Single Portal Segmental Labral Reconstruction of the Hip

Many techniques have been described for reconstruction of the acetabular labrum, but the procedure is known to be technically rigorous leading to lengthy procedure times and traction times. Increasing efficiency of the procedure with respect to graft preparation and delivery remain areas for potential improvement. We describe a simplified procedure for arthroscopic segmental labral reconstruction using peroneus longus allograft and a single working portal to shuttle the graft into the joint via suture anchors placed at the terminal extents of the graft defect. This method allows for efficient preparation, placement and fixation of the graft that can be completed in under 15 minutes.

Postless Tape Augmentation for Posterior Cruciate Ligament Reconstruction

Many techniques have been described for posterior cruciate ligament (PCL) reconstruction, but residual laxity remains an ongoing challenge. Suture or tape augmentation during ligament reconstruction has become a popular option to prevent graft elongation but comes at the expense of additional costs due to implants for augment fixation, and concern for stress shielding of the graft if the augment and graft are not equally tensioned. We introduce a technique for postless tape augmentation during allograft PCL reconstruction that allows for equal tensioning of graft and augment through the use of a sheath and screw construct without the need for additional implants for augment fixation.

Literature Review of Subscapularis Tear, Associated injuries, and the Available Treatment Options

The population of Hawai'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

Effectiveness of Accelerated Recovery Performance for Post-ACL Reconstruction Rehabilitation

Atrophy and protracted recovery of normal function of the ipsilateral quadriceps femoris muscle following anterior cruciate ligament reconstruction surgery is well documented. The Accelerated Recovery Performance trainer is a type of electrical stimulation device that delivers a high-pulse frequency via a direct current, making it unique from many other devices on the market. The purpose of the present study was to investigate the effects of the direct current (via the Accelerated Recovery Performance trainer protocol) on gains in thigh circumference following anterior cruciate ligament reconstruction. Twenty-five patients were enrolled following isolated anterior cruciate ligament reconstruction and randomly assigned to either an isometric rehabilitation protocol augmented with the Accelerated Recovery Performance trainer protocol (experimental group) or the isometric rehabilitation protocol alone (control group). The two groups participated in sixteen sessions of directed rehabilitation over a two-month time period. Patients were followed with serial thigh circumference measurements at 5, 10, 15, and 20 centimeters above the superior patellar pole. Comparison of the overall mean circumferential gains in thigh circumference of the involved leg demonstrated approximately 3:1 gains in the ARP group over the control group, demonstrating it to be superior to isometric rehabilitation alone with regards to gains in thigh girth. The Accelerated Recovery Performance trainer protocol should be considered for post-anterior cruciate ligament reconstruction rehabilitation in order to reverse disuse atrophy of the ipsilateral quadriceps femoris.

Computer-animated model of accommodation and theory of reciprocal zonular action

This report presents a computer-animated model of the structures of accommodation based on new understanding of the anatomy of the zonular apparatus integrated with current understanding of the mechanism of accommodation. Analysis of this model suggests a new, consolidated theory of the mechanism of accommodation including a new theory of reciprocal zonular action. A three-dimensional animated model of the eye in accommodation and disaccommodation was produced in collaboration with an experienced medical animator. Current understanding of the anatomy of the zonule and the attachments of the vitreous zonule to the anterior hyaloid membrane is incomplete. Recent studies have demonstrated three components of the vitreous zonule: (1) anterior vitreous zonule (previously “hyalocapsular” zonule), which attaches the ciliary plexus in the valleys of the ciliary processes to the anterior hyaloid membrane in the region medial to the ciliary body and Weiger’s ligament; (2) intermediate vitreous zonule, which attaches the ciliary plexus to the anterior hyaloid peripherally; and (3) posterior vitreous zonule, which creates a sponge-like ring at the attachment zone that anchors the pars plana zonules. The pars plana zonules attach posteriorly to the elastic choroid above the ora serrata. Analysis of the computer-animated model demonstrates the synchronized movements of the accommodative structures in accommodation and disaccommodation. Utilizing model-based reasoning, it is shown that the posterior zonules attach to and provide traction to the anterior vitreous membrane and Weiger’s ligament. This model supports the concept that the ciliary body/zonule/anterior hyaloid complex contributes to the changes in the posterior lens capsule during accommodation, supporting an extralenticular component to accommodation and demonstrating an alternative to the “vitreous support” theories. There is a reciprocal action of the anterior zonules and the posterior zonules. During ciliary body contraction, the anterior zonules lose tension while the posterior zonules stretch and exert force on the posterior lens capsule playing a role in shaping the posterior lens thickness and curvature. During ciliary body relaxation, the posterior zonules lose tension as the lens flattens and is pulled back by the increasing tension of the anterior zonules.

Connexin43 deficiency reduces the sensitivity of cortical bone to the effects of muscle paralysis

We have shown previously that the effect of mechanical loading on bone depends in part on connexin43 (Cx43). To determine whether Cx43 is also involved in the effect of mechanical unloading, we have used botulinum toxin A (BtxA) to induce reversible muscle paralysis in mice with a conditional deletion of the Cx43 gene in osteoblasts and osteocytes (cKO). BtxA injection in hind limb muscles of wild-type (WT) mice resulted in significant muscle atrophy and rapid loss of trabecular bone. Bone loss reached a nadir of about 40% at 3 weeks after injection, followed by a slow recovery. A similar degree of trabecular bone loss was observed in cKO mice. By contrast, BtxA injection in WT mice significantly increased marrow area and endocortical osteoclast number and decreased cortical thickness and bone strength. These changes did not occur in cKO mice, whose marrow area is larger, osteoclast number higher, and cortical thickness and bone strength lower relative to WT mice in basal conditions. Changes in cortical structure occurring in WT mice had not recovered 19 weeks after BtxA injection despite correction of the early osteoclast activation and a modest increase in periosteal bone formation. Thus BtxA-induced muscle paralysis leads to rapid loss of trabecular bone and to changes in structural and biomechanical properties of cortical bone, neither of which are fully reversed after 19 weeks. Osteoblast/osteocyte Cx43 is involved in the adaptive responses to skeletal unloading selectively in the cortical bone via modulation of osteoclastogenesis on the endocortical surface.

Comparison of myopes and hyperopes after laser in situ keratomileusis monovision

PURPOSE

To compare the results of laser in situ keratomileusis (LASIK) monovision in myopes and hyperopes.

SETTING

Private practice, Little Silver, New Jersey, USA.

METHODS

In this retrospective study, 391 consecutive patients older than 40 years who had LASIK between December 1999 and June 2001 were examined. All patients were asked to complete a questionnaire, and study results are based on the analysis of data from patient charts correlated with questionnaire responses.

RESULTS

Visual results were excellent in both groups, with all monovision patients achieving 20/30 acuity or better in the distance eye and J2 or better acuity in the near eye. Satisfaction scores were high in all groups. Statistical analysis indicated that visual results for distance were better in myopes than in hyperopes (P =.043), enhancements were higher in monovision (P =.04) and in hyperopia (P =.08), and satisfaction was higher among myopes (P =.012) and full distance patients (P =.002). Monovision hyperopes had the most difficulty with 6 side effects (P =.00).

CONCLUSION

Hyperopic monovision was a viable but more problematic solution to correcting presbyopia than myopic monovision.

Laser in situ keratomileusis monovision

PURPOSE

To evaluate the outcome of monovision after laser in situ keratomileusis (LASIK).

SETTING

Private practice, Little Silver, New Jersey, USA.

METHODS

In this retrospective study, 432 consecutive patients (864 eyes) who had LASIK between January 1998 and October 1999 with a follow-up of 6 to 28 months were examined. All patients older than 40 years were asked to complete a questionnaire, and study results were based on analysis of data from the patient charts correlated with the questionnaire responses.

RESULTS

Women chose monovision over full distance correction more than twice as often as men (P =.00). Although the patients who had full distance correction reported somewhat higher levels of postoperative satisfaction than the monovision patients, the differences were not statistically significant (P =.41). Overall, 96% of patients were satisfied with monovision after LASIK, and 4% chose enhancement to full distance correction.

CONCLUSION

Monovision after LASIK was a valuable and viable option for the management of presbyopia.

Drug-induced pemphigoid. A spectrum of diseases

Drug-induced ocular pemphigoid has been reported to occur after long-term use of topical glaucoma medications. We have reviewed the literature on drug-induced ocular pemphigoid and have added our experience with five patients with glaucoma who developed ocular cicatricial (benign mucosal) pemphigoid after treatment with various topical glaucoma medications. We also describe a case of timolol-induced ocular pemphigoid. The presentation and progression of drug-induced ocular cicatricial pemphigoid can be variable. We propose that drug-induced ocular pemphigoid represents a spectrum of diseases ranging from a self-limiting, toxic form to a progressive, immunologic form.

A comparison of intrinsic endoplasmic reticulum membrane proteins in maturing seeds and germinated seedlings of castor bean

The intrinsic membrane proteins of the endoplasmic reticulum from endosperm of maturing and germinated seedlings of castor bean (Ricinus communis) were studied. Preparations were simultaneously subjected to two-dimensional polyacrylamide gel electrophoresis. At least 30 separate proteins were distinguished by staining the gels with Coomassie R-250. The characteristic protein profiles obtained from 0.2 m KCl-washed membranes of each endoplasmic reticulum source are highly reproducible. Of these proteins, three to six that were present in maturing seed were found also in germinating seedlings. In general, the majority of membrane proteins from the endoplasmic reticulum of maturing seed were of a higher molecular weight than those from germinated seedlings.

Transplantation of congenitally opaque corneas

Nine transparent grafts in fifteen eyes with congenitally opaque corneas with a one- to ten-year follow-up are described. Patients ranged in age at the time of surgery from two to thirty months. Vision in all but two of the eyes with transparent grafts improved. The operative complications included an exaggerated anterior displacement of the lens-iris diaphragm and difficulty obtaining a water-tight wound closure because of the flaccidity of the infant host tissue. The postoperative complications included a peculiar late-developing glaucoma, graft rejection, infection, and early suture loosening.

Hallermann-Streiff syndrome associated with sclerocornea, aniridia, and a chromosomal abnormality

An infant with the features of Hallermann-Streiff syndrome also had the previously unreported ocular signs of sclerocornea, buphthalmos, congenital glaucoma, and aniridia. Chromosome analysis revealed an elongation of one of the arms of the tenth chromosome. The infant was the product of a consanguinous marriage between distant cousins and a distant cousin of the patient also had the typical features of the Hallermann-Streiff syndrome.

Staphylococcus epidermidis endophthalmitis following intraocular lens implantation

A 90-year-old man developed a hypopyon following cataract extraction with intraocular lens implantation. The hypopyon cleared with topical corticosteroid therapy but recurred whenever the corticosteroid therapy was reduced. At surgery for the removal of the intraocular lens an opaque anterior vitreous membrane was excised. Cultures of the anterior vitreous grew Staphylococcus epidermidis. The diagnosis was further confirmed by the histology of the anterior vitreous membrane, which showed Gram-positive cocci in the macrophages and polymorphonuclear leucocytes. This case shows that corticosteroids may completely mask an endophthalmitis from an organism of low virulence such as Staphylococcus epidermidis. Endophthalmitis from an organism of low virulence should be considered in any case of persistent postoperative inflammation.

A long-term implantable aqueous delivery system for the external rabbit eye

An implantable system is described which continuously delivered an aqueous solution to the external surface of six rabbit eyes for 6 weeks. A polytetrafluoroethylene tube was implanted in the superior conjunctival fornix 4 weeks prior to the implantation of the Infusaid pump. The pump provides a fluid source which is easily refilled and requires no batteries or external power source.

Alternate and classical pathway components of complement in the normal cornea

Activation of complement by either the classical or alternate pathway may be involved in corneal inflammation. This study was undertaken to determine whether the normal human cornea contains components for both classical and alternate pathway activation of complement. Direct immunofluorescence of corneas from human donors using fluorescein-labeled antiserums was used to demonstrate C1q, C3, C4, and C5. The C1q component (the recognition unit of the classical pathway and largest complement component) was found in the periphery of the cornea. Normal donor corneas were also eluted in phosphate-buffered saline at 4 degrees C for one to four days. Ouchterlony plates, in which the corneal eluate was reacted against antiserums to complement components, disclosed the presence of C1q, C3, C4, C5, properdin, and properdin factor B. Plasminogen was also found. Radial immunodiffusion was used to obtain estimates of the concentrations of C3, C4, and C5 in the cornea.

Management of Thygeson's superficial punctate keratitis

Four patients had Thygeson's superficial punctate keratitis of one to 16 years' duration. One patient was completely unresponsive to topical corticosteroids, and the remaining three patients had only partial resolution of signs or symptoms while using topical corticosteroids. In all cases, rapid resolution of the epithelial lesions occurred with symptomatic relief after patching for 24 hours or after the use of therapeutic soft contact lenses. Three of the four patients have tolerated daily or extended wear of soft contact lenses accompanied by relief of both signs and symptoms. The use of therapeutic soft contact lenses may provide an alternative to topical corticosteroids in the treatment of Thygeson's superficial punctate keratitis.

Graft edema after suture removal

Graft edema developed after removal of continuous monofilament sutures in six eyes of six patients in whom no wound dehiscence occurred. All sutures were removed at least one year after penetrating keratoplasty, and graft edema was noted one day after suture removal. In all cases, partial or total resolution of graft edema occurred after treatment with corticosteroids. In two of the grafts, the edema resolved after treatment with topical corticosteroids alone, whereas the remaining four grafts required the addition of systemic or subtenon corticosteroids, or both, for resolution. The trauma associated with suture removal may cause endothelial decompensation either by direct injury to the cornea or by a secondary iritis. To the best of our knowledge, graft edema after suture removal is a late complication of penetrating keratoplasty that has not been previously emphasized.

Ascites with papilloedema and paeipheral neuropathy of unknown etiology

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