Bottomup regulates environmental innovations and diversity from the oceans over time

Meniscus repairs for vertical, peripheral tears can be troublesome due to poor tissue quality and/or vascularity that can lead to re-rupture and subsequent removal. The gold standard, inside-out repair technique, has been challenged by all-inside devices for the benefit of improved efficiency and less morbidity but for the sake of expense and potential structural inferiority. Successful meniscus repair requires multiple components, only one of which is deciding the repair construct of choice. I feel the most important aspect will always be the indication based on tear configuration while respecting biology, because all fixation will eventually fail if the meniscus does not ultimately heal. While all-inside devices may have biomechanical properties that are similar to inside-out techniques, the burden of proof still lies on showing superiority of these devices in a clinical setting. Clinically, I still use inside-out repair techniques for large tears or for high-demand patients due to its structural integrity and small penetration of the meniscus.A better understanding of hip-preservation patients lies in our ability to analyze and collect data. Collecting the appropriate outcome measures is required to improve treatments, personalize health care, and drive policy. Current research suggests legacy measures and Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used in data collection, but which measures are best? PROMIS computer-adaptive tests are an attractive outcome measure source because they allow for low-burden data capture with reduced completion times and limited floor and ceiling effects. PROMIS provides numerous reliable, sensitive, and domain-specific measurements capturing a patient's health outcomes. PROMIS has been shown to correlate with hip and other legacy outcome measures, but because PROMIS is more general than some legacy measures, it may be less responsive. PROMIS measures are applicable across a wide spectrum of health measures for our patients, including hip femoroacetabular impingement, but should not replace the legacy measure of the International Hip Outcome Tool 12. However, PROMIS should still be measured because it may allow greater comparison to studies of other conditions resulting in diminished reporting bias.Tenodesis of the long head of the biceps tendon has long been a source of dialogue, discussion, debate, and dogma. In general, the shoulder literature has been exhaustive regarding various biceps tenodesis techniques and outcomes, and studies have shown positive clinical outcomes of tenodesis, regardless of location, along the proximal humerus. Fewer studies have evaluated the outcomes of revision tenodesis; however, those that have looked at this have generally found that a revision to a subpectoral tenodesis site is usually quite successful.Snapping scapula syndrome and scapulothoracic bursitis are rare, often painful or functionally limiting conditions that can present owing to underlying anatomic abnormalities or can be idiopathic in nature. When there are no underlying structural abnormalities, diagnosis can be challenging and frequently patients will present with chronic pain having received multiple diagnostic and treatment modalities with no success. Injections into the scapulothoracic bursa, in conjunction with physical therapy, have been shown to be effective for the patient with snapping scapula syndrome and/or scapulothoracic bursitis, when recognized. Yet, some cases are recalcitrant to conservative treatment, and surgical intervention is required. As with any procedure, patient selection for surgical intervention is critical and based on the diagnostic workup-particularly, the response to diagnostic or therapeutic injections. The best surgical outcomes may be achieved in patients who receive bursectomy in conjunction with partial scapulectomy, and negative prognostic factors include older age, lower preoperative psychological score, and longer duration of symptoms.Rotator cuff tears (RCT) with concomitant frozen shoulder is a challenging clinical scenario that I, along with many other shoulder surgeons, commonly encounter. Some controversy exists regarding the optimal treatment. Does one address the shoulder stiffness first and regain range of motion (ROM) via nonoperative or operative means, then treat the rotator cuff tear later, or should it all be done at the same time surgically via a concomitant arthroscopic capsular release with or without manipulation under anesthesia (MUA) followed by a rotator cuff repair (RCR) in the same setting? I believe there is overwhelming evidence in the literature to support the latter. Address both pathologies concomitantly through a single stage surgery! In the setting of the RCT with adhesive capsulitis, I routinely recommend early concomitant arthroscopic capsular release with gentle MUA and then perform an arthroscopic RCR in one stage. This is then followed by an accelerated postoperative protocol which is balanced with some protection for healing. We have reported excellent outcomes with this approach. Similarly, I have found this approach to be highly effective, reproducible, and efficient, with high patient satisfaction and outcomes comparable to my patients who undergo arthroscopic RCR without stiff shoulders.Often referred to as a "sports hernia" or "core muscle injury," athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. Symptoms can appear acutely or insidiously, primarily as groin and lower abdominal pain that can radiate toward the perineum and proximal adductors. Pain is exacerbated by athletic activity such as kicking, cutting, and sprinting. The pubis acts as a pivot point between the abdominal musculature and lower-extremity adductors, and therefore, pain with palpation over the symphysis or its surrounding structures is typical in athletic pubalgia. Symptoms can be reproduced during a resisted sit-up or with a forced cough or sneeze. Clinical examination should include an evaluation of articular hip pathology to identify underlying femoroacetabular impingement syndrome. Selleck Sorafenib D3 Magnetic resonance imaging can aid in ruling out other pathologies and identify specific findings including tears or strains of the ipsilateral rectus abdominis or adductor tendons.