A Rare Case of Rotator Cuff Interposition Causing Humeral Head Subluxation Following Anterior Shoulder Dislocation.

This case report aims to highlight that not all shoulder dislocations are simple to treat and that early recognition of complications is key in managing these injuries successfully. We report the case of a 68-year-old gentleman who presented to Accident and Emergency (A&E) following a fall and sustaining an anterior dislocation of his right shoulder. This was reduced under sedation; however, the patient had an ongoing feeling that his shoulder "was not right." The subsequent investigation demonstrated persistent anterior subluxation of the humeral head with rotator cuff interposition in the glenohumeral joint. This case appears to be the first of its kind to be reported in which the supraspinatus, subscapularis, and long head of biceps were collectively interposed. This was treated operatively with open reduction and rotator cuff repair, even though the procedure was technically difficult due to tissue fibrosis and the formation of adhesions. The patient progressed well and had a good clinical outcome. This case highlights that rotator cuff interposition following shoulder dislocation is a rare but debilitating complication and is often neglected in initial care. We must recognise that patients are their own experts, and if they report something is "not right," further investigation and prompt treatment are required.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures.

BACKGROUND: Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain. PURPOSE/HYPOTHESIS: The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders. RESULTS: Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment. CONCLUSION: The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

The anterior tibiofibular ligament has a constant distal fascicle that contacts the anterolateral part of the talus.

PURPOSE: The anterior tibiofibular ligament (ATiFL) and its distal fascicle have been the subject of numerous studies, mainly due to the involvement of this ligament in anterolateral soft-tissue impingement of the ankle. There is currently no firm evidence related to the incidence of the distal fascicle or the frequency with which it is in contact with the talus, or whether this is a constant anatomic finding. In addition, the terminology used to refer to this structure is not accurate and varies widely in previous studies. The purpose of this study was to perform an anatomic study on a large number of specimens to clarify the anatomy of the anterior tibiofibular ligament, and specifically its distal fascicle, and its possible role in anterior ankle impingement syndrome. METHODS: During a 7-year period (2010-2016), cadaveric ankle specimens dissected at our Anatomy Department were included in this study, accounting for a total of 154 ankles. The incidence of the distal fascicle and its contact with the talus were documented. RESULTS: One hundred and seventeen ankles were included [78 men, 39 women, with a median age of 79.3 years (range 51-100 years)]. The ATiFL was found to have a distal fascicle in 100% of ankles, contacting the anterolateral part of the talus in all cases. The contact was increased in plantarflexion and reduced in dorsiflexion and finally disappeared completely in maximum dorsiflexion. CONCLUSIONS: The ATiFL has a constant distal fascicle that is in contact with the talus in the neutral position and in plantar flexion. Contact disappears in maximum dorsiflexion.

Dolor crónico del tobillo: banda fibrosa (Web Impingement) / Chronic ankle pain. Web impingement

Objetivo: Presentamos una serie de pacientes con dolor crónico de tobillo y estudios por imágenes negativos, en los que hallamos solamente una banda fibrosa intraarticular como causa probable del dolor en la artroscopia diagnóstica. Métodos: Entre el año 2010 y 2016 se realizaron 212 artroscopias anteriores de tobillo. En 19 pacientes (8,96%) se encontró una banda fibrosa intrarticular. En 13 pacientes se encontraban asociadas con otras patologías y solo en 6 pacientes (2,83%) fueron aisladas, sin lesión asociada. El promedio de edad fue de 40,42 años. El seguimiento promedio de 20,42 meses. La mayoría de los pacientes fueron atendidos en centros de aseguradoras de riesgo de trabajo. Resultados: Se utilizó el score AOFAS con un promedio para el preoperatorio de 55,63 y para el postoperatorio de 92.26. No hubo complicaciones en esta serie. Conclusiones: La banda fibrosa es una patología infrecuente, con sintomatología clínica similar a la de otras patologías que producen un síndrome friccional anterior de partes blandas del tobillo. La mayoría tenía antecedentes traumáticos. Los estudios por imágenes utilizados fueron la radiografía y la Resonancia. Ninguno de ellos fue de utilidad en el diagnóstico. La banda fibrosa es una de las diferentes formas de impingement en la cara anterior del tobillo y puede ser una causa de fricción y dolor. Dado que los estudios por imágenes no fueron concluyentes, la artroscopía fue nuestro método de elección para el diagnóstico y tratamiento en los pacientes con dolor crónico de tobillo con imágenes negativas. Tipo de trabajo: Serie de casos. Nivel de evidencia: IV.

Purpose: We present a series of patients with chronic anterior ankle pain and negative imaging studies, in which we found an isolated fibrous intrarticular band as a probable cause of pain in diagnostic arthroscopy. Methods: Between 2010 and 2016 we performed 212 anterior ankle arthroscopies. In 19 patients (8,96%) a fibrous web like band was found. In 13 cases they were associated with other diseases and only 6 of them (2.83 %) were isolated. Average age was 42 years. Follow up was between 4 months and 3 years (average 20.42 months). Most of them were workers compensation patients. Results: We used the AOFAS scores with an average value of 55,63 preoperative and 92.26 points postoperative. No complications were found in this series. Conclusions: Intra articular fibrous band is an infrequent pathology, with clinical presentation similar to other soft tissues anterior impingement. Most of them had previous trauma. Imaging studies performed were radiographs and MRI, but they have not proven to be useful due to their low or none sensitivity to this condition. Intra articular fibrous bands is one of the causes of anterior impingement of the ankle, and may be a cause of friction and pain. Most of them had history of previous trauma. Imaging studies were not conclusive, and arthroscopy was our election method for diagnosis and treatment in patients with chronic ankle pain and negative imaging studies. Type of study: Case series. Level Of Evidence: IV.

Dealing with the Stiff Ankle: Preoperative and Late Occurrence.

In patients with a stiff ankle replacement, appropriate resection of scarred capsular structures, hypertrophic bone debridement, and careful release of tendons should be performed to achieve good outcomes. Appropriately sized and correctly implanted components are required to restore ankle function to as normal as possible. Although not proven, the better a total ankle replacement is balanced, the less likely scar and heterotopic bone formation will occur. In patients with a stiff and painful ankle replacement, a preoperative diagnostic workup is mandatory to understand the underlying pathologic process and plan appropriate treatment. All underlying causes should be addressed.

Imaging the implant-soft tissue interactions in total knee arthroplasty.

BACKGROUND: In Total Knee Arthroplasty (TKA), residual pain may be secondary to soft tissue impingements, which are difficult to visualize around chromium-cobalt implants using medical imaging, so their interactions remain poorly understood. The goal of this work was to establish a protocol for in-vitro imaging of the soft tissues around TKA, usable during throughout the range of motion (ROM). METHODS: The full size range of a commercially available TKA prosthesis was manufactured by 3D-printing in non-magnetic and non-radiopaque polymer and implanted in 12 cadaveric knees. The relations between these implants and the soft tissues (Popliteus tendon, Medial and Lateral Collateral Ligament, Patellar and Quadriceps tendons) were analyzed, using MRI (5 embalmed specimens) and CT scans after injection of the tissues with barium-sulfate (3 embalmed and 4 fresh-frozen specimens). RESULTS: Both MRI and CT scans enabled good identification of the soft tissues before TKA implantation. MRI produced minimal loss in signal and contrast, and neither the low temperature nor the embalming fluids compromised image quality. CT scans were more precise after TKA implantation, particularly the borders of the implant and the differentiation of soft tissues. Full ROM investigation, manual segmentation and three-dimensional reconstructions were possible only with the CT scan. CONCLUSION: The experimental approach described in this study was successful in visualizing the interactions between the soft tissue and the implants before and after TKA and during the full ROM. The coordinate system allows to localize precisely the different anatomic structures and to quantify any change due to prosthetic implantation.

Reducing the distal profile of dual mobility liners can mitigate soft-tissue impingement and liner entrapment without affecting mechanical performance.

Soft-tissue impingement with dual mobility liners can cause anterior hip pain and intra-prosthetic dislocation. The hypothesis of this study was that reducing liner profile below the equator (contoured design) can mitigate soft-tissue impingement without compromising inner-head pull-out resistance and hip joint stability. The interaction of conventional and contoured liners with anterior soft tissues was evaluated in cadaver specimens via visual observation and fluoroscopic imaging. Resistance to inner-head pull-out was evaluated via finite element analyses, and hip joint stability was evaluated by rigid-body mechanics simulation of dislocation in two modes (A, B). Cadaveric experiments showed that distal portion of conventional liners impinge on anterior hip capsule and cause iliopsoas tenting at low flexion angles (≤30°). During hip extension, the rotation imparted to the liner from posterior engagement with femoral neck was impeded by anterior soft-tissue impingement. The iliopsoas tenting was significantly reduced with contoured liners (p ≤ 0.04). Additionally, the contoured and conventional liners had identical inner-head pull-out resistance (901 N vs. 909 N), jump distance (9.4 mm mode-A, 11.7 mm mode-B) and impingement-free range of motion (47° mode-A, 29° mode-B). Thus, soft-tissue impingement with conventional dual mobility liners may be mitigated by reducing liner profile below the equator, without affecting mechanical performance. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:889-897, 2016.

Arthroscopic Treatment and Prognostic Classification of Anterior Soft Tissue Impingement of the Ankle.

BACKGROUND: Anterior soft tissue impingement of the ankle has been described based on the etiology and location, but no classification has been reported. Arthroscopic treatment is usually considered effective, even if the behavior of the different forms of impingement is not clear. The purpose of this study was to analyze the factors affecting long-term results. METHODS: Forty-two patients with a mean age of 32.6 years were arthroscopically treated between 2004 and 2008. Impingement lesions were identified according to clinical examination and confirmed by MRI. Soft tissue impingement was detected and classified according to location (anteromedial, anterolateral, syndesmotic or diffuse). Patient data, foot morphology, and previous trauma or surgery were recorded. Patients were evaluated after a mean of 90.1 months' follow-up with the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system. RESULTS: The mean AOFAS score improved from 40.6 preoperatively to 82.6, 78.4, and 74.8, respectively, at the 2-, 4-, and 6-year follow-ups (P < .05). The anterolateral form showed higher scores compared to the diffuse or anteromedial forms. Age, foot morphology, and previous trauma or surgery did not affect the results. Body mass index of more than 26 and male gender were associated with worse outcomes. CONCLUSION: Arthroscopic debridement proved effective in the treatment of soft tissue impingement. Furthermore, we were able to classify the location of the anterior soft tissue impingement of the ankle, which may have prognostic importance. LEVEL OF EVIDENCE: Level IV, case series.

Ankle Lesions, Associated with Anterior Soft Tissue Impingement / 대한족부족관절학회지

PURPOSE: To evaluate clinical features of ankle lesions, associated with anterior soft tissue impingement. MATERIALS AND METHODS: We retrospectively reviewed 21 patients who had chronic anterior ankle pain as initial symptom and associated ankle lesions with anterior soft tissue impingement. Based on preoperative radiologic findings, physical examination intra-operative findings, appropriate procedures were done for lesions by either arthroscopic or minimal open procedure or combined. Clinical evaluation was done using American Orthopedic Foot and Ankle Society, ankle-hind foot score (AOFAS score) and visual analog scale (VAS) on last follow up. RESULTS: Associated lesion(s) to anterior soft tissue impingement of the ankle were 16 cases of osteochondral lesion of talus, 14 cases of bony impingement, 6 cases of ankle lateral instability, 5 cases of loose body, 4 cases of os subfibulare. AOFAS score was 58.9 +/- 5.1 preoperatively and 74 +/- 9.1 on last follow up. Clinical satisfaction score using VAS showed excellent in 3 cases, good in 11, fair in 3, poor in 4. CONCLUSION: The patients who had anterior soft tissue impingement would have various associated lesions on their ankle. In such cases, preoperative counseling for variety of postoperative results would be needed.

Arthroscopic treatment of ankle soft tissue impingement syndrome / 中国微创外科杂志

Objective To study clinical and pathological characteristics and effects of arthroscopic treatment of ankle soft tissue impingement syndrome(ASTIS). Methods A total of 21 cases of ASTIS underwent arthroscopic operations from November 2000 to April 2005.The impingement soft tissues were removed under arthroscope at 13.6?9.9 months after injury.The resected tissues were pathologically examined following surgery.The efficacy of arthroscopy was assessed using the American Orthopaedic Foot and Ankle Society(AOFAS) rating scores. Results Arthroscopic findings showed the most common impingement tissue was synovium(20 cases),followed by distal fascicle of the anterior tibiofibular ligament(5 cases),fibrous scar tissue(4 cases),anterior talofibular ligament(3 cases),and meniscoid tissue(3 cases).ASTIS accompanying cartilage injuries was found in 16 cases.All the cases were followed for 7~60 months(mean,34.3?9.4 months).The AOFAS scores significantly increased postoperatively than preoperatively,with total scores from 67.0?9.7 to 94.0?6.4(t=-7.205,P=0.000) and subjective scores from 20.7?6.6 to 35.7?4.9(t=-5.003,P=0.000). Conclusions Ankle soft tissue impingement syndrome often occurs after ankle sprain along the anterolateral portion of the ankle.Common impingement tissues are synovium,ligament,scar tissue,and meniscoid tissue.Arthroscopic treatment of ankle soft tissue impingement syndrome is satisfactory.