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Background Failure of suture anchor fixation in rotator cuff repair can occur at different interfaces. Prior studies show fixation at the bone-anchor interface can be augmented using polymethylmethacrylate (PMMA) cement, and screw fixation into bone can be strengthened using bioabsorbable tricalcium phosphate cement. Questions/purposes We wished to determine whether augmentation of suture anchor fixation using bioabsorbable tricalcium phosphate cement would increase pullout strength of suture anchors from bone and the number of cycles to failure, to determine the mode of failure after cement augmentation, and to compare strength and mode of failure with those after augmentation with PMMA.Methods We used 10 matched pairs of cadaveric proximal humeri and implanted a metal screw-type suture anchor in one side and on the other side injected tricalcium phosphate cement into the anchor holes before anchor placement. We tested all specimens to failure using a ramped cyclic loading protocol. Results Tricalcium phosphate cement augmentation increased the final load to failure by 29% and the number of cycles to failure by 20%. Visual inspection confirmed that failure occurred at the cement-bone interface. Conclusions Tricalcium phosphate cement appears to augment suture anchor fixation into bone, reducing the risk of anchor pullout and failure. Clinical Relevance When relying on suture anchor fixation in bone of questionable quality, we suggest considering augmentation of suture anchor fixation with bioabsorbable cement. This method also provides potential for bioabsorbability and may be more amenable to arthroscopic application.

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Background: Integrated lateral lumbar interbody fusion (LLIF) devices have been shown to successfully stabilize the spine and avoid complications related to posterior fixation. However, LLIF has increased subsidence risk in osteoporotic patients. Cement augmentation through cannulated pedicle screws enhances pedicle fixation and cageendplate interface yet involves a posterior approach. Lateral application of cement with integrated LLIF fixation has been introduced and requires characterization. The present study set out to evaluate kinematic and load-to-failure properties of a novel cement augmentation technique with an integrated LLIF device, alone and with unilateral pedicle fixation, compared with bilateral pedicle screws and nonintegrated LLIF (BPS þ S). Methods: Twelve specimens (L3-S1) underwent discectomy at L4-L5. Specimens were separated into 3 groups: (1) BPS þ S; (2) polymethyl methacrylate (PMMA) augmentation, integrated LLIF, and unilateral pedicle screws (PMMA þ UPS þ iS); and (3) PMMA and integrated LLIF (PMMA þ iSA) without posterior fixation. Flexion-extension, lateral bending, and axial rotation were applied. A compressive load was applied to L4-L5 segments until failure. An analysis was performed (P , .05). Results: Operative constructs significantly reduced motion relative to intact specimens in all motion planes (P , .05). BPS þ S provided the most stability, reducing motion by 71.6%-86.4%, followed by PMMA þ UPS þ iS (68.1%-79.4%) and PMMA þ iSA (62.9%-81.9%); no significant differences were found (P. .05). PMMA þ UPS þ iS provided the greatest resistance to failure (2290 N), followed by PMMA þ iSA (1970 N) and BPS þ S (1390 N); no significant differences were observed (P. .05). Conclusions: Cement augmentation of vertebral endplates via the lateral approach with integrated LLIF moderately improved cage-endplate strength compared to BPS þ S in an osteoporotic model; unilateral pedicle fixation further improved failure load. Reconstruction before and after application of unilateral pedicle screws and rods was biomechanically equivalent to anteroposterior reconstruction. Overall, initial results suggest that integrated LLIF with cement augmentation may be a viable alternative in the presence of osteoporosis.

A new breed of medical businessperson is needed for the 21st century When health care costs continued to escalate in the face of declining reimbursement, a paradigm shift in the delivery of health care occurred. This shift involved the widespread growth of managed care and a drastic transfer of power out of physicians' hands. A battle over patient management and physician reimbursement thus ensued between physicians and their nonmedical administrative counterparts. Physicians are losing this battle. The focus used to be patients and the treatment of their diseases, regardless of cost. The issue of cost has now pushed its way into the algorithm of everyday management. With the decline in the quality of medical care that many physicians and patients feel accompanies managed care systems, the efficient use of health care resources has become paramount. All of these changes point to the need for people who can speak the languages of both business and medicine-people who can bridge the 2 worlds.The rapidly evolving medical economy has led to several new educational pathways. One of these pathways involves the joint medical degree and master's in business administration (MD-MBA) program, now available at many of the most prestigious schools. An MBA provides several tools that are vital to physicians facing the challenges of medicine today. Students develop administrative, negotiating, communication, and leadership skills. According to Bruce Chernof, medical director of Health Net and codirector of the MD-MBA program at UCLA, communication skills are by far the most important. One could argue that medical school is 4 years spent learning the language of medicine. However, most physicians learn only this language. People who wish to bridge business and medicine need to learn the basics of both disciplines.Fluency in business and clinical medicine not only empowers physicians to effectively negotiate with third-party payers, it also enables them to better relate to industry leaders and hospital administrators, which translates into more efficient health care delivery. In addition, department chairs and other hospital administrators are spending increasingly more time on business-related issues. Chernof asserts, "the challenge going forward is that decisions are no longer simple, and they're hugely expensive." The health care industry needs people who know how to allocate resources in this era of cost cutting. Accordingly, a training in business gives physicians the credibility to implement new, more efficient practice methods and treatment algorithms to large systems of care. With advanced leadership skills, physicians with business training will have the credentials to lead the medical community in the ongoing battle between cost and quality.A dual degree is not a ubiquitous solution, however. Most physicians wish to be strict clinicians and have no need for an MBA. Sam Shen, a current MD-MBA student at UCLA, warns that "doing a dual degree gives you more options, but at the same time, too many options hurt your long-te...

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