Intraoperative Photographs Research Articles

Contrasting Histopathology and Crystal Deposits in Kidneys of Idiopathic Stone Formers Who Produce Hydroxy Apatite, Brushite, or Calcium Oxalate Stones

Our previous work has shown that stone formers who form calcium phosphate (CaP) stones that contain any brushite (BRSF) have a distinctive renal histopathology and surgical anatomy when compared with idiopathic calcium oxalate stone formers (ICSF). Here we report on another group of idiopathic CaP stone formers, those forming stone containing primarily hydroxyapatite, in order to clarify in what ways their pathology differs from BRSF and ICSF. Eleven hydroxyapatite stone formers (HASF) (2 males, 9 females) were studied using intra-operative digital photography and biopsy of papillary and cortical regions to measure tissue changes associated with stone formation. Our main finding is that HASF and BRSF differ significantly from each other and that both differ greatly from ICSF. Both BRSF and ICSF patients have significant levels of Randall's plaque compared with HASF. Intra-tubular deposit number is greater in HASF than BRSF and nonexistent in ICSF while deposit size is smaller in HASF than BRSF. Cortical pathology is distinctly greater in BRSF than HASF. Four attached stones were observed in HASF, three in 25 BRSF and 5-10 per ICSF patient. HASF and BRSF differ clinically in that both have higher average urine pH, supersaturation of CaP, and calcium excretion than ICSF. Our work suggests that HASF and BRSF are two distinct and separate diseases and both differ greatly from ICSF.

Localizing ECoG electrodes on the cortical anatomy without post-implantation imaging.

IntroductionElectrocorticographic (ECoG) grids are placed subdurally on the cortex in people undergoing cortical resection to delineate eloquent cortex. ECoG signals have high spatial and temporal resolution and thus can be valuable for neuroscientific research. The value of these data is highest when they can be related to the cortical anatomy. Existing methods that establish this relationship rely either on post-implantation imaging using computed tomography (CT), magnetic resonance imaging (MRI) or X-Rays, or on intra-operative photographs. For research purposes, it is desirable to localize ECoG electrodes on the brain anatomy even when post-operative imaging is not available or when intra-operative photographs do not readily identify anatomical landmarks.MethodsWe developed a method to co-register ECoG electrodes to the underlying cortical anatomy using only a pre-operative MRI, a clinical neuronavigation device (such as BrainLab VectorVision), and fiducial markers. To validate our technique, we compared our results to data collected from six subjects who also had post-grid implantation imaging available. We compared the electrode coordinates obtained by our fiducial-based method to those obtained using existing methods, which are based on co-registering pre- and post-grid implantation images.ResultsOur fiducial-based method agreed with the MRI–CT method to within an average of 8.24 mm (mean, median = 7.10 mm) across 6 subjects in 3 dimensions. It showed an average discrepancy of 2.7 mm when compared to the results of the intra-operative photograph method in a 2D coordinate system. As this method does not require post-operative imaging such as CTs, our technique should prove useful for research in intra-operative single-stage surgery scenarios.To demonstrate the use of our method, we applied our method during real-time mapping of eloquent cortex during a single-stage surgery. The results demonstrated that our method can be applied intra-operatively in the absence of post-operative imaging to acquire ECoG signals that can be valuable for neuroscientific investigations.

Sea urchin spine arthritis of the proximal interphalangeal joint of the hand: radiological, intraoperative and histopathological findings.

Penetrating sea urchin spine injuries, can lead to devastating, irreversible consequences. Persistent inflammation, cutaneous granuloma, neuroma, tenosynovitis, arthritis and destructive arthritis, leading to permanent loss of function and digit amputation, can occur. We present a case of a patient who developed sea urchin spine arthritis of the proximal interphalangeal joint. Only 17 cases of sea urchin spine arthritis of the hand have been documented in the medical literature. However, in this case, the article also includes sequential radiographs, histopathological slides, and intra-operative photographs.

Clinical analysis and surgical considerations of atherosclerotic cerebral aneurysms: experience of a single center.

ObjectiveAtherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results.Materials and MethodsWe retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes.ResultsAmong 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups.ConclusionIn the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.

Clinical experience with CorMatrix extracellular matrix in the surgical treatment of mitral valve disease

To determine the clinical utility of an acellular bioscaffold as a structural material for mitral valve repair (MVr). This was a retrospective study of patients undergoing partial or subtotal leaflet replacement and/or leaflet extension to treat mitral regurgitation or acute endocarditis and/or reconstruction of atrial-ventricular continuity after annular decalcification. The material used for repair was a bioresorbable extracellular matrix (ECM) material indicated for cardiac tissue repair (CorMatrix Cardiovascular, Inc, Roswell, Ga). After the necessary debridement, the ECM bioscaffold was tailored and sewn to the native mitral valve tissue. Intraoperative photographs and serial, follow-up echocardiograms were used for evaluation. From September 2008 to February 2013, MVr requiring the addition of patch material was performed in 19 patients. The median echocardiographic follow-up was 10.9 months (range, 4 days to 48 months). Oneearly and 2 late deaths were unrelated to MVr. No perioperative or late strokes occurred. Two patients with a history of cancer, chemotherapy, and radiotherapy experienced failure of the initial MVr, necessitating reintervention. The other MVrs continued to show good valvular function and no calcification on echocardiographic follow-up of 4 days to 48 months. The ECM bioscaffold is a satisfactory material for MVr in a variety of surgical situations, including endocarditis. It appears to resist calcification and infection. Additional studies are warranted to determine the long-term durability of repairs made with ECM, and its appropriate use in patients who have previously undergone radiotherapy or chemotherapy.

A Simple Effective Method for Generation of a Permanent Record of the Critical View of Safety during Laparoscopic Cholecystectomy by Intraoperative “Doublet” Photography

The Critical View of Safety (CVS) is an established method for identifying the cystic duct during laparoscopic cholecystectomy. Its goal is to prevent misidentification of the bile ducts and avoid biliary injury. However, a visual record of CVS is not usually made. Intraoperative photography has the potential to record CVS and increase the safety of laparoscopic cholecystectomy. The objective of this study was to develop a simple and effective technique for recording CVS during laparoscopic cholecystectomy. Techniques for photographing and rating photographs of CVS were developed. Surgeons were trained in methods of photographing both anterior and posterior views of CVS during laparoscopic cholecystectomy. Independent observers scored these views individually and together. The term doublet view was used when both anterior and posterior views of CVS were used for rating. Three criteria for CVS were used for scoring photographs. A total score of ≥ 5 of 6 points was considered satisfactory, and a total score <5 of 6 points was considered unsatisfactory. Photographs of 28 patients were obtained. Critical View of Safety photographs were satisfactory in either anterior or posterior single images in 43 of 56 (76.8%) instances, and doublet photographs were satisfactory in 27 of 28 (96.4%) instances (p = 0.02). Body mass index >40 predicted a higher likelihood of unsatisfactory individual CVS photos (p = 0.02); however, there was no correlation between patient or pathologic factors and the scores of doublet views. With training and adherence to straightforward photographic techniques, intraoperative doublet photography can record CVS accurately. This method is performed easily, and could be used for recording of CVS in the medical record.

Meniscus Tear Patterns in Relation to Skeletal Immaturity

Background: Meniscus tear patterns in the pediatric population have not been well described. Purpose: To delineate the pattern of meniscus tears and the likelihood of repair at the time of surgery in both children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was performed on all patients between the ages of 10 and 19 years who underwent arthroscopic surgery for a meniscus injury at a single institution. Patients with open growth plates were classified as children, while those with closed growth plates were classified as adolescents. Demographic data were documented, including age, sex, body mass index (BMI), mechanism of injury, and time from injury to surgery. Operative reports and intraoperative photographs were used to assess the tear pattern (type, location, zone) as well as all concomitant procedures and injuries. Tears were classified as discoid, vertical, bucket-handle, radial, oblique, horizontal, fray, root detachment, or complex. Results: Of the 293 patients reviewed, 197 (67%) had lateral meniscus tears, 65 (22%) had medial meniscus tears, and 31 (11%) had tears to both menisci. The cohort was separated into 119 (41%) children (mean age, 13.5 years) and 174 (59%) adolescents (mean age, 16.4 years). Children were more likely to have discoid meniscus tears, lower BMI, and meniscus injuries not associated with ligamentous injuries (P < .05). The rate of associated ligament injuries in children was 28% compared with 51% in adolescents. Overall, the most frequent tear pattern was complex (28%), followed by vertical (16%), discoid (14%), bucket-handle (14%), radial (10%), horizontal (8%), oblique (5%), fray (3%), and root detachment (2%). Complex tears were associated with boys (32% vs 20% in girls; P < .03) and greater mean BMI (27.4 vs 25.1 kg/m2 in those with noncomplex tears; P < .002), even when taking sex into account. Surgical repair was performed in 47% of all cases (56% in those treated within 3 months of injury vs 42% in those treated after 6 months; P < .03), and there was no difference in the repair rate between the two age groups (49% in children vs 46% in adolescents; P > .05). Conclusion: Adolescents and children sustain more complex meniscus injuries that are often less repairable than previously reported in the literature. Factors that are associated with greater tear complexity include male sex and obesity. Our findings also suggest that the earlier treatment of meniscus tears may increase the likelihood of repair in younger patients.

Modified Cervicofacial Rotation Flap with Tissue Expansion for Cosmetic Resection of a Large Hemifacial Congenital Nevus

Objectives: A 23-year-old Armenian female was evaluated in Armenia by the senior author and sponsoring church members for a deforming 8.5 × 6 cm heavily pigmented congenital nevus involving the right hemiface (cheek, eyelids, nose). The lesion affected function of the right lower eyelid. The patient wore her hair long with bangs as a camouflaging mask to wrap around her face. Methods: She was shortly thereafter brought to the United States for cosmetic reconstructive surgery for this lesion. She underwent a 2-stage procedure: tissue expander placement with full thickness skin graft of the right lower eyelid defect, with subsequent removal of the expander two months later and modified cervicofacial angle rotation flap with full thickness skin graft to the nasal bridge, creating a superb cosmetic closure. Conclusions: Intra-operative photographs detail the 2-staged angle rotation flap reconstruction.

Rhinoplasty

Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later. The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases. The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm. The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications. Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

Superficial Acral Fibromyxoma on the Second Toe

Superficial Acral Fibromyxoma on the Second Toe

Electrode localization for planning surgical resection of the epileptogenic zone in pediatric epilepsy

In planning for a potentially curative resection of the epileptogenic zone in patients with pediatric epilepsy, invasive monitoring with intracranial EEG is often used to localize the seizure onset zone and eloquent cortex. A precise understanding of the location of subdural strip and grid electrodes on the brain surface, and of depth electrodes in the brain in relationship to eloquent areas is expected to facilitate pre-surgical planning. We developed a novel algorithm for the alignment of intracranial electrodes, extracted from post-operative CT, with pre-operative MRI. Our goal was to develop a method of achieving highly accurate localization of subdural and depth electrodes, in order to facilitate surgical planning. Specifically, we created a patient-specific 3D geometric model of the cortical surface from automatic segmentation of a pre-operative MRI, automatically segmented electrodes from post-operative CT, and projected each set of electrodes onto the brain surface after alignment of the CT to the MRI. Also, we produced critical visualization of anatomical landmarks, e.g., vasculature, gyri, sulci, lesions, or eloquent cortical areas, which enables the epilepsy surgery team to accurately estimate the distance between the electrodes and the anatomical landmarks, which might help for better assessment of risks and benefits of surgical resection. Electrode localization accuracy was measured using knowledge of the position of placement from 2D intra-operative photographs in ten consecutive subjects who underwent intracranial EEG for pediatric epilepsy. Average spatial accuracy of localization was 1.31 ± 0.69 mm for all 385 visible electrodes in the photos. In comparison with previously reported approaches, our algorithm is able to achieve more accurate alignment of strip and grid electrodes with minimal user input. Unlike manual alignment procedures, our algorithm achieves excellent alignment without time-consuming and difficult judgements from an operator.

Cerebrovascular segmentation and planning of depth electrode insertion for epilepsy surgery

Depth electrodes are inserted in the brain to locate the epileptogenic zone without craniotomy, but there is risk of surgical hemorrhage. Preoperative planning is required to mitigate this risk. A preoperative imaging, segmentation and three dimensional (3D) visualization procedure was developed to provide neurosurgeons with cortical and vascular anatomy information for surgical planning and neuronavigation. Cerebral vascular imaging was performed with phase-contrast magnetic resonance angiography (PC-MRA). Fuzzy c-means was performed to extract brain parenchyma from the PC-MRA images. A multi-scale vessel enhancement filter and thresholding process were combined to segment the vasculature and suppress background noise in the PC-MRA images. Finally, 3D visualization of the vasculature and cortical structures was implemented using volume rendering. Quantitative and qualitative validation of the vascular segmentation method were done. Using manual vascular segmentation as the gold standard, our method produced a satisfactory result: sensitivity was as high as 90% at a specificity level of 95%. Moreover, comparing the 3D visualizations of the vasculature and cortical structure for 4 patients with their respective intraoperative craniotomy photographs showed high levels of similarity. A new automated segmentation and visualization procedure provides sufficient and accurate cortical and vascular anatomy information compared to intraoperative photographs. This method has potential to assist neurosurgeons with planning and neuronavigation for depth electrode insertion with avoidance of cerebral hemorrhage.

Rapid and Accurate Anatomical Localization of Implanted Subdural Electrodes in a Virtual Reality Environment

An accurate and rapid anatomical localization of implanted subdural electrodes is essential in the invasive diagnostic process for epilepsy surgery. To demonstrate our experience with a three-dimensional (3D) virtual reality simulation software (Dextroscope®, Bracco Imaging, Milano, Italy) in the postoperative localization of subdural electrodes. Postoperative thin-slice computed tomography (CT) scans were coregistered to preoperative 3D magnetic resonance (MR) images in the Dextroscope environment in 10 patients. Single-electrode contacts were segmented and their positions in relation to specific brain anatomic structures were obtained by 3D reconstruction within the Dextroscope environment. The spatial accuracy was tested by comparing the positions of the electrode contacts as visible in the 3D reconstruction with intraoperative photographs. Image processing time was also recorded. The 3D stereoscopic reconstruction provided an accurate representation of the implanted electrodes with highly detailed visualization of the underlying anatomy. The mean absolute difference between 3D reconstruction and intraoperative photographs was 2.4 mm ± 2.2 mm. The processing time to obtain the 3D reconstructions did not exceed 15 minutes. The results indicate that the 3D virtual reality simulation software used in our series is a useful tool for rapid and precise localization of subdural electrodes implanted for invasive electroencephalography (EEG) recordings.

Double Dissociation Between Visual Recognition and Picture Naming

Study of the corticosubcortical functional anatomy of reading and picture naming. To study the role of the left basal occipitotemporal area and its white matter pathways. Three patients underwent awake surgery for lesions in the left basal posterotemporal region with intraoperative electrostimulations. Intraoperative testing consisted of naming, reading, and recognition of symbols. Location of the stimulation sites was obtained by comparing the surgical cavity in the postoperative magnetic resonance imaging with the tags precisely located in each one of these sites seen on intraoperative photographs. A double dissociation was elicited, inducing specific visual recognition and reading disturbances during stimulation in the left posterobasal temporal cortex, without naming impairment. Stimulation of the inferior part of the sagittal stratum (inferior longitudinal fascicle) generated the same response, while a specific picture-naming impairment, consisting of semantic paraphasia, was obtained when stimulating superiorly to this fascicle, over the lateral wall and roof of the ventricle (inferior fronto-occipital fascicle). We propose the existence of a dual visual language route in the left dominant hemisphere. The first pathway seems to run basally, from the occipital lobe to the posterobasal temporal cortex, mediated by the left inferior longitudinal fascicle, subserving visual recognition. The second pathway might run superiorly and more medially, from the occipital pole directly to the frontal areas, and could be underlain by the inferior fronto-occipital fascicle, involved in naming (semantic processing). Such a model might have both fundamental and clinical implications for the selection of the tasks during awake mapping as well as for postsurgical rehabilitation.

Method for securing titanium cerebellar retractors

Background:Traditional stainless steel retractors can interfere with electromagnetic neuronavigation and intraoperative magnetic resonance imaging (ioMRI). In such cases, titanium instruments are frequently used; however, they often shift during the procedure. The authors describe a simple technique, illustrated with intraoperative photographs, for securing titanium cerebellar retractors into place to keep both the retractors and tissues in their desired locations throughout a craniotomy.Methods:Titanium retractors were used by our institute's neurosurgical service during operations utilizing electromagnetic neuronavigation or ioMRI. Once the retractor was in the desired position, a 2-0 silk suture was placed around a retractor tong and tied outside the skin. Two sutures were placed on either side of the titanium retractor in the same fashion.Results:Retractors were subsequently noted to remain in their desired position throughout the operative procedure.Conclusions:The authors describe a technique for securing titanium cerebellar retractors into their desired position during a craniotomy to minimize their movement during the procedure. This simple technique can help to eliminate a potential frequent source of surgeon frustration, and has proven to be quick to perform, safe, and practicable.

Comparison of the Amount of Iliopsoas Tendon Lengthening That Occurs after ArthroscopicLabral-Level and Lesser Trochanteric Tenotomies

Objectives:The success of arthroscopic iliopsoas tenotomies (AIT’s) performed at the level of the lesser trochanter for treatment of a painful snapping tendon is well documented. Currently, iliopsoas labral-level tenotomies have been advocated for treatment of this problem. However, a recent study reported a high incidence (∼50%) of recurrent snapping after iliopsoas tendon (IT) releases at this level (1). The purpose of this study was to determine if there is a difference in the amount of tendon separation/lengthening following AIT’s at the labral and lesser trochanteric levels. To date, the amount of tendon separation that occurs after releases at these two sites has not been reported. Methods:From the senior author’s data base of 900 hip arthroscopies, 80 patients who had arthroscopic iliopsoas tenotomies performed:1) at the level of the labrum (40 patients); or 2) at the lesse rtrochanter (40 patients) were identified. The amount of tendon separation/lengthening in these 80 patients was determined either from direct intra-operative measurements (40 patients) or from measurements made off of the intra-operative photographs. Image magnification on the intra-operative photographs was controlled for by basing the measurements of tendon separation on the known dimensions of the radiofrequency probe or 5 mm cannula that was present in each iliopsoas release picture (Figure 1). Two sample t tests were used for data analysis with p = <0.05 defined as significant. Results:Average age of the 40 patients with labral-level (LL) tenotomies was 36 years (range 16-58 years), and there were 9 males and 31 females and 19 left and 21 right hips in this group. Average age of the 40 patients with lesser trochanteric (LT) tenotomies was 32 years (range 17-55 years), and there were 8 males and 32 females, and 11 left and 29 right hips in this group. In the LL tenotomy group, the average tendon separation was 8.3 ± 2.04 mm. In the LT tenotomy group, the average tendon separation was 13.3 ± 3.01 mm. The 0.5 cm difference in the amount of tendon separation between the two groups was statistically significant at the p<0.001 level. Conclusion:An arthroscopic, lesser trochanteric iliopsoas tenotomy produces significantly greater (0.5 cm) tendon separation than tenotomies performed at the level of the labrum. The difference in the amount of tendon separation that occurs at these two sites may explain the high rates of recurrent snapping (∼50%) that have been reported with arthroscopic and open labral-level releases.

The Accurate Diagnosis of Biceps-Labral Complex Lesions with MRI and “3-Pack” Physical Examination: A Retrospective Analysis with Prospective Validation

Objectives:Effective treatment of Biceps-Labral (B-L) Complex lesions is predicated upon accurate diagnosis. Diagnostic algorithms include both physical examination and MRI. We sought to evaluate the contribution of MRI and physical examination to the accurate diagnosis of B-L Complex lesions.Methods:A retrospective review of 273 surgical cases of lesions of the B-L Complex was performed comparing the preoperative documented clinical "Three Pack" examination to the preoperative Radiologist's MRI reading in accurately predicting lesions of the B-L Complex seen at the time of surgery, and as documented by intraoperative photos and videos. After the completion of this retrospective review, an additional 145 patients(116 symptomatic, 29 matched controls) were enrolled in a prospective validation study of the "Three Pack" examination. All patients were examined independently and separately by three examiners without contamination: the senior surgeon, the sports medicine fellow, and the senior surgeon' s PA. Results were adjusted for order of examination.All B-L Complex Lesions were documented at surgery by digital photos and or video.Results:In the retrospective review, the MRI accurately described the labral tears found at surgery in only 45% of the cases. Of the documented biceps lesions, only 28% of the time was the biceps read on MRI as abnormal. When the preop ACT was positive, a positive"arthroscopic"ACT (where the biceps incarcerates between the humeral head and glenoid) or labral tear was noted in 88% of the cases. There were no cases where the preop ACT was negative and the "arthroscopic" ACT was positive. However, when the "arthroscopic"ACT was positive, 46% of the time there was no tear of the labrum. The average age of the patients with a positive "arthroscopic" ACT was 34 yo. In the subsequent prospective validation of the "Three Pack", The interobserver reliability for the "three pack" evaluation was quite strong with Kappa values between.700 to.850 for all tests, indicating substantial (.61-.80) to almost perfect (.81-1.00) agreement categories. This was in contrast to other "traditional" tests performed (Speed's, Yergason's, full and empty can tests), where only moderate agreement at best (.41-.60) was noted. Tenderness to BGP had a high sensitivity and specificity of.978 and.703 respectively for groove lesions; a positive throwing test had a moderate sensitivity of.694 and higher specificity of.745; the ACT (O'Brien Sign) had a very high sensitivity for labral tears and biceps incarceration,.897 and.914 respectively, with moderate specificities of.562 and.602 respectively. Seventy percent of patients had more than 1 site of pain and pathology confirmed at surgery. 88% of patients had a positive ACT in the symptomatic shoulder vs 11% in the unaffected shouder (and 18% of controls) for a p value<.001; 87% of patients had a positive BGP testversus 18% in the unaffected shoulder ( and 11% of controls) for a p value of <.001 as well.Seventy six percent of unaffected shoulders had all three tests negative.Conclusion:The "Three Pack" Examination is a highly reliable approach for evaluating painful lesions of the B- L Complex, with strong interobserver reliability. This more comprehensive approach to the B-L complex is also important as many patients have more than one site of pain and pathology. A positive Active Compression Test appears to be a normal finding as well, seen in 18% of patients who have never had shoulder pain, and had never felt that pain before.

Isolated rupture of a single bundle of a bifid distal biceps brachii tendon

I njury of the biceps tendon nearly always affects the proximal biceps tendon, usually in the setting of rotator cuff injury with involvement of the restraints of the long head of the biceps. Significant injury to the distal biceps tendon is far less common, with an estimated rate of 1.2 per 100,000 patients per year. In these patients, differentiation between a partial and complete tear is of central importance in the determination of subsequent management. Unfortunately, even in the presence of tendon retraction owing to disruption of the bicipital aponeurosis or lacertus fibrosis, identification of complete rupture can be confounded by associated hemorrhage, edema, bursitis, or scarring in the setting of an acute or chronic injury. Furthermore, accurate characterization of distal biceps tendon injury can be complicated by the presence of normal variants of conventional biceps tendon anatomy. For instance, with bifid insertion of the distal biceps tendon, isolated rupture of a single bundle of a bifid tendon can mimic a partial tear of a nonbifurcated tendon. In such patients, MRI may offer the only noninvasive means to identify anatomic variations and their associated injuries. In this article, we describe a rare MRI diagnosis of isolated tendon rupture confined to the medial bundle of a congenitally bifid distal biceps tendon and provide radiographic-pathologic correlation in the form of intraoperative photographs that confirm the imaging findings. To our knowledge, this is only the fifth such case to be reported in the literature, and only the second with operative correlation. Potential implications of this anatomic variation on subsequent management are discussed. The patient gave consent to publish this case. CASE REPORT

The Watering Can Technique for Prevention of Postoperative Epidural Hematoma Recurrence

Background: Postoperative epidural hematomas (EDH) are relatively common occurrences following emergent or elective craniotomies. While a number of strategies have been reported for management of traumatic EDH, there is no consensus among surgeons regarding the most effective treatment of postoperative EDH. Objective: We describe a novel surgical technique for treatment of postoperative EDH that has proved useful in the prevention of EDH recurrence. Methods: A technique was developed using multiple linear arrays of dural tenting sutures to prevent EDH recurrence in the postoperative setting. Following removal of the EDH, bleeding points are identified and controlled. Dural tenting sutures are then placed in linear array over the entire exposed dural surface. Absorbable gelatin sponges are then placed between the dural tenting sutures in an alternating fashion. Holes corresponding to the dural sutures are drilled into the bone flap, which is fastened to the surrounding skull. Dural sutures are then secured to the overlying bone. The final appearance of the repair resembles a common gardening watering can (WC), hence, the proposed title of the technique. Results: The WC technique for treatment of postoperative EDH is presented. Intraoperative photographs as well as an artist's rendition of the steps involved in the repair are detailed. Of the more than 20 cases of postoperative EDH repaired using the WC method, zero patients required return to the operating room for recurrence. Conclusions: The WC technique for treatment of postoperative EDH provides a simple, effective strategy that may improve outcomes and limit morbidity relative to conventional methods.

Acute Calcific Deposition in the Lateral Collateral Ligament of the Knee

We present a rare case of a patient presenting with acute onset knee pain, which was subsequently diagnosed and treated as acute calcific deposition in the lateral collateral ligament. A 51-year-old gentleman presented to the emergency department with acute onset, excruciating, and left knee pain. There was no preceding history of trauma or systemic upset. Examination revealed exquisite tenderness over the lateral aspect of the knee with leg edema and an associated knee effusion. Blood tests showed a raised C-reactive protein. Plain radiographs of the knee showed a poorly defined calcific deposition with a "cloud-like" configuration. Following exclusion of all more threatening causes of symptoms, the patient was diagnosed with acute calcific tendinitis. The patient's pain was unremitting despite intravenous opiates, and he was taken to the operation theater for exploration and removal of the irritant crystal deposition from the lateral fibular collateral ligament resulting in complete resolution of symptoms. Acute calcific deposition in the lateral collateral ligament is a rare condition. There have been very few reports of this in the literature to date, and no reported cases of surgical excision. Calcific deposition can be treated successfully using conservative measures with symptoms settling after 4 to 6 weeks, however operative excision has been shown to be appropriate in specific cases. Acute calcific deposition should be considered in patients with unexplained acute knee pain and swelling, following the exclusion of other more common conditions. We present the first operatively treated case with accompanying radiology images, intraoperative medical photography, and histological slides.