures or meniscus allograft transplantation was evaluated in a systematic review assessed and concluded that HTO combined with cartilage procedures led to excellent short-term and mid-term survival and good clinical outcomes, while deterioration was detected after 10 years [60]. Another study of 43 patients with HTO and ACI showed long-term, improved cartilage survival, and a decreased rate of revision in patients with mild varus deformity (<5°) of knee joint [61]. HTO was intended to preserve the joint and chondral surfaces as much as possible to delay the time interval until total knee arthroplasty. In order to be successful and preserve the joint as much as possible, we also prefer to apply concurrent cartilage procedure to delay the TKA as much as possible.
La Prade et al. reported about the modified Cincinnati Knee Scores (CKS) in patients younger than 55 years old who underwent HTO for medial OA and varus deformity in a single surgeon study from 2000 to 2007. They had strict inclusion and exclusion criteria which excluded patients undergoing additional procedures or treatments. Each patient was applied an offloading brace pre-operatively. If the patient did not get symptom relief, they were not offered a HTO. Forty-seven patients were available for follow-up. The CKS improved from 42.9 to 65.1 (
Howells et al. reviewed 164 consecutive patients that underwent lateral closing wedge HTO between 2000 and 2002. Among them, 100 patients met the inclusion criteria and had a follow-up duration of 5–10 years post-operatively. Data were collected prospectively; however, the study reviewed the data retrospectively. To assess outcome WOMAC and KSS were used. At 5 years, 87% of survival rate was reported with the remainder undergoing TKA. This rate dropped to 79% after 10 at 10 years. It was detected that those requiring revision to TKA had a significantly lower WOMAC score (47 vs. 65,
The authors declare no conflict of interest.
God created human beings and honored them over other creatures; therefore, keeping life is one of utmost urges. This urge to save lives is challenged in time of major incidents when patients’ needs are exceeding care resources. Moreover, with the increase in global population and escalation in the costs of healthcare, more patients are visiting emergency departments (EDs) all over the world to cut expenses and bypass remote appointments. Most EDs today adopt a triage system to prioritize patients who need urgent care.
\n“The process of determining the most important people or things from amongst a large number that require attention” [1].
\nIt is the sorting of victims by giving them grade to prioritize them for treatment and transportation in order to maximize the number of survivors in major incidents and war victims [2]. According to the assigned grade, patients will have their priority in attending by healthcare givers, investigations, and operation rooms.
\nThe term triage is similar to “rationing” and “allocation” which is practiced on a daily basis in every field. For the term triage to be applied for a situation, there are three prerequisites that must be fulfilled:
There is shortage of resources in comparison to the needs.
There should be a system set to triage by the health body or facility.
Trained health personnel should do the triage [3].
Triage started as war time medical effort driven by the increased number of wounded and shortage of resources. In addition the need for manpower during wars affected the priorities in triage in some armies.
\nIt is believed that the first time triage used in military medicine to prioritize treatment for the wounded was by Baron Dominque Jean Larry (8 July 1766–25 July 1842). He made rules that the wounded are treated by the severity of their clinical conditions regardless of the rank; even enemies were treated in the same way [4].
\nThe next milestone in triage was attributed to British rear admiral John Crawford Wilson (1834–4 July 1885) [5]. He differentiated between the severity levels of the wounded; he wrote in his book
Triage in the American civil war was depending on the first-come, first-served basis regardless of the severity, salvageability, or best use of limited resources [3].
\nThe World War I with the development of more lethal weapons like machine guns and chemical gases with a large number of wounds that could be treated pushed the military surgeons to apply and refine triage protocols. This has led to the concept of “The greatest good of the greatest number.” This is the rule for triage practiced in military and civilian life during major incidents now [7]. This rule means that at time of limited resources and facing huge demand, some patients can be saved if long time and large amount of resources devote to them, but this will not be done. The reason to not offering help to those patients is that we can save much more number of wounded patients (who are less critical) using the same resources during the same time. We may save 10 patients instead of one. The pressure of escalating numbers of wounded soldiers with limited fighters in the battles made some health strategic planners in the armies to give higher priorities to patients that can be treated and sent back to front war lines rapidly over seriously injured patients that need urgent intervention for long duration. Winslow listed the two objectives of triage as “1st, conservation of manpower; 2nd, the conservation of the interest of the sick and wounded” [8].
\nIn the World War II, the weapons were more developed with the introduction of tanks and air forces. On the other hand, medications and health services improved. The health strategic planners still concentrate on supporting the troops. They direct resources for soldiers who are able to fight rather than injured or diseased ones.
\nWith the improvement of transportation and less dependence on the manpower in modern wars, it is rarely nowadays needed to leave somebody without treatment for the sake of others. The triage decision now is to which facility best transfer the patient and what is the optimum method of transportation.
\nHealth system ethics has been developing and improving since the eighteenth century by the First Geneva Conventions (1859) and Nuremberg Act [9]. In 1979, Beauchamp and Childress published their book
Respect of autonomy
Beneficence
Non-maleficence
Justice
To have a triage system, there are three requirements to be fulfilled:
There should be shortage of resources in comparison to the need.
There should be a system set by health authority to be used in such circumstances (point A).
There are personnel trained on the system who will implement it.
If there is no shortage, then no need to use triage, but for every patient, the health facility will do its best to treat the patient.
A triage system should be set by the health authority or facility administration to be followed by anyone doing this task. The aim of this step is to look for the benefit of the community and the population as a whole and not to just part of it.
Trained personnel to practice the triage to ensure the justice and prevent personal preference.
During major incidents, there are situations in which the triage officer should take some decisions that may be hard and not in the best interest of some patients. The decisions made by the planners in the First and Second World Wars and before are made not by patients’ will or his best interest and benefit. Below is the discussion of the principles one by one:
Respect of autonomy: During a normal life, this is the first patient’s right. No intervention should be done unless the patient understands the issue fully and accepts it. For this reason, the informed consent is needed to be signed by the patient. In time of major incidents with a large number of patients present, there should be prioritization of patients according to system agreed upon by the hospital or health authority. In time of major incidents, absolute knowledge of the whole community needs is predominant over individual liberty. It is sure that some people will not be happy with delaying them regardless of their presentation time or their degree of severity.
Beneficence: In 1964, the World Medical Association (WMA) developed the Declaration of Helsinki as a set of ethical principles for experimentation on human beings. The declaration strongly emphasizes
Later in the chapter, there is a section regarding exceptions to the general rules.
Non-maleficence: Non-maleficence means doing non-harming or inflicting the least harm possible to reach a beneficial outcome [11]. In this meaning trying to save as much as possible of the community can explain depriving some patients from treatment or delay them until suitable time and resources are available. In this issue we may not consider all people as the same, for example, if there is a healthcare giver and a fighter that are wounded, then we should not count each as one person, because when the healthcare giver is treated, he will help in saving the other.
Justice: In justice we mean that each patient should take what he needs and no one should be disadvantaged or deprived from treatment. People may misunderstand the meaning well and have high expectations to treat all patients as the highest-priority patient. To explain this we should differentiate between
Ownership of resources is challenged in time of major incidents, and the hospital should accept and treat any patient involved in the incident (according to the plan) [3].
Although triage depends mainly on patients’ injury severity, there are conditions which oblige the officer to modify his triage decision or in austere condition to decide to whom priority of care is given. The triage officer should look to the whole picture of the community, putting in his mind the aims at that particular time he is doing it and the full resources in addition to the type of patients he is dealing with. The following are examples of special conditions which need special care and by no means are they exhaustive:
Children: Dealing with children is sensitive not only from the emotional side but also the practical side. Children have more expected life span than old people, and in time of limited resources with the equality of other factors, priority should be given to children for the sake of the community.
Pregnant women: In dealing with pregnant women, we are dealing with two lives; therefore, they have double importance and should take priority.
Emergency services personnel: All those personnel should not be counted as one person; if we give them priority and save them, they will help in saving more lives. We give them the value of the expected number of lives they may save. In addition taking care of someone injured rapidly will encourage other to put all their efforts, knowing that their colleagues will treat them in high priority if they are injured, and this will improve the quality of care given to all patients.
People with special skills or knowledge or with special importance: There are some people who possess some special knowledge and skills or have some special importance to the country. Those should also get special treatment and priority. This will need confirmation of their status and priority from local or national authority to recognize them during major incidents.
The surrounding circumstance: If there is a critical need to manpower like in war condition, for example, then the triage officer may make the highest priority to simple cases that can be treated with minimal resources and time and go back to combat area. Another example is facing floods and waiting for central help, until extra help reaches them, and there is a desperate need for all hands even the slightly wounded; otherwise, the whole area and local community will have grave outcomes.
Combination of the abovementioned conditions needs the triaging officer to put his priority at that single moment.
We can divide triage systems into several categories:
Military triage system
Major incidents in civilian life
Emergency department triage system which is used for managing patients on a daily basis
The triage systems used in military and major incidents “that occur in civilian life” are the same, and it will be discussed in combination. They differ in the infrastructures supporting each one, with clear overlap between them.
Table 1 shows some of scoring systems used to evaluate the severity of the injuries which is the base for triage.
\nYear introduced | \nAbbreviation | \nName | \n
---|---|---|
1970 | \nAIS | \nAbbreviated injury scale | \n
1971 | \nTI | \nTrauma index | \n
1974 | \nGCS | \nGlasgow Coma Scale | \n
1974 | \nTISS | \nTherapeutic intervention | \n
1974 | \nISS | \nInjury severity score | \n
1980 | \nTI | \nTriage index | \n
1980 | \nTRISS | \nTrauma injury and severity score | \n
1981 | \nAPACHE | \nAcute physiological and chronic health evaluation | \n
1982 | \nPGCS | \nPediatric GCS | \n
1987 | \nPT | \nPediatric trauma score | \n
1987 | \nOIS | \nOrgan injury scale (AAST) | \n
1988 | \nPRISM | \nPediatric risk of mortality score | \n
1989 | \nAP | \nAnatomical profile | \n
1989 | \nRTS | \nRevised trauma score | \n
1989 | \nT-RTS | \nTriage version of RTS | \n
1990 | \nASCOT | \nA severity characterization of trauma | \n
1994 | \nUST | \nUniform scoring system for trauma (Utstein style) | \n
1994 | \nAPSC | \nAcute physiology score for children | \n
1996 | \nICD-9-CM | \nICD-9 clinical modification based on AIS and ISS | \n
1996 | \nTOXALSTM | \nToxic advanced life support TM | \n
1997 | \nNISS | \nNew ISS | \n
2001 | \nASPTS | \nAge-specific pediatric trauma score | \n
2002 | \nPAAT | \nPediatric age-adjusted TRISS | \n
2003 | \nSTART | \nSimple triage and rapid treatment | \n
2003 | \nJUMP-START | \nPediatric version of START | \n
List of scoring systems [14].
The year input is the first time the system was introduced. Some has been updated later.
There are different categories for triage in major incidents. They are the physiological and the anatomical methods.
\nThe physiological systems are easily learned and need simple training; any health personnel can be trained and perform it. Moreover it can be reproduced easily and is a reliable method of following up the patient’s condition. On the other hand, it is time-consuming and not suitable for incidents with a huge number of victims.
\nAnatomical systems of triage are fast and depend on visual recognition of injuries. These methods need a good amount of experience in injuries and when the patient needs surgery. It is difficult to reproduce the results as it is subjective and not objective. A very large number of victims is suitable for this type of triage.
\nAfter knowledge of the anatomical and physiological condition of patients, the triage officer needs to know the comorbidities to and other circumstances (discussed above in the section of special situations) to give the patient the final triage level.
\nThe most common triage systems used in major incidents are as follows:
There are studies comparing the full GCS to the motor reaction alone. It is believed that motor response is better predictive of patients’ condition than full GCS [16]. Recently the use of GCS in triage is objected because it is time-consuming and can be interpreted in different combinations for the same score [17].
There are several other systems, but they are used to assess and predict prognosis in trauma patients and not used for prioritizing them during response to major incidents.
Flowchart for START triage system [
Flow sheet for JumpSTART triage system [
Eyes | \n\n | Verbal | \n\n | Motor | \n\n |
---|---|---|---|---|---|
Spontaneous | \n4 | \nOrientated | \n5 | \nObey commands | \n6 | \n
To sound | \n3 | \nConfused | \n4 | \nLocalizing | \n5 | \n
To pressure | \n2 | \nWords | \n3 | \nNormal flexion | \n4 | \n
None | \n1 | \nSounds | \n2 | \nAbnormal flexion | \n3 | \n
\n | \n | None | \n1 | \nExtension | \n2 | \n
\n | \n | \n | \n | None | \n1 | \n
Glasgow Coma Scale (GCS). (glasgowcomascale.org) [15].
Triage-revised trauma score [19].
Step 1: Different variables in TRTS. Step 2: Interpretation of the results.
Categories and urgencies in the emergency triage system | \n|
---|---|
Category | \nUrgency of the condition | \n
One | \nPatients in this category should be attended immediately when presented | \n
Two | \nPatients will have priority and seen in the next doctor available. By passing que of patients present | \n
Three | \nTo place the patient’s file at the front of the waiting list | \n
Four | \nWait for their que or may be advised to go to a primary health facility | \n
Five | \nDischarged from emergency side and advised to visit the primary health facility | \n
The five levels of triage in emergency department [21].
There are several triaging systems in different countries like the Manchester triage system which is widely used in the UK hospitals and the Canadian triage system (CTAS) and others, all using five levels and basically similar in sorting patients. There are minimal differences in the bench mark for the time frame each category should be seen within.
\nWith the rush and chaos occurring during response to major incidents, there are mistakes that may be committed by the triaging officer. Under-triage and over-triage are the wrong decisions that may occur:
Triage is a key step in managing major incidents properly. It is not contradicting bioethics, but it is looking from a different focus to make the best to the whole community. It has no rigid rules, and the triage officer must look for different aspects of resources and patients’ situation to make the best triage decision leading to most benefits for all.
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The main global health organizations have incorporated patient safety in their review of work practices. The data provided by the medical laboratories have a direct impact on patient safety and a fault in any of processes such as strategic, operational and support, could affect it. To provide appreciate and reliable data to the physicians, it is important to emphasize the need to design risk management plan in the laboratory. Failure Mode and Effect Analysis (FMEA) is an efficient technique for error detection and reduction. Technical Committee of the International Organization for Standardization (ISO) licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. FMEA model helps to identify quality failures, their effects and risks with their reduction/elimination, which depends on severity, probability and detection. 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Leadership in health services is important for following innovations and adapting to current situations. Nurses working together with other health personnel in hospitals providing health services constitute an important group in leadership. Nursing, which is a key force for patient safety and safe care, is a human-centered profession, and therefore leadership is a key skill for nurses at all levels. The leadership styles of nurse managers are believed to be an important determinant of job satisfaction and persistence of nurses. The need for nurses with leadership skills and the need for nurses to develop their leadership skills are increasing day by day. There are several leadership styles defined in nursing literature. These leadership styles are examined under the titles of relational leadership style, transformational leadership, resonant leadership, emotional intelligence leadership, and participatory leadership. The task-focused leadership style is explored under the headings of transactional and autocratic leadership, laissez-faire leadership, and instrumental leadership.",book:{id:"9047",slug:"nursing-new-perspectives",title:"Nursing",fullTitle:"Nursing - New Perspectives"},signatures:"Serpil Çelik Durmuş and Kamile Kırca",authors:null},{id:"58916",title:"Factors Affecting the Attitudes of Women toward Family Planning",slug:"factors-affecting-the-attitudes-of-women-toward-family-planning",totalDownloads:8485,totalCrossrefCites:9,totalDimensionsCites:18,abstract:"Everyone has the right to decide on the number and timing of children without discrimination, violence and oppression, to have the necessary information and facilities for it, to access sexual and reproductive health services at the highest standard. Deficient or incorrect family planning methods, wrong attitudes and behaviors toward the methods and consequent unplanned pregnancies, increased maternal and infant mortality rates are the main health problems in most countries. Individuals’ learning modern family planning methods and having positive attitude for these methods may increase the usage of these methods and contributes the formation of healthy communities. 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Over periods of time, some of these norms become standards that all members of the community are expected to adhere to. Deviance from these standards is seen as absurd, wrong, or frankly abnormal. However, many of these cultural mores have no scientific basis and, some of them actually promote behaviors with negative health consequences. This chapter examines the cultural practices of some communities in Africa and their health consequences and, explores ways to address the challenges.",book:{id:"9138",slug:"public-health-in-developing-countries-challenges-and-opportunities",title:"Public Health in Developing Countries",fullTitle:"Public Health in Developing Countries - Challenges and Opportunities"},signatures:"Radiance Ogundipe",authors:[{id:"302308",title:"Dr.",name:"Radiance",middleName:null,surname:"Ogundipe",slug:"radiance-ogundipe",fullName:"Radiance Ogundipe"}]},{id:"55808",title:"The Role of Legumes in Human Nutrition",slug:"the-role-of-legumes-in-human-nutrition",totalDownloads:5378,totalCrossrefCites:59,totalDimensionsCites:100,abstract:"Legumes are valued worldwide as a sustainable and inexpensive meat alternative and are considered the second most important food source after cereals. 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His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. 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He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334239",title:"Prof.",name:"Leung",middleName:null,surname:"Wai Keung",slug:"leung-wai-keung",fullName:"Leung Wai Keung",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Hong Kong",country:{name:"China"}}}]}},subseries:{item:{id:"27",type:"subseries",title:"Multi-Agent Systems",keywords:"Collaborative Intelligence, Learning, Distributed Control System, Swarm Robotics, Decision Science, Software Engineering",scope:"Multi-agent systems are recognised as a state of the art field in Artificial Intelligence studies, which is popular due to the usefulness in facilitation capabilities to handle real-world problem-solving in a distributed fashion. The area covers many techniques that offer solutions to emerging problems in robotics and enterprise-level software systems. Collaborative intelligence is highly and effectively achieved with multi-agent systems. Areas of application include swarms of robots, flocks of UAVs, collaborative software management. Given the level of technological enhancements, the popularity of machine learning in use has opened a new chapter in multi-agent studies alongside the practical challenges and long-lasting collaboration issues in the field. It has increased the urgency and the need for further studies in this field. We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!1,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. 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We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:null,selectedSubseries:null},seriesLanding:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"June 24th, 2022",hasOnlineFirst:!0,numberOfOpenTopics:4,numberOfPublishedChapters:314,numberOfPublishedBooks:31,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},subseries:[{id:"14",title:"Cell and Molecular Biology",keywords:"Omics (Transcriptomics; Proteomics; Metabolomics), Molecular Biology, Cell Biology, Signal Transduction and Regulation, Cell Growth and Differentiation, Apoptosis, Necroptosis, Ferroptosis, Autophagy, Cell Cycle, Macromolecules and Complexes, Gene Expression",scope:"The Cell and Molecular Biology topic within the IntechOpen Biochemistry Series aims to rapidly publish contributions on all aspects of cell and molecular biology, including aspects related to biochemical and genetic research (not only in humans but all living beings). We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics include, but are not limited to: Advanced techniques of cellular and molecular biology (Molecular methodologies, imaging techniques, and bioinformatics); Biological activities at the molecular level; Biological processes of cell functions, cell division, senescence, maintenance, and cell death; Biomolecules interactions; Cancer; Cell biology; Chemical biology; Computational biology; Cytochemistry; Developmental biology; Disease mechanisms and therapeutics; DNA, and RNA metabolism; Gene functions, genetics, and genomics; Genetics; Immunology; Medical microbiology; Molecular biology; Molecular genetics; Molecular processes of cell and organelle dynamics; Neuroscience; Protein biosynthesis, degradation, and functions; Regulation of molecular interactions in a cell; Signalling networks and system biology; Structural biology; Virology and microbiology.",annualVolume:11410,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"79367",title:"Dr.",name:"Ana Isabel",middleName:null,surname:"Flores",fullName:"Ana Isabel Flores",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRpIOQA0/Profile_Picture_1632418099564",institutionString:null,institution:{name:"Hospital Universitario 12 De Octubre",institutionURL:null,country:{name:"Spain"}}},{id:"328234",title:"Ph.D.",name:"Christian",middleName:null,surname:"Palavecino",fullName:"Christian Palavecino",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000030DhEhQAK/Profile_Picture_1628835318625",institutionString:null,institution:{name:"Central University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",fullName:"Francisco Javier Martin-Romero",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",institutionString:null,institution:{name:"University of Extremadura",institutionURL:null,country:{name:"Spain"}}}]},{id:"15",title:"Chemical Biology",keywords:"Phenolic Compounds, Essential Oils, Modification of Biomolecules, Glycobiology, Combinatorial Chemistry, Therapeutic peptides, Enzyme Inhibitors",scope:"Chemical biology spans the fields of chemistry and biology involving the application of biological and chemical molecules and techniques. In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. This topic will closely deal with all emerging trends in this discipline.",annualVolume:11411,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null,editorialBoard:[{id:"241413",title:"Dr.",name:"Azhar",middleName:null,surname:"Rasul",fullName:"Azhar Rasul",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRT1oQAG/Profile_Picture_1635251978933",institutionString:null,institution:{name:"Government College University, Faisalabad",institutionURL:null,country:{name:"Pakistan"}}},{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",fullName:"Sergey Sedykh",profilePictureURL:"https://mts.intechopen.com/storage/users/178316/images/system/178316.jfif",institutionString:null,institution:{name:"Novosibirsk State University",institutionURL:null,country:{name:"Russia"}}}]},{id:"17",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",annualVolume:11413,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},{id:"18",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/181736",hash:"",query:{},params:{id:"181736"},fullPath:"/profiles/181736",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()