Arthroscopic anatomy of the posterior ankle ligaments

Purpose: Our objective was to define the arthroscopic anatomy of the posterior ankle ligaments. Type of Study: Anatomic study. Methods: Twenty fresh-frozen feet were dissected in order to examine the morphology of the posterior ankle ligaments and their variations. In addition, arthroscopic examination was performed in 8 feet with standard anteromedial and anterolateral portals. Posterior ligamentous structures were identified and marked with suture. Following arthroscopy, careful dissection was performed and previously marked anatomic structures were identified. Results: At the time of anatomic dissection, the posteroinferior tibiofibular ligament, also called the tibial slip, was found to be a constant structure with varying size and shape, and well evident during arthroscopy due to its oblique course. The deep component of the posteroinferior tibiofibular ligament, also called the transverse ligament, is well defined during arthroscopy. The 2 ligaments not well visualized during arthroscopy are the superficial component of the posteroinferior tibiofibular ligament and the posterior talofibular ligament. Conclusions: These findings should be of interest in interpreting findings encountered during arthroscopic examination of ankle, and when a posterior soft-tissue impingement syndrome must be ruled out.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 4 (April), 2002: pp 353–358     

The glenohumeral micromotion and influence of the glenohumeral ligaments during axial rotation in varying abduction angle

BackgroundThe patients with shoulder instability or disorders in overhead athletes have been considered to have an abnormal micromotion at the glenohumeral joint. However, the normal range of the micromotion has not been available during axial rotation with various abduction angles, especially above 90° abduction. This study aimed to investigate the glenohumeral translation and influence of the glenohumeral ligaments during axial rotation with up to maximum abduction.MethodsFourteen healthy volunteers performed active axial rotations at 0°, 90°, 135°, and maximal abduction angles. The positions of the humeral head center relative to the glenoid at maximally external, neutral, and maximally internal rotations (ER, NR, IR, respectively) for each abduction angle were evaluated using two- (2D) and three-dimensional (3D) shape matching registration techniques. The shortest pathway and its length between the origin and insertion of the superior, middle, and inferior glenohumeral ligaments (SGHL, MGHL, and IGHL, respectively) were calculated for each position.ResultsThe glenohumeral joint showed 3.1 mm of superoinferior translation during axial rotation at 0° abduction (P < 0.0001), and 2.6 mm and 4.5 mm anteroposterior translation at 135° and maximal abduction (P < 0.0001), respectively. The SGHL and MGHL reached a maximum length at ER with 0° abduction, and the anterior and posterior bands of the IGHL reached a maximum at ER with 90° abduction and IR with 0° abduction.ConclusionsThese findings indicated that the SGHL played a role as an inferior suppressor at 0° abduction, while the anterior band of IGHL played a role as an anterior stabilizer at 90° abduction. Every glenohumeral ligament did not get taut and the anteroposterior translation became greater with increasing abduction angle, above 90°. These results could be used as a reference when comparing with the pathological shoulders in the future study.     

Simulated humeral avulsion of the glenohumeral ligaments: a new instability model

Humeral avulsion of the glenohumeral ligaments (HAGL) is an infrequent cause of shoulder instability. Experimental studies on this lesion are rare. This study was undertaken to determine the extent of humeral-based capsuloligamentous damage required for dislocation to occur. In 65 fresh cadaver shoulders, a humeral-sided ligamentous cutting sequence was done. After each step, degree of sulcus, translation, and instability were evaluated with an electromagnetic tracking device. There was a high degree of correlation between the amount of cut done and the resulting degree of instability. The order of the ligamentous cuts had no significant influence. For a dislocation to occur at least 3 zones had to be cut. Simulated HAGL can be used as a model for shoulder instability, although further experiments are needed to validate this model fully. Extensive capsuloligamentous lesions on the humeral side seem to be required before dislocation can occur. This may be a factor explaining the relative paucity of HAGL in clinical series.     

Anatomy and function of the glenohumeral ligaments in anterior shoulder instability

The anatomy of the glenohumeral ligaments has been shown to be complex and variable and their function is highly dependent on the position of the humerus with respect to the glenoid. The superior glenohumeral ligament with the coracohumeral ligament was shown to be an important stabilizer in the inferior direction, even though the coracohumeral ligament is much more robust than the superior glenohumeral ligament. The middle glenohumeral ligament provides anterior stability at 45 degrees and 60 degrees abduction whereas the inferior glenohumeral ligament complex is the most important stabilizer against anteroinferior shoulder dislocation. Therefore, this component of the capsule is the most frequently injured structure. An appropriate surgical procedure to repair the inferior glenohumeral ligament complex after shoulder dislocation must be considered. In addition, a detached labrum can lead to recurrent anterior instability and a compromised inferior glenohumeral ligament complex. However, additional capsular injury usually is necessary to allow anterior dislocation.     

Percutaneous tensioning of the glenohumeral ligaments during arthroscopic bankart repair

Tensioning of the inferior glenohumeral ligament complex (IGLC) before arthroscopoic repair is a critical step in restoring stability. This article describes a simple surgical technique to tension the IGLC percutaneously before arthroscopic fixation. This technique eliminates the need for grasping instruments and a second anterior portal.     

Review article: Patient-level outcomes: the missing link

Treatment of chronic kidney disease (CKD) may be life-saving, but can disrupt every aspect of a patient's life and the lives of family members. Many patients with CKD are elderly with significant comorbidities and sometimes therapies to improve survival may be less important than those that improve or maintain quality of life. In this setting, patient-level benefits become particularly important goals of therapy. Randomized controlled trials (RCT) are also essential to justify expensive therapies, such as medications used in the treatment of CKD mineral and bone disorders. Surprisingly, data to support the efficacy of these drugs for patient-level outcomes remains limited. In fact, fewer RCT are conducted in renal medicine than in any other medical specialty and reliance is often placed on association data and the assessment of intermediate and biochemical end-points. While some of these may prove to be valid surrogates for clinically important outcomes, some may not. Inclusion of patient-level outcomes in clinical research provides a missing link that can inform a more comprehensive approach to clinical practice and patient care. Incorporating measures of health-related quality of life into clinical trials can make outcomes more relevant and may be relatively simple. This paper provides examples of reliable, validated instruments to measure health-related quality of life domains and functional status, together with practical instructions for their use. Most could be incorporated into RCT of CKD mineral and bone disorder treatments. Inclusion of outcomes that are perceived by patients to be significant should become standard practice in renal medicine and in clinical renal research.     

Arthroscopic treatment of bidirectional glenohumeral instability: two- to five-year follow-up

This investigation presents the results of arthroscopic repair of bidirectional (inferior with either an anterior or a posterior component) glenohumeral instability in 54 patients with 2-year minimum follow-up. The study group consisted of 43 males and 11 females. The average age at the time of operation was 32 years (range, 15-55 years); the average interval from operation to final evaluation was 34 months (range, 26-63 months). The American Shoulder and Elbow Surgeons' Shoulder Index and the Constant, Rowe, and University of California at Los Angeles scores were recorded preoperatively and at final evaluation. Preoperatively, no patients rated good to excellent overall (according to the Rowe Scale), whereas at final follow-up 91% (49 of 54 patients) rated good to excellent. The American Shoulder and Elbow Surgeons' Shoulder Index improved to 94 from 45.5 (P =.001). The absolute Constant score improved to 92 from 57 (P =.001). The Rowe score improved to 92 from 20.3 (P =.001). The University of California at Los Angeles total score improved to 32.7 from 18.6 (P =.001). Average passive external rotation at 90 degrees of abduction measured 89.5 degrees. Forty patients returned to sports, but 10 (25%) of these patients participated at a lower level. For each of 4 patients, the index operation was considered a failure because of persistent instability; 1 patient underwent a second operative procedure. Thermal capsulorraphy (with a Holmium laser) of the glenohumeral ligaments was used to supplement suture repair, but in no shoulder was thermal capsulorraphy used as the only treatment. The etiology of bidirectional glenohumeral instability is complex, and operative correction of multiple intraarticular lesions was necessary.     

X-linked rickets and tumor-acquired osteomalacia:PHEX and the missing link

Dietary rickets has been recognized as a major cause of skeletal abnormalities in the industrialized world for more than 350 years. In recent times, familial and tumor forms of rickets were found to be resistant to vitamin D₃ supplementation and light. The main nondietary types of rickets and osteomalacia include: a) X-linked vitamin D-resistant, hypophosphatemic rickets; b) hereditary hypercalciuria with hypophosphatemic rickets; c) Dent's disease including certain types of renal Fanconi syndrome; d) renal 1α-hydroxylase deficiency; e) defects in the 1,25-dihydroxy vitamin D₃ receptor (end-organ resistance); f) autosomal dominant forms of rickets; and g) oncogenic hypophosphatemic osteomalacia. This review will describe the recent advances in our knowledge of the molecular defects in hypophosphatemic rickets and tumor-acquired osteomalacia. This paper was presented at the 2nd International Forum “The Frontiers of Nephrology,” Tokyo, May 10, 1998.     

An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability

Between 1976 and 1985, we repaired avulsion of the glenohumeral ligaments in sixty-three shoulders (sixty-one patients) that had traumatic anterior glenohumeral instability. We describe the indications for operation, the operative technique, and the findings at the time of operation. We located thirty-seven patients (thirty-nine shoulders) for clinical follow-up (average, 5.49 years). One patient had recurrent anterior dislocation four years postoperatively, but no patient needed reoperation. The average range of motion was 171 degrees of forward elevation and 84 degrees of external rotation in abduction. According to the criteria of Rowe et al., 97 per cent of the results were good or excellent.     

Arthroscopic removal of giant loose bodies in the glenohumeral joint

INTRODUCTION

Loose bodies within the joint because of any cause have the potential for continued growth.

PRESENTATION OF CASE

A 41-year-old man had suffered multiple recurrent dislocations of his left shoulder, accompanied with pain. His anterior apprehension and relocation tests were positive, but no other sign was noted on physical examination. On magnetic resonance imaging and at arthroscopy, two giant loose bodies were seen. They were in the axillary recess and were removed arthroscopically.

DISCUSSION

Most authors recommend surgical removal of the cartilaginous loose bodies to ameliorate the symptoms. Furthermore, the majority of authors recommend a synovectomy to decrease the risk of recurrence. Depending on the size of the chondral loose bodies, removal can be performed via an arthrotomy, arthroscopy with mini-open arthrotomy, or arthroscopy.

CONCLUSION

The source of the loose body should be determined carefully. Other lesions may be associated with the loose body. Arthroscopic treatment is a good option for removing the loose body.     

Arthroscopic repair of anterior glenohumeral instability and rotator interval lesions

As the techniques and instrumentation for shoulder arthroscopy continue to improve and evolve, its role in the treatment of anterior shoulder instability progresses also. With more surgeons becoming familiar with these advancements and techniques, arthroscopic stabilization results continue to improve and help arthroscopy become the "preferred method" for the treatment of shoulder instability. Adjunct procedures such as closure of the rotator interval also are helping to improve our arthroscopic results and are an important improvement in our understanding of the pathoanatomy of shoulder instability repairs.     

Anorexia nervosa, osteoporosis and circulating leptin: the missing link

Summary  

Methods: Leptin levels were measured in 103 consecutive women with anorexia nervosa. Results: Spine BMD and Z-score values were found to be significantly lower in the low tertile compared with the highest tertile. Duration of amenorrhea and leptin level accounted for 27% of the variance in lumbar spine BMD.     

Arthroscopic reconstruction of the lateral ankle ligaments: Radiological evaluation and short-term clinical outcome

Purpose

The purpose of this study was to describe the positioning of bone tunnels of arthroscopic anatomical reconstruction of lateral ankle ligaments (AAR-LAL) and identify radiological measurements associated with short-term clinical outcome one year after surgery.