"V"ictory transosseous equivalent suture configuration for arthroscopic rotator cuff tear repairs of iatrogenically completed PASTA lesions and full-thickness "U"-shaped tears.

The cost of numerous anchors in rotator cuff surgery is high from both an economic standpoint as well as a physiologic one. More anchors means increased cost and increased surgical time; additionally, the greater number of anchors placed, the greater the expense on the native bone that they inevitably replace. It is therefore in the surgeon's and patient's best interest to use the appropriate number of anchors, no more and no less, with the appropriate number being that which allows for strong, stable fixation with minimal gap formation and maximal healing potential and recovery. The transosseous equivalent repair technique described herein uses a single double-loaded bioabsorbable suture anchor placed along the medial border of the rotator cuff foot print and the humeral head articular cartilage margin followed by 1 pushlock (Arthrex, Naples, Florida) anchor placed laterally on the vertical aspect of the greater tuberosity. It is designed for small to medium "U"-shaped tears and for iatrogenically completed partial articular supraspinatus tendon avulsions of moderate to large size, the so-called PASTA lesion. The use of selective knot placement allows for the conversion of a linear construct into a "V" configuration, optimizing repair strength and allowing for earlier rehabilitation while maximizing the healing biology seen with increased footprint contact dimensions and less repair gap formation.

Olecranon osteotomy repair: the tensioned locking plate technique.

The tensioned locking plate technique takes advantage of two fracture healing modalities. A direct healing effect from osteon bridging due to lag screw compression is combined with axial and angular stability provided by a locking plate construct.

The combined olecranon osteotomy, lateral paratricipital sparing, deltoid insertion splitting approach for concomitant distal intra-articular and humeral shaft fractures.

Fractures of the distal humerus involving the articular surface can be challenging. The complexity of these fracture patterns increases when the distal fracture is associated with a concomitant humeral shaft fracture with significant proximal extension. The combined exposure technique described here allows for consistent and controlled posterior humeral exposure proximally from the traverse of the axillary nerve to the distal trochlear tip. It is especially useful for complex segmental fracture patterns where distal intra-articular involvement is present and a single approach is desired.

Biomechanical analysis of femoral tunnel pull-out angles for anterior cruciate ligament reconstruction with bioabsorbable and metal interference screws.

BACKGROUND: Fixation strength of metal and bioabsorbable interference screws has not been evaluated while varying the anterior cruciate ligament graft tension angle. HYPOTHESIS: There is no difference in fixation strength between 2 types of interference screws for anterior cruciate ligament graft fixation while the graft tension angle is varied relative to the femoral tunnel. STUDY DESIGN: Controlled laboratory study. METHODS: Forty-eight anterior cruciate ligament reconstructions were performed using immature porcine femurs stripped of soft tissue and doubled-over porcine flexor digitorum profundus tendon grafts. Specimens were randomized to bioabsorbable or titanium interference screw fixation. Specimens were randomized to one of three pull angles (0 degrees , 30 degrees , 60 degrees ) representing loading at different knee flexion angles (n = 8/group). Reconstructed ligaments were tensioned to 10 N followed by 200 loading cycles between 10 and 150 N and a final failure test. Construct elongation (mm) at 100 and 200 cycles and failure load (N) were analyzed using a 2-way analysis of variance (P < .05). RESULTS: Screw material interacted significantly with graft tension angle, as the bioabsorbable screw specimens demonstrated significantly greater fixation strength when tensioned at greater angles. Specimens fixed with bioabsorbable screws showed significantly less elongation at both 100 and 200 cycles and significantly greater failure load compared with titanium screws. CONCLUSION: Bioabsorbable interference screws acutely have increased fixation strength compared with titanium interference screws for anterior cruciate ligament grafts loaded at greater tension angles. CLINICAL RELEVANCE: The strength of anterior cruciate ligament reconstruction fixation increases with increasing divergence between the tension angle and femoral tunnel, a condition seen when the knee approaches full extension.

The acorn Beath couple: articular salvation for double-bundle femoral tunnels in cruciate ligament reconstruction.

With the recent increase in interest in arthroscopic double-bundle cruciate reconstructions, efficient, safe, and reproducible techniques are needed. This technical trick is applicable to both arthroscopic anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction when double-bundle femoral tunnels are performed through an accessory far lateral or far medial incision as with the all-inside femoral tunnel drilling approach. A standard double-bundle cruciate reconstruction technique is applied until placement of the femoral footprint Beath pins in anticipation of tunnel drilling. Femoral footprint targeting with a Beath pin requires use of a far accessory portal. Before the long Beath pin is introduced into the joint, an acorn reamer is placed over the Beath pin to within 5 mm of the pin tip, thus creating an acorn Beath couple. The eyelet pin end is loaded onto a quick-release pin collet driver, leaving the acorn reamer free to turn. The acorn Beath couple is then introduced into the appropriate accessory portal and positioned in the center of the desired femoral footprint. An assistant holds the acorn reamer shaft while the Beath pin is advanced. The collet driver is then disengaged from the pin and replaced with an adjustable chuck and secured to the acorn reamer shaft of the acorn Beath couple. The femoral tunnel is drilled to the appropriate depth, and the Beath pin is pulled out the anterior thigh. Doing so disengages the acorn reamer and allows for safe removal of the reamer from the notch. The technique is then repeated with the coupling of a 4.5 Endobutton reamer and the Beath pin.

Simplified arthroscopic rotator interval capsule closure: an alternative technique.

The anatomy of the "coracoid eclipse" of the rotator cuff, the rotator interval, has been studied extensively. Its importance in shoulder stability with respect to inferior and posterior translation has been described. Historically, open repairs for instability indirectly addressed interval lesions and closure based simply on the definition of the deltopectoral approach with its subscapularis advancement and capsular shift in a "pants-over-vest" manner. With results of arthroscopic repairs of glenohumeral instability approaching those of open procedures, the importance of simplification without sacrificing outcome has become a forefront in arthroscopic shoulder surgery. We present an alternative technique for interval closure by means of a 3/32-inch smooth Steinmann pin modified at its proximal and distal ends. A standard 3-portal technique consisting of the anterior superior portal, anterior mid-glenoid portal, and the posterior superior portal is used. The technique does not require the use of a suture shuttle nor does it require the placement of the arthroscope in the subacromial space for suture tying. A Tennessee slider knot is tied intra-articularly, thus allowing for tension modification before definitive alternate locking half-hitch placement. Intra-articular knot tying also allows for added security because suture slack is eliminated, thus avoiding air knots.

The unique complications of coccidioidomycosis of the spine: a detailed time line of disease progression and suppression.

STUDY DESIGN: A case report is presented. OBJECTIVE: We report a detailed time-line of disease progression and suppression in a patient with disseminated Coccidioidomycosis of the spine. The importance of consistent and thorough treatment to prevent disease recurrence is underscored. SUMMARY OF BACKGROUND DATA: Coccidioides immitis is a dimorphic fungus that lives as a saprophyte in arid, alkaline soils and as a parasite in the tissues of its host. Endemic to the arid soil of the American Southwest and Central and South America, its disease prevalence is increasing. There are 100,000 new infections diagnosed each year, of which 34% are symptomatic. Of the symptomatic individuals 5-10% will develop a serious pulmonary infection and of those that have a serious infection less than 1% will develop chronic pulmonary disease and/or extrapulmonary dissemination. METHODS: A 36-year-old black woman with a 3-year history of recent migration to the desert Southwest and a family history of sarcoidosis presented to her primary care physician with shortness of breath and a cough of 2 months' duration. An anterior-posterior radiograph revealed bilateral hilar lymphadenopathy and sarcoidosis was diagnosed. The patient was placed on oral prednisone and progressively worsened. She was referred to the Orthopedic Clinic with a complaint of severe back pain. RESULTS: Plain radiographs of the lumbar spine revealed lytic erosion of the sacral promontory. Computed tomography confirmed the sacral lesion in addition to revealing involvement of the fifth lumbar vertebral body. Over the ensuing years the patient underwent a course of operative and chemotherapeutic therapies. She endured numerous complications of the disease, one of which is being reported for the first time. Control of her disease has been accomplished through radical surgical debridement, spinal stabilization with concomitant local and systemic chemotherapy. CONCLUSIONS: The prevalence and distribution of Coccidioidomycosis is increasing as is the likelihood of seeing its often unique and bizarre clinical manifestations and complications. If included in the differential diagnosis, the disease can be recognized earlier and the likelihood of numerous complications can be avoided. Once bony involvement is diagnosed a regimen of aggressive surgical debridement as well as consistent chemotherapy must be employed if remission and/or eradication of the illness are sought.