Arthroscopic Management of a Rare Case of Melioidotic Septic Arthritis of the Ankle in a New Endemic Area on the Southwest Coast of India: A Case Report.

CASE: We report a case of melioidotic septic arthritis of the ankle and secondary osteomyelitis of the talus in a 64-year-old farmer with diabetes mellitus. Arthroscopic drainage and debridement, followed by 6 months of appropriate antibiotic therapy, resulted in a good short-term outcome. CONCLUSION: Melioidotic septic arthritis of the ankle is extremely rare. This case report highlights the possibility of this disease occurring on the Indian subcontinent.

Clinico-Radiological Correlation of Subcoracoid Impingement with Reduced Coracohumeral Interval and its Relation to Subscapularis Tears in Indian Patients.

INTRODUCTION: Clinically, subcoracoid impingement is characterized by pain at the anterior aspect of the shoulder that is induced by adduction, internal rotation and forward flexion. This position leads to narrowing of the Coraco-Humeral Interval (CHI)-that is, the space between the coracoid process and the lesser tuberosity of the humerus. Structures in the rotator interval are at greatest risk for impingement which includes the Subscorapularis tendon, tendon of the long head of the biceps, and the middle gleno-humeral ligament. This may result in Rotator interval pathologies such as subscapularis tear and long head of biceps tendon subluxation or fraying. AIM: To study the prevalence of radiological evidence of reduced Coraco-Humeral Interval (CHI) in patients with clinically evident Subcoracoid impingement and to examine the presence of Subscapularis tears in these patients. MATERIALS AND METHODS: Twenty four patients (6 males, 18 females, average age 52.83 years) were included in this prospective study who were diagnosed to have rotator cuff tears clinically. Nine of these patients were clinically found to have concomitant subcracoid impingement. All patients were subjected to MRI of shoulder. Measurement of the CHI was done in images with humerus in maximal internal rotation. Presence of subscapularis tear was examined intraoperatively. Statistical evaluation of the data was performed using Student's t-test and Fisher's exact test and the results were applied to two cohorts of patients. One cohort consisted of patients who had a CHI value of less than 5.5mm and the other cohort had a CHI value greater than 5.5mm. Average CHI values in patients with and without a subscapularis tear were determined. RESULTS: Nine patients who had clinical subcoracoid impingement were found to have an average CHI of 5.33mm. All nine of them had an associated tear of subscapularis with long head of Biceps tendon subluxation and/or fraying. Remaining 15 patients had an average CHI of 10.48 and they did not have either signs of Subcracoid impingement or subscapularis tear but had a tear elsewhere (Supraspinatus or Infraspinatus). Difference between these two groups was found highly significant (p-value<0.001). All patients with a CHI value of equal to, or less than 5.5mm had a subscapularis tear, whereas only 11% of patients with a CHI value more than 5.5mm had a tear (p-value<0.001, highly significant). CONCLUSION: Reduction in the CHI has a significant association with rotator interval pathologies such as subscapularis tears and subluxation or fraying of long head of biceps tendon. Treatment of such patients should include modalities such as coracoplasty or anterior shoulder stabilisation. We recommend that clinical evidence of subcoracoid impingement should lead to further Investigation in the form of MRI and estimation of CHI. A CHI of less than 5.5 mm may indicate subscapulais tear in Indian patients.

Stress Distribution in Superior Labral Complex and Rotator Cuff During In Vivo Shoulder Motion: A Finite Element Analysis.

PURPOSE: To quantitatively and qualitatively evaluate the impingement behavior between structures within the glenohumeral joint under simulated abduction-external rotation (ABER) motion using finite element analysis. METHODS: Computed tomography (CT) scanning of 1 shoulder in a volunteer was performed at 0° and 120° of shoulder abduction with external rotation (ABER position), followed by magnetic resonance imaging at 0° of abduction. The CT and magnetic resonance images were then imported into a customized software program to undergo 3-dimensional reconstruction followed by finite element modeling of the bone and soft tissue including the upper part of the rotator cuff and glenohumeral labral complex. Glenohumeral motion from 0° to the ABER position was simulated by CT images in 2 different humeral positions. On the basis of simulated humeral motion with respect to the scapula, we measured the stress value on the biceps-labral complex and upper part of the rotator cuff as a consequence of their structural deformation. In addition, we intended to design 2 types of labra--a normal stable labrum and an unstable posterosuperior labrum--to evaluate the geometric alteration and resulting stress change on the posterosuperior labrum against a compressive force from the humeral head and rotator cuff. RESULTS: In the ABER position, the posterosuperior labrum was deformed by the humeral head and interposed posterior part of the rotator cuff. When viewed from the rotator cuff, the posterior part of the rotator cuff came into contact with the posterosuperior labrum as external rotation increased. The measured peak contact stress values were 19.7 MPa and 23.5 MPa for the posterosuperior labrum and the upper rotator cuff, respectively. The stress values for both structures decreased to 5.8 MPa and 18.1 MPa, respectively, in the simulated SLAP model. The root of the long head of the biceps became compressed halfway through the range of motion by the humeral head, especially from the part involving horizontal extension and external rotation, resulting in a high stress of 22.4 MPa. CONCLUSIONS: In this simulated SLAP model, the posterosuperior labrum was medially displaced by the humeral head and upper rotator cuff in the ABER position, causing a functional loss of the spacer effect. CLINICAL RELEVANCE: In SLAP lesions, the posterosuperior labrum loses its ability to function as a spacer in certain positions (especially ABER) and may decrease the important spacer effect between the humerus and the rotator cuff; this may lead to posterosuperior subluxation of the humeral head or rotator cuff abnormalities and tears during repetitive ABER tasks.

In vivo analysis of acromioclavicular joint motion after hook plate fixation using three-dimensional computed tomography.

BACKGROUND: The clavicle hook plate can be used to treat acromioclavicular and coracoclavicular ligament injury or distal clavicular fracture with comminution. However, the hook plate can induce subacromial impingement, resulting in discomfort from the hardware. METHODS: Our inclusion criteria were (1) men and women aged older than 20 years and (2) the presence of comminuted distal clavicular fractures (Neer type IIB) fixed with a hook plate (Synthes, Oberdorf, Switzerland). Three-dimensional computed tomography was obtained before removal of the hook plate. Seven patients were enrolled prospectively. The mean age was 42 years (range, 24-60 years). Zero degree images and abduction images were obtained. The sagittal cut surface was obtained 5 mm medial from the distal clavicle. The equator of the cut surface of the clavicle was compared with the full abduction model to analyze rotation. The center of the cut surface of the clavicle was compared with the full abduction model to analyze translation. RESULTS: The average difference in rotation of the distal clavicle between both shoulders was 16° (range, 3°-22°; P = .001). The mean difference in anterior translation of the distal clavicle was 2.2 mm (range, -0.7 to 5.6 mm; P = .030). CONCLUSION: Hook plate fixation at the acromioclavicular joint causes decreased internal rotation and increased anterior translation of the distal clavicle with respect to the medial acromion, indicating that the scapula relative to the thorax has decreased posterior tilting and increased external rotation in shoulders fixed using a hook plate.