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The most important factor that complicates the work of dysmorphologists is the significant phenotypic variability of the human face. Next-Generation Phenotyping (NGP) tools that assist clinicians with recognizing characteristic syndromic patterns are particularly challenged when confronted with patients from populations different from their training data. To that end, we systematically analyzed the impact of genetic ancestry on facial dysmorphism. For that purpose, we established the GestaltMatcher Database (GMDB) as a reference dataset for medical images of patients with rare genetic disorders from around the world. We collected 10,980 frontal facial images - more than a quarter previously unpublished - from 8,346 patients, representing 581 rare disorders. Although the predominant ancestry is still European (67%), data from underrepresented populations have been increased considerably via global collaborations (19% Asian and 7% African). This includes previously unpublished reports for more than 40% of the African patients. The NGP analysis on this diverse dataset revealed characteristic performance differences depending on the composition of training and test sets corresponding to genetic relatedness. For clinical use of NGP, incorporating non-European patients resulted in a profound enhancement of GestaltMatcher performance. The top-5 accuracy rate increased by +11.29%. Importantly, this improvement in delineating the correct disorder from a facial portrait was achieved without decreasing the performance on European patients. By design, GMDB complies with the FAIR principles by rendering the curated medical data findable, accessible, interoperable, and reusable. This means GMDB can also serve as data for training and benchmarking. In summary, our study on facial dysmorphism on a global sample revealed a considerable cross ancestral phenotypic variability confounding NGP that should be counteracted by international efforts for increasing data diversity. GMDB will serve as a vital reference database for clinicians and a transparent training set for advancing NGP technology.

Study Objectives: The effect of recombinant human growth hormone (rhGH) on sleep-disordered breathing (SDB) in Malaysian children with Prader-Willi syndrome (PWS) is under-investigated. We determined (1) the short- and long-term effects of rhGH and (2) factors associated with worsening SDB in children with PWS receiving rhGH., Methods: This retrospective study included children with PWS (with and without rhGH) who had undergone at least 1 polysomnography. Outcomes measured were the presence of SDB before and after starting rhGH and the progress of SDB with and without rhGH. Serial insulin-like growth factor 1 (IGF-1) measurements were recorded., Results: One-hundred and thirteen polysomnograms were analyzed. The majority (92.3%) of initial polysomnograms showed SDB, with a median (interquartile range) apnea-hypopnea index of 5.0 (2.6, 16.3) events/h. The age for receiving rhGH was a median (IQR) of 1.9 (0.7, 3.4) years. One-third (36.8%) had worsening SDB after initiating rhGH, which was associated with higher IGF-1 levels post-rhGH ( P = .007). After a median of 5 years of rhGH, 73.6% maintained or reduced their positive airway pressure settings. Without rhGH, 80% had increased their positive airway pressure settings. Worsening SDB while on rhGH was associated with higher body mass index, lower rhGH dose, higher IGF-1 levels, and non-15q deletion., Conclusions: The majority of Malaysian children with PWS had SDB. At initiation of rhGH, one-third of patients had worsening SDB, associated with increased IGF-1 levels. Stabilization of SDB was more frequently seen in those receiving long-term rhGH. Worsening SDB while on rhGH was associated with a higher body mass index, receiving a lower dose of rhGH, higher IGF-1 levels, and non-15q deletion., Citation: Tan YT, Azanan MS, Hng SY, et al. Long-term effect of growth hormone on sleep-disordered breathing in Malaysian children with Prader-Willi syndrome: a retrospective study. J Clin Sleep Med . 2024;20(8):1291-1299., (© 2024 American Academy of Sleep Medicine.)

The ABC and ACMG variant classification systems were compared by asking mainly European clinical laboratories to classify variants in 10 challenging cases using both systems, and to state if the variant in question would be reported as a relevant result or not as a measure of clinical utility. In contrast to the ABC system, the ACMG system was not made to guide variant reporting but to determine the likelihood of pathogenicity. Nevertheless, this comparison is justified since the ACMG class determines variant reporting in many laboratories. Forty-three laboratories participated in the survey. In seven cases, the classification system used did not influence the reporting likelihood when variants labeled as "maybe report" after ACMG-based classification were included. In three cases of population frequent but disease-associated variants, there was a difference in favor of reporting after ABC classification. A possible reason is that ABC step C (standard variant comments) allows a variant to be reported in one clinical setting but not another, e.g., based on Bayesian-based likelihood calculation of clinical relevance. Finally, the selection of ACMG criteria was compared between 36 laboratories. When excluding criteria used by less than four laboratories (<10%), the average concordance rate was 46%. Taken together, ABC-based classification is more clear-cut than ACMG-based classification since molecular and clinical information is handled separately, and variant reporting can be adapted to the clinical question and phenotype. Furthermore, variants do not get a clinically inappropriate label, like pathogenic when not pathogenic in a clinical context, or variant of unknown significance when the significance is known., (© 2024. The Author(s).)

ESCO2 spectrum disorder is an autosomal recessive developmental disorder characterized by growth retardation, symmetrical mesomelic limb malformation, and distinctive facies with microcephaly, with a wide phenotypic continuum that ranges from Roberts syndrome (MIM #268300) at the severe end to SC phocomelia (MIM #269000) at the milder end. ESCO2 encodes a 601-amino acid protein belonging to the Eco1/Ctf7 family of acetyltransferases that is involved in the establishment of sister chromatid cohesion, which is essential for accurate chromosome segregation and genomic stability and thus belongs to a group of disorders called "cohesinopathies". We describe a 15-year-old Malaysian female who presented with the characteristic triad of ESCO2 spectrum disorder, with an equivocal chromosomal breakage study and normal karyotyping findings. She was initially suspected to have mosaic Fanconi anemia but whole exome sequencing (WES) showed a likely pathogenic homozygous splice variant c.955 + 2&#95;955+5del in the ESCO2 gene. During the 15-year diagnostic odyssey, she developed type 2 diabetes mellitus, primary ovarian insufficiency, increased optic cup-to-disc ratio with tortuous vessels bilaterally, and an evolving but distinct facial and skin hypopigmentation phenotype. Of note, there was an absence of learning disabilities. Our findings provide further evidence for ESCO2 spectrum disorder in an Asian child and contribute to defining the clinical and radiographic spectrum., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Tae, RA and Thong.)

Introduction: : Asian children with cystic fibrosis (CF) managed in Malaysia have significant morbidity with limited access to life-sustaining treatments. We determined the morbidity and treatment cost of CF in a resource-limited country., Methods: This cross-sectional study included all children diagnosed with CF in our centre. Data on clinical presentation, genetic mutation, serial spirometry results and complications were collected. Out-of-pocket (OOP) and healthcare costs over 1 year were retrieved for patients who were alive. Cohen's d and odds ratio (OR) were used to determine the effect size., Results: Twenty-four patients were diagnosed with CF. Five patients died at a median (range) age of 18 (0.3-22) years. F508deletion (c. 1521&#95;1523delCTT) was found in 20% of the alleles, while 89% of the variants were detected in nine patients. Body mass index (BMI) Z score was >-1.96 in 70.6% of patients. Two thirds (68%) were colonised with Pseudomonas aeruginosa, and this was associated with lower weight (P = 0.009) and BMI (P = 0.02) Z scores. Only 18% had FEV 1 Z scores >-1.96. Early symptom onset (d = 0.74), delayed diagnosis (d = 2.07), a low FEF 25-75 Z score (d = 0.82) and a high sweat conductance (d = 1.19) were associated with death. Inpatient cost was mainly from diagnostic tests, while medications contributed to half of the outpatient cost., Healthcare utilisation cost was catastrophic, amounting to 20% of the total income., Conclusion: Asian children with CF suffer significant complications such as low weight, low lung function and shortened lifespan. P. aeruginosa colonisation was frequent and associated with poor growth. Healthcare cost to parents was catastrophic., Competing Interests: None

Infantile neuroaxonal dystrophy 1 (INAD) (OMIM #256600) is a rare infantile onset neurodegenerative disease characterised by neuroregression and hypotonia, evolving into generalized spasticity, blindness and dementia. We report our diagnostic approach of a pair of siblings with psychomotor regression, hypotonia, optic atrophy and auditory neuropathy. The brain magnetic resonance imaging (MRI) showed progressive cerebellar atrophy. Genetic testing of the PLA2G6 confirmed presence of compound heterozygous novel mutations. As the variant c. 196C>T (p.Gln66X) was a truncating variant, it was considered as pathogenic while the variant c. 2249G>A (p. Cys750Tyr) was considered as "likely pathogenic" by bioinformatics analyses. Our patient expands the clinical phenotype of INAD as it described the first South-East Asian patient with INAD-associated auditory neuropathy. Our report highlights the importance of increased awareness of this condition amongst clinicians, the use of deep phenotyping using neuroimaging and the clinical utility of gene sequencing test in the delineation of syndromes associated with infantile neurodegenerative disease., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the clinical and radiological outcomes of distal radius fractures treated by percutaneous fixation using distal radius-ulna pinning and to assess its effectiveness especially for preventing fracture settling., Methods: We retrospectively reviewed 18 distal radius fractures (15 AO type A2 and 3 AO type C1). Range of motion and Disabilities of the Arm, Shoulder, and Hand scores were evaluated. We measured radiographic parameters at the final follow-up and compared them with those on immediate postoperative x-rays., Results: All fractures united and average time to initial healing was 6.9 weeks (range, 6-7 wk). Average follow-up was 29 months (range, 26-43 mo). Average wrist flexion and extension were 70° and 65°, respectively. Average forearm supination and pronation were 82° and 83°, respectively. Average pain score was 1.2 and average Disabilities of the Arm, Shoulder, and Hand score was 13. Mean difference of ulnar variance, volar tilt, and radial inclination between immediate and final follow-up x-rays was 0.7 mm, 1°, and less than 1°, respectively., Conclusions: Percutaneous fixation of distal radius fractures using distal radius-ulna pinning had favorable radiologic and functional outcomes and was effective in preventing fracture settling during initial healing in unstable extra-articular fractures and some simple sagittal split intra-articular fractures., Type of Study/level of Evidence: Therapeutic III., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Atrophy of rotator cuff muscles has been considered an irreversible phenomenon. The purpose of this study is to evaluate whether atrophy is truly irreversible after rotator cuff repair., Methods: We measured supraspinatus muscle atrophy of 191 patients with full-thickness rotator cuff tears on preoperative magnetic resonance imaging and postoperative multidetector computed tomography images, taken at least 1 year after operation. The occupation ratio was calculated using Photoshop CS3 software. We compared the change between pre- and postoperative occupation ratios after modifying the preoperative occupation ratio. In addition, possible relationship between various clinical factors and the change of atrophy, and between the change of atrophy and cuff integrity after surgical repair were evaluated., Results: The mean occupation ratio was significantly increased postoperatively from 0.44 ± 0.17 to 0.52 ± 0.17 (p < 0.001). Among 191 patients, 81 (42.4%) showed improvement of atrophy (more than a 10% increase in occupation ratio) and 33 (17.3%) worsening (more than a 10% decrease). Various clinical factors such as age tear size, or initial degree of atrophy did not affect the change of atrophy. However, the change of atrophy was related to repair integrity: cuff healing failure rate of 48.5% (16 of 33) in worsened atrophy; and 22.2% (18 of 81) in improved atrophy (p = 0.007)., Conclusions: The supraspinatus muscle atrophy as measured by occupation ratio could be improved postoperatively in case of successful cuff repair.

Background: The assessment of fatty degeneration of rotator cuff muscles with a reliable grading system is very important. However, there is no generally accepted tool to measure it quantitatively., Purpose: This work was undertaken to introduce a new method to evaluate fatty degeneration by calculating the occupation ratio of the supraspinatus, to determine the correlation between this occupation ratio and the degree of Goutallier's fatty degeneration or tear size of rotator cuff muscles and to assess the correlation between multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) using this new measuring tool., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Sixty-one patients with full-thickness rotator cuff tears who had undergone arthroscopic rotator cuff repair were included. The occupation ratio was measured using the magic selection tool in Photoshop on MDCT and both T1- and T2-weighted oblique sagittal magnetic resonance images of Y-view. One-way analysis of variance was used to determine the association between this occupation ratio and the degree of fatty degeneration as assessed by Goutallier's method. The correlation between the occupation ratio and tear size, and the correlation of the occupation ratio between MDCT and MRI, were evaluated using the Pearson correlation coefficient. In addition, the interobserver and intraobserver reliabilities of this measuring tool were assessed on each image by 2 orthopaedic surgeons and analyzed using interclass correlation coefficients., Results: Comparison of the occupation ratio measured by this new method with the Goutallier grade of fatty degeneration on MDCT and MRI revealed a highly significant correlation, with all P values < .001. Also, comparison of this new occupation ratio and cuff tear size showed a reverse correlation on MDCT, T1-weighted magnetic resonance images, and T2-weighted images, with Pearson correlation coefficients of -.61, -.56, and -.50 (all P < .001) by rater 1, and -.57, -.53, and -.43 (all P < .001) by rater 2. Comparison of the occupation ratio between MDCT and MRI demonstrated significant correlation, with Pearson correlation coefficients of .78 and .87 between MDCT and T1-weighted magnetic resonance images and .73 and .82 between MDCT and T2-weighted images. The interobserver and intraobserver reliabilities of this new measuring tool on MDCT and both T1- and T2-weighted magnetic resonance images were excellent in all images, with interobserver correlation of .89, .92, and .91 and intraobserver correlation of .89 and .96, .90 and .98, and .85 and .97, respectively., Conclusion: This new quantitative measuring tool to evaluate the fatty degeneration of rotator cuff muscles was reliable and correlated well with both the preexisting grade of fatty degeneration and cuff tear size. Also, there was a significant correlation between oblique sagittal images of MDCT and MRI using this method; therefore, MDCT can be another option for imaging modality, comparable with MRI, for the evaluation of fatty degeneration of rotator cuff muscles.

Hypothesis: The purpose of this study was to develop and validate a disease-specific appraisal method for patients with rotator cuff disorders. The Korean Shoulder Scoring System (KSS) includes 5 domains totalling 100 points: function, 30 points; pain, 20; satisfaction, 10; range of motion, 20; and muscle power, consisting of strength, 10; and endurance, 10., Method: The KSS was used to evaluate clinical outcomes of 430 patients with rotator cuff disorder for a period of 6 months postoperatively., Result: The KSS had an acceptable level of internal consistency (alpha = 0.840). The KSS scores also correlated strongly with the Constant scores (r = 0.802), but less so with the American Shoulder and Elbow Surgeons scores (r = 0.602) and the University of California Los Angeles shoulder scores (r = 0.573). A large effect size (r = 1.234) and a standardized response mean (r = 1.317) for KSS were evident at 6 months postoperatively., Conclusion: The KSS is a useful measurement tool that combines subjective and objective evaluations for shoulder function related to rotator cuff disorders.

Background: Revision Bankart operations frequently show capsulolabral buttress loss and recurrent soft tissue Bankart lesion. Capsulolabral augmentation is designed to increase glenohumeral stability by 2 separate mechanisms: deepening the glenoid concavity and reducing capsular laxity. This is accomplished by shifting the capsule to buttress the glenoid labrum., Hypothesis: A retained capsulolabral buttress may show loss of height and slope at a certain period after surgery, regardless of stability. Thus, the authors wanted to confirm the importance of an intraoperative establishment of capsulolabral buttress in terms of stability., Study Design: Case-control study; Level of evidence, 3., Methods: Arthroscopically repaired Bankart lesions in 21 consecutive shoulders that showed no frank dislocation were evaluated using axial and oblique coronal T2-weighted magnetic resonance imaging at 3 timepoints (preoperative period, average postoperative week 6 and a nearly full range of motion recovery, and postoperative month 6 with a return to daily activity). The authors measured 2 parameters (height and slope) on axial (mainly capsulolabral containment) and oblique coronal images (mainly inferior glenohumeral ligament) at the anteroinferior portion of the glenoid (5 mm above the most inferior anchor). In addition, they compared the above-mentioned parameters at postoperative month 6 by magnetic resonance imaging in 21 controls and in 21 patients whose instability recurred after surgery (not included in the prospective study)., Results: There was a significant increase between the preoperative period and postoperative week 6 in all 4 parameters (P < .0001). There was also a significant increase between the preoperative period and postoperative month 6 in all 4 parameters (P < .0001). However, no statistically significant difference was observed between postoperative week 6 and postoperative month 6 in all 4 parameters (P > .1). Furthermore, significant differences were observed between normal controls and patients with recurrent instability (P < .001) and between the authors' cases and patients with recurrent instability not in the study (P < .001). However, no difference was observed between their cases and normal shoulders (P > .1)., Conclusion: After suture anchor Bankart repair, initial capsulolabral buttress property was maintained at 6 months postoperatively. Furthermore, the buttress was more prominent in stable and normal shoulders than in recurrent instability shoulders. Therefore, the authors believe that the establishment of a capsulolabral buttress is meaningful during Bankart repair.

The objective of our study was to investigate the outcome of an active non-operative treatment of the acute isolated posterior cruciate ligament (PCL) injury using cylinder cast immobilization and brace with tibial supporter. This study included 17 acute and isolated PCL injuries with two years or more of follow-up for each patient. We applied a cylinder cast immobilization with tibial supporter with full extension of the knee for 6 weeks, and then another 6 weeks of PCL brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. There was improved anteroposterior stability with some residual laxity and improved clinical results at the last follow-up. The conservative treatment utilizing cylinder cast immobilization and brace may be one of the recommendable treatment methods in an isolated and acute PCL injury.

Mesenchymal stem cells (MSCs) exist in bone marrow and other musculoskeletal tissues. These cells contribute to the homeostasis of musculoskeletal tissue as well as support for the growth and differentiation of primitive hemopoietic cells. Recent advancements in tissue engineering and regenerative medicine have highlighted MSCs as a potential source of cells which would differentiate to a variety of tissue tailored to individual needs. This paper briefly outlines the current status of MSCs, focusing on their biological characteristics and potential for clinical applications.

Purpose: Posterior cruciate ligament (PCL) injuries have potential for intrinsic healing and several magnetic resonance imaging studies have reported that the PCL healed with continuity but also with residual laxity. The goal of our study was to introduce a new method and investigate the outcome of tensioning of the remnant PCL and reconstruction of the anterolateral (AL) bundle of the PCL using modified inlay technique., Type of Study: Therapeutic study., Methods: Forty-nine patients who underwent tensioning of the remnant PCL and reconstruction of the AL bundle of the PCL were evaluated 45.7 months (range, 24 to 78 months) on average after surgery. Tensioning was performed by distal transfer of the tibial attachment. The AL bundle of the PCL was reconstructed with 4 bundles of hamstring tendon (34 cases), bone-patellar tendon-bone graft (7 cases), or Achilles tendon allograft (8 cases), arthroscopically at the femoral tunnel and by the modified inlay technique through a posteromedial approach in the supine position. In 35 patients who had a combined posterolateral rotatory instability, the posterolateral corner reconstruction was performed. Stability was assessed by stress radiographs with the Telos device and maximal manual testing with KT-1000 arthrometer. The clinical results were assessed by IKDC and OAK scores. Physical examination was performed using the posterior drawer test, varus stress test, posterolateral drawer test, and dial test in 30 degrees and 90 degrees flexion., Results: The average side-to-side difference of posterior tibial translation on posterior stress radiographs decreased from 10.4 +/- 2.1 mm to 2.2 +/- 1.0 mm. The average side-to-side difference in maximal manual test with the KT-1000 arthrometer also decreased from 8.2 +/- 1.5 mm to 1.9 +/- 1.0 mm. The final IKDC score was A in 10 (20.4%), B in 33 (67.3%), and C in 6 (12.2%) patients. The average OAK score improved from 63.3 +/- 8.3 to 91 +/- 7.3., Conclusions: Good clinical results and very good posterior stability were achieved with tensioning of the remnant PCL and reconstruction of the AL bundle using the modified inlay technique in chronic PCL injuries. With this technique, the surgeon can operate without changing the patient's position during surgery., Level of Evidence: Level IV, therapeutic study.

There is a controversy about the capacity of the mesenchymal stem cells (MSCs) from aged individuals to proliferate and differentiate into cartilage. The purpose of this study was to investigate the optimal condition to culture human MSCs from the aged individuals (>50 years) for cartilage tissue engineering. We tested the hypothesis that effective proliferation and chondrogenesis can be achieved with human MSCs from aged individuals under appropriate conditions. To investigate the best condition for proliferation, MSCs were cultured in medium containing four concentrations subsets (0, 0.05, 0.5, 5 ng/mL) of recombinant human TGF-beta2 and FGF-2, either with or without fetal calf serum. The cell numbers were counted 0, 1, 3, and 7 days after growth factors were given. For the induction of chondrogenesis in 3-dimensional (3-D) culture, cells were cultured in pellets with chondrogenic medium containing combinations of various growth factors. After 4 weeks of culture, the pellets were fixed and evaluated with Safranin-O staining for proteoglycan and immunohistochemical staining for type II collagen. RT-PCR was also performed for the mRNAs of type I collagen, type II collagen, and cartilage oligomeric protein (COMP). In a monolayer culture, TGF-beta2 in concentrations of 0.5 and 5 ng/mL caused significant reduction in cell number irrespective of the presence of serum. FGF-2 of 5 ng/mL most effectively increased cell number even in the absence of serum. In a pellet culture, remarkable chondrocyte-like differentiation of cells was induced around the peripheral areas of a pellet with 5 ng/mL of TGF-beta2, accompanied by increased proteoglycan and type II collagen production. The addition of 100 ng/mL of IGF-I induced notable increase in proteoglycan contents. The results of RT-PCR mirrored those of histological studies. This study shows that an effective proliferation and chondrogenesis may be obtained with proper combinations of growth factors and mesenchymal stem cells from aged individuals.

Background: To compare closed intramedullary nailing with open plate and screw fixation and set the indications for each treatment modality in distal metaphyseal fractures of tibia, 64 consecutive cases of fractures that had been randomly treated with either method were prospectively followed up., Method: Thirty-four patients were in the group treated with closed intramedullary nailing (Group I) and 30 patients were treated with open reduction and internal fixation with anatomic plates and screws (Group II). They were observed for 2 years, and the end results were compared between the two groups., Results: The duration of operation was 72 minutes in Group I and 89 minutes in Group II (p = 0.02). The period of time before radiologic union was 18 weeks in Group I and 20 weeks in Group II (p = 0.89). There was one superficial infection in Group I and six superficial infections and one deep infection in Group II (p = 0.03). The average angulation was 2.8 degrees in Group I and 0.9 degrees in Group II (p = 0.01). The ankle dorsiflexion at the final follow-up was 14 degrees in Group I and 7 degrees in Group II (p = 0.001). The Olerud and Molander functional ankle score was 88.5% of normal side in Group I and 88.2% in Group II (p = 0.71)., Conclusion: Our results have shown that locked intramedullary nails have an advantage in the duration of operation, restoration of motion, and reduced wound problems, and anatomic plate and screws can restore alignment better than intramedullary nails. It can be concluded from this study that intramedullary nails are recommended for fractures associated with soft-tissue damage of Tscherne C2 or higher. In other cases, the authors think that either treatment modality can yield expected results.

Background: The tibial inlay method for reconstruction of the posterior cruciate ligament has been performed with the patient in the prone or lateral decubitus position. The purpose of this report is to present a modification of this method wherein the patient is positioned supine throughout the procedure., Methods: Between May 1995 and September 1998, twelve patients who had an isolated tear of the posterior cruciate ligament underwent reconstruction with use of the modified tibial inlay technique. Eleven patients were evaluated after a minimum duration of follow-up of two years. Stability was measured on posterior stress radiographs and with a maximum manual displacement test performed with a KT-1000 arthrometer. Clinical evaluation was carried out with use of the scoring systems of the Orthopädische Arbeitsgruppe Knie and the International Knee Documentation Committee. Second-look arthroscopy was performed in five patients at the time of follow-up., Results: The mean side-to-side difference in displacement (and standard deviation) was reduced from 10.8 +/- 1.9 mm preoperatively to 3.4 +/- 2.4 mm at the time of follow-up as measured on the stress radiographs, and it was reduced from 9.0 +/- 2.1 mm preoperatively to 1.8 +/- 1.2 mm at the time of follow-up as measured with the KT-1000 arthrometer. The average Orthopädische Arbeitsgruppe Knie score was improved from 71.6 +/- 6.8 to 92.5 +/- 4.8 points. All eleven patients had a satisfactory clinical outcome at the time of the final clinical evaluation. The second-look arthroscopic examination in the five patients showed no evidence of partial tearing or abrasion of the graft., Conclusions: Use of our modified tibial inlay technique for reconstruction of the posterior cruciate ligament achieved a good clinical result in eleven of twelve patients. The advantages of the technique are (1) minimal tendon abrasion at the posterior opening of the tibial tunnel, and (2) elimination of the need to change the patient's position during surgery.

Background: The tibial inlay method for reconstruction of the posterior cruciate ligament has been performed with the patient in the prone or lateral decubitus position. The purpose of this report is to present a modification of this method wherein the patient is positioned supine throughout the procedure., Methods: Between May 1995 and September 1998, twelve patients who had an isolated tear of the posterior cruciate ligament underwent reconstruction with use of the modified tibial inlay technique. Eleven patients were evaluated after a minimum duration of follow-up of two years. Stability was measured on posterior stress radiographs and with a maximum manual displacement test performed with a KT-1000 arthrometer. Clinical evaluation was carried out with use of the scoring systems of the Orthopädische Arbeitsgruppe Knie and the International Knee Documentation Committee. Second-look arthroscopy was performed in five patients at the time of follow-up., Results: The mean side-to-side difference in displacement (and standard deviation) was reduced from 10.8 +/- 1.9 mm preoperatively to 3.4 +/- 2.4 mm at the time of follow-up as measured on the stress radiographs, and it was reduced from 9.0 +/- 2.1 mm preoperatively to 1.8 +/- 1.2 mm at the time of follow-up as measured with the KT-1000 arthrometer. The average Orthopädische Arbeitsgruppe Knie score was improved from 71.6 +/- 6.8 to 92.5 +/- 4.8 points. All eleven patients had a satisfactory clinical outcome at the time of the final clinical evaluation. The second-look arthroscopic examination in the five patients showed no evidence of partial tearing or abrasion of the graft., Conclusions: Use of our modified tibial inlay technique for reconstruction of the posterior cruciate ligament achieved a good clinical result in eleven of twelve patients. The advantages of the technique are (1) minimal tendon abrasion at the posterior opening of the tibial tunnel, and (2) elimination of the need to change the patient's position during surgery.

The functional outcome of operative and nonoperative treatment of suprascapular neuropathy was compared to determine the preferred method of treatment for each etiology of nerve injury. The predictive value of preoperative electromyography also was studied. Fifty-three patients were evaluated at least 1 year (average, 28 months) from the time of operative (n = 36) or nonoperative (n = 17) treatment. A modified American Shoulder and Elbow Surgeons self-assessment score was obtained at presentation and at final followup. Electromyography data were obtained at initial presentation. Minimal electromyographic changes associated with denervation were associated with a limited response to treatment, especially in patients with nerve compression secondary to spinoglenoid notch cysts. Pretreatment electromyographic findings, therefore, were predictive of treatment response. Overall, operative and nonoperative treatment of these suprascapular nerve injuries resulted in significant functional improvement, but the results varied depending on the etiology of the injury. Spinoglenoid notch cysts responded significantly better to operative treatment, with the results for open surgery being the same as the results for arthroscopic decompression. In addition, compressive lesions attributable to suprascapular notch entrapment had the best improvement with surgical decompression. Traumatic lesions, including traction and direct closed injuries, had an equal response to operative and nonoperative treatment. Overuse injuries did not improve with operative treatment. Viral neuritis improved with nonoperative treatment and never was treated with surgery. Overall, traumatic injuries resulted in significantly worse final outcomes than any other etiologic processes. In the nonoperative group, neuropathy secondary to spinoglenoid cysts resulted in significantly worse function. The outcome of treatment is dependent on the severity and etiology of the nerve injury, and the method of treatment.