Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study.

Purpose: To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors. Methods: Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision. Results: A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors. Conclusions: Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important. Clinical Relevance: There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes.

BACKGROUND: In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications. METHODS: We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis. RESULTS: Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications. CONCLUSION: The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

Investigation of the efficacy and safety of ultrasoundstandardized autologous blood injection as treatment for lateral epicondylitis.

BACKGROUND: There are various conservative treatment options for lateral epicondylitis (LE). The aim is to evaluate pain, daily functioning, and complications after ultrasound-standardized autologous blood injections in patients with LE. METHODS: For this prospective cohort study, consecutive patients (>18 years) diagnosed with LE were included. Autologous blood was injected using a medical device containing an injection disposable with 12 small needles (Instant Tennis Elbow Cure [ITEC]) device. Patient-Rated Tennis Elbow Evaluation (PRTEE), subjective elbow score (SES), palpation and provocation pain, satisfaction, and complications of treatment were measured at baseline and two months after treatment. Paired t-tests and Fisher's exact tests were used for calculating the difference between pre- and post-treatment outcomes. RESULTS: Fifty-five elbows were analyzed. Mean time between pre- and post-treatment was 11.1 weeks (standard deviation [SD], 8.9 weeks). The mean PRTEE score decreased from 68.2 (SD, 15.7) before surgery to 53.2 (SD, 25.9; p<0.001) after. The mean SES improved from 36.9 (SD, 20.8) to 51.7 (SD, 27.4; p<0.001). Despite this improvement, only 44.7% of patients showed relevant clinical improvement in PRTEE, and 37.3% showed significant clinical improvement based on SES. Four patients reported a complication and the injection disposable failed three times. CONCLUSIONS: Ultrasound-standardized autologous blood injection using the ITEC device is not an effective tool in reducing symptoms related to LE. This study showed that only half of all patients experienced a positive effect. In this heterogeneous cohort of patients, we showed no added value of ultrasound standardization.

Long Head of Biceps Tenotomy Is Not Inferior to Suprapectoral Tenodesis in Arthroscopic Repair of Nontraumatic Rotator Cuff Tears: A Multicenter, Non-inferiority, Randomized, Controlled Clinical Trial.

PURPOSE: To determine if long head of the biceps (LHB) tenotomy is not inferior to suprapectoral LHB tenodesis when performed in conjunction with arthroscopic repair of small- to medium-sized nontraumatic rotator cuff tears. METHODS: This multicenter, randomized, non-inferiority trial recruited 100 participants older than 50 years who had a supraspinatus and/or infraspinatus tear sagittally smaller than 3 cm and arthroscopically confirmed LHB pathology. During arthroscopic rotator cuff repair, we randomized 48 patients to undergo suprapectoral LHB tenodesis and 52 patients to undergo LHB tenotomy. Data were collected preoperatively and at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome was non-inferiority of the Constant-Murley score (CMS) at 1-year follow-up. Secondary outcomes included the Dutch Oxford Shoulder Score; Disabilities of the Arm, Shoulder and Hand questionnaire; Popeye deformity; elbow flexion strength index; arm cramping pain; and quality of life (EQ-5D score). The integrity of the rotator cuff repair was assessed with magnetic resonance imaging. Differences between intervention groups were analyzed by mixed modeling. RESULTS: The mean CMS in the LHB tenotomy group improved from 44 (95% confidence interval [CI], 39-48) to 73 (95% CI, 68-79). In patients with LHB tenodesis, the mean CMS improved from 42 (95% CI, 37-48) to 78 (95% CI, 74-82). The difference between groups at 1-year follow-up was 4.8 (97.5% CI, -∞ to 11.4), with a P value for non-inferiority of .06. The secondary outcomes also improved over time, with no remarkable differences between groups. A Popeye deformity occurred in 33% of tenodesis patients and 47% of tenotomy patients (P = .17). Tenotomy was performed with a shorter operative time (73 minutes vs 82 minutes, P = .03). Magnetic resonance imaging showed a recurrent rotator cuff tear in 20% of all cases. CONCLUSIONS: Although statistically "inconclusive" regarding non-inferiority of the CMS at 1-year follow-up, any observed differences between patients with LHB tenotomy and those with LHB tenodesis in all outcome scores were small. LEVEL OF EVIDENCE: Level I, randomized controlled trial and treatment study.

The normative Western Ontario Rotator Cuff Index values for age and sex.

BACKGROUND: The Western Ontario Rotator Cuff Index (WORC) is a widely used disease-specific outcome tool developed for patients with rotator cuff injuries. The determination of age- and sex-adjusted normative WORC values enables us to determine whether a procedure is more beneficial in specific patient groups because the results can be compared with a matched standard. The purpose of this study was to determine normative WORC values and assess whether the WORC needs an adjusted score for age and sex. METHODS: We included participants using an online data-capturing program. We collected the following variables: age, sex, presence of shoulder pathology, Subjective Shoulder Value, and WORC score. We defined the mean normative WORC score per age category and analyzed sex differences in WORC scores per age category and in all domains of the WORC score. RESULTS: A total of 470 participants filled out the questionnaire. We excluded 44 participants because of pre-existing shoulder complaints or incomplete questionnaires. The mean total WORC score was 94% (standard deviation, 9%), and the mean total WORC score in every age and sex category was >90%. Of all participants, 85% scored between 91% and 100%; 63 participants (15%) scored 100%. The mean overall Subjective Shoulder Value was 98% (standard deviation, 6%). We found no statistically significant differences between sexes in the overall score, in the domain scores, and within the age categories. CONCLUSION: We defined normative values for the WORC questionnaire in a random prospective cohort and found no difference in scores between sexes. The mean normative scores all were within the variance of the maximum, and the WORC score did not deteriorate with age. It seems that the results of this subjective questionnaire change with the participant's perspective. An adjusted WORC score for age and sex is not necessary. This information can serve as a basis for comparison with patients with shoulder disease.

The Popeye sign: a doctor's and not a patient's problem.

BACKGROUND: The Popeye sign is a frequently reported finding following long head of the biceps (LHB) surgery and may be more often detected by doctors than by patients. This study investigates agreement between patients and doctors regarding the presence of a Popeye sign following LHB surgery. METHOD: This interobserver study investigates agreement between patients and consulting physicians with regard to assessment of a Popeye sign in patients following LHB surgery. Furthermore, this was compared with assessments by non-consulting physicians (observers) using digital photographs of the operated arm, taken both preoperatively and postoperatively. Data about gender, age, and body mass index (BMI) were collected to investigate their role in doctor's reporting of a Popeye sign. Patient's dissatisfaction with a Popeye sign in the operated arm was evaluated as well. RESULTS: Ninety-seven patients (mean age 61 ± 6.0 years, 62% male) underwent LHB surgery. A Popeye sign was reported by 2 patients (2%) as opposed to 32 cases (40%) by consulting physicians, of which only 1 case was in agreement. Krippendorff's alpha (Kalpha) for agreement between observers for preoperative photographs was 0.074 (95% CI -0.277, 0.382) and 0.495 (95% CI 0.317, 0.659) for postoperative cases. Kalpha between observers and consulting physicians for pre- and postoperative cases were 0.033 (95% CI -970, 0.642) and 0.499 (95% CI 0.265, 0.699), respectively. Phi coefficient analysis showed a moderate, statistically significant correlation between male sex and Popeye sign identification. Rank-biserial calculation revealed negligible correlation between BMI and age with regard to detecting a Popeye sign by both consulting physicians and observers. Dissatisfaction about swelling in the upper arm was reported in 1 case, though in a location that did not correspond to the location of a Popeye sign. CONCLUSION: The Popeye sign is more often identified by doctors than by patients after undergoing LHB surgery. BMI and age are not related to the detection of a Popeye sign, but sex is moderately correlated. Together with the low percentage of dissatisfaction of patients with this swelling, this signifies that a Popeye sign seems to be a doctor's rather than a patient's problem.

Responsiveness and disease specificity of the Western Ontario Rotator Cuff index.

The goal of this study was to determine the disease specificity and responsiveness of the Western Ontario Rotator Cuff Index (WORC). Responsiveness, two cut-off points of the minimal important change, the area under the curve, standard error of measurement, the minimal detectable change and the standardized response mean were determined. Patients undergoing a rotator cuff repair need to improve more than 35 points to be considered clinical importantly improved. The WORC is disease specific and has a high responsiveness in patients undergoing rotator cuff repair and patients with disease of the rotator cuff without rotator cuff tears.

Demand, capacity, and access of the outpatient clinic: A framework for analysis and improvement.

RATIONALE: While theoretical frameworks for optimization of the outpatient processes are abundant, practical step-by-step analyses to give leads for improvement, to forecast capacity, and to support decision making are sparse. AIMS AND OBJECTIVES: This article demonstrates how to evaluate and optimize the triad of demand, (future) capacity, and access time of the outpatient clinic using a structured six-step method. METHODS: All individual logistical patient data of an orthopaedic outpatient clinic of one complete year were analysed using a 6-step method to evaluate demand, supply, and access time. Trends in the data were retrospectively analysed and evaluated for potential improvements. A model for decision making was tested. Both the analysis of the method and actual results were considered as main outcomes. RESULTS: More than 25 000 appointments were analysed. The 6-step method showed to be sufficient to result in valuable insights and leads for improvement. While the overall match between demand and capacity was considered adequate, the variability in capacity was much higher than in demand, thereby leading to delays in access time. Holidays and subsequent weeks showed to be of great influence for demand, capacity, and access time. Using the six-step method, several unfavourable characteristics of the outpatient clinic were revealed and a better match between demand, supply, and access time could have been reached with only minor adjustments. Last, a clinic specific prediction and decision model for demand and capacity was made using the 6-step method. CONCLUSIONS: The 6-step analysis can successfully be applied to redesign and improve the outpatient health care process. The results of the analysis showed that national holidays and variability in demand and capacity have a big influence on the outpatient clinic. Using the 6-step method, practical improvements in outpatient logistics were easily found and leads for future decision making were contrived.

Abduction Brace Versus Antirotation Sling After Arthroscopic Cuff Repair: The Effects on Pain and Function.

PURPOSE: To study the effects on pain as the main outcome parameter and on function and cuff integrity as the secondary outcome parameters after arthroscopic rotator cuff repair in the short term comparing the abduction brace with an antirotation sling for postoperative shoulder immobilization. METHODS: Eligible patients were between the ages of 18 and 75 years who were diagnosed with a traumatic or degenerative tear of the supraspinatus and/or infraspinatus tendon, confirmed by magnetic resonance imaging, for which an arthroscopic footprint repair was indicated and performed. Patients were randomly allocated to the antirotation sling or abduction brace group. Postoperative pain and use of analgesics were accurately registered up to 3 months after surgery using a patient diary. Follow-up examinations including the Constant-Murley score, Western Ontario Rotator Cuff index, and glenohumeral range of motion were scheduled 6 weeks, 3 and 6 months, and 1 year after surgery. RESULTS: The average level of pain measured directly postoperation up to 1 year after surgery was not significant different between groups. Postoperatively, function scores and glenohumeral range of motion improved significantly for both groups; however, no differences were observed between groups. No retears were observed on ultrasonograph 3 months after surgery. CONCLUSIONS: In the short term, the level of pain, function, and quality of life were not significantly different between the use of an abduction brace and that of an antirotation sling after arthroscopic rotator cuff repair. Based on these findings, the abduction brace used in this study does not seem to be the solution for decreasing the pain experienced in the first postoperative weeks after arthroscopic rotator cuff repair, and both are recommendable. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Response shift of the Western Ontario Rotator Cuff index in patients undergoing arthroscopic rotator cuff repair.

HYPOTHESIS: This study determined the response shift in patients undergoing rotator cuff repair using the Western Ontario Rotator Cuff index (WORC), a disease-specific quality of life questionnaire. We hypothesized there would be a response shift with a positive recalibration (overestimated their preoperative disability) on the WORC and increases over time. METHODS: The study prospectively included 36 patients undergoing arthroscopic rotator cuff repair. At baseline, 3 months (T1), and 1 year (T2) after surgery the WORC, EuroQol (EQ)-5D-3L, and the patient's level of satisfaction after surgery were scored. To evaluate the response shift, patients also completed the WORC at 3 months (Pre-T1) and 1 year (Pre-T2) as how they perceived themselves to have been before surgery. RESULTS: The result on Pre-T1 and Pre-T2 results revealed that patients retrospectively rated their overall WORC score comparable with the baseline WORC score (Pre-T0; T0 = 40.5 ± 18.4, Pre-T1 = 45.0 ± 22.7, Pre-T2 = 34.3 ± 21.3). No response shift was observed on all domains except a negative recalibrated response shift for emotional disability on T1 (P = .04). CONCLUSIONS: No significant group-level response shift was observed using the WORC, except for the subdomain emotional disability at 3 months after arthroscopic rotator cuff repair. With the absence of any shift in patient's perception on the self-administered quality of life-related WORC questionnaire, this study suggests one could retrospectively reliably conduct group-level preoperative baseline information on quality of life up to 1 year after surgery.

Predictors of disease-specific quality of life after arthroscopic rotator cuff repair.

PURPOSE: Disease-specific instruments of quality of life (QOL) are more sensitive to disease-specific changes. The purpose of this study is to identify prognostic factors for disease-specific QOL after all-arthroscopic rotator cuff (RC) repair using the Western Ontario Rotator Cuff Index (WORC). METHODS: A total of 140 patients were evaluated after an RC repair with a mean follow-up of 22 ± 6.7 months. Evaluations included the WORC, EQ-5D and anchor questions. Preoperative patient demographics and radiologic characteristics were assessed to identify predictors of disease-specific QOL. RESULTS: Most patients (81.4 %) were satisfied with their surgical result. Minor tear retraction (odds ratio [OR] 2.97, p = 0.030), male gender (OR 3.67, p = 0.003), no social benefits (OR 3.67, p = 0.042) and pre-surgical complaints for more than six months (OR 3.03, p = 0.021) were independent predictors for superior postoperative WORC score in multivariable analysis. None of these factors were predictive for a higher EQ-5D score. CONCLUSION: These findings highlight the important impact of retraction on QOL after RC repair and underline the utility of disease-specific instruments. Future studies should focus on how these significant predictors can be used to improve decision making and to develop new treatment approaches.

Prognostic factors for recovery after arthroscopic rotator cuff repair: a prognostic study.

BACKGROUND: Studies concerning prognostic factors of recovery after arthroscopic rotator cuff repair mostly focus on tendon integrity or functional recovery as an outcome. Little is known about how they influence quality of life after surgery. We therefore tried to identify prognostic factors having an impact on quality of life after arthroscopic rotator cuff repair. METHODS: This study included 30 patients who underwent arthroscopic rotator cuff repair. We assessed Western Ontario Rotator Cuff Index as primary outcome and RAND-36, Constant-Murley score, and a shoulder hindrance score as secondary outcomes. Patients were repeatedly measured: once preoperatively and 4 times postoperatively. Preoperative range of motion, obesity, fatty infiltration, and cuff retraction were preselected as prognostic factors. RESULTS: Patients were significantly improved at 3 months and 6 months after arthroscopic rotator cuff repair. In multiple regression analysis, none of the preselected factors could be identified as a prognostic factor influencing quality of life after arthroscopic rotator cuff repair (measured with the Western Ontario Rotator Cuff Index). For the outcome variables RAND-36 (6 months, 1 year) and shoulder hindrance score (1 year), fatty infiltration Goutallier stages 1 and 2 and retraction grades II, III, and IV were significant predictors. CONCLUSION: Although fatty infiltration and retraction grade predict the RAND-36 and shoulder hindrance score, this study could not support preoperative range of motion, obesity, fatty infiltration, or retraction of the cuff as a prognostic factor for quality of life after arthroscopic rotator cuff repair. This study shows that if selection of patients is done properly, these factors do not influence a successful outcome.

Prognostic factors for successful recovery after arthroscopic rotator cuff repair: a systematic literature review.

STUDY DESIGN: Systematic literature review. OBJECTIVES: To perform a systematic review of the literature on prognostic factors for successful recovery after arthroscopic rotator cuff repair. BACKGROUND: Rotator cuff lesion is a common shoulder disorder, with a prevalence ranging from 13% in people over 50 years of age to more than 50% in people over 80 years of age. Several factors can affect the extent to which a person will recover after the surgical repair of a rotator cuff tear. More knowledge about these prognostic factors may lead to a better understanding of why the recovery process is successful in some patients but not in others. METHODS: A systematic literature search from 1995 to November 2013 was performed to identify studies reporting prognostic factors for successful recovery after arthroscopic rotator cuff repair. RESULTS: A total of 455 studies were initially identified, 10 of which were included in the review. For all included studies, the percentage of patients with complete tendon healing at final assessment ranged from 60% to 88%. Twelve prognostic factors, which could be divided into 4 categories, were identified as being associated with better recovery: demographic factors (younger age, male gender), clinical factors (higher bone mineral density, absence of diabetes mellitus, higher level of sports activity, greater preoperative range of motion, absence of obesity), factors related to cuff integrity (smaller sagittal size of the cuff lesion, less retraction of the cuff, less fatty infiltration, no multiple tendon involvement), and factors related to the surgical procedure (no concomitant biceps or acromioclavicular joint procedures). CONCLUSION: Knowledge and understanding of prognostic factors should be used in the decision-making process concerning arthroscopic rotator cuff repair to offer better care to patients. LEVEL OF EVIDENCE: Prognosis, level 2a-.

The conceptually equivalent Dutch version of the Western Ontario Rotator Cuff Index (WORC)©.

BACKGROUND: The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff, originally developed in English. The purpose of this study was to cross-culturally adapt the WORC for use in the Dutch population and to evaluate reliability, agreement and floor and ceiling effects of this Dutch version in a population of patients with rotator cuff disease. METHODS: Reliability was tested by measuring the Cronbach's alpha for internal consistency and intraclass correlation coefficients (ICC) for test-retest reliability. Agreement was measured using the Standard Error of Measurement (SEM(agreement)); and the smallest detectable change (SDC) was calculated based on the SEM. Pearson Correlations Coefficients were used to comparing the WORC with the RAND-36, the Constant Score and 11-point shoulder hindrance scale. RESULTS: Fifty-seven patients entered into this study of whom 50 were available for test-retest validation. The internal consistency of the Dutch WORC tested by Cronbach's alpha was 0.95 for the total questionnaire. The ICC for the WORC is 0.91 with a 95% confidence interval of 0.85-0.95. Standard Error of Measurement was 6.0 points with a Smallest Detectable Change of 16.7 points on a 0-100 scale. Pearson Correlations Coefficients showed a significant positive correlation between the Dutch WORC and Constant Score (r = 0.60) and a strong reversed correlation with the shoulder hindrance scale (r = -0.75). CONCLUSION: The Dutch WORC seems to be a reliable health-related quality of life questionnaire for patients with rotator cuff disorders. TRIAL REGISTRATION: NCT01532492.

Validation of the Western Ontario Rotator Cuff index in patients with arthroscopic rotator cuff repair: a study protocol.

BACKGROUND: Arthroscopic rotator cuff repair is described as being a successful procedure. These results are often derived from clinical general shoulder examinations, which are then classified as 'excellent', 'good', 'fair' or 'poor'. However, the cut-off points for these classifications vary and sometimes modified scores are used.Arthroscopic rotator cuff repair is performed to improve quality of life. Therefore, disease specific health-related quality of life patient-administered questionnaires are needed. The WORC is a quality of life questionnaire designed for patients with disorders of the rotator cuff. The score is validated for rotator cuff disease, but not for rotator cuff repair specifically. The aim of this study is to investigate reliability, validity and responsiveness of WORC in patients undergoing arthroscopic rotator cuff repair. METHODS/DESIGN: An approved translation of the WORC into Dutch is used. In this prospective study three groups of patients are used: 1. Arthroscopic rotator cuff repair; 2. Disorders of the rotator cuff without rupture; 3. Shoulder instability. The WORC, SF-36 and the Constant Score are obtained twice before therapy is started to measure reliability and validity. Responsiveness is tested by obtaining the same tests after therapy.

Outcome of total claviculectomy in six cases.

Total claviculectomy is a rare surgical procedure that has been performed for more than 90 years for a variety of indications, such as malignancy, trauma, and infection. What are the results for the pain score, and what is the influence of a total claviculectomy on the range of motion of the shoulder? We could not find the answers in the literature and analyzed 6 cases of total claviculectomy. The pain scores are good in a chronic osteitis case and in the two malignancy cases. In the 3 posttraumatic cases, the indication was pain, and all 3 had poor results because of persistent pain. All 6 patients had full range of motion. A resection of the entire clavicle did not disturb the motion of the shoulder. A tendency but no final conclusions can be drawn because of too few patients and heterogeneous indications.

Oblique radiograph for the detection of bone spurs in anterior ankle impingement.

OBJECTIVE: The aim of this study was to develop a radiographic view to detect anteromedial talotibial osteophytes that remain undetected on standard radiographs. DESIGN AND PATIENTS: In 10 cadaver specimens the maximal size was measured of anteromedial tibial osteophytes that remain undetected on a standard lateral radiograph projection, due to the presence of the anteromedial tibial rim. The average projection of the most prominent anterolateral tibial rim over the anteromedial rim was found to be 7.3 mm. A 7 mm barium-clay osteophyte was attached to this anteromedial rim of the distal tibia. Anteromedial osteophytes become most prominent on an oblique view, in which the radiographic beam is tilted into a 45 degrees craniocaudal direction with the leg in 30 degrees external rotation. This oblique view was compared with the findings of arthroscopic surgery in 25 consecutive patients with anterior ankle impingement syndrome. RESULTS: Medially located tibial and talar osteophytes remained undetected on a standard lateral projection and became visible on the oblique anteromedial impingement (AMI) radiograph. Anterolateral tibial and talar osteophytes were well detected on a standard lateral radiograph projection but were invisible on the AMI view. There was a high correlation between the location of the osteophyte and the location of symptoms and the findings at arthroscopy. CONCLUSION: A combination of lateral and oblique radiographs can be used to differentiate between anteromedial and anterolateral bony ankle impingement.