Isolated injury to the latissimus dorsi is rare. Partial tendon tears may be successfully treated nonsurgically. Complete tendon ruptures require surgical repair. Tendon repair can be approached either through an anterior deltopectoral incision with a secondary small posterior axillary incision or through a long posterior axillary incision. Suture anchors can be used to repair the latissimus dorsi to the humeral attachment. Although the literature is limited to single-patient case series, most patients have returned to full athletic activity after surgical repair.

Patellar tendon reconstruction in the setting of a nonrepairable patellar tendon rupture can be a technically difficult and extensive procedure. An alternative surgical technique for patellar tendon reconstruction with Achilles tendon allograft utilizes tibial tubercle interference fixation for the bone plug. This technique uses simple instrumentation and is less traumatic to the knee which may allow an easier patient recovery.

George, Michael S. MD; Khazzam, Michael MD; Chin, Paul MD, PhD; Dumont, Guillaume MD; Russell, Robert MD Author Information

Creation of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction via the anteromedial portal can reproducibly achieve femoral tunnel positioning at the center of the femoral ACL footprint. Anteromedial portal drilling requires knee hyperflexion, which is awkward to perform. Knee hyperflexion to 120° can easily be achieved in the figure-4 position for femoral tunnel drilling via the anteromedial portal. The leg is hyperflexed in the figure-4 position on a Mayo stand. The offset femoral guide, guidewire, and drill are placed at the femoral ACL footprint via the anteromedial portal to create the femoral tunnel.

Failed rotator cuff repair may be caused by surgical complications, diagnostic errors, technical errors, failure to heal, and traumatic failure. Revision rotator cuff repair is made technically more difficult by poor tissue quality, tissue adhesions, and retained suture and suture anchor material. Historically, open revision rotator cuff repair yields inferior results compared with primary rotator cuff repair; however, more recent studies show 52% to 69% satisfactory results in small-sized or medium-sized tears. Arthroscopic revision rotator cuff repair yields greater than 60% good or excellent results. Poor tissue quality, detachment of the deltoid origin, and multiple previous surgeries are risk factors for poor results in revision rotator cuff repair.

Creation of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction via the anteromedial portal can reproducibly achieve femoral tunnel positioning at the center of the femoral ACL footprint. Anteromedial portal drilling requires knee hyperflexion, which is awkward to perform. Knee hyperflexion to 120 degrees can easily be achieved in the figure-4 position for femoral tunnel drilling via the anteromedial portal. The leg is hyperflexed in the figure-4 position on a Mayo stand. The offset femoral guide, guidewire, and drill are placed at the femoral ACL footprint via the anteromedial portal to create the femoral tunnel.

Disorders of the long head of the biceps (LHB) tendon can exist in conjunction with several other shoulder pathologies. Currently, the function of the LHB tendon remains unresolved. It is clear, however, that this tendon can be a significant source of shoulder pain and dysfunction. We have reviewed the anatomy, pathophysiology, classification, diagnosis, and treatment of disorders involving the LHB tendon. We also have reviewed the literature to help make treatment decisions.

Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra-articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini-open techniques involve limited incision in the lower one half of the subscapularis.

Acute rotator cuff tear is commonly associated with tearing of the proximal biceps tendon, but has never been reported to occur simultaneously with a distal biceps tendon rupture. A 38-year-old right-hand-dominant strongman competitor attempted a 300-pound overhead axle press and experienced immediate pain in the right shoulder and elbow. He had no known systemic risk factors for tendon ruptures including hyperparathyroidism, hemodialysis, alcoholism, rheumatoid arthritis, statin medications, fluoroquinolones, and steroid use.Right shoulder magnetic resonance imaging (MRI) showed a full-thickness supraspinatus tear with 3 cm of retraction. There was minimal fatty infiltration of the supraspinatus on the sagittal cuts consistent with acute rupture. The subscapularis was intact. The long head of the biceps tendon had mild medial subluxation but was completely within the bicipital groove. Right elbow MRI showed a complete distal biceps tendon rupture. Thirteen days after his injury, the patient underwent arthroscopic supraspinatus repair and proximal biceps tenodesis. Distal biceps tendon repair was performed using the modified 2-incision muscle-splitting technique. At 24-month follow-up, the patient was pain free and had returned to full activity including weightlifting but had not returned to strongman competition.This is the first report of simultaneous acute full thickness ruptures of the rotator cuff and distal biceps tendon. This case report underscores the importance of a complete physical examination and a high index of suspicion for additional concomitant injuries, particularly in athletes with unusually high stresses to the body.

Subcoracoid suture and/or graft passage is a technically difficult aspect of acromioclavicular joint reconstruction with free soft tissue grafts. The Suture Lasso can be used for subcoracoid passage in a simple, safe, and easily reproducible fashion.

Suture passage in arthroscopic rotator cuff repair can be technically difficult. The suture lasso is typically passed antegrade from the bursal side of the rotator cuff. Antegrade passage of the suture lasso can be particularly difficult when visualization is limited. Reverse passage of the suture lasso from the undersurface can be used to place sutures in technically challenging circumstances. The suture lasso is placed retrograde through the undersurface of the rotator cuff and used as a suture shuttle to bring sutures back through the rotator cuff. This technique is easily reproducible and cost-effective, and it requires only 2 working arthroscopy portals.

A simple and effective technique is described for incorporating arthroscopic biceps tenodesis into arthroscopic suture anchor rotator cuff repair.

Osteoarthritis (OA) can cause severe pain and dysfunction of the shoulder. When conservative treatment fails and operative treatments such as shoulder arthroplasty and open glenohumeral resurfacing are not advisable, shoulder arthroscopy may be used to treat shoulder OA. Arthroscopic treatment of concomitant pathology in the shoulder including subacromial decompression, labral repair, capsular release, microfracture, and distal clavicle excision have been shown to yield good results when combined with glenohumeral debridement in the treatment of shoulder OA. Arthroscopic glenohumeral resurfacing has recently been described and has shown encouraging results. Arthroscopic treatment appears to have better results in shoulders with a lesser degree of osteoarthritis.

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts between health and sport. However, modern sports medicine has emerged with the goal of improving performance and preventing injury, and the concept of the "team physician" has become an integral part of athletic culture. With this distinction come unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technology. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues.

Anterior cruciate ligament reconstruction is commonly performed using the all-endoscopic (also known as all-inside or single-incision) method or the rear-entry (also known as outside-in or two-incision) method. We report a systematic review of four prospective, randomized clinical trials comparing these two operative techniques. Operative time was shorter in the all-endoscopic groups in two studies. A higher percentage of patients in the rear-entry group had a difference of 3 mm or less on the KT-2000 arthrometer, although the two surgical techniques were similar in the other studies. A higher rate of return to full activity was achieved in patients undergoing the rear-entry technique in one study. All four studies were similar in pain medication used, progression of rehabilitation, range of motion, quadriceps or hamstring strength, patellofemoral pain, one-leg hop test, Lysholm, Tegner, and International Knee Documentation Committee scores. Overall, these studies show similar outcomes comparing the all-endoscopic and rear-entry anterior cruciate ligament reconstruction techniques. Level of Evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Isolated fractures of the greater tuberosity of the humerus can occur in anterior shoulder dislocations or as the result of an impaction injury against the acromion or superior glenoid. Greater tuberosity fractures may be associated with partial-thickness rotator cuff tears and labral tears, which may be the cause of persistent pain after fracture healing. Nondisplaced and minimally displaced fractures are typically treated successfully nonsurgically. Surgical fixation is recommended for fractures with > 5 mm of displacement in the general population or > 3 mm of displacement in active patients involved in frequent overhead activity. Open surgical repair is performed with suture or screw fixation. Recently, arthroscopic techniques have produced promising results. Careful follow-up and supervised rehabilitation optimize results after both nonsurgical and surgical treatment.

Failed anterior cruciate ligament (ACL) reconstruction presents a difficult clinical challenge. Successful revision ACL reconstruction depends on identifying the causes of failure and correcting technical or diagnostic errors. Failed ACL reconstruction may be either traumatic or atraumatic. Atraumatic failures may be attributable to technical errors, diagnostic errors, or failure of graft incorporation. Published outcomes of revision ACL reconstruction have been worse than for primary ACL reconstruction. The preoperative evaluation, surgical techniques, and clinical outcomes of revision ACL reconstruction are reviewed.

Subacromial impingement syndrome is a common cause of shoulder pain. The purpose of this article is to review the clinical presentation, physical examination findings, and differential diagnosis of impingement syndrome. Using an evidence-based approach, we propose an algorithm for the management of subacromial impingement syndrome including indications for nonoperative management, advanced imaging, and operative management. (c) 2005 Elsevier Inc. All rights reserved.