Identifying and Exposing the Proximal Biceps in Its Groove: The "Slit" Technique.

Proximal biceps tendon pathology is a common source of shoulder symptoms. Thus, visualization of the entire extent of the biceps tendon is often required for both diagnostic and therapeutic purposes. Accurately recognizing the presence and extent of biceps pathology intraoperatively is made more difficult, however, due to the extra-articular location of a significant portion of the biceps tendon as it courses within the bicipital groove. Unfortunately, identification of the biceps groove in the subacromial space is often challenging due to the lack of visual and tactile landmarks. A technique that facilitates efficient and reliable bicipital groove identification and biceps tendon visualization along its entire course within the groove is presented.

Diabetic myonecrosis: likely an underrecognized entity.

Diabetic myonecrosis is a rare complication of long-standing diabetes mellitus that presents as acute onset of swelling and pain of the affected muscles. The differential diagnosis includes cellulitis/pyomyositis, necrotizing fasciitis, neoplasm, and deep venous thrombosis (DVT). Missed diagnoses can lead to unnecessary invasive diagnostic procedures and inappropriate treatment. The diagnosis is established by the clinical presentation and findings on magnetic resonance imaging (MRI) scan. A 30-year-old African-American man presented with a painful mass affecting the medial aspect of the right thigh for several months. Initial laboratory studies showed white blood cell count of 8800 cells/mm(3), D-dimer value of 0.55 µg/mL, HgBA1c level of 15.1%, glucose level of 352 mg/dL, erythrocyte sedimentation rate of 22 mm/h, and C-reactive protein level of 222 mg/L. An MRI scan was obtained, and diabetic myonecrosis was diagnosed and treated. One year later, the patient had similar symptoms of pain in the contralateral thigh. Repeat workup and MRI scan were obtained. The MRI abnormalities originally seen in the right thigh 1 year earlier were present in the left thigh, with complete resolution of the abnormalities seen in the right thigh. Treatment with bed rest and analgesics resulted in symptom resolution. Patients with diabetic myonecrosis typically have no fever, normal white blood cell count, mildly increased erythrocyte sedimentation rate, and elevated C-reactive protein level in 50% of cases. They lack the radiologic signs of fascial enhancement or well-defined, rim-enhancing collections that are seen in necrotizing fasciitis and pyomyositis/abscess. The onset of severe pain and the lack of mass effect on imaging differentiate diabetic myonecrosis from tumor-like conditions such as vascular malformations or soft tissue tumors. Normal D-dimer levels and ultrasound Doppler examination of the extremity help to rule out DVT. The typical MRI scan findings and clinical presentation can lead to the diagnosis of diabetic myonecrosis, allowing the physician to avoid invasive tests, such as muscle biopsy, and to reassure patients that this condition is self-limiting with appropriate treatment.

Effects of alcohol injection in rat sciatic nerve as a model for Morton's neuroma treatment.

BACKGROUND: Previous studies have shown that the injection of dehydrated alcohol has been successful for the treatment of Morton's neuroma in the foot. In this study, we determined the cellular effect of injection of alcohol into and around the sciatic nerve of rats and measured the extent of cell necrosis and/or any associated histologic or inflammatory changes. METHODS: Twenty-two male (~375 g) Wistar rats were randomized into 2 groups each receiving alcohol injections into or around the sciatic nerve after nerve exposure under sterile technique. Group 1 rats were injected with a 0.5 ml solution of 0.5% Marcaine in the left sciatic nerve as a control group. In the right sciatic nerve a 0.5 ml solution of 4% ethanol with 0.5% Marcaine was injected. Group 2 rats received 0.5 ml of 20% ethanol with 0.5% Marcaine injected into the left sciatic nerve and 0.5 ml of 30% ethanol with 0.5% Marcaine injected into the right sciatic nerve. In each group, the rats were placed in 3 subgroups: intraneural, perineural, perimuscular injections. All rats were sacrificed and tissue harvested for histologic evaluation at day 10 post injection. RESULTS: No evidence of alcohol-associated cell necrosis, apoptosis, or apparent inflammation was observed in histologic specimens of any injected nerves, perineural tissue, or muscles in controls or experimental groups regardless of concentration of ethanol injected on day 10. CONCLUSION: We concluded that alcohol injection (≤30% ethanol) into and/or around the sciatic nerve or the adjacent muscle of rats has no histologic evidence of necrosis or inflammation to the nerve or surrounding tissue. There was no observable histological change in apoptosis, or cell number, in response to the alcohol injection. CLINICAL RELEVANCE: The lack of any measureable changes in nerve or adjacent muscle histology with ethanol injection into the rat sciatic nerve (and surrounding tissues) raises questions about the efficacy of using ethanol injections in the treatment of Morton's neuroma in human clinical practice.

Management of giant liver cysts.

BACKGROUND: Liver cysts are often asymptomatic. Symptomatic liver cysts are uncommon and can be managed by percutaneous aspiration, laparoscopic/open marsupialization, or resection. Our aim is to review our experience with management of giant liver cysts (GLC). MATERIALS AND METHODS: An IRB approved chart review of patients with liver cysts between 1995-2009 was performed. There were 34 GLC in 24 patients, 20 (83%) were females (mean age of 59.2 y). Pain was the main symptom in 20 patients. The average cyst size was 15.66 cm (6-32 cm) with 14 cysts over 15 cm in size. Two patients with GLC (11 and 15 cm) decided not to have surgery; 16 patients underwent laparoscopic surgery with one recurrence. One patient with laparoscopic marsupialization at another center was managed by open marsupialization and repair of the bile leak. Four of the patients underwent open marsupialization and one underwent open resection. Four patients with prior percutaneous aspiration had recurrences (100%), three underwent laparoscopic and one open marsupialization. An 8-wk pregnant patient underwent percutaneous aspiration of a 32 cm cyst to alleviate symptoms until delivery. RESULTS: The mean hospital stay for laparoscopic marsupialization was 5.57 d compared with 9.2 d for open procedure. Three (18.7%) postoperative complications (bile leak, recurrence, bleeding) occurred in the laparoscopic group, and one (20%) bile leak in the open group, with a mean follow-up of 41 mo. CONCLUSION: Laparoscopic marsupialization of GLC is as effective and safe as open procedures in preventing cyst recurrence regardless of cyst size and location, and affords a relatively shorter hospital stay.