Posterior Extension Research Articles

Feasibility of thoracoscopic approach for retrosternal goitre (posterior mediastinal goitre): Personal experiences of 11 cases.

INTRODUCTION:Posterior mediastinal goitres constitute of a unique surgical thyroid disorder that requires expert management. Occasionally, they require thoracic approach for the completion of thyroidectomy. In this paper, we describe the feasibility and utility of a novel thoracoscopic approach for such goitres.MATERIALS AND METHODS:This is a retrospective study conducted at a tertiary care endocrine surgery department in South India over a period of 5 years from January 2010 to December 2014. We developed a novel thoracoscopic technique for posterior mediastinal goitres instead of a more morbid thoracotomy or sternotomy. All the clinical, investigative, operative, pathological and follow-up data were collected from our prospectively filled database. Statistical analysis was done with SPSS 15.0 version. Descriptive analysis was done.OPERATIVE TECHNIQUE OF THORACOSCOPIC THYROIDECTOMY:Single lumen endotracheal tube (SLETT) was used of anaesthetic intubation and general inhalational anaesthesia. Operative decubitus was supine with extension and abduction of the ipsilateral arm. Access to mediastinum was obtained by two working ports in the third and fifth intercostal spaces. Mediastinal extension was dissected thoracoscopically and delivered cervically.RESULTS:Out of 1,446 surgical goitres operated during the study period, 72 (5%) had retrosternal goitre. Also, 27/72 (37.5%) cases had posterior mediastinal extension (PME), out of which 11 cases required thoracic approach. We utilised thoracoscopic technique for these 11 cases. The post-operative course was uneventful with no major morbidity. There was one case of recurrent laryngeal nerve (RLN) injury and hoarseness of voice in the third case. Histopathologies in 10 cases were benign, out of which two had subclinical hyperthyroidism. One case had multifocal papillary microcarcinoma.CONCLUSIONS:We opine that novel thoracoscopic technique is a feasibly optimal approach for posterior mediastinal goitre, especially for benign and non-invasive malignant goitres.

Management of anterior caliceal stones >15mm.

Anterior caliceal stones represent a challenge to endourologist to select the best modality of management with the least morbidity. To study different treatment modalities of management of anterior caliceal stones >15mm. It is an observational prospective study of patients with anterior caliceal stones more than 15mm. Inclusion criteria were patients with isolated anterior caliceal stones, or branched anterior caliceal stones with posterior caliceal extension. Patients were evaluated using non-contrast CT preoperatively. They were divided into three groups: group 1 underwent PCNL through posterior caliceal puncture in cases with wide anterior calyx infundibulum or obtuse infundibulopelvic pelvic, group 2 underwent PCNL through anterior caliceal access in cases with narrow infundibulum or acute infundibulopelvic angel and group 3 underwent flexible ureteroscopy and laser lithotripsy. Intraoperative and postoperative findings were recorded and compared. Eighty eight patients were included in this study, Group 1 (44 patients) group 2 (28 patients), and group 3 (16 patients). Operative time was not significantly different across the three groups (68±11.5, 72±9 and 74±11min in group 1, 2 and 3, respectively, P=0.053). Fluoroscopy time was significantly shorter for group 3 (2±0.5m, P=0.0001) compared to group 1 and 2 (5.6±4.6 and 4.5±1.4min), respectively. There were no significant differences in stone-free rates after initial treatment between the three groups; 84, 82, and 69%, in groups 1, 2 and 3, respectively (P=0.4). Postoperative hemoglobin drop was noted to be highest for group 2 and lowest for group 3 which was significantly different (1.7±0.8, 2.2±1.1, and 0.3±0.3g/dl, for patients in groups 1, 2 and 3 respectively, P=0.0001). Group 2 showed the highest post-operative complication rate (21%) in comparison to group 1 (11%) and group 3 (6%), however, differences were not statistically significant (P=0.3). PCNL through posterior or anterior caliceal puncture is an excellent modality to treat anterior caliceal stones with high stone clearance rate. Despite the higher chance of bleeding with anterior caliceal puncture, it is still inevitably needed in difficult anterior caliceal stones with unfavorable anatomy. RIRS is a good alternative to PCNL with the advantage of less radiation exposure and less bleeding.

Extension of the frontal sinus into the roof of the optic canal: a cadaveric case report

This case reports a bilateral asymmetrical posterior extension of the frontal sinuses into the orbital roof with an unusual expansion into the roof of the optic canal in a 55-year-old male cadaver. The posterior extensions of the sinus were lined by mucoperiosteum and were separated from the underlying orbital contents and optic nerve by a thin plate of bone. This knowledge of an unusual anatomic variation of the frontal sinus may help understand better the ocular and intracranial complications associated with frontal sinus pathologies.

Does ultrasound provide any added value in breast contouring for radiotherapy after conserving surgery for cancer?

BackgroundWhole breast irradiation after conserving surgery for breast cancer requires precise definition of the target volume. The standard approach uses computed tomography (CT) images. However, since fatty breast and non-breast tissues have similar electronic densities, difficulties in differentiating between them hamper breast volume delineation. To overcome this limitation the breast contour is defined by palpation and then radio-opaque wire is put around it before the CT scan. To optimize assessment of breast margins in the cranial, caudal, medial, lateral and posterior directions, the present study evaluated palpation and CT and determined whether ultrasound (US) provided any added value.MethodsTwenty consecutive patients were enrolled after they had provided informed consent to participating in this prospective study which was approved by the Regional Public Health Ethics Committee. Palpation and US defined breast margins and each contour was marked and outlined with a fine plastic wire. Breasts were then contoured on axial CT images using the breast window width (WW) and window level (WL) (401 and 750 Hounsfield Units –HU- respectively), at which setting the plastic wires were invisible. Then, the lung window function (WW 1601 HU; WL −300 HU) was inserted to visualize the plastic wires which were used as guidelines to contour the palpable and US breast volumes. As each wire had a different diameter, both volumes were easily defined on CT slices. Results were analyzed using descriptive statistics, percentage overlap and reproducibility measures (agreement and reliability).ResultsVolumes: US gave the largest and palpation the smallest. Agreement was best between palpation and CT. Reliability was almost perfect in all correlations. Extensions: Cranial and posterior were highest with US and smallest with palpation. Agreement was best between palpation and CT in all extensions except the cranial. Since strong to almost perfect agreement emerged for all comparisons, reliability was high.ConclusionsUS may be useful in defining the cranial and posterior extensions, mainly when tumours are localized there. This study demonstrates that the now standard radio-opaque wires around the palpable breast may not be needed in breast contouring.

Morphology and ontogeny of multiple lateral-line canals in the rock prickleback, Xiphister mucosus (Cottiformes: Zoarcoidei: Stichaeidae).

The structure and ontogeny of lateral-line canals in the Rock Prickleback, Xiphister mucosus, were studied using cleared-and-stained specimens, and the distribution and morphology of neuromasts within lateral-line canals were examined using histology. X. mucosus has seven cephalic canals in a pattern that, aside from four branches of the infraorbital canals, is similar to that of most teleostean fishes. Unlike most other teleosts, however, X. mucosus features multiple trunk lateral-line canals. These include a short median posterior extension of the supratemporal canal and three paired, branching canals located on the dorsolateral, mediolateral, and ventrolateral surfaces. The ventrolateral canal (VLC) includes a loop across the ventral surface of the abdomen. All trunk canals, as well as the branches of the infraorbitals, are supported by small, dermal, ring-like ossifications that develop independently from scales. Trunk canals develop asynchronously with the mediodorsal and dorsolateral canals (DLC) developing earliest, followed by the VLC, and, finally, by the mediolateral canal (MLC). Only the mediodorsal and DLC connect to the cephalic sensory canals. Fractal analysis shows that the complexity of the trunk lateral-line canals stabilizes when all trunk canals develop and begin to branch. Histological sections show that neuromasts are present in all cephalic canals and in the DLC and MLC of the trunk. However, no neuromasts were identified in the VLC or its abdominal loop. The VLC cannot, therefore, directly function as a part of the mechanosensory system in X. mucosus. The evolution and functional role of multiple lateral-line canals are discussed.

Bryconops munduruku (Characiformes: Characidae), a new species of fish from the lower Tapajós River basin, Brazil.

A new species of Bryconops is described from a right tributary of the lower Tapajós River, State of Pará, Brazil. Bryconops munduruku, sp. nov., differs from its congeners, except B. inpai and B. piracolina, by having a black adipose fin (vs. adipose fin hyaline in alcohol) and, except B. inpai, by possessing two humeral blotches (vs. lack of humeral blotch or only one humeral blotch). Bryconops munduruku differs from B. inpai by having a uniform color pattern on the posterior portion of the side of the body (vs. a dark stripe extending posteriorly from the half of the anal-fin base onto the base of the middle caudal-fin rays). It differs further from B. inpai and B. piracolina by the presence of a black adipose fin that is hyaline along its base (vs. entirely black adipose fin in B. inpai and B. piracolina). The new species is allocated in the subgenus Creatochanes by having a maxillary bone with one to three teeth on both sides, and its posterior extension reaching the junction of second and third infraorbital bones.

Fistule congénitale médiane de la lèvre supérieure associée à un syndrome de Goldenhar : à propos d’un cas

We present the case of a patient with Goldenhar syndrome associated with congenital fistula in the middle of philtrum at the upper lip. The patient was supported from birth for Goldenhar syndrome. Several procedures were performed in childhood to correct a macrostomia and mandibular hypoplasia right. At 14 years old, she has a rhinoplasty to correct a complex nasal malformation. During the procedure, a hole in the upper central incisor inter-space is found. It is extended by a fistula which runs through the front palate towards the vomer rail at the base of the partition. This fistula is blind behind the vomer and can be completely resected. Pathological examination of the resection reveals a squamous lining. The median fistula of the upper lip are extremely rare : less than 30 cases reported in the literature. The unusual run of the fistula and the recent appearance of a pituitary syndrome in this patient makes us look for a continuity between it and Rathke's pocket by computed tomography imaging type. The association of Goldenhar syndrome and median congenital fistula of the upper lip was never yet described in the literature. The association with hypopituitarism was suspected with the posterior extension of the malformation, not confirmed by the scanner, but strongly suspected jointly by the neurosurgical and plastic surgery team.

Lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair: midterm outcomes.

We evaluated the midterm outcomes of lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair. Between October 2007 and December 2012, 341 consecutive patients with significant mitral regurgitation underwent lifting posterior mitral annuloplasty using a specially designed fabric annuloplasty strip that lifts the middle portion of the posterior annulus. Associated procedures for mitral valve repairs, such as patch valvuloplasty for posterior leaflet prolapse (n=80), new chord placement for anterior leaflet prolapse (n=33), commissurotomy (n=29), and posterior leaflet extension (n=23), were performed in 141 patients (41.3%). Thirty-day mortality was 0.9%. Nine late deaths (2.6%) occurred. Mean overall survival at 5 years was 96.0%±1.1%. During the mean follow-up period of 38±17 months, six patients (1.8%) underwent valve-related reoperation (5-year freedom from valve-related reoperation, 98.1%±0.8%). At 5 years, mean freedom from recurrence of mitral regurgitation grade 3+ to 4+ (moderate to severe) was 95.1%±1.6%. The mean valve pressure gradient (PG) was 3.2±1.5 mmHg across all strip sizes at the time of follow-up. Lifting posterior mitral annuloplasty using an innovative annuloplasty strip in mitral valve repair has a low rate of recurrent regurgitation or valve-related reoperation with rare relevant complications.

Sexual dimorphism of sulcal morphology of the ferret cerebrum revealed by MRI-based sulcal surface morphometry.

The present study quantitatively assessed sexual dimorphism of cortical convolution and sulcal morphology in young adult ferrets by MRI-based sulcal surface morphometry. Ex vivo T1-weighted (short TR/TE) MRI of the ferret cerebrum was acquired with high spatial resolution at 7-tesla. The degree of cortical convolution, evaluated quantitatively based on 3D MRI data by sulcation index (SI), was significantly greater in males (0.553 ± 0.036) than in females (0.502 ± 0.043) (p < 0.001). The rostrocaudal distribution of the cortical convolution revealed a greater convolution in the frontal region of the cortex in males than in females and by a posterior extension of the convolution in the temporo-parieto-occipital region of males. Although the cerebral width in the frontal region was not different between sexes, the rhinal fissure and rostral region of splenial sulcus were more infolded in males than in females. On the contrary, the cerebral width was greater in males in the temporo-parieto-occipital region, and male-prominent posterior extension of infolding was noted in the lateral sulcus, caudal suprasylvian sulcus, pesudosylvian sulcus, hippocampal sulcus, and the caudal region of splenial sulcus. Notably, the caudal descending region of lateral sulcus was clearly infolded in males, but obscured in females. The present results suggest a region-related sexual dimorphism of the sulcal infolding, which is reflected by local cortical expansion in the ferret cerebrum. In particular, male-favored sulcal infolding with expansion of the temporo-parieto-occipital neocortex may be relevant to the human cerebral cortex regarding visuo-spatial and emotion processing, which are known to differ between sexes. The present results will provide fundamental information assessing sex-related changes in the regional sulcal infolding, when ferrets with experimentally-induced gyrification abnormality will be used as models for male-prevalent or male-earlier-onset neurodevelopmental disorders.

Plastie abdominale en deux positions

Lipoabdominoplasty is a way to improve morphological outcomes by treating the areas not accessible to resection during classical abdominoplasty, especially hips. However, patients can present a lateral and posterior fat extension, not accessible to an anterior liposuction. This situation is managed by a first step with liposuction in the prone position. The aim of this study was to determine whether lipoabdominoplasty performed in two positions increases morbidity compared with lipoabdominoplasty in supine position only. This was a retrospective study of 137 patients who underwent lipoabdominoplasty between 2009 to 2013. Eighty-five patients underwent a one position lipoabdomynoplasty and 52 a two positions lipoabdomynoplasty. Medical records were reviewed to collect data regarding patient demographics, operative technique, volume of liposuction and complications. The posterior liposuction has significantly increased the length of procedure (mean: 43.3 minutes). The volume of liposuction was significantly higher when the procedure was performed with prone and supine position (2789.6 mL versus 1373.8 mL, P<0.001). There was no significant difference between the two groups regarding complications and blood loss. Lipoabdominoplasty in two positions is an effective technique with the same morbidity as a lipoabdominoplasty in supine position only. The procedure finds its indication, between classic abdominoplasty and bodylift, for patients with lateral and posterior fat extension without posterior skin excess.

Anterior Transpetrosal Approach Combined with Partial Posterior Petrosectomy for Petroclival Meningiomas with Posterior Extension

An anterior transpetrosal approach (ATPA) is suitable for treating upper petroclival lesions. However, the limit of the ATPA is reached when the tumor extends posterolaterally over the internal auditory canal (IAC) along the petrous edge. In such cases, ligation of the posterior part of the superior petrosal sinus (SPS) is necessary. To overcome this limitation, we combined the ATPA with a partial posterior petrosectomy in 8 patients who had petroclival meningiomas extending posterolaterally over the IAC. We resected only the Trautmann triangle in addition to the Kawase triangle to secure the space to ligate the posterior portion of the SPS. Because the tympanic cavity and bony labyrinth of the ear were not exposed, we were able to preserve hearing function and lower the risk of cerebrospinal fluid leakage. Furthermore, this approach enables easy ligation of the SPS and the tentorium posterior to the tumor attachment. This combined technique also allows visualization of the petrosal vein, which is important for surgery of the posterior fossa. Total and near-total tumor removal was achieved in 6 patients (75%) with no permanent complications and no cerebrospinal fluid leakage. Postoperative hearing impairment was not found in any of the patients who underwent this surgery. The ATPA combined with partial posterior petrosectomy is an effective method for removal of complicated petroclival meningiomas that extend posterolaterally over the IAC along the petrous edge.

Optochemical dissection of T-box gene-dependent medial floor plate development.

In addition to their cell-autonomous roles in mesoderm development, the zebrafish T-box transcription factors no tail a (ntla) and spadetail (spt/tbx16) are required for medial floor plate (MFP) formation. Posterior MFP cells are completely absent in zebrafish embryos lacking both Ntla and Spt function, and genetic mosaic analyses have shown that the two T-box genes promote MFP development in a non-cell-autonomous manner. On the basis of these observations, it has been proposed that Ntla/Spt-dependent mesoderm-derived signals are required for the induction of posterior but not anterior MFP cells. To investigate the mechanisms by which Ntla and Spt regulate MFP development, we have used photoactivatable caged morpholinos (cMOs) to silence these T-box genes with spatiotemporal control. We find that posterior MFP formation requires Ntla or Spt activity during early gastrulation, specifically in lateral margin-derived cells that converge toward the midline during epiboly and somitogenesis. Nodal signaling-dependent MFP specification is maintained in the absence of Ntla and Spt function; however, midline cells in ntla;spt morphants exhibit aberrant morphogenetic movements, resulting in their anterior mislocalization. Our findings indicate that Ntla and Spt do not differentially regulate MFP induction along the anterior-posterior axis; rather, the T-box genes act redundantly within margin-derived cells to promote the posterior extension of MFP progenitors.

The transverse musculo-cutaneous gracilis flap for breast reconstruction: How to avoid complications.

The transverse musculocutaneous gracilis (TMG) flap has become a common solution for breast reconstruction. However, the safe skin paddle limits are not yet understood. In this study, we attempted to address this issue based on our experiences with inferior and posterior skin paddle extension. Forty-four breast reconstructions with TMG flaps performed between November 2010 and January 2014 were analyzed retrospectively. For the first 20 cases, the flap skin paddle was extended 3 cm posteriorly to the middle thigh (group 1). For the next 20 flaps (group 2), the posterior tip was limited to this line, whereas more fat was recruited inferiorly. In the four cases of group 3, the skin flap was extended posteriorly with a second vascular pedicle from the profunda artery perforator (PAP) flap. The weights and the dimensions of the flaps, operating durations, and postoperative complications of the entire series were analyzed. Groups 1 and 2 were statistically compared. Flap complications were statistically more frequent in group 1 compared with group 2 (45 vs. 0%, P = 0.0012); 40% posterior flap tip necrosis was observed in group 1. Conversely, donor site complications were statistically more frequent in group 2 than in group 1 (40 vs. 5%, P = 0.019) with 35% inner thigh dehiscence. In the TMG with extended PAP flap group, the operating duration was 77 min longer compared with the rest of the series with no donor site complications. In one case, limited necrosis occurred at the anterior skin tip. Harvesting the posterior portion of the TMG up to the middle of the posterior thigh may lead to partial flap necrosis. Extending subcutaneous fat removal under the inferior skin incision may increase the risk of donor site complications. Adding a second vascular pedicle from the PAP flap may improve posterior TMG tip perfusion at the expense of a longer operation.

Anterior Transpetrosal Approach Combined with Partial Posterior Petrosectomy for Petroclival Meningiomas with Posterior Extension

Anterior Transpetrosal Approach Combined with Partial Posterior Petrosectomy for Petroclival Meningiomas with Posterior Extension

Consistent ipsilateral development of the posterior extension of the quadrangular cartilage and bony spur formation in nasal septal deviation.

Septal spurs are exceedingly common structural deformities that contribute to nasal obstruction and often require surgical correction. The posterior extension of the quadrangular cartilage (PEQC) and its relationship with septal spurs have not been previously examined. We seek to examine the anatomic and histologic relationship of the PEQC and concurrent septal spurs in patients undergoing septoplasty. Prospective cohort study. Facial plastic and rhinology center in tertiary hospital setting. Thirty patients with septal deviation are described in this series. The quadrangular cartilage and associated septal spur were removed en bloc from patients undergoing septoplasty. The length of the PEQC, the side of spur deviation, and the relationship of the PEQC to the spur (ipsilateral vs contralateral) were recorded. The mean length of the PEQC, beyond the bony-cartilaginous junction, was 30.06±6.06 mm. The PEQC was present on the ipsilateral side of the spur deviation in all 30 patients (100%). At sites of septal spur formation, the quadrangular cartilage possesses an average 3-cm extension beyond its junction with the bony components of the septum. This cartilaginous extension is exclusively found on the same side of spur deviation. These findings have implications on our understanding of the ontogeny of commonly found septal spurs and deviations, as well as treatment strategies and cartilage graft harvesting.

Lateral transzygomatic middle fossa approach and its extensions: Surgical technique and 3D anatomy

BackgroundVarious approaches to lesions involving the middle fossa and cavernous sinus (CS), with and without posterior fossa extension have been described. In the present study, we describe the surgical technique for the extradural lateral tranzygomatic middle fossa approach and its extensions, highlight relevant 3D anatomy. MethodsSimulations of the lateral transzygomatic middle fossa approach and its extensions were performed in four silicon-injected formalin fixed cadaveric heads. The step-by-step description and relevant anatomy was documented with 3D photographs. ResultThe lateral transzygomatic middle fossa approach is particularly useful for lesions involving the middle fossa with and without CS invasion, extending to the posterior fossa and involving the clinoidal region. This approach incorporates direct lateral positioning of patient, frontotemporal craniotomy with zygomatic arch osteotomy, extradural elevation of the temporal lobe, and delamination of the outer layer of the lateral CS wall. Extradural drilling of the sphenoid wing and anterior clinoid process allows entry into the CS through the superior wall and exposure of the clinoidal segment of the ICA. Posteriorly, drilling the petrous apex allows exposure of the ventral brainstem from trigeminal to facial nerve and can be extended to the interpeduncular fossa by division of the superior petrosal sinus. ConclusionThe present study illustrates 3D anatomical relationships of the lateral transzygomatic middle fossa approach with its extensions. This approach allows wide access to different topographic areas (clinoidal region and clinoidal ICA, the entire CS, and the posterior fossa from the interpeduncular fossa to the facial nerve) via a lateral trajectory. Precise knowledge of technique and anatomy is necessary to properly execute this approach.

The Role of Fibers in the Femoral Attachment of the Anterior Cruciate Ligament in Resisting Tibial Displacement

PurposeThe purpose was to clarify the load-bearing functions of the fibers of the femoral anterior cruciate ligament (ACL) attachment in resisting tibial anterior drawer and rotation.MethodsA sequential cutting study was performed on 8 fresh-frozen human knees. The femoral attachment of the ACL was divided into a central area that had dense fibers inserting directly into the femur and anterior and posterior fan-like extension areas. The ACL fibers were cut sequentially from the bone: the posterior fan-like area in 2 stages, the central dense area in 4 stages, and then the anterior fan-like area in 2 stages. Each knee was mounted in a robotic joint testing system that applied tibial anteroposterior 6-mm translations and 10° or 15° of internal rotation at 0° to 90° of flexion. The reduction of restraining force or moment was measured after each cut.ResultsThe central area resisted 82% to 90% of the anterior drawer force; the anterior fan-like area, 2% to 3%; and the posterior fan-like area, 11% to 15%. Among the 4 central areas, most load was carried close to the roof of the intercondylar notch: the anteromedial bundle resisted 66% to 84% of the force and the posterolateral bundle resisted 16% to 9% from 0° to 90° of flexion. There was no clear pattern for tibial internal rotation, with the load shared among the posterodistal and central areas near extension and mostly the central areas in flexion.ConclusionsUnder the experimental conditions described, 66% to 84% of the resistance to tibial anterior drawer arose from the ACL fibers at the central-proximal area of the femoral attachment, corresponding to the anteromedial bundle; the fan-like extension fibers contributed very little. This work did not support moving a single-bundle ACL graft to the side wall of the notch or attempting to cover the whole attachment area if the intention was to mimic how the natural ACL resists tibial displacements.Clinical RelevanceThere is ongoing debate about how best to reconstruct the ACL to restore normal knee function, including where is the best place for ACL graft tunnels. This study found that the most important area on the femur, in terms of resisting displacement of the tibia, was in the central-anterior part of the femoral ACL attachment, near the roof of the intercondylar notch. The testing protocol did not lead to data that would support using a large ACL graft tunnel that attempts to cover the whole natural femoral attachment area.

The Effects of 2 Landing Techniques on Knee Kinematics, Kinetics, and Performance During Stop-Jump and Side-Cutting Tasks

Background: Anterior cruciate ligament injuries (ACL) commonly occur during jump landing and cutting tasks. Attempts to land softly and land with greater knee flexion are associated with decreased ACL loading. However, their effects on performance are unclear. Hypothesis: Attempts to land softly will decrease peak posterior ground-reaction force (PPGRF) and knee extension moment at PPGRF compared with a natural landing during stop-jump and side-cutting tasks. Attempts to land with greater knee flexion at initial ground contact will increase knee flexion at PPGRF compared with a natural landing during both tasks. In addition, both landing techniques will increase stance time and lower extremity mechanical work as well as decrease jump height and movement speed compared with a natural landing during both tasks. Study Design: Controlled laboratory study. Methods: A total of 18 male and 18 female recreational athletes participated in the study. Three-dimensional kinematic and kinetic data were collected during stop-jump and side-cutting tasks under 3 conditions: natural landing, soft landing, and landing with greater knee flexion at initial ground contact. Results: Attempts to land softly decreased PPGRF and knee extension moment at PPGRF compared with a natural landing during stop-jump tasks. Attempts to land softly decreased PPGRF compared with a natural landing during side-cutting tasks. Attempts to land with greater knee flexion at initial ground contact increased knee flexion angle at PPGRF compared with a natural landing during both stop-jump and side-cutting tasks. Attempts to land softly and land with greater knee flexion at initial ground contact increased stance time and lower extremity mechanical work, as well as decreased jump height and movement speed during both stop-jump and side-cutting tasks. Conclusion: Although landing softly and landing with greater knee flexion at initial ground contact may reduce ACL loading during stop-jump and side-cutting tasks, the performance of these tasks decreased, as indicated by increased stance time and mechanical work as well as decreased jump height and movement speed. Clinical Relevance: Training effects tested in laboratory environments with the focus on reducing ACL loading may be reduced in actual competition environments when the focus is on athlete performance. The effects of training programs for ACL injury prevention on lower extremity biomechanics in athletic tasks may need to be evaluated in laboratories as well as in actual competitions.

Delaminated rotator cuff tear: extension of delamination and cuff integrity after arthroscopic rotator cuff repair

The purpose of this study was to evaluate the extension of delamination and the cuff integrity after arthroscopic repair of delaminated rotator cuff tears. Sixty-five patients with delaminated rotator cuff tears were retrospectively reviewed. The delaminated tears were divided into full-thickness delaminated tears and partial-thickness delaminated tears. To evaluate the medial extension, we calculated the coronal size of the delaminated portion. To evaluate the posterior extension, we checked the tendon involved. Cuff integrity was evaluated by computed tomography arthrography. The mean medial extension in the full-thickness and partial-thickness delaminated tears was 18.1 ± 6.0 mm and 22.7 ± 6.3 mm, respectively (P = .0084). The posterior extension into the supraspinatus and the infraspinatus was 36.9% and 32.3%, respectively, in the full-thickness delaminated tears, and it was 27.7% and 3.1%, respectively, in the partial-thickness delaminated tears (P = .0043). With regard to cuff integrity, 35 cases of anatomic healing, 10 cases of partial healing defects, and 17 cases of retear were detected. Among the patients with retear and partial healing of the defect, all the partially healed defects showed delamination. Three retear patients showed delamination, and 14 retear patients did not show delamination; the difference was statistically significant (P = .0001). The full-thickness delaminated tears showed less medial extension and more posterior extension than the partial-thickness delaminated tears. Delamination did not develop in retear patients, but delamination was common in the patients with partially healed defects.

Clinical presentation and disease characteristics of femoroacetabular impingement are sex-dependent.

Cam-type femoroacetabular impingement (FAI) is generally described as being more common in males, with pincer-type FAI being more common in females. The purpose of this study was to determine the effect of sex on FAI subtype, clinical presentation, radiographic findings, and intraoperative findings in patients with symptomatic FAI. We compared cohorts of fifty consecutive male and fifty consecutive female patients who were undergoing surgery for symptomatic FAI. Detailed information regarding clinical presentation, radiographic findings, and intraoperative pathology was recorded prospectively and analyzed. FAI subtype was classified on the basis of clinical diagnosis and radiographic evaluation. Female patients had significantly greater disability at presentation, as measured with use of the modified Harris hip score (mHHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the SF-12 (12-Item Short Form Health Survey) physical function subscore (all p ≤ 0.02), despite a significantly lower UCLA (University of California at Los Angeles) activity score (p = 0.03). Female patients had greater hip motion (flexion and internal rotation and external rotation in 90° of flexion; all p ≤ 0.003) and less severe cam-type morphologies (a mean maximum alpha angle of 57.6° compared with 70.8° for males; p < 0.001). Males were significantly more likely to have advanced acetabular cartilage lesions (56% of males compared with 24% of females; p = 0.001) and larger labral tears with more posterior extension of these abnormalities (p < 0.02). Males were more likely than females to have mixed-type FAI and thus a component of pincer-type FAI (combined-type FAI) (62% of males compared with 32% of females; p = 0.003). We found distinct, sex-dependent disease patterns in patients with symptomatic FAI. Females had more profound symptomatology and milder morphologic abnormalities, while males had a higher activity level, larger morphologic abnormalities, more common combined-type FAI morphologies, and more extensive intra-articular disease. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.