The Brush Foundation studies on human growth and development, begun in 1931 and terminated in 1942, have been intensively reviewed and studied by Dr Greulich and Miss Pyle in the formulation of this Radiographic Atlas of Skeletal Development of the Hand and Wrist Serial radiographs of from 2 to 20 hand-films made at successive examinations of each of 1000 boys and girls made up the radiographic material Standards were selected that were judged to be the most representative of the central tendency or anatomic mode of each chronologic age group from birth through 18 years

Radiographic Atlas of Skeletal Development of the Hand and Wrist

Polylactic acid (PLA) controlled delivery carriers for biomedical applications.

Repair of massive rotator cuff tears is technically difficult but often feasible. Technical and biological challenges to a successful repair include inelastic poor-quality tendon tissue, scarring, muscle atrophy, and fatty infiltration.

Fatty infiltration of the involved rotator cuff muscles has been identified as an important negative prognostic factor for the outcome after repair of massive rotator cuff tears.

Tendon transfer is a good option for young patients and manual laborers with an irreparable massive rotator cuff tear.

Arthroplasty can be considered for the treatment of symptomatic massive rotator cuff tears in patients who have glenohumeral arthritis.

Massive Tears of the Rotator Cuff

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle

Purpose To analyze the relationship between functional outcomes and postoperative cuff integrity (anatomic outcome), and to reveal the factors affecting outcomes of rotator cuff repair. Methods Seventy-eight patients who had undergone repair of full-thickness rotator cuff tear received both computed tomographic arthrography (CTA) and functional evaluation a minimum of 1 year after surgery. The mean follow-up period was 19.6 months (range, 12 to 39 months). Anatomic outcome was evaluated by CTA. Functional outcomes were evaluated by visual analogue scale (VAS) for pain and satisfaction with the operation, Constant score, simple shoulder test (SST), and American Shoulder and Elbow Surgeons (ASES) score. Various clinical and structural factors were included for statistical analysis. Results All patients displayed significant improvement in all functional evaluations at the final visit. Functional outcome did not correlate with anatomic outcome ( P > .05). A few variables did relate to functional outcome: female or old age statistically correlated with the score of SST, and the size of the tear correlated with the ASES score ( P Conclusions Rotator cuff repair brought significant functional improvement. However, the functional outcome did not correlate with the anatomic outcome. The fatty degeneration of the infraspinatus muscle served as an independent predictor of the postoperative integrity of the rotator cuff. Level of Evidence Level IV, prognostic case series.

Prognostic Factors Affecting Anatomic Outcome of Rotator Cuff Repair and Correlation With Functional Outcome

BackgroundMany osteochondritis dissecans lesion fixation techniques are effective. A new absorbable copolymer screw maybe suitable for this application.PurposeTo characterize the mechanical and in vitro absorption properties of a copolymer fixation screw and determine theclinical efficacy of using the screw to fix osteochondritis dissecans lesions.Study DesignCase series and laboratory study; Level of evidence, 4.MethodsSeven patients diagnosed with unstable, partially open osteochondritis dissecans lesions were treated withdebridement of the bed and fixation with 2.5-mm diameter screws made of Lacto Sorb copolymer; the patients were nonweightbearingfor 6 weeks. Clinical and radiographic follow-up was for 25 to 37 months. Biomechanical testing was performed in syntheticbone over a 12-week period on buffer-incubated specimens.ResultsSix of the 7 osteochondritis dissecans lesions healed clinically and radiographically; the osteochondritis dissecansfragment was removed from the seventh patient (unhealed). No...

Fixation of osteochondritis dissecans lesions using poly(l-lactic acid)/ poly(glycolic acid) copolymer bioabsorbable screws.

Because of the increasing number of skeletally immature athletes who compete in highly demanding sports, more children than previously are sustaining anterior cruciate ligament injuries. Treatment and patient compliance with treatment recommendations are problematic. Pediatric issues include those specific to evaluation, projected growth, and surgery. Strict activity modification can protect the knee from further injury and delay surgery, sometimes until maturity. Surgical options include physeal-sparing, partial transphyseal, and complete transphyseal procedures. Surgical procedures are demanding because typical drilling and fixation techniques can affect the physis and possibly lead to growth disturbances. A wide range of growth disturbances has been reported; these must be understood to perfect surgical technique and avoid potential growth concerns. Surgical challenges, options regarding delayed surgery, and possible outcomes all need to be clearly communicated to the patient and parents.

Surgical management of anterior cruciate ligament injuries in patients with open physes.

Dr Larsen is from the Central Utah Clinic, Department of Orthopedics, Provo, Utah, and Drs Moinfar and Moorman are from the Sports Medicine Service at Duke Medical Center, Durham, NC. Reprint requests: Claude T. Moorman III, MD, Duke University Medical Center, Box 3639, Durham, NC 27710. The posterolateral corner of the knee has been referred to as the “dark” side of the knee.1 It has earned this reputation from the complexity of its anatomy and the poor predictability of outcomes with the widely varied surgical reconstructions. Multiple techniques to reconstruct the posterolateral corner have been described. However, none has emerged as a gold standard in either chronic or acute situations.4 Our technique has evolved over time to a fi bular-based technique for several reasons. First, the technique can be performed with a single autograft hamstring tendon, which is easy to harvest and provides consistently good tissue for grafting. Second, the technique is relatively easy to master and requires minimal tourniquet time. Third, remaining native tissue can be preserved and incorporated into the reconstruction construct. Fourth, no tunnels are required that may collide with the femoral anterior cruciate ligament tunnel in combined reconstructions. Finally, it also offers the advantage of avoiding allograft tissue, which can be of variable quality and is associated with a higher infection rate. Allografts also take longer to revascularize and incorporate into host tissue than autograft.7 A fi bular-based technique preserves native tissue and therefore can be used as a purely reconstructive technique or to augment an acute repair. Techniques that require more dissection behind the tibia create additional iatrogenic injury to native tissue and prolong the case. A recent study compared the biomechanical results of a fi bular-based reconstruction to a combined fi bular and tibialbased reconstruction.5 The knees were stressed in varus and external rotation at both 30 and 90 and compared to the intact side. There were no statistical differences between the fi bular and combined techniques. A fi bular-based technique can be used in all posterolateral corner injuries, both acute and chronic. This includes instances with associated tibiofi bular dislocations. In this situation, the fi bula is stabilized to the tibia with a 6.5-mm cancellous screw, and the posterolateral corner reconstruction is then performed in the usual manner. In our experience, the screw fi xation has been adequate to keep the fi bula reduced and allow secure healing of both the posterolateral corner and the proximal tibiofi bular joint. Larson et al3 evaluated the isometry of the ligaments on the lateral side of the knee. They demonstrated the fi bular head is isometric to the epicondyle throughout knee range of motion. Their data showed a graft taken from any position on the fi bular head to the lateral epicondyle would provide restraint to varus stress at any position of knee fl exion. The posterior aspect of the fi bular head had a more isometric relationship with the anterior portion of the lateral epicondyle. Similarly, the anterior fi bular head had an isometric relationship with the posterior aspect of the lateral epicondyle. If our reconstruction is performed correctly, both limbs should be isometric. The fi rst limb leaves the anterior fi bula and wraps around the posterior aspect of the screw in the lateral epicondyle. The second limb courses from the posterior fi bular head and wraps around the same screw anteriorly. The anterior limb of the graft reproduces the lateral collateral ligament (LCL). The posterior limb represents the course of the popliteofi bular ligament. This is not an anatomical reconstruction of the ligament. It does provide isometric fi xation that will provide support throughout range of motion on the posterolateral aspect of the knee. In the same study, Larson et al4 also demonstrated a graft coursing from the lateral epicondyle to the posterolateral tibia is not isometric and only provides support in knee extension.

Posterolateral corner reconstruction: fibular-based technique.

Purpose: The purpose of this study was to assess the functional results of arthroscopic repair of massive rotator cuff tears in patients who had stage 3 and 4 fatty degeneration of the rotator cuff musculature, according to the Goutallier scale. Methods: From January 1997 to December 2001, 22 patients with massive rotator cuff tears and Goutallier stage 3 or 4 fatty degeneration of the infraspinatus, with a mean age of 66.5 ± 9.26 years, underwent arthroscopic rotator cuff repair and were available for follow-up. The average tear size was 4.8 ± 0.85 cm in medial-to-lateral width and 6.2 ± 1.53 cm in anterior-to-posterior length, with an approximate tear size area of 30.0 ± 10.0 sq cm, and involved 2 tendons (supraspinatus and infraspinatus) or 3 tendons (supraspinatus, infraspinatus, and subscapularis) in each case. The mean time from surgery to follow-up was 39.3 months (range, 24-60 months). In addition to comparison of preoperative and postoperative range of motion, strength and University of California, Los Angeles (UCLA) score, outcomes were also assessed with the Constant score. Results: The increase of mean active forward elevation was 53.7° (preoperative: 103.2° and postoperatively: 156.9°). The gain of mean active external rotation was 19.1° (preoperative: 35.7° and postoperative: 54.8°). The gain of mean external rotation power was 1.9 (preoperative: 2.3 and postoperative: 4.2). The improvement in the UCLA score was 17.2 points (preoperative: 12.3 and postoperative: 29.5). The mean postoperative Constant score was 74.8/100, and the weighted postoperative Constant score was 88.5/100. In 5 patients with fatty degeneration greater than 75% (advanced stage 4), results were less dramatically improved than in 17 patients with fatty degeneration of 50% to 75%, all of whom exhibited clinical improvement. However, clinical improvement was achieved even in 2 of 5 patients with advanced stage 4 involvement. Conclusions: Arthroscopic rotator cuff repair in patients with grade 3 or 4 fatty degeneration (≥50%) can provide significant functional improvement. Those with 50% to 75% fatty degeneration showed a much greater degree of improvement (with all 17 cases exhibiting beneficial postoperative increases in their UCLA scores ranging from 12 to 26 points) than those with >75% fatty degeneration (with only 2 of 5 cases showing an increase of 10 or more points in their UCLA scores). However, clinical improvement was observed in 86.4% of cases that would have been classified as likely to fail by the Goutallier criteria. Level of Evidence: Level IV, therapeutic case series.

Arthroscopic Repair of Massive Rotator Cuff Tears With Stage 3 and 4 Fatty Degeneration

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Mitchell W. Larsen

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Papers

Fixation of osteochondritis dissecans lesions using poly(l-lactic acid)/ poly(glycolic acid) copolymer bioabsorbable screws.

Surgical management of anterior cruciate ligament injuries in patients with open physes.

Posterolateral corner reconstruction: fibular-based technique.

Arthroscopic Repair of Massive Rotator Cuff Tears With Stage 3 and 4 Fatty Degeneration