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Purpose The optimal coronal alignment is still under debate. However, in most of the studies, alignment was only assessed using radiographs, which are not accurate enough for assessment of tibial and femoral TKA position. The primary purpose of this study was to assess the relationship between coronal TKA alignment using 3D-reconstructed CTs and clinical outcome in patients with preoperative varus in comparison with patients with natural or valgus deformity. It was the hypothesis that neutral limb alignment shows a better outcome after TKA. Methods Prospectively collected data of 38 patients were included. The clinical and radiological follow-up was 24 months. The patients were grouped into two groups with regard to their preoperative limb alignment. Group A (varus) consisted of 21 patients with preoperative varus of 3° or more, while group B (non-varus) consisted of 17 patients with neutral (− 3 < 0 > + 3) or valgus alignment (> + 3). For assessment of TKA component position and orientation, 3D-reconstructed CT was used. The measurements of the deviation from the whole limb mechanical axis (HKA angle) and the joint line alignment in the femoral (mLDFA) and the tibial side (MPTA) were assessed in the preoperative leg as well as during follow-up after TKA. For clinical outcome assessment, the Knee Society Score (KSS) was used at 1 and 2 years postoperatively. Correlation between KSS score and each variable was done using a linear and quadratic regression model ( p  < 0.05). Results The mean postoperative HKA angle was − 1.3 (varus) in the varus group and + 1.4 (valgus) in the non-varus group. Overall, significant correlations between the preoperative and postoperative alignments were found. In the preoperatively non-varus group, a highly significant correlation was found between neutral limb alignment (HKA = 0° ± 3°) and higher KSS ( r 2  = 0.74, p  = 0.00). In the varus group, no correlation was found between the postoperative whole limb alignment and the components’ position in the coronal plane to KSS score. Conclusion A significant correlation was found between neutral limb alignment and higher KSS only in patients with preoperative non-varus alignment. The concept of constitutional varus alignment is still under debate. Moreover, it appears that one should aim for a more individualized, alignment target based on the individual knee morphotype. Level of evidence Diagnostic study, Level II.

Born in the mid-1800s, the Impressionist movement redefined the way artists approached their craft, opening the doors to previously unheard-of freedom in methods, viewpoint, and execution. This book examines Impressionist art, the tools, the techniques, the artists, and the artwork that so many generations have come to know and love.

Purpose The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts. Methods Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied. Results The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1–8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair. Discussion The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. Level of evidence II

A look at several dangerous reptiles.

Earth's inventory of principle volatiles C, H, N, and S is a legacy of its early stages of accretion and differentiation. Elemental ratios (C/H, C/N, C/S) are powerful tools for understanding early processing of Earth's volatiles, as they monitor relative fractionations through important processes even when absolute concentrations are less well defined. The C/H ratio of the bulk silicate Earth (BSE), defined from surface reservoirs and minimally degassed oceanic basalts is 1.3 ± 0.3, which is 5-15 times lower than the C/H ratio of carbonaceous and enstatite chondrites and 2-5 times lower than ordinary chondrites. The BSE C/N ratio is superchondritic (40 ± 8; Bergin et al. 2015) while the C/S ratio (0.49 ± 0.14) is nearly chondritic. Successful models of volatile acquisition and processing must account for the effects of accretion, core formation, and atmospheric loss on all three of these ratios.Simple models of equilibration between a magma ocean, the overlying atmosphere, and alloy destined for the core are used to explore the influence of core formation and atmospheric loss on major volatile concentrations and ratios. Among major volatile elements, C is most siderophile, and consequently core formation leaves behind a non-metallic Earth with low C/H, C/N, and C/S ratios compared to originally accreted materials and compared to the BSE. Compared to the predicted effect of early differentiation, the relatively high C/X ratios of the BSE argue in part that significant volatile replenishment occurred after core formation ceased, possibly in the form of a late veneer. However, a late veneer with chondritic composition is insufficient to explain the pattern of major volatile enrichments and depletions because BSE C/H and C/N ratios are non-chondritic. The C/H ratio is best explained if an appreciable fraction of H in the BSE predates delivery in the late veneer. Although atmospheric blow-off is an attractive explanation for the high C/N ratio, available data for C and N solubility and metal/silicate partitioning suggest that atmospheric blow-off cannot counter core formation to produce subchondritic C/N. Thus, unless virtually all core-forming metal segregated prior to volatile accretion (or relative C and N solubilities are appreciably different from those assumed here), the BSE C/N ratio suggests that accreting materials had elevated ratios compared to carbonaceous chondrites. One possibility is that a fraction of Earth's volatiles accreted from differentiated C-rich planetesimals similar to the ureilite parent body. Reconciling C/H, C/N, and C/S ratios of the BSE simultaneously presents a major challenge that almost certainly involves a combination of parent body processing, core formation, catastrophic atmospheric loss, and partial replenishment by a late veneer. The chondritic C/S ratio of the BSE and relatively low S content of the BSE constrains the BSE C concentration, but a potential complicating factor in interpreting the BSE C/S ratio is the possible effect of segregation of an S-rich matte to the core during the later parts of core-mantle differentiation.

Discusses the factors that motivate human behavior.

Purpose The currently used system to classify the lower limb alignment (neutral, varus, valgus) does not consider the orientation of the joint line or its relationship to the overall lower limb alignment. Similarly, current total knee arthroplasty (TKA) alignment concepts do not sufficiently consider the variability of the native coronal alignment. Therefore, the purpose of this study was (1) to introduce a new classification system for the lower limb alignment, based on phenotypes, and (2) to compare the alignment targets of different TKA alignment concepts with the native alignment of non-osteoarthritic patients. Methods Two recent articles phenotyped the lower limb, the femur and tibia of 308 non-osteoarthritic knees of 160 patients [male to female ratio = 102:58, mean age ± standard deviation 30 ± 7 years (16–44 years)]. The present study introduces functional knee phenotypes, which are a combination of all previously introduced phenotypes. The functional knee phenotypes therefore enable an evaluation of all parameters in relation to each other and thus a comprehensive analysis of the coronal alignment. The existing functional knee phenotypes in the female and male population were investigated. In addition, how many non-osteoarthritic knees had an alignment within the range of current TKA alignment targets (mechanical, anatomical and restricted kinematic alignment) was investigated. Therefore, it was defined which functional knee phenotypes represented a target of the TKA alignment concepts and which percentage of the population had such a phenotype. Results Out of 125 possible functional knee phenotypes, 43 were found (35 male, 26 and 18 mutual). The most common functional knee phenotype in males was NEU HKA 0° + NEU FMA 0° + NEU TMA 0° (19%), followed by VAR HKA 3° + NEU FMA 0° + VAR TMA 0° (8.2%). The most common functional knee phenotype in females was NEU HKA 0° + NEU FMA 0° + NEU TMA 0° (17.7%), closely followed by NEU HKA 0° + NEU FMA 0° + VAL TMA 0° (16.6%). The functional knee phenotype representing a mechanical alignment target was found in 5.6% of the males and 3.6% of the females. The phenotype representing an anatomical alignment target was found in 18% of the males and 17% in females. Five of the nine phenotypes representing a restricted kinematic alignment target were found in this population (male 5, female 4, mutual 4). They represented 31.3% of all males and 45.1% of all females. Conclusion A more individualized approach to TKA alignment is needed. The functional knee phenotypes enable a simple, but detailed assessment of a patient’s individual anatomy and thereby could be a helpful tool to individualize the approach to TKA. Level of clinical evidence III, retrospective cohort study.

By determining the solidus of carbonated peridotite at high pressure it was demonstrated that melting beneath mid-ocean ridges may occur at greater depths than usually assumed — down to 330 kilometres or more. The onset of partial melting beneath mid-ocean ridges governs the cycling of highly incompatible elements from the mantle to the crust 1 , the flux of key volatiles (such as CO 2 , He and Ar) 1 , 2 and the rheological properties of the upper mantle 3 . Geophysical observations 4 , 5 , 6 indicate that melting beneath ridges begins at depths approaching 300 km, but the cause of this melting has remained unclear. Here we determine the solidus of carbonated peridotite from 3 to 10 GPa and demonstrate that melting beneath ridges may occur at depths up to 330 km, producing 0.03–0.3% carbonatite liquid. We argue that these melts promote recrystallization and realignment of the mineral matrix, which may explain the geophysical observations. Extraction of incipient carbonatite melts from deep within the oceanic mantle produces an abundant source of metasomatic fluids and a vast mantle residue depleted in highly incompatible elements and fractionated in key parent-daughter elements. We infer that carbon, helium, argon and highly incompatible heat-producing elements (such as uranium, thorium and potassium) are efficiently scavenged from depths of ∼200–330 km in the upper mantle.