Surgical Management of Discoid Lateral Meniscus With Anterior Peripheral Instability: Retaining an Adequate Residual Meniscus Volume.

Discoid lateral meniscus (DLM) presents with differing pathoanatomy and may exhibit various types of tears. The treatment strategy is based on the presence and location of instability as a result of deficient capsular attachment. Recently, meniscal stabilization after saucerization has been recommended for DLM to preserve the meniscus shape, prevent extrusion, and mitigate against the progression of osteoarthritis. In addition to stabilization, the resection volume is important to prevent osteoarthritic changes. Although there was no tear and no displacement of the lateral meniscus on magnetic resonance imaging, some DLMs were found to have tears and peripheral instability during arthroscopy. Therefore, the assessment of peripheral instability during surgery is very important to achieve a desirable clinical outcome. This Technical Note describes an arthroscopic technique for anterior peripheral stabilization of the DLM, in which we highlight the surgical procedure for repair of the anterior horn, reassess the instability around the popliteal hiatus after the anterior horn is repaired, and the stabilization of the posterior horn, if necessary.

Arthroscopic Saucerization With Inside-Out Repair and Anterocentral Shift of a Discoid Lateral Meniscus With Retention of Adequate Volume of Residual Meniscus.

ABSTRACT: Preservation of the meniscus has been shown to influence the progression of osteoarthritic changes in the knee. Discoid lateral meniscus (DLM) is classified on the basis of the presence and location of instability resulting from deficient capsular attachments. Recently, meniscal stabilization after saucerization was recommended in cases of DLM to preserve the meniscus shape and avoid the progression of osteoarthritis. However, it is difficult to identify the accurate resection volume and residual meniscal width during surgery, especially when there is an anterocentral shift of the DLM. This Technical Note describes an arthroscopic technique for an anterocentral shift of the DLM in which we highlight the resection point and confirm the methods of retaining an adequate volume of residual meniscus to restore and maintain the shape and function of the meniscus. LEVEL OF EVIDENCE: Level 1, Knee; Level 2, Meniscus.

Arthroscopic Posterior Capsular Release for Loss of Knee Extension.

Arthrofibrosis, as a result of osteoarthritis, after trauma, or after knee surgery, can have significant implications for patient function, satisfaction, and outcomes. When extensive conservative management fails to achieve satisfactory results, surgical intervention may be necessary. Arthroscopic techniques to release anterior adhesions are often viewed as easier and safer than posterior releases required for flexion contractures. We present our technique of a safe, effective, and reproducible arthroscopic complete posterior capsulotomy.

Factors Related to Postoperative Osteochondritis Dissecans of the Lateral Femoral Condyle After Meniscal Surgery in Juvenile Patients With a Discoid Lateral Meniscus.

PURPOSE: The purpose was to assess the incidence of postoperative osteochondritis dissecans (OCD) and the related epidemiologic factors following meniscal surgery for juvenile discoid lateral meniscus (DLM). METHODS: The study was a retrospective review of 103 knees in 89 patients with a mean age of 12.1 years who underwent arthroscopic meniscal surgery for DLM. Mean follow-up was 4.2 years. The surgical procedures were either saucerization, saucerization with repair or subtotal meniscectomy, depending on the type of DLM tear. Postoperative OCD lesions were identified radiographically. Age, sex, weight, Lysholm score, Tegner activity scale, exercise frequency, and surgical procedure were compared between the postoperative OCD diagnosis group and non-OCD control group. RESULTS: Postoperative OCD was diagnosed in 8/103 (7.8%) knees following DLM surgery. The incidence of postoperative OCD was significantly greater for patients age less than 10 years old, and male sex, low weight, Lysholm score, Tegner activity scale preinjury and after returning to sports, and exercise frequency per week on univariate analyses. On multivariate analyses, postoperative OCD occurred more commonly with subtotal meniscectomy than with saucerization or saucerization with repair, and in patients less than 11 years of age. Receiver operating characteristic curve analysis revealed a cutoff value of age at surgery of 10 years. CONCLUSIONS: Subtotal meniscectomy and patients younger than 10 years at the time of surgery are at greater risk for postoperative OCD. To decrease this risk, if possible, we recommend performing saucerization or saucerization with repair in patients undergoing surgery for DLM. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Prevention, Reduction, and Stabilization of Dog-Ear Deformities During Arthroscopic Rotator Cuff Repair.

Arthroscopic rotator cuff repairs (ARCRs) are common procedures that have been increasing in incidence. When performing ARCR, the surgeon often identifies an undesirable flap or fold, referred to as a "dog-ear" deformity, between sutures or knots. The height and/or thickness of a dog-ear deformity may decrease the rotator cuff-to-acromion distance, resulting in possible impingement and repair compromise. Furthermore, the goal of ARCR is to achieve complete restoration of the tendon-to-footprint relation. To restore the entire footprint, this lesion must be reduced and stabilized. We present a technique using looped sutures to augment the rotator cuff repair and prevent dog-ear formation.

Technique for Double Row Superior Capsule Reconstruction with Dermal Allograft.

Superior capsular reconstruction (SCR) is increasingly being used as a procedure for addressing irreparable rotator cuff tears. The procedure was initially described for failed rotator cuff repairs where the retears are severely retracted and when grade 3-4 fatty infiltration and atrophy exist. The SCR procedure can also be considered for irreparable rotator cuff tears in patients that are either too young or too high demand to be appropriate candidates for arthroplasty. Early short and medium term follow up studies support SCR with favorable outcomes compared with other salvage procedures.

Technique for Arthroscopically Assisted Superficial and Deep Medial Collateral Ligament-Meniscotibial Ligament Repair With Internal Brace Augmentation.

Deep medial collateral ligament (MCL) injury leads to meniscal lift-off and extrusion of the medial meniscus, resulting in instability and increased medial compartment pressures with subsequent cartilage damage. Repair of the deep MCL meniscotibial ligament in concert with superficial MCL repair or reconstruction is intended to restore the native anatomy , stability, and function of the medial meniscus. We present an arthroscopically assisted technique using standard arthroscopy portals and a medial open approach.

Technique for Transtibial Knotless Repair of Lateral Meniscus Root Avulsion.

Tear of the meniscal root results in loss of circumferential hoop tension in the meniscus and increased tibiofemoral contact pressure, leading to cartilage wear. Repair of the meniscal root can restore function of the meniscus. Many techniques for root repair have recently been described. We present a technique for root repair using a transtibial socket and knotless suture technique that can be performed through standard arthroscopy portals.

A Comparative Evaluation of a Parent-Training Program -Republished Article.

This report is one of a series of outcome evaluation studies for parent-training procedures tailored specifically to families of preadolescent antisocial children. Referred families were screened to identify 19 problem children who were observed in their homes to be high-rate social aggressors. Cases were randomly assigned to the parent-training procedures or to a waiting-list comparison group. All but one of the latter accepted a referral for treatment elsewhere in the community. After an average of 17hours of therapy time, the cases in the experimental group were terminated. Posttreatment observation data were collected in the homes of both the experimental and the comparison groups. The results indicated that, relative to the changes in the comparison sample, the parent-training sample showed a significantly greater reduction in the observed rates of deviant child behavior.

Arthroscopy Up to Date: Anterior Cruciate Ligament Anatomy.

PURPOSE: To categorize and summarize up-to-date anterior cruciate ligament (ACL) research published in Arthroscopy and The American Journal of Sports Medicine and systematically review each subcategory, beginning with ACL anatomy. METHODS: After searching for "anterior cruciate ligament" OR "ACL" in Arthroscopy and The American Journal of Sports Medicine from January 2012 through December 2014, we excluded articles more pertinent to ACL augmentation; open growth plates; and meniscal, chondral, or multiligamentous pathology. Studies were subcategorized for data extraction. RESULTS: We included 212 studies that were classified into 8 categories: anatomy; basic science and biomechanics; tunnel position; graft selection; graft fixation; injury risk and rehabilitation; practice patterns and outcomes; and complications. Anatomic risk factors for ACL injury and post-reconstruction graft failure include a narrow intercondylar notch, low native ACL volume, and increased posterior slope. Regarding anatomic footprints, the femoral attachment is 43% of the proximal-to-distal lateral femoral condylar length whereas the posterior border of the tendon is 2.5 mm from the articular margin. The tibial attachment of the ACL is two-fifths of the medial-to-lateral interspinous distance and 15 mm anterior to the posterior cruciate ligament. Anatomic research using radiology and computed tomography to evaluate ACL graft placement shows poor interobserver and intraobserver reliability. CONCLUSIONS: With a mind to improving outcomes, surgeons should be aware of anatomic risk factors (stenotic femoral notch, low ligament volume, and increased posterior slope) for ACL graft failure, have a precise understanding of arthroscopic landmarks identifying femoral and tibial footprint locations, and understand that imaging to evaluate graft placement is unreliable. LEVEL OF EVIDENCE: Level III, systematic review of Level III evidence.

Advantages and Disadvantages of Transtibial, Anteromedial Portal, and Outside-In Femoral Tunnel Drilling in Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: Controversy exists regarding the best method for creating the knee anterior cruciate ligament (ACL) femoral tunnel or socket. The purpose of this study was to systematically review the risks, benefits, advantages, and disadvantages of the endoscopic transtibial (TT) technique, anteromedial portal technique, outside-in technique, and outside-in retrograde drilling technique for creating the ACL femoral tunnel. METHODS: A PubMed search of English-language studies published between January 1, 2000, and February 17, 2014, was performed using the following keywords: "anterior cruciate ligament" AND "femoral tunnel." Included were studies reporting risks, benefits, advantages, and/or disadvantages of any ACL femoral technique. In addition, references of included articles were reviewed to identify potential studies missed in the original search. RESULTS: A total of 27 articles were identified through the search. TT technique advantages include familiarity and proven long-term outcomes; disadvantages include the risk of nonanatomic placement because of constrained (TT) drilling. Anteromedial portal technique advantages include unconstrained anatomic placement; disadvantages include technical challenges, short tunnels or sockets, and posterior-wall blowout. Outside-in technique advantages include unconstrained anatomic placement; disadvantages include the need for 2 incisions. Retrograde drilling technique advantages include unconstrained anatomic placement, as well as all-epiphyseal drilling in skeletally immature patients; disadvantages include the need for fluoroscopy for all-epiphyseal drilling. CONCLUSIONS: There is no one, single, established "gold-standard" technique for creation of the ACL femoral socket. Four accepted techniques show diverse and subjective advantages, disadvantages, risks, and benefits. LEVEL OF EVIDENCE: Level V, systematic review of Level II through V evidence.

Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis.

PURPOSE: The purpose of this study was to compare arthroscopic versus open examination of the proximal long head of the biceps tendon (LHB) in patients undergoing open, subpectoral tenodesis. METHODS: Eighty consecutive patients were prospectively enrolled, of whom 62 were included in the study. During arthroscopy, the most distal extent of the LHB visualized was marked with a Bovie device. The tendon was pulled into the joint with an arthroscopic grasper, showing additional LHB and was again marked with the device. LHB fraying, flattening, redness, and degeneration were graded as absent, mild, moderate, or severe. During open subpectoral tenodesis, the grossly visualized LHB was graded in the same manner and the locations of both marks plus the total length of the LHB observed during open visualization were measured and recorded. After subpectoral tenodesis, the excised portion of the LHB was histologically graded as normal, fibrosis/tendinosis, or inflamed. RESULTS: On average, during open tenodesis, 95 mm (range, 75 to 130 mm) of LHB was visualized. This was greater than the length visualized during diagnostic arthroscopy of 16 mm (range, 5 to 28 mm), or 17%, and the length visualized while pulling the tendon into the joint with an arthroscopic grasper of 30 mm (range, 15 to 45 mm), or 32%. The difference in LHB length observed during open versus arthroscopic examination with a grasper was statistically significant (P < .0001). In addition, when compared with LHB pathology observed in an open manner, arthroscopic visualization showed only 67% of pathology, underestimated noted pathology in 56% of patients, and overestimated noted pathology in 11% of patients. Histologic evaluation showed fibrosis/tendinosis in 100% of cases but inflammation in only 5%. CONCLUSIONS: When compared with open inspection during subpectoral tenodesis, arthroscopic examination of the LHB visualizes only 32% of the tendon and may underestimate pathology. LEVEL OF EVIDENCE: Level II, diagnostic study-development of diagnostic criteria based on consecutive patients with universally applied gold standard.

Preventing Child Behavior Problems and Substance Use: The Pathways Home Foster Care Reunification Intervention.

This paper evaluated the Pathways Home manualized selective preventive intervention designed to prevent reunification failures once children are returned home to their biological parent(s) after first time stays in foster care (n = 101). The theoretically based intervention focused on support and parent management practices designed to prevent the development of child behavior problems including internalizing and externalizing problems, and substance use. Intent to treat analyses employed probability growth curve approaches for repeated telephone assessments over 16 weeks of intervention. Findings showed that relative to services as usual reunification families, the Pathways Home families demonstrated better parenting strategies that were in turn associated with reductions in problem behaviors over time. Growth in problem behaviors in turn predicted foster care re-entry. Maternal substance use cravings were a risk factor for growth in problem behaviors that were buffered by participation in the Pathways Home intervention.

Joint trajectories of symptoms of disruptive behavior problems and depressive symptoms during early adolescence and adjustment problems during emerging adulthood.

The joint, longitudinal trajectories of symptoms of disruptive behavior problems and of depression were examined in a community sample drawn from neighborhoods with elevated rates of delinquency. Growth mixture modeling was applied to a 6 year transition period from childhood to adolescence, age 10 to 16 years, to identify latent classes of trajectories for each symptom type. Several classes emerged for the two types of symptoms, namely a group of youth with high levels of disruptive behavior, a group with increasing levels, and a group with low levels, as well as a group with increasing levels of depression, a group with high levels, a group with decreasing levels, and a group with low levels. Within each symptom type, membership in either the high or in the increasing classes was related to a variety of problematic outcomes during emerging adulthood. The co-occurrence of the disruptive behavior and depression classes was then evaluated using parallel process analysis. Youth exhibiting high depressive symptoms were at increased risk for disruptive behavior problems, and youth with increasing disruptive behavior problems were at risk for depressive symptoms. However, only a very small number of youth had both a high depression trajectory and a high disruptive behavior trajectory. Implications of the findings for the design of prevention and treatment programs are discussed.

Negative emotionality and externalizing problems in toddlerhood: overreactive parenting as a moderator of genetic influences.

The current study examines the interplay between parental overreactivity and children's genetic backgrounds as inferred from birth parent characteristics on the development of negative emotionality during infancy, and in turn, to individual differences in externalizing problems in toddlerhood. The sample included 361 families linked through adoption (birth parents and adoptive families). Data were collected when the children were 9, 18, and 27 months old. Results indicated links between individual levels and changes in negative emotionality during infancy and toddlerhood to externalizing problems early in the third year of life. Findings also revealed an interaction between birth mother negative affect and adoptive mother overreactive parenting on children's negative emotionality. This Genotype × Environment interaction predicted externalizing problems indirectly through its association with negative emotionality and revealed stronger effects of genetic risk for children with less overreactive parenting from their mothers. Limitations of this study and directions for future research are discussed.

Genetic liability, environment, and the development of fussiness in toddlers: the roles of maternal depression and parental responsiveness.

Using a longitudinal, prospective adoption design, the authors of this study examined the effects of the environment (adoptive parents' depressive symptoms and responsiveness) and genetic liability of maternal depression (inferred by birth mothers' major depressive disorder [MDD]) on the development of fussiness in adopted children between 9 and 18 months old. The sample included 281 families linked through adoption, with each family including 4 individuals (i.e., adopted child, birth mother, adoptive father and mother). Results showed that adoptive mothers' depressive symptoms when their child was 9 months old were positively associated with child fussiness at 18 months. A significant interaction between birth mothers' MDD and adoptive mothers' responsiveness indicated that children of birth mothers with MDD showed higher levels of fussiness at 18 months when adoptive mothers had been less responsive to the children at 9 months. However, in the context of high levels of adoptive mothers' responsiveness, children of birth mothers with MDD did not show elevated fussiness at 18 months. Findings are discussed in terms of gene-environment interactions in the intergenerational risk transmission of depression.

Infant pathways to externalizing behavior: evidence of Genotype x Environment interaction.

To further the understanding of the effects of early experiences, 9-month-old infants were observed during a frustration task. The analytical sample was composed of 348 linked triads of participants (adoptive parents, adopted child, and birth parent[s]) from a prospective adoption study. It was hypothesized that genetic risk for externalizing problems and affect dysregulation in the adoptive parents would independently and interactively predict a known precursor to externalizing problems: heightened infant attention to frustrating events. Results supported the moderation hypotheses involving adoptive mother affect dysregulation: Infants at genetic risk showed heightened attention to frustrating events only when the adoptive mother had higher levels of anxious and depressive symptoms. The Genotype x Environment interaction pattern held when substance use during pregnancy was considered.

Gene expression profiling identifies two regulatory genes controlling dormancy and ABA sensitivity in Arabidopsis seeds.

Seed dormancy is a very important trait that maximizes the survival of seed in nature, the control of which can have important repercussions on the yield of many crop species. We have used gene expression profiling to identify genes that are involved in dormancy regulation in Arabidopsis thaliana. RNA was isolated from imbibed dormant (D) and after-ripened (AR) ecotype C24 seeds, and then screened by quantitative RT-PCR (qRT-PCR) for differentially expressed transcription factors (TFs) and other regulatory genes. Out of 2207 genes screened, we have identified 39 that were differentially expressed during the first few hours of imbibition. After analyzing T-DNA insertion mutants for 22 of these genes, two displayed altered dormancy compared with the wild type. These mutants are affected in genes that encode a RING finger and an HDZip protein. The first, named DESPIERTO, is involved in ABA sensitivity during seed development, regulates the expression of ABI3, and produces a complete loss of dormancy when mutated. The second, the HDZip (ATHB20), is expressed during seed germination in the micropylar endosperm and in the root cap, and increases ABA sensitivity and seed dormancy when mutated.

Patterns and predictors of growth in divorced fathers' health status and substance use.

Health status and substance use trajectories are described over 18 months for a county sample of 230 divorced fathers of young children aged 4 to 11. One third of the sample was clinically depressed. Health problems, drinking, and hard drug use were stable over time for the sample, whereas depression, smoking, and marijuana use exhibited overall mean reductions. Variance components revealed significant individual differences in average levels and trajectories for health and substance use outcomes. Controlling for fathers' antisociality, negative life events, and social support, fathering identity predicted reductions in health-related problems and marijuana use. Father involvement reduced drinking and marijuana use. Antisociality was the strongest risk factor for health and substance use outcomes. Implications for application of a generative fathering perspective in practice and preventive interventions are discussed.

Evaluating mediators of the impact of the Linking the Interests of Families and Teachers (LIFT) multimodal preventive intervention on substance use initiation and growth across adolescence.

Substance use outcomes were examined for 351 youth participating in a randomized controlled trial designed to assess the efficacy of a school-based multimodal universal preventive intervention, Linking the Interests of Families and Teachers (LIFT). Frequency of any use of tobacco, alcohol, and other drugs was assessed via self-report from grades 5 through 12. Latent variable growth models specified average level, linear growth and accelerated growth. The LIFT intervention had a significant effect on reducing the rate of growth in use of tobacco and illicit drugs, particularly for girls, and had an overall impact on average levels of use of tobacco, alcohol, and illicit drugs. Average tobacco use reductions were mediated by increases in family problem solving. The intervention had significant indirect effects on growth in substance use through intervention effects on reduced playground aggression and increased family problem solving. The intervention was also associated with roughly a 10% reduced risk in initiating tobacco and alcohol use. Implications for future studies of multimodal preventive interventions are discussed.