Finding and defining the ideal patellar resection plane in total knee arthroplasty

Asymmetric resection of the patella during total knee arthroplasty (TKA) correlates with anterior knee pain, bony impingement and patellar maltracking. Despite this, there is no consensus regarding the desired landmarks; the cut is often done freehand; and there has been no quantitative comparison of proposed resection planes. The objectives of this study were to: determine the intra- and inter-surgeon repeatability of two radiographic resection definitions (medial–divot, MD, and medial–lateral extents, MLE); calculate two additional definitions from the radiographic patellar circumferences (parallel to the anterior surface, ANT, and perpendicular to the anteroposterior tangent points, PERP); compare the clinical resection line to the previous four definitions before and after introducing the MD method clinically; and identify distinguishing features of patellae with better vs. worse resection angles. We hypothesized that the MD method would improve repeatability both radiographically and clinically, that the different radiographic definitions would produce comparable angles, and that we could identify distinguishing features. For the radiographic study, three surgeons drew lines on 40 preoperative X-rays plus 9 interspersed repetitions of 3 of these X-rays. For the clinical study, we compared the patellar resection angle for 20 patients immediately before and after implementing the new method. Given that the clinical goal is to have equal distances from the resection surface to the anterior surface, we compared all results to the ANT definition as the theoretically ideal definition. Confirming the first hypothesis, intra-surgeon repeatability (10 repetitions of 3 X-rays) and inter-surgeon repeatability (3 surgeons×40 X-rays) were both significantly better using the new MD method compared to the MLE method (p<0.001). Contrary to the second hypothesis, clinical use of the MD method did not improve resection symmetry. Contrary to the third hypothesis, the PERP definition was significantly different from the other three definitions. In agreement with the fourth hypothesis, female patellae and more deformed patella had significantly greater asymmetry (p<0.001). Given the inherent variability shown in drawing the ‘patellar horizon’, we encourage researchers to draw the line several times and average the results when comparing tilt or the resection angle to this horizon. Based on the distinguishing characteristics of asymmetrically resurfaced patellae in our series, we recommend that clinicians be particularly careful when resecting laterally deformed patellae and the patellae of female patients.     

全膝关节置换术后多模式镇痛中非选择与选择性COX-2抑制剂的对比应用研究

目的：评价全膝关节置换术后病人早期功能锻炼过程中应用选择性环氧化酶-2（COX-2）抑制剂帕瑞昔布钠与非选择性环氧化酶（COX）抑制剂氟比洛芬酯之间的镇痛效果是否存在差异,以及对早期功能锻炼结果的影响。方法：前瞻性、随机、双盲、平行对照研究,根据纳入/排除标准,连续选取2009年6月至2010年3月在我科行单侧人工全膝关节置换术的病人60名。手术均采用腰麻联合硬膜外阻滞麻醉,由同一组手术医师完成,术中假体安装前关节周围软组织注射＂鸡尾酒＂镇痛液（罗哌卡因注射液150mg＋肾上腺素（1：1000）0.5ml,由生理盐水稀释为100ml）。手术结束后进行病人自控静脉镇痛（PCIA）。术后当天患者在护士的指导下进行股四头肌收缩功能锻炼及直腿抬高功能锻炼。术后第一天起行膝关节被动伸屈功能锻炼（CPM）及主动伸屈功能锻炼。术后第3至5天患者停PCIA镇痛后,进行试验干预。帕瑞昔布钠组给予注射用帕瑞昔布钠40mg,静注1/12小时。氟比洛芬酯组给予氟比洛芬酯注射液100mg,静注1/12小时。观察病人术后第3至5天静息状态下和活动锻炼时膝关节最大主动屈曲时的疼痛强度（VAS评分）,手术侧膝关节的主动伸屈活动度及术后1月复查时的手术侧膝关节的主动伸屈活动度,KSS评分,术后第2天与第6天的血红蛋白值。结果：两组病人给药后在静息状态及膝关节最大主动屈曲时,在不同时间点的VAS评分、膝关节主动活动度及术后1月患者膝关节的主动活动度和KSS评分的差异均无统计学意义（P〉0.05）。应用抗凝治疗后,帕瑞昔布钠组患者血红蛋白下降值与氟比洛芬酯组存在差异（P=0.042）。结论：尚不能认为人工全膝关节置换术后多模式镇痛中同时抑制COX-1和COX-2与选择性抑制COX-2之间存在差异。但应用选择性COX-2抑制剂（帕瑞昔布钠）镇痛更安全,因其有利于减少全膝关节置换术后患者抗凝治疗过程中的隐性失血。     

地佐辛超前镇痛对全膝关节置换术患者围术期细胞因子的影响

目的：探讨地佐辛超前镇痛对全膝关节置换术患者围术期白介素-6（IL-6）、白介素-8（m-8）和肿瘤坏死因子-α（TNF-α）浓度的影响。方法：40例择期行单侧全膝关节置换术患者,随机分为超前镇痛组（实验组）和术后镇痛组（对照组）,每组20例。均采用蛛网膜下腔麻醉,患者静脉自控镇痛（PCIA）：地佐辛0．8mg／kg,生理盐水稀释至100mL。负荷剂量：5mL,持续剂量：2mL／h,追加剂量：0．5mL／次,锁定时间：15min。实验组于入室后10分钟麻醉操作前开始静脉负荷量和背景量,对照组于术毕开始PCIA镇痛,方法同实验组,记录患者术后6、8、12、24小时的疼痛视觉模拟评分（VAS评分）以及术后48小时内患者恶心呕吐的发生情况,于入室后10分钟麻醉操作前（T1）、手术开始后10分钟（T2）、术毕2h（T3）、4h（T4）、8h05）、24h（T6）时间点抽取静脉血样,测定细胞因子IL-6、IL-8、TNF-α水平。结果：术后6h、8h、12h时间点VAS评分实验组较对照组明显降低（P〈0．05）,24hVAS评分变化不大,无统计学差异（P〉0．05）。术后48小时内,实验组发生恶心呕吐1例,对照组2例。与本组T1比较,血浆IL-6、IL．8浓度实验组在各时点变化不大,无统计学差异（P〉0．05）,对照组浓度升高（P〈0．05）。组间比较,相同时点血浆IL-6、IL-8浓度实验组均低于对照组（P〈0．05）。两组血浆TNF-α浓度比较差异无统计学意义（P〉0．05）。结论：全膝关节置换术术前预先给予地佐辛可产生良好的超前镇痛效果,减少患者围术期细胞因子的产生。     

新辅助化疗联合人工膝关节置换治疗膝关节附近骨肉瘤

目的:评价新辅助化疗联合人工膝关节置换治疗膝关节附近骨肉瘤的临床疗效。方法:38例膝关节附近骨肉瘤采用新辅助化疗和人工膝关节置换,所有病例均进行肿瘤细胞坏死率、5年内肿瘤局部复发率、5年生存率和膝关节功能评估。结果:38例患者新辅助化疗后肿瘤细胞坏死率平均95.8%;随访6-9年,38例患者中5年内肿瘤局部复发12例(31.6%),5年后生存31例(81.6%),膝关节功能优良率92.1%。结论:新辅助化疗联合人工膝关节置换治疗膝关节附近骨肉瘤可有效提高骨肉瘤5年生存率,保存患肢功能,是骨肉瘤保肢治疗的一种较好的方法。     

人工全髋关节置换术中Delta陶瓷的界面选择

目的:Delta陶瓷较Forte陶瓷在材料复合方面进步明显,并采用了36 mm大直径球头的设计,其组成的界面具有耐磨性好,关节活动度大,稳定性佳,不易脱位等优点,适合年轻及活动量大的患者,但其价格较其他界面更为高昂.观察采用Delta陶瓷-陶瓷界面与Delta陶瓷-高交联聚乙烯界面假体行全髋关节置换术的患者术后效果的差异.方法:选取2009年10月-2012年10月在我院选择Delta陶瓷-高交联聚乙烯界面行全髋关节置换术的35例患者(A组),以同期在我院选择Delta陶瓷-陶瓷界面26例行全髋关节置换术的患者(B组)作为对照.通过随访影像学复查,以及术后Harris功能评分进行临床效果的评价.结果:所有患者均得到随访,随访时间6个月到2年.所有患者在影像学方面,未发现松动下沉,脱位以及碎裂等现象.假体周围未见骨溶解所致透亮线形成以及异位骨化.两组患者行人工全髋关节置换术后Harris评分较术前均有显著提高,但两组之间无显著差异.结论:Delta陶瓷作为最新一代的生物陶瓷,其优异性能毋庸置疑.采用Delta陶瓷-陶瓷界面及Delta陶瓷-高交联聚乙烯界面在短期内未见明显差异,其中长期效果仍有待进一步随访观察.     

The effect of patient positioning on the precision of model-based radiostereometric analysis

A repeatable method for in vivo and in vitro measurement of polyethylene wear in total knee replacement (TKA) is needed. This research examines the model-based radiostereometric analysis’ (MBRSA) in vitro precision under different patient-radiograph orientations and flexion angles of the knee using a TKA phantom. Anterior–posterior and medial–lateral imaging orientations showed the highest precision; better than 0.036 mm (3-dimensional translation) and 0.089° (3-dimensional rotation). Flexion of the knee did not affect MBRSA precision. Medial–lateral imaging is advantageous as it allows for flexion of the knee joint during an RSA examination, thus providing greater information for wear measurement.     

Biotribology of a mobile bearing posterior stabilised knee design - Effect of motion restraint on wear,tibio-femoral kinematics and particles

The objective of our study was to evaluate the impact of a biphaseal anterior–posterior (AP) and internal–external (IE) motion restraint system on the wear behaviour, tibio-femoral kinematics and particle release of a mobile bearing posterior stabilised knee design in comparison to the widely used linear restraint.     

The implication of the osteolysis threshold and interfacial gaps on periprosthetic osteolysis in cementless total hip replacement

Osteolysis around joint replacements may develop due to migration of wear particles from the joint space into gaps between the interface bone and the implant where they can accumulate in high concentrations to cause tissue damage. Osteolysis may appear in various postoperative times and morphological shapes which can be generalized into linear and focal. However, there are no clear explanations on the causes of such variations. Patients’ degree of sensitivity to polyethylene particles (osteolysis thresholds), the local particle concentration and the access route provided by the interface gaps have been described as determining factors. To study their effects, a 2D computational fluid dynamics model of the hip joint capsule in communication with an interfacial gap and the surrounding bone was employed. Particles were presented using a discrete phase model (DPM). High capsular fluid pressure was considered as the driving force for particle migration. Simulations were run for different osteolysis thresholds ranging from $5\times {10}^8$ to $1\times {10}^{12}$ particle number per gram of tissue and fibrous tissue generation in osteolytic lesion due to particles was simulated for the equivalent of ten postoperative years. In patients less sensitive to polyethylene particles (higher threshold), osteolysis may be linear and occur along an interfacial gap in less than 5% of the interfacial tissue. Focal osteolysis is more likely to develop in patients with higher sensitivity to polyethylene particles at distal regions to an interfacial gaps where up to 80% of the interfacial tissue may be replaced by fibrous tissue. In these patients, signs of osteolysis may also develop earlier (third postoperative year) than those with less sensitivity who may show very minor signs even after ten years. This study shows the importance of patient sensitivity to wear particles, the role of interfacial gaps in relation to morphology and the onset of osteolysis. Consequently, it may explain the clinically observed variation in osteolysis development.     

The superdiamagnetic effect of magnetic fields on one and two component multilamellar liposomes

For multilamella vesicles of DMPC, DPPC, DSPC, binary mixtures of DMPC-DPPC, DMPC-DSPC, DMPC-DPPE, DOPC and egg lecithin, the optical turbidity decreases significantly on the application of a magnetic field in excess of about 0.2 T, provided that the temperature is above the pretransition value. The turbidity reaches a limiting value for magnetic fields of about 2 T. The effect is attributed to augmentation of the diamagnetic anisotropy of the lipid molecules by clustering within the bilayer, with consequent orientation of either the individual ‘superdiamagnetic’ clusters or the whole liposome. It is suggested that, since most animal cell membranes are largely in the liquid crystalline phase, it is possible that homogeneous magnetic fields as low as 0.2 T may cause biologically significant changes within the membrane.     

The protective effect of peony extract on acute myocardial infarction in rats

To investigate the protective effects, and the mechanisms involved, of an extract of the medicinal herb radix paeoniae rubra (PE) on cardiovascular disease, acute myocardial infarction (AMI) was induced by ligation of the left coronary artery in Sprague Dawley rats. Animals were randomly divided into six groups: control, sham-operated, AMI, AMI + PE low dose, AMI + PE high dose, and AMI + positive control. Myocardial enzymes, cytokines, oxidative stress, blood coagulation times, a marker for early stage apoptosis, caspase-3 activity, and expression levels of bax, bcl-2 and fas in isolated primary cardiomyocytes were examined. In contrast with control and sham groups, significant increases in the following parameters were measured in the blood of AMI group animals: activities of cardiac enzymes including glutamic oxaloacetic transaminase, creatine kinase, creatine kinase-MB, lactate dehydrogenase, α-hydroxybutyric dehydrogenase, and levels of IL-10, TNFα, and lipid peroxidation. Under the same conditions, superoxide dismutase activity, thrombin time and activated partial thromboplastin time decreased significantly. PE showed a dose-dependent protection against AMI-induced alterations in cardiac enzymes, cytokines, oxidative stress, and coagulation. In AMI cardiomyocytes, compared with control and sham groups, the left ventricular end-diastolic pressure, early stage apoptosis, caspase-3 activity and expression levels of bax, bcl-2 and fas significantly increased, while the ratio bcl-2/bax decreased. PE showed dose-dependent protection. These results suggest that PE is an effective agent for protecting against AMI; possible mechanisms may include the regulation of cardiac enzymes, cytokines, oxidative stress, coagulation and apoptosis.     

The effect of forearm support on children’s head, neck and upper limb posture and muscle activity during computer use

Use of computers by children has increased rapidly, however few studies have addressed factors which may reduce musculoskeletal stress during computer use by children. This study quantified the postural and muscle activity effects of providing forearm support when children used computers. Twelve male and 12 female children (10–12 years) who regularly used computers were recruited. Activities were completed using a computer with two workstation configurations, one of which provided for forearm support on the desk surface. 3D posture was analysed using an infra-red motion analysis system. Surface EMG was collected from five muscle groups in the neck/shoulder region and right upper limb. Providing a support surface resulted in more elevated and flexed upper limbs. The use of forearm or wrist support was associated with reduced muscle activity for most muscle groups. Muscle activity reductions with support were of sufficient magnitude to be clinically meaningful. The provision of a supporting surface for the arm is therefore likely to be useful for reducing musculoskeletal stresses associated with computing tasks for children.     

The effect of conspecific attraction on metapopulation dynamics

Random dispersal direction is assumed in all current metapopulation models. This assumption is called into question by recent experiments demonstrating that some species disperse preferentially to sites occupied by conspecifies. We incorporate conspecific attraction into two metapopulation models which differ in type of dispersal, the Levins model and a two-dimensional stepping-stone model. In both models, conspecific attraction lowers the proportion of occupied habitat patches within a metapopulation at equilibrium.     

The effect of different strengths of extremely low-frequency electric fields on antioxidant status,lipid peroxidation,and visual evoked potentials

The aim of the study was to investigate the effects of extremely low-frequency electric field (ELF EF) on visual evoked potential (VEP), thiobarbituric acid reactive substances (TBARS), total antioxidant status (TAS), total oxidant status (TOS), and oxidant stress index (OSI). Thirty female Wistar rats, aged 3 months, were divided into three equal groups: Control (C), the group exposed to EF at 12 kV/m strength (E12), and the group exposed to EF at 18 kV/m strength (E18). Electric field was applied to the E12 and E18 groups for 14 days (1 h/day). Brain and retina TBARS, TOS, and OSI were significantly increased in the E12 and E18 groups with respect to the control group. Also, TBARS levels were significantly increased in the E18 group compared with the E12 group. Electric fields significantly decreased TAS levels in both brain and retina in E12 and E18 groups with respect to the control group. All VEP components were significantly prolonged in rats exposed to electric fields compared to control group. In addition, all latencies of VEP components were increased in the E18 group with respect to the E12 group. It is conceivable to suggest that EF-induced lipid peroxidation may play an important role in changes of VEP parameters.     

The effect of age at introduction and number of milk-portions on the behaviour of group housed dairy calves fed by a computer controlled milk feeder

This study is an investigation of the effect of age at introduction (6 days versus 14 days) and number of milk-portions (four milk-portions a day versus eight milk-portions a day) on integration into a large dynamic group of calves, fed by a computer controlled milk feeder. Forty calves (Jerseys, Danish Reds and Holstein-Friesians) were allocated equally to the two age conditions (A6 and A14) and the two milk-portion conditions (M4 and M8) in a 2 × 2 factorial design, according to sex and breed, and introduced into the group in pairs (one A6 and one A14). The behaviour of each pair was video-recorded for 8 h from 8 a.m. to 4 p.m. and 1 h from 1 to 2 a.m. on days 1, 8 and 15 after introduction.

The A6 calves performed less licking and sniffing, changed posture more often and tended to spend less time standing than the A14 calves. In the course of time A14 calves lay closer to other calves than the A6 calves.

The M8 calves, which were offered the same daily milk allowance as the M4 calves stood for a longer time in the milk feeding station and the M8 calves also sucked the empty teat more frequently than the M4 calves. Finally, the M8 calves initiated more social play behaviour than the M4 calves. On the first day after introduction the M8 calves lay closer to other calves than the M4 calves.

The results suggest that calves integrate better into a group when introduced at the age of 14 days than at the age of 6 days. Distributing the milk into eight daily milk-portions, rather than four milk-portions in the first period after introduction, increased milk feeder occupancy, which may facilitate learning to use the milk feeder. Surprisingly, more milk-portions also stimulated play behaviour, which is suggested to be due to M8 calves encountering more calves in the milk feeder area.     

The effect of trauma on Neanderthal culture: A mathematical analysis

Traumatic lesions are often observed in ancient skeletal remains. Since ancient medical technology was immature, severely traumatized individuals may have frequently lost the physical ability for cultural skills that demand complex body movements. I develop a mathematical model to analyze the effect of trauma on cultural transmission and apply it to Neanderthal culture using Neanderthal fossil data. I estimate from the data that the proportion of adult individuals who suffered traumatic injuries before death was approximately 0.79–0.94, in which 0.37–0.52 were injured severely and 0.13–0.19 were injured before adulthood. Assuming that every severely traumatized individual and a quarter to a half of the other traumatized individuals lost the capacity for a cultural skill that demands complex control of the traumatized body part, I estimate that if an upper limb is associated with a cultural skill, each individual had to communicate closely with at least 1.5–2.6 individuals during adulthood to maintain the skill in Neanderthal society, and if a whole body is associated, at least 3.1–11.5 individuals were necessary. If cultural transmissions between experts and novices were inaccurate, or if low frequency skills easily disappeared from the population due to random drift, more communicable individuals were necessary. Since the community size of Neanderthals was very small, their high risk of injury may have inhibited the spread of technically difficult cultural skills in their society. It may be important to take this inhibition into consideration when we study Neanderthal culture and the replacement of Neanderthals by modern humans.     

The effect of superspreading on epidemic outbreak size distributions

Recently, evidence has been presented to suggest that there are significant heterogeneities in the transmission of communicable diseases. Here, a stochastic simulation model of an epidemic process that allows for these heterogeneities is used to demonstrate the potentially considerable effect that heterogeneity of transmission will have on epidemic outbreak size distributions. Our simulation results agree well with approximations gained from the theory of branching processes. Outbreak size distributions have previously been used to infer basic epidemiological parameters. We show that if superspreading does occur then such distributions must be interpreted with care. The simulation results are discussed in relation to measles epidemics in isolated populations and in predominantly urban scenarios. The effect of three different disease control policies on outbreak size distributions are shown for varying levels of heterogeneity and disease control effort.     

The effect of treatment on pathogen virulence

The optimal virulence of a pathogen is determined by a trade-off between maximizing the rate of transmission and maximizing the duration of infectivity. Treatment measures such as curative therapy and case isolation exert selective pressure by reducing the duration of infectivity, reducing the value of duration-increasing strategies to the pathogen and favoring pathogen strategies that maximize the rate of transmission. We extend the trade-off models of previous authors, and represents the reproduction number of the pathogen as a function of the transmissibility, host contact rate, disease-induced mortality, recovery rate, and treatment rate, each of which may be influenced by the virulence. We find that when virulence is subject to a transmissibility-mortality trade-off, treatment can lead to an increase in optimal virulence, but that in other scenarios (such as the activity-recovery trade-off) treatment decreases the optimal virulence. Paradoxically, when levels of treatment rise with pathogen virulence, increasing control efforts may raise predicted levels of optimal virulence. Thus we show that conflict can arise between the epidemiological benefits of treatment and the evolutionary risks of heightened virulence.     

The effect of intrinsic stochasticity on transmitted HIV drug resistance patterns

Estimates of transmitted HIV drug-resistance prevalence vary widely among and within epidemiological surveys. Interpretation of trends from available survey data is therefore difficult. Because the emergence of drug-resistance involves small populations of infected drug-resistant individuals, the role of stochasticity (chance events) is likely to be important. The question addressed here is: how much variability in transmitted HIV drug-resistance prevalence patterns arises due to intrinsic stochasticity alone, i.e., if all starting conditions in the different epidemics surveyed were identical? This ‘thought experiment’ gives insight into the minimum expected variabilities within and among epidemics. A simple stochastic mathematical model was implemented. Our results show that stochasticity alone can generate a significant degree of variability and that this depends on the size and variation of the pool of new infections when drug treatment is first introduced. The variability in transmitted drug-resistance prevalence within an epidemic (i.e., the temporal variability) is large when the annual pool of all new infections is small (fewer than 200, typical of the HIV epidemics in Central European and Scandinavian countries) but diminishes rapidly as that pool grows. Epidemiological surveys involving hundreds of new infections annually are therefore needed to allow meaningful interpretation of temporal trends in transmitted drug-resistance prevalence within individual epidemics. The stochastic variability among epidemics shows a similar dependence on the pool of new infections if treatment is introduced after endemic equilibrium is established, but can persist even when there are more than 10,000 new infections annually if drug therapy is introduced earlier. Stochastic models may therefore have an important role to play in interpreting differences in transmitted drug-resistance prevalence trends among epidemiological surveys.     

The effect of boundary conditions on epicardial potential distributions

This study presents a comparison of semi-analytical and numerical solution techniques for solving the passive bidomain equation in simple tissue geometries containing a region of subendocardial ischaemia. When the semi-analytical solution is based on Fourier transforms, recovering the solution from the frequency domain via fast Fourier transforms imposes a periodic boundary condition on the solution of the partial differential equation. On the other hand, the numerical solution uses an insulation boundary condition. When these techniques are applied to calculate the epicardial surface potentials, both yield a three well potential distribution which is identical if fibre rotation within the tissue is ignored. However, when fibre rotation is included, the resulting three-well distribution rotates, but through different angles, depending on the solution method. A quantitative comparison between the semi-analytical and numerical solutiontechniques is presented in terms of the effect fibre rotation has on the rotation of the epicardial potential distribution. It turns out that the Fourier transform approach predicts a larger rotation of the epicardial potential distribution than the numerical solution. The conclusion from this study is that it is not always possible to use analytical or semi-analytical solutions to check the accuracy of numerical solution procedures. For the problem considered here, this checking is only possible when it is assumed that there is no fibre rotation through the tissue.     

The effect of meniscal tears and resultant partial meniscectomies on the knee contact stresses: a finite element analysis

Knee osteoarthritis (OA) is believed to result from high levels of contact stresses on the articular cartilage and meniscus after meniscal damage. This study investigated the effect of meniscal tears and partial meniscectomies on the peak compressive and shear stresses in the human knee joint. An elaborate three-dimensional finite element model of knee joint including bones, articular cartilages, menisci and main ligaments was developed from computed tomography and magnetic resonance imaging images. This model was used to model four types of meniscal tears and their resultant partial meniscectomies and analysed under an axial 1150 N load at 0° flexion. Three different conditions were compared: a healthy knee joint, a knee joint with medial meniscal tears and a knee joint following partial meniscectomies. The numerical results showed that each meniscal tear and its resultant partial meniscectomy led to an increase in the peak compressive and shear stresses on the articular cartilages and meniscus in the medial knee compartment, especially for partial meniscectomy. Among the four types of meniscal tears, the oblique tear resulted in the highest values of the peak compressive and shear stresses. For the four partial meniscectomies, longitudinal meniscectomy led to the largest increase in these two stresses. The lateral compartment was minimally affected by all the simulations. The results of this study demonstrate meniscal tear and its resultant partial meniscectomy has a positive impact on the maintenance of high levels of contact stresses, which may improve the progression of knee OA, especially for partial meniscectomy. Surgeons should adopt a prudent strategy to preserve the greatest amount of meniscus possible.