Trifurcated radial nerve in the spiral groove of the humerus.

A 62-year-old man presented with a nonunion of the humerus shaft. Using a standard triceps splitting approach, a longitudinal incision along the posterior aspect of the arm was created. Three independent radial nerves coursed posteriorly and inferolaterally around the humerus were identified in spiral groove. Three nerves resembled in the size, color, and course in the operative field. Although the prevalence of the anomaly is probably quite low, the possibility of identification of this anomalous condition of radial nerve should be kept in mind when performing posterior approach on the humerus.

Mattress suture-bridge technique for bursal-side partial-thickness rotator cuff tears.

The standard procedure used to repair partial-thickness tears involves initial progression of the lesion to a full-thickness tear prior to tendon repair. However, the option for a bursal-side partial-thickness rotator cuff tear includes the preservation of as much of the remaining intact fibers as possible. Instead of inserting suture anchors in the medial row, as in the conventional suture-bridge technique, two mattress sutures are inserted into the rotator cuff. Full-thickness access is achieved using a percutaneous spinal needle and medial mattress sutures to preserve the articular bone attachment of the remnant fibers and to compress the repaired tendon on the footprint. Our method can help preserve the remnant rotator cuff tendon without tissue damage and can restore the normal rotator cuff footprint.

Displaced fracture of the coracoid process associated with acromioclavicular dislocation: a two-bird-one-stone solution.

We describe a surgical treatment for a displaced fracture of the coracoid process associated with acromioclavicular dislocation. This treatment involves fixing the coracoid process using a cannulated screw without acromioclavicular fixation under fluoroscopic guidance. The benefits of this treatment are that fixation with a cannulated screw simultaneously reduces both the displaced fracture of the coracoid process and the acromioclavicular joint via the intact coracoclavicular ligament, thus reducing the complications associated with transacromial pin fixation.

Arthroscopic transtendon suture-bridge technique for concurrent articular- and bursal-side partial-thickness rotator cuff tears.

The transtendon suture-bridge technique is primarily indicated in concurrent articular- and bursal-side partial-thickness rotator cuff tears. The articular aspect of the footprint is restored using the transtendon technique while maintaining the remaining lateral footprint of the rotator cuff. The bursal aspect of the footprint is restored via the suture-bridge technique using the tied suture stands, after applying the transtendon technique while maintaining the remaining medial footprint of the rotator cuff. Using a combination of the transtendon and suture-bridge techniques, the articular and bursal aspects of the footprint are restored while maintaining the remaining footprint of the rotator cuff.

Revision of a pull-out suture anchor in the lateral row during the suture-bridge technique: technical note.

The repeated pulling-out of a suture anchor in the lateral row despite repeated attempts at insertion during a rotator cuff repair is not uncommon with the suture-bridge technique, especially in patients with osteoporosis. We describe a simple procedure for dealing with the pull-out of a PushLock anchor in the lateral row using a suture anchor with a suture eyelet during rotator cuff repair applying the suture-bridge technique.

Adhesive capsulitis of the shoulder: dimensions of the rotator interval measured with magnetic resonance arthrography.

BACKGROUND: This study was performed to define the dimensions of the rotator interval (RI) in adhesive capsulitis using magnetic resonance (MR) arthrography preoperatively to clarify and evaluate pathology. METHODS: We performed a retrospective review of a series of 73 shoulders that underwent MR arthrography. The shoulders were grouped according to their diagnosis: group I comprised 47 shoulders without adhesive capsulitis; group II comprised 26 shoulders with adhesive capsulitis. Using MR arthrography, we estimated the height, base, RI area, width, RI index, and RI ratio. RESULTS: The group II shoulders differed significantly in height, base, RI area, RI index, and RI ratio from the group I shoulders. There were statistically significant differences in RI dimensions between patients with and without adhesive capsulitis of the shoulder. CONCLUSIONS: Estimating the dimensions of the RI in adhesive capsulitis using MR arthrography may prove to be valuable for assessing patients preoperatively.

Arthroscopic footprint reconstruction of bursal-side delaminated rotator cuff tears using the suture-bridge technique.

For a bursal-side retracted laminated rotator cuff tear, simple repair of the retracted bursal-side rotator cuff might be insufficient because the repaired tendon could remain as an intratendinous tear of the rotator cuff. We present a repair method for intratendinous rotator cuff tears using the suture-bridge technique. We believe that this method helps to preserve the remnant rotator cuff tendon without tissue damage and restores the normal rotator cuff footprint in bursal-side delaminated rotator cuff tears.

A long head of the biceps tendon confluent with the intra-articular rotator cuff: arthroscopic and MR arthrographic findings.

Many anomalous origins of the long head of the biceps tendon (LHBT) have been reported. However, developmental anomalies of the LHBT are rarely encountered in daily practice. We report a patient with an anomalous LHBT that was adherent to and confluent with the rotator cuff throughout its intra-articular course and present the clinical, magnetic resonance arthrography, and arthroscopic findings.

Arthroscopic three-point double-row repair for acute bony Bankart lesions.

After mobilizing anteroinferior osseous Bankart lesion from the glenoid neck, a suture anchor loaded with differently colored non-absorbable braided sutures is placed on the medial edge in the glenoid neck along the rim fracture through the anterior-inferior trans-subscapularis tendon portal. Two same-colored suture limbs on the anchor are then pulled through the labrum using PDS suture shuttling simultaneously. These steps are repeated for the others suture limbs. The two same-color suture limbs located inferiorly are retrieved using the trans-subscapularis tendon portal. Both suture strands are threaded through the eyelet of a PushLock anchor on the distal end of the driver. The anchor is advanced into the pilot hole completely. These steps are repeated for a second anchor at the upper edge of the fracture in the glenoid rim using the anterior portal. This technique confers effective, firm fixation of the bony Bankart lesion by three-point fixation without the suture material crossing the glenoid cavity.

Deformities associated with the suture-bridge technique for full-thickness rotator cuff tears.

PURPOSE: This study was performed to evaluate the incidence and cause of deformities associated with the suture-bridge technique in rotator cuff tears. METHODS: We performed a prospective review of a consecutive series of 100 shoulders with full-thickness tears (50 with medium tears, 43 with large tears, and 7 with massive tears) treated by use of the suture-bridge technique in 2007. The surgical technique was classified according to the number of suture anchors inserted in the medial and lateral rows (2 x 2 suture bridges in 82 cases, 3 x 2 in 12, and 3 x 3 in 6). On arthroscopy, the development of a marginal dog-ear deformity and central bird-beak deformity during the repair was investigated. These deformities were corrected by use of the modified suture-bridge technique or by insertion of an additional suture anchor. RESULTS: Dog-ear deformities occurred in 47 cases and were most frequent in large tears treated with a 2 x 2 suture bridge (21 cases). Dog-ear deformities in 2 x 2 suture bridges were more frequent in large tears than in medium tears (P < .05), and with large tears, they were more frequent with 2 x 2 suture bridges than with 3 x 2 suture bridges (P < .05). Bird-beak deformities occurred in 13 cases and were most frequent in large tears treated with 2 x 2 suture bridges (9 cases). Bird-beak deformities with 2 x 2 suture bridges were more frequent in large tears than in medium tears (P < .05), and with large tears, they were more frequent with 2 x 2 suture bridges than with 3 x 2 suture bridges (P < .05). CONCLUSIONS: To reduce deformities associated with the suture-bridge technique during rotator cuff repair, individualized repair methods may be applied according to the size and pattern of the rotator cuff tear. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Tension band sutures using a washer for a proximal humerus fracture.

To prevent distraction and varus deformity between the humeral head and shaft, tension band sutures placed between the head of the interlocking screw and the rotator cuff, and we recommend using nonabsorbable sutures. We describe our simple procedure to overcome these difficulties in tension band suturing after reducing a proximal humerus fracture to maintain the reduction.

Arthroscopic fixation for displaced greater tuberosity fracture using the suture-bridge technique.

With the described technique, two bioabsorbable suture anchors are inserted to create a medial row through the intact cuff for fixation of the fragment of the greater tuberosity. The medial row is repaired with a sliding knot. After confirmation of the fracture site, pilot holes for a PushLock anchor (Arthrex, Naples, FL) are prepared directly in line with the medial anchors and approximately 5 to 10 mm distal to the lateral edge of the fragment of the greater tuberosity. A suture strand from each anchor in the medial row is retrieved. Both suture strands are threaded through the PushLock eyelet on the distal end of the driver. The anchor is advanced completely into the pilot hole. These steps are repeated for a second anchor. If a dog-ear deformity is observed at the margin after complete reduction of the greater tuberosity, a stitch is made by use of a suture hook and one strand of the uncut suture from the lateral row of the joint via the modified suture-bridge technique. Arthroscopic reduction and internal fixation of displaced greater tuberosity fractures with the suture-bridge technique described by us provide adequate fixation with improvement of the pressurized contact area of the fracture and can be used as an additional modality of arthroscopic treatment.

Can the glenopolar angle be used to predict outcome and treatment of the floating shoulder?

OBJECTIVE: Displaced ipsilateral fractures of the clavicle and the glenoid neck are usually the result of high-energy trauma. The objective of this study is to evaluate the association of the glenopolar angle (GPA) with the clinical outcome of the floating shoulders. METHODS: Seven patients treated conservatively and nine patients with clavicular fracture treated operatively were evaluated retrospectively. The GPA of the affected (a-GPA) and unaffected (u-GPA) shoulders, and the change (d-GPA) were measured. The Constant-Murley score of the affected (a-CS) and unaffected (u-CS) shoulders, and the change (d-CS) were measured at the last follow-up. RESULTS: The mean follow-up was 25 months, and the score was 69.7 points. Patient age had no effect on the clinical outcome, and the change in GPA in the affected shoulder between the initial and last follow-up for the nonoperated and operated groups did not differ statistically (p > 0.05). There were positive correlations between a-CS and a-GPA (r = 0.760, p < 0.05) and between d-GPA and d-CS (r = 0.643, p < 0.05) and negative correlations between a-GPA and d-CS (r = -0.962, p < 0.05) and between d-GPA and a-CS (r = -0.703, p < 0.05). CONCLUSION: The simple measurement of GPA may yield useful prognostic information and help in making decisions concerning the floating shoulder.

Modified single-portal type II SLAP repair.

We present a simplified, cost-effective method for repairing a type II SLAP lesion that requires only one working portal in the rotator interval. The rotator cuff tendon or muscle is not violated when using this portal. The biceps root can be firmly reattached anteriorly and posteriorly using one double-loaded absorbable bone anchor with a suture eyelet. By retrieving the anterior limbs of the anchor percutaneously using a spinal needle and PDS suture, tangling of the anchor suture or premature knot formation are avoided during shuttling and knot tying.

Arthroscopic separate labral repair and capsular plication with a suture anchor.

Capsular volume reduction is becoming a more popular procedure for treating the unstable shoulder. We present a novel technique of arthroscopic labral repair and capsular plication using a single suture anchor with two nonabsorbable braided sutures that repairs the involved labrum and capsule separately. It is a simple technique from the standpoint of simultaneous labral repair and capsular plication, making it easily reproducible and cost-effective.