Capsular Ligamentous Complex Research Articles

Is external rotation the correct immobilisation for acute shoulder dislocation? An MRI study

Anterior dislocation of the shoulder is frequent, with high rates of recurrence. Immobilization in external rotation (ER) seems to improve results, although few studies have actually demonstrated this. The present MRI study examined the impact of ER on labral and capsular ligamentous complex lesions after primary dislocation. A prospective study was started up on January 1st, 2007. Inclusion criteria were: acute initial anteromedial dislocation of the shoulder, without past history of shoulder trauma. There were 23 such patients, with a mean age of 37 years. Early MRI scan used the following protocol: one acquisition in internal rotation followed by one in ER. Study criteria were: hemarthrosis, ER amplitude, rotator cuff status, bone lesion, and labral lesion stage (Habermeyer's classification) and displacement (Itoi criteria). There were 12 right and 11 left shoulders. Mean time to MRI was 3.7 days. There were three rotator cuff tears, no glenal lesions, and 14 humeral notches. Hemarthrosis was almost systematically present, with its distribution modified by ER in 75% of cases; three patients showed no posterior hemarthrosis, in whatever rotation. Mean ER was 37 degrees. On Habermeyer's classification, there were 12 stage-1 lesions, and 10 stage-2; one patient had no labral lesion. All separated labra were reduced in ER, five (21%) totally. In six cases, labral displacement changed according to rotation. All anterior joint effusion was reduced in ER, in three cases totally. According to Itoi among others, immobilization in ER is the way to reduce recurrence of anterior dislocation. The present study confirmed that labral reduction was systematic with ER, but it was by no means always complete. ER seemed more effective in reducing the separation. Results further confirmed that ER reduced anterior capsule volume, a recurrence factor. ER reduced hemarthrosis, anterior capsule detachment and labral lesions, and never the contrary. The interest of immobilization in ER to prevent shoulder instability needs confirming by long-term clinical studies; we are therefore extending the present MRI study by a clinical study of ER immobilization in all patients showing significant labral lesion reduction. Level IV. Retrospective therapeutic study.

Turf Toe: Soft Tissue and Osteocartilaginous Injury to the First Metatarsophalangeal Joint

The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Turf toe has been reported to occur in athletes who participate in sporting activities. An injury to the plantar capsular ligamentous complex can result in acute and chronic pain, resulting in time lost from sports participation for a short- or long-term period. Classification of this injury is based on clinical findings and imaging studies, including plain radiographs and magnetic resonance imaging. The early recognition of this injury is crucial to successful treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. In the high-performance or elite athlete, a turf toe or severe dorsiflexion injury can be disabling, and can threaten an athlete's career if not treated properly.

Does an ulnar styloid fracture interfere with the results of a distal radius fracture?

BackgroundThe ulnar styloid is a supportive structure for the capsular ligament complex of the distal radioulnar joint. The relation between fractures of the ulna and distal radius is not clear, especially in regard to whether ulnar fractures predict worse outcomes for distal radius fractures. The objective of this study was to analyze the influence of ulnar styloid fractures in patients with reducible and unstable distal radius fractures. MethodsA total of 100 patients with unstable and reducible distal radius fractures, with or without an ulnar styloid fracture, were randomly assigned to treatment with transarticular bridging external fixation or transulnar percutaneous pinning. Follow-up was obtained for 91 patients. For the secondary data analysis, three patient cohorts were created: a no ulnar styloid fracture group with the radius fracture treated by pinning or external fixation (n = 30); an ulnar styloid fracture with radius fracture group treated by external fixation (n = 31); and an ulnar styloid fracture with radius fracture treated by pinning (n = 30). Functional and radiological outcomes were measured at 6 and 24 months. Functional outcome measures included wrist pain (visual analogue scale) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. ResultsAt 24 months, patients with both fractures had worse wrist pain and worse scores on the DASH questionnaire than the patients with an isolated distal radius fracture; and those treated by pinning had less wrist pain and showed better scores on the DASH questionnaire than the patients treated by fixation. ConclusionsUlnar styloid fracture may be a predictive factor of worse functional outcome for distal radius fracture. Pinning and above-the-elbow casting, used to treat ulnar styloid fractures, led to better function than fixation.

Stabilization of first metatarsophalangeal instability with plantar plate tenodesis

First metatarsophalangeal instability is an uncommon condition. It is resulted from disruption of the capsular-ligamentous complex, e.g. after dislocation of the hallux metatarsophalangeal joint or after turf-toe injury. The patient will experience pain with push-off and hallux rigidus type of symptoms. We present a technique to stabilize the first metatarsophalangeal joint by anchoring the plantar plate to the extensor hallucis longus tendon.

The latarjet procedure for recurrent anterior shoulder instability: Rationale and technique

The Latarjet coracoid transfer procedure provides a “triple blocking” effect in the treatment of anterior shoulderinstability. First, the coracoid bone block increases the anterior posterior diameter of the inferior portion of the glenoid fossa, making it more difficult for the humeral head to subluxate or dislocate. Second, the conjoined tendon acts as a sling reinforcing the inferior capsular ligamentous complex and the inferior portion of the subscapularis. Finally, repair of the inferior capsular ligamentous complex to the stump of the coracoacromiai ligament reconstructs the capsulolabral anatomy. We describe our preferred technique for this procedure. With proper patient selection and systematic surgical technique, instability can be eliminated without loss of external rotation in more than 98% of cases.

MR arthrography of the labral capsular ligamentous complex in the shoulder: imaging variations and pitfalls.

Using MR arthrography, we examined normal anatomy, anatomic variations, and pitfalls of imaging the labral capsular ligamentous complex in the asymptomatic shoulder. We obtained 108 MR arthrograms of the glenohumeral joint in 95 asymptomatic volunteers with axial (108 shoulders) and oblique coronal (56 shoulders) images. We examined labral shape, patterns of capsular insertion, presence or absence of glenohumeral ligaments, and pitfalls of imaging. Our patients were men (auxiliary policemen) between 19 and 24 years old (mean age, 21 years). The shapes of labra were triangular (anterior part, 64%; posterior part, 47%), round (17%; 33%), flat (2%; 17%), cleaved (11%; 1%), notched (3%; 0%), or absent (2%; 2%). Using the system of Mosely and Overgaard, the anterior capsular insertion was type 1 in 63% of shoulders, type 2 in 20%, and type 3 in 17%; the posterior capsular insertion was type 1 in 60% of shoulders, type 2 in 31%, and type 3 in 9%. The superior and inferior glenohumeral ligaments were present in 99% of shoulders, but the middle glenohumeral ligament was present in only 79%. We also detected many pitfalls of MR imaging in identifying findings such as the undercutting of the labrum by cartilage (32% of shoulders), prominent axillary folds (46%), sublabral holes (7%) or recesses (33%), Buford complexes (2%), and sulci between the biceps tendon and superior labrum (30%). Knowledge of normal anatomy and anatomic variations of the labral complex is important for the examination of the shoulder with MR arthrography.

Magnetic resonance evaluation of the labral capsular ligamentous complex: a pictorial review.

Magnetic resonance imaging of the shoulder is a common imaging test, and in the course of routine evaluation it can provide accurate information regarding the labral capsular ligamentous complex (LCLC). Common patterns of labral injury include fraying, flap tears and labral distraction, which can be readily identified on both coronal and axial planes by paying attention to signal and morphological characteristics. Capsular and ligamentous pathology may be subtle, but is recognizable using a high-resolution technique that has differential contrast between native intra-articular fluid and the adjacent labrum and capsular restraints. Common patterns of capsular injury include a thickened, hyperintense capsule, sometimes with disruption and retraction. The inferior glenohumeral ligament is the primary stabilizer of the shoulder joint, and although failure of this structure is uncommon, the injury is easily identified. Shoulder instability is a common presentation, the diagnosis of which is dependent upon recognizing various injury patterns including Bankart lesions, reverse Bankart lesions, anterior labroligamentous periosteal sleeve avulsion (ALPSA) and failure of the inferior glenohumeral ligament.

Cine-MR imaging of the shoulder.

Shoulder lesions are usually examined with the joint in only one or two positions. We examined the shoulder with the joint in a variety of positions. We also assessed the application of cine-MR to the detection of instability and impingement. The cine-MR examinations were performed in 30 patients and 15 healthy volunteers. We used an open 0.2 T system and a closed 1.0 T system. Spoiled gradient echo 2D T1-weighted images and turbo spin-echo T1- and T2-weighted images were obtained with a field of view of 180 mm. The examinations were videotaped and evaluated later. Normal variations of the glenohumeral joint were easy to recognize. Sub-luxations and luxations of the humeral head as well as rupture of the labrum were identified. It was also possible to identify the labrum with a signal change after arthroscopic refixation. And we were able to objectively assess distances between the osseous structures during dynamic movement. Unlike static MR, cine-MR would appear to be useful in visualizing the capsular ligament complex of the gleno-humeral joint in impingement and instability. It also provides information on dynamic changes and may thus prove to be an important tool for shoulder diagnostics. The method may provide an early diagnosis in the sub-acromial impingement syndrome.

Biodegradation and restitution of the intercellular matrix in preserved fragments of dense fibrous connective tissue after their grafting into the recipient

Results are presented from a study in which the structural arrangement of the intercellular matrix was examined in preserved connective tissue fragments (allografts) after their implantation into rabbits to repair posttraumatic space-occupying defects in the capsular-ligamentous complex of the knee joint. Stages of biodegradation and restitution undergone by the interstitial substance of connective tissues after the implantation of allografts are identified.

CT and MR evaluation of the labral capsular ligamentous complex of the shoulder.

Stability of the glenohumeral articulation is dependent on the integrity of the rotator cuff, labrum, glenohumeral ligaments, capsular elements, and bony glenoid. The importance of the soft-tissue elements in maintaining stability has been well documented in the surgical literature but has only recently been introduced into the radiologic literature. The purpose of this essay is to illustrate the normal labrum, capsular complex, and glenohumeral ligaments, including common congenital variations as depicted by CT arthrography and MR imaging, and to describe the pathologic findings leading to shoulder instability.

Primary Total Knee Arthroplasty in Patients With Fixed Valgus Deformity

Ninety-nine knees in 81 patients evaluated from two to ten years and having enough valgus deformity to require specific soft-tissue release were studied. They were also compared to a control group of 40 knees in 31 patients with no angular deformity greater than 5 degrees, who were matched for age and diagnosis. All procedures were performed using a minimally constrained, posterior-cruciate-ligament-sparing prosthesis. Pre- and postoperative axial alignment was measured on weight-bearing long-standing roentgenographs. Analysis included examination for lucent lines in postoperative fluoroscopically positioned roentgenographs and clinical data summarized using the 100-point scoring systems developed by The Knee Society. Knees were classified as having Type I, II, or III valgus deformities: Type I was defined as valgus deformity secondary to bone loss in the lateral compartment and soft-tissue contracture with medial soft tissues intact; Type II was defined as obvious attenuation of the medial capsular ligament complex; and Type III was defined as severe valgus deformity with valgus malpositioning of the proximal tibial joint line after overcorrected proximal tibial osteotomy. Only cases of Type I and Type II were represented in the 99 knees reported. Type I patients were treated with lateral soft-tissue release, and Type II patients were treated with medial capsular ligament tightening (i.e., ligament reconstruction procedures on the medial side). The Knee Society postoperative knee score was 87.6 (+/- 10.6) and mean postoperative functional score was 52.3. Alignment was well corrected and knee scores for the Type I and II groups were almost identical as were the functional scores. The results were grouped as 72% excellent, 18% good, 7% fair, and 2% poor. Notably, the control group was 39 of 40 patients excellent, and only one poor. Ligament stability was satisfactorily established by lateral release in Type I and with the combined medial plication in the Type II patients. The ligament-tightening procedures were on the average 40 minutes longer than those for the Type I or the control groups. The controversial nature of the simultaneous ligament reconstruction method is recognized, but good experience is reported.

Lateral capsualr ligament complex: anatomical and surgical considerations.

Acute avulsion of the bony attachment of the lateral capsular ligament was observed on x-ray films in September 1975. Seven instances were confirmed at surgery during the following 29-month period. The avulsion was reproduced in six amputation specimens which were dissected to identify the components of the lateral capsular complex. Dynamic studies were performed on a set of amputation specimens to determine the role of the various structures contributing to lateral rotary instability. The dissection revealed that the lateral capsular ligament complex has vertical and horizontal components. The dynamic studies showed that lateral pivot shift was produced by a lateral capsular release, a complete section of the anterior cruciate ligament, and a partial tibial collateral ligament release. Based on these observations, 30 patients have subsequently had reconstructive surgery to eliminate their lateral rotational instability. In the reconstruct procedure, both the bony attachment of the lateral capsular ligament and the iliotibial tract with Gerdy's tubercle have been moved anteriorly and inferiorly without separating their interconnections or any attachments. Clinical experience in these 30 patients supports the evidence obtained in the dynamic studies. Restoration of stability is secure when both the lateral capsular ligament and the iliotibial tract are advance with their anatomical connections intact.