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Ryuzo ARAI, Masahiko KOBAYASHI, Shinichiro NAKAMURA, Takashi NAKAMURA
2010 Volume 34 Issue 2 Pages
289-291
Published: 2010
Released on J-STAGE: September 03, 2010
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It is important to understand the precise structure of the soft tissue around the superior glenoid in order to consider the etiology of SLAP (superior labrum anterior and posterior) lesions. The purpose of this study was to histoanatomically investigate the fibers of the superior labrum. Forty-nine embalmed shoulder joints of cadavers were used. After the shoulder girdle was cut off, posterior rotator cuff muscles were detached from the capsule. The posterior capsule was resected taking care not to injure the glenoid and anterior soft tissue. After recording macroscopic findings by a digital camera, Hematoxylin-Eosin stain was performed in 11 shoulders. Furthermore, Elastica van Gieson was stained in selected specimens. In the posterior part, the long head of the biceps tendon (LHB) fibers intermingled with the superior labrum. LHB fibers were kept from connecting to the anterosuperior labrum by the sheet-like structure branching off the rotator interval tissue. This sheet-like structure was abundant in elastic fibers, which were not found much in other parts of the superior labrum, and different from the superior glenohumeral ligament. The results suggest that most of the LHB fibers exist in the posterior portion of the glenoid which resist the traction force from the biceps brachii muscle. This is quite reasonable considering that the bicipital groove is usually located more anteriorly than the LHB origin. As the sheet-like structure histologically connects the rotator interval tissue and anterosuperior labrum, the anterosuperior labrum could work as a part of the flexible support system of the humeral head which tends to move slightly anteriorly.
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Kengo KIRIMURA, Atsuhiko MOGAMI, Kiyohito NAITO, Kazuo KANEKO
2010 Volume 34 Issue 2 Pages
293-296
Published: 2010
Released on J-STAGE: September 03, 2010
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We investigated the shape and development of the human shoulder from shoulder anatomy of Macaca.
We examined (1)location and shape of the acromion (2) anatomical investigation of the rotator cuff insertion to the humerus head (3) The presence of the coracoacromial ligament (4) shape of the supraglenoid tubercle, in 4 cadaveric shoulder of Macaca Mulatta.
The following results were found (1)The acromion of apes was smaller than that of humans. The acromion did not cover up most of the humerus head. (2) The humeral head had individually the rotator cuff insertion part to subscapularis, supraspinatus, the infraspinatus tendon, and the overlapped point with each other was not found. Greater and lesser tubercle size were approximately similar, and the long head of the biceps tendon was located in the center. Also, the teres minor muscle tendon was not present. (3) The acromial position is located on the back of the rib cage rather than human. The coracoacromial ligament was not present. (4) The supraglenoid tubercle was noticeably concave from cranial to the caudal,with the craninal portion jutting forward to overhang.It was suggested that an infraspinatus muscle tendon was an important muscle in a rotator cuff and the coracoacromial ligament occurred as an antero-superior supporting tissue of the shoulder.
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Hideya YOSHIMURA, Keiichi AKITA, Atsuo KATO, Kumiko YAMAGUCHI, Tomoyuk ...
2010 Volume 34 Issue 2 Pages
297-299
Published: 2010
Released on J-STAGE: September 03, 2010
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The sternoclavicular (SC) joint has a critical role in the function of the shoulder, because it is a medial fulcrum of clavicular movement, having a wide range of motion and great force. However, the involvement of the joint has not been well documented. The purpose of the current study is to investigate the structure of the discus in the SC joint. Specimens from 20 joints of 10 cadavers were examined in this study. The specimens were decalcified and cut along the coronal plane. Each coronary sliced specimen was paraffin-embedded to be examined by histologically. Specific attention was given to the attachment between the discus and the intercalvicular ligament. The discus attached above the posterosuperior border of the clavicle and below the lateral end of the clavicular notch of the sternum. The superior part of the discus, together with the joint capsule, is inserted into the medial end of the clavicle and is thicker than the inferior one. The specimens in which the medial borders of the clavicles overhung the clavicular notch of the sternum showed the interclavicular ligaments connecting the superior and posterior borders of discus. In the specimens with a good joint congruity, the discus was attached with the periosteum of the clavicular notch of the sternum. The discus was perforated at the center of the inferior part in 5 specimens. The findings of this study suggested that the existence of the interclavicular ligament depended on the bony congruity of the SC joint and this ligament fibro-connecting with the joint capsule provided stability of the discus of the SC joint. The disc function is considered to be as a shock absorber within the joint. Our findings indicated that the forces along the lower part of discus during elevation or anterior-posterior rotation might result in the perforation of this part.
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Atsuo KATO, Kumiko YAMAGUCHI, Keiichi AKITA, Tomoyuki MOCHIZUKI, Hiroy ...
2010 Volume 34 Issue 2 Pages
301-304
Published: 2010
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In order to understand the functions of teres minor, examining the compositions of teres minor muscle and the innervation of the muscle is very important. We used 20 shoulders from 10 cadavers in this study. We investigated the composition of the muscle bundles of teres minor and the innervation of this muscle. In addition, we examined four shoulders to investigate the insertions of the muscle bundles of teres minor muscle histologically. Teres minor muscle was composed of the upper part and the lower part. The upper part originated from the dorsal surfaces of the lateral edge of the scapula. The lower part originated from the fascia between teres minor muscle and infraspinatus muscle and the inferior surfaces of the lateral edge of the scapula. Two parts changed the positional relationship in the orgin and insertion. The upper part was situated inferiorly in the origin, however it was situated superiorly in the insertion. These two parts could not be separated from each other clearly. In the area of insertion, the upper part had a round-shaped attachment in the posterior surface of the greater tuberosity. On the other hand, the lower part had a line-shaped attachment in the surgical neck of the humerus. In cross-section of teres minor, its intramuscular tendon had two parts ; thick part superiorly, and thin part inferiorly. Teres minor was innervated by branches of the axillary nerve from the dorsal surface. The upper part and the lower part were innervated by independent branches of one nervous trunk to the muscle. According to the present findings of the innervations, the upper part and the lower part of teres minor muscle are almost totally independent from each other like two heads of the one muscle.
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Akira GOTO, Makoto TANAKA, Hayato KOISHI, Wataru SAHARA, Kazuomi SUGAM ...
2010 Volume 34 Issue 2 Pages
305-308
Published: 2010
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The bony anatomy of the shoulder is one of minimal constraint. Therefore, glenohumeral ligaments play an important role in stabilizing the shoulder. The focus of many biomechanical investigations has been to clarify the function of glenohumeral ligaments at the extremes of shoulder motion “end range motion”. Atraumatic multidirectional instability is often associated with disability of glenohumeral ligaments, during mid range motion. However, it is impossible to know how they function in vivo during shoulder motion. To help elucidate this stabilizing role, we conducted in vivo three-dimensional kinematics of the normal shoulder joint using a three-dimensional image matching technique. Magnetic resonance images of 14 shoulder joints of 7 healthy volunteers were acquired for 7 isometric abduction positions between 0° and 180°. By combining in vivo three-dimensional kinematic data, with in vitro anatomical study of the ligaments, we simulated three-dimensional shortest paths between the origin and insertion of each ligament in each abduction position. At 0° of abduction, the posterior band of the coracohumeral ligament displayed a maximum length of 41.4mm ± 4.8. At 30° of abduction, the superior glenohumeral ligament displayed a maximum length of 38.0mm ± 5.2. At 60° of abduction, the anterior band of the coracohumeral ligament and the middle glenohumeral ligament displayed maximum lengths of, 39.3mm ± 5.0, 48.1mm ± 6.6 respectively. At 120° of abduction, the anterior band of the inferior glenohumeral ligament displayed a maximum length of 56.6mm ± 4.0. The present study had some limitations. The origin and insertion of the ligaments were determined only on the basis of the anatomical information of another subject. Although this measurement could not reflect the actual ligament length in each subject, we think that the maximum length of these results is an important influence on the function of the soft tissue stabilizer and could be essential when considering surgical procedures and physical exercise after surgery.
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Makoto TANAKA, Kazuomi SUGAMOTO, Hiroshi MINAGAWA
2010 Volume 34 Issue 2 Pages
313-316
Published: 2010
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Disorders of the biceps long-head tendon(LHB) can be one of the sources of pain after rotator-cuff repairs. It is important to evaluate the presence of LHB disorders preoperatively, in order to minimize or manage the postoperative shoulder pain. However, they are difficult to be assessed by MRI and physical examinations. Therefore, we used ultrasonography(US) to evaluate the LHB lesion, and analysed the diagnostic values of clinical examinations. We performed ultorasonographic evaluation of 122 shoulders of 61 outpatients over the age of 50. One patient (2 shoulders) was removed from this study because of poor study of US due to the patient's obesity. Therefore, final objectives were 120 shoulders of 60 patients. We also tested Speed's test, Yergason's test and the tenderness of the bicipital groove (TD) of all patients and analysed the sensitivity, specificity and positive and negative predictive values(PPV, NPV) of each test. 56 out of 122 shoulders had the LHB lesions under the US, including 19 effusions, 4 effusions+subluxations, 5 subluxations, 4 natural tenodesis, 13 hypertrophies + subluxations, 2 dislocations, and 9 tears. LHBs were difficult to detect in 2 shoulders of 1 obese patient. Sensitivities of Speed's test, Yergason's and TD for the LHB lesion by US were 16.1%, 5.3% and 39.3%, respectively. Specificities of each test were 95.3%, 96.9%, 79.7%. The PPVs and NPVs were 75.0%, 60.0%, 62.9% and 56.5%, 53.9%, 60.0%, respectively. Specificities of each physical examination were high but those sensitivities, PPVs and NPVs were low, as previously reported. The results confirmed the low reliabilities of Speed's test, Yergason's test and TD. LHB lesions at bicipital grooves, which are difficult to be evaluated by MRI or arthroscopy, can be easily and accurately detected by US.
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Hisahiro TONOTSUKA, Hiroyuki SUGAYA, Norimasa TAKAHASHI, Yoshihiro HAG ...
2010 Volume 34 Issue 2 Pages
317-320
Published: 2010
Released on J-STAGE: September 03, 2010
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Recently, several authors insist on the importance of evaluating the glenoid morphology using 3DCT prior to arthroscopic stabilization. On the other hand, conventional radiography such as West Point view can not effectively demonstrate the anterior glenoid rim. We developed a new X-ray method which can easily demonstrate anterior glenoid rim lesions. The purpose of this study is to evaluate this new method through comparison with the West Point View. Subjects consisted of 40 patients with unilateral recurrent anterior glenohumeral instability, including 34 males and 6 females. Informed consent was obtained from all patients prior to initiating this study. Radiographic evaluation was performed with X-rays in the new method and West Point view on both sides. Diagnostic capability of the new method was evaluated by 2 blinded orthopaedic surgeons regarding morphology of the anterior glenoid rim through the comparison with the West Point view and 3DCT of the same shoulder. The new method clearly demonstrated the anterior glenoid rim in 39 shoulders (97.5%) whereas the West Point view demonstrated it only in 22 shoulders (55.0%). Thirty-four shoulders (85.0%) were diagnosed as positive anterior glenoid rim lesions in the new method while only 9 shoulders (22.5%) were diagnosed as pathological in the West Point view. Further, 37 shoulders (92.5%) corresponded with the 3DCT findings. The new X-ray method is useful in evaluating the anterior glenoid rim morphology in shoulders with recurrent anterior glenohumeral instability.
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Norimasa TAKAHASHI, Hiroyuki SUGAYA, Hisahiro TONOTSUKA, Yoshihiro HAG ...
2010 Volume 34 Issue 2 Pages
321-324
Published: 2010
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Glenoid bone loss is a significant risk factor in surgery for anterior glenohumeral instability. We formulated a new radiographic technique which enables us to observe the glenoid morphology without the fluoroscopy. The purpose of this study is to assess the effectiveness of the new radiographic technique in a series of patients with anterior glenohumeral instability. Ninety five patients with recurrent anterior glenohumeral instability were included in this study. The X-ray was applied from 15-20 degrees cranially in lateral decubitus position. The glenoid views were classified into three groups including a fragment type, an attritional type and a normal type using contra-lateral control by three blinded observers. The results were verified by 3DCT. The fragment types and attritional types were classified to three subtypes, including small, medium, large and mild, moderate, severe respectively. The diagnostic rate in each type and subtype were obtained and a sensitivity and specificity were calculated. According to 3DCT, there were 33 fragment types (16 small, 17 medium to large), 55 attritional types (30 mild, 25 moderate to severe) and 7 normal types. The diagnostic rates using the radiographs were 62.6% in fragment type (small 64.6, medium to large 58.8), 76.2% in the attritional type (mild 55.6, moderate to severe 86.7) and 69.7 in the normal type. Sensitivity/specificity in each group was as follows, fragment: 62.6/94.1%, attritional: 62.4/70.8% and normal: 76.1/82.6%. Our new method diagnosed the glenoid morphology with the rate 63 to 76%. The better diagnostic rate was obtained in the moderate to severe attritional type compared to the mild attritional type. The modest sensitivities were found in each type and the higher specificity was observed in fragment type. We concluded that our new method can be valuable for the screening of glenoid morphology in patients with glenohumeral instability.
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Katsuhiro OTA, Hiroaki TSUTSUI, Kenichi MIHARA, Kazuhide SUZUKI, Daisu ...
2010 Volume 34 Issue 2 Pages
325-328
Published: 2010
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The aim of this study is to reveal the relationship of the shoulder joint components from humeral elevation using X-ray. We selected 39 people without current shoulder symptoms or history of previous injuries of the shoulders. The X-rays were taken both arm at side and the maximum elevated position of the shoulder joint. As the result of this study, humerus was abducted 167.78 degrees. Clavicle was shifted 16.85 degrees. Sternum was shifted 8.1mm inferiorly. CL angle was 123.72 degrees. Scapular upward rotation was 51.89. The relation of each component has a significant correlation between ABD and scapular upward rotation, scapular upward rotation and clavicle, sternum and clavicle, CL angle and clavicle, and to take part also by ABD in the CL angle and the GH angle. During elevation of the arm, the scapular upward rotation and the range of GH joint took great part adding the small part of momentum of the clavicle. It was possible to guess at the motor function of the component during shoulder elevation with 2 pictures, and it's use as some help in functional diagnosis was suggested.
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Masatoshi AMAKO, Hiroshi ARINO, Yoshifumi TSUDA, Masamitsu TANAKA, Shi ...
2010 Volume 34 Issue 2 Pages
329-332
Published: 2010
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Virtual CT arthroscopy has been recently developing to visualize intra- articular lesions. We made an attempt to use this diagnostic tool for the evaluation of the superior labral lesions. 20-25ml room air was injected into the glenohumeral joint under a fluoroscopy. A multi-slice CT was taken on the shoulder position of the maximum flexion and abduction with two different elbow positions: flexion and extension. This is a clinical test for diagnosing superior labral injury, and named with forced shoulder abduction and elbow flexion test, defined as positive when pain was relieved by elbow flexion. The image data were put into the image reconstruction software, and the joint surface view of the glenoid was obtained. The images were compared between two elbow positions. The long head of the biceps tendon and the superior labral complex was able to be viewed with the 3D shoulder virtual arthroscopy. Type II SLAP lesion could be diagnosed with peel back phenomenon to compare the two images with different elbow positions. 3D virtual images are considered to be essential for preoperative surgical planning, especially arthroscopic surgery. 3D shoulder virtual arthroscopy is also a useful tool to detect type II SLAP lesion.
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Isshin MATSUMOTO, Yoichi ITO, Tomoya MANAKA, Naoto OEBISU, Nobuyuki NA ...
2010 Volume 34 Issue 2 Pages
333-337
Published: 2010
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Subacromial impingement syndrome or rotator cuff tears are very common shoulder diseases which occur in the subacromial bursa. Subacromial injection of anesthetic during subacromial bursography is very helpful for understanding the pathological condition in the subacromial bursa. The aim of this study was to evaluate the correlation between visual change in the subacromial bursa and its pathology and to identify the significance of subacromial bursographies. We retrospectively evaluated subacromial bursographies of 133 shoulders in 133 patients (78 males, 55 females), who were diagnosed as having subacromial impingement in 71 cases, stiff shoulder in 39 cases, calcifying tendonitis in 5 cases, and partial thickness rotator cuff tear in 18 cases. We classified four types of bursographies based on the visualized portion such as subacromial portion: SA, subcoracoid portion: SC and subdeltoid portion: SD according to the Mikasa's classification. <Type 1: SA, Type 2: SA and SC, Type 3: SA and SD, Type 4: SA, SC and SD> Anesthetic was used during subacromial bursography; pain block effect and improvement of the shoulder motion were statistically analyzed. We observed 76 cases of type 1, 21 cases of type 2, 35 cases of type 3 and 1 case of type 4. There was a correlation between stiff shoulder and SA narrowed subtype in type 1. Pain block effect in type 2 was more significant than other types.Our results showed that four types of new image classification of subacromial bursography are helpful for understanding the pathology in subacromial bursa.
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Masahiko MATSUDA
2010 Volume 34 Issue 2 Pages
339-341
Published: 2010
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The aim of this study is to clarify the natural course of Rockwood grade 3 acute acromioclavicular dislocation without medications.
19 patients who had been diagnosed Rockwood grade 3 acute acromioclavicular dislocation at Yamagata Saisei Hospital from 1998 to 2007, and had also been followed without medications were investigated. They were all men, whose average age at injury was 32.4 years(range, 16 to 67 years). The mean follow-up period was 5.8 years(range, 2 to 9 years). We evaluated pain, limitation of motion, click, appearance, weakness, sensory disturbance, sport activity and satisfaction. The pain, limitation of motion and satisfaction were evaluated with visual analogue scale(VAS: range, 0 to 100). The average point of pain was 7.3(range, 0 to 23), ten cases were 0 points. The average point of limitation of motion was 12.4(range, 0 to 35), nine cases were 0 points. Click existed in 8 cases. Severe float were in seven cases, mild float were in 12 cases. Only one case had weakness, sensory disturbance and discomfort of throwing activity. The average satisfaction was 91.5(range, 84 to 100), seven cases were 100 points.
The natural course of Rockwood grade 3 acute acromioclavicular dislocation without medications had a satisfactory outcome, except for appearance.
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Yu MOCHIZUKI, Yoshihiko NAGATA, Mitsuo OCHI, Shin YOKOYA, Hiromichi OO ...
2010 Volume 34 Issue 2 Pages
343-345
Published: 2010
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We investigated the useful biomaterials for the purpose of the regeneration of the soft tissues of the traumatic instability of the shoulder joint. Based on experimental study, the polyglycolic acid sheet (PGA sheet) was the most suitable material for the regeneration of the soft tissues of the traumatic instability of shoulder joint. We clinically used the PGA sheet for the regeneration of the anteroinferior glenohumeral ligament complex (AIGHL complex) in cases of traumatic instability of the shoulder joint. From 2000, we performed arthroscopic Bankart repair on 330 traumatic instability cases. Out of the 330 cases, we experienced ten cases whose capsule and AIGL complex became thin compared with uninjured cases. 7 cases were male, 3cases were female. The average age was 25.6 years old. The average times of dislocation were 5.8 times. We grafted the PGA sheet to the injured site arranging the size of the graft to adapt to the injured site. We evaluated the clinical results using JSS shoulder instability score. The average JSS shoulder instability score improved from 45.6 points to 91.2 points postoperatively. We did not experience redislocation cases. There was not any difference in the external rotation compared with the uninjured side. There were few reports of the clinical usage of biomaterials for the regeneration of the soft tissues. We applied the PGA sheet for the purpose of the regeneration of the AIGHL complex. The clinical results were preferable.
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Yoshimasa SAKOMA, Nobuhisa SHINOZAKI, Yoshiaki ITOIGAWA, Nobuyuki YAMA ...
2010 Volume 34 Issue 2 Pages
347-350
Published: 2010
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The aim was to clarify the relationship between the anterior apprehension tests at three different abduction angles and the intraarticular pathologies. We retrospectively studied 110 subjects diagnosed with recurrent anterior dislocation of the shoulder. The anterior apprehension test was performed with the arm at 60, 90, and 120 degrees of abduction. We compared the results of the apprehension test with the conditions of SGHL, MGHL, the existence of SLAP lesion and HAGL lesion, the extent of Bankart lesion, the sizes of the osseous defect of the glenoid and the Hill-Sachs lesion. There was no significant correlation between the results of the apprehension test and the extent of Bankart lesion, the condition of MGHL, and the existence of SLAP lesion and HAGL lesion. The SGHL existed in all cases with a negative apprehension test at 60 degrees of abduction, whereas it was torn or absent in 17% of subjects with positive apprehension at 60 degrees. There was a significant difference between two groups (p = 0.011). There were no correlations between the results of the apprehension test and the sizes of the glenoid defect and the Hill-Sachs lesion. The anterior apprehension test performed at 60 degrees of abduction might reflect the integrity of the SGHL.
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Kazuhide SUZUKI, Hiroaki TSUTSUI, Kenichi MIHARA, Daisuke MAKIUCHI, Na ...
2010 Volume 34 Issue 2 Pages
351-353
Published: 2010
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The purpose of this study was to evaluate the complications of arthroscopic Bankart repair using absorbable suture anchors, in traumatic anterior instability of the shoulder. We retrospectively studied 357 patients (287 males and 70 females) ranging from 15 to 68 years of age (average, 25 years old ). The mean follow-up was 21.7 months (range 12-86 months) after surgery. Medical records were reviewed to identify complications in the studied patients. The patients were divided into three groups, P group performed arthroscopic Bankart repair using Panalok anchors, PLs group performed using Panalok loop anchors with single suture technique, and PLd group performed using Panalok loop anchors with dual sutures technique. We performed arthroscopic Bankart repair using 2 to 4 Panalok or Panalok loop suture anchors (average, 3.4) and 5 to 8 sutures (Ethibond) in the PLd group. We evaluated the rate of complications in arthroscopic surgery and after surgery. Dislocation and pulling out of the anchor was seen in 7 cases, breakage of the anchor was seen in 2 cases. There were 28 cases of accidental removal of the sutures from the anchor and tangling of the sutures, and there were 15 cases of damage of sutures. There were some cases of equipment failures including a synovial rasp, a drill, 5 cases of suture punch, 10 cases of suture grasper, 4 cases of cannula, 2 cases of the tip of VAPR. There was a small number of postoperative complications, a nerve injury, none of DVT, none of infection, none of complex regional pain syndrome (CRPS), none of hemarthrosis. Complications associated with arthroscopic Bankart repair are relatively rare. Almost all of the complications were concerned with the technique and instruments in surgery. It was possible to remove the broken instruments arthroscopically. Though injury of sutures was seen especially in PLd group, we can respond to these troubles by using strong sutures and with improvement of drill guide.
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Hiroki FUNASAKI, Mamoru YOSHIDA, Iwao KAN, Soki KATO, Masayuki MOROHAS ...
2010 Volume 34 Issue 2 Pages
355-358
Published: 2010
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The purpose was to evaluate the clinical features and the results of arthroscopic surgery in patients over 40 years of age, who had recurrent dislocations of the shoulder without a full-thickness tear of the rotator cuff. There were 12 patients (male: 5, female: 7) who underwent arthroscopic surgery and were followed for more than 1 year. Their average age at surgery was 47 years old, ranging from 40 to 74 years. All patients underwent arthroscopic Bankart repair using suture anchors. Age at first injury, sports activity, arthroscopic findings, JSS-SIS, and the change of ROM after the surgery were evaluated.
Nine patients had the first dislocation of the shoulder in their twenties. In 4 patients, the interval without dislocation lasted for more than 10 years, even though their shoulders dislocated several times in their teens or twenties. The major reasons for surgery were inability to reduce the dislocation manually and interference with activities of daily living, and/or shoulder re-dislocation at the re-start of sports activities in women in their forties. The JSS-SIS was an average 51 points before the surgery, the pain score was average 10.5 points, and the ROM score average 15.3. That was average 92 points at the final follow-up. The ROM ratio versus the opposite side was 87% in elevation and 63% in external rotation at 6 months after surgery. These values improved to 92% and 80%, respectively, at 1 year after surgery, and had no statistical difference compared to those in patients less than 40 years of age. Arthroscopic Bankart repair for patients over 40 with recurrent dislocation of the shoulder produced satisfactory results. Postoperative limitation of ROM was decreased with the procedure.
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Yoshihiro HAGIWARA, Hiroyuki SUGAYA, Norimasa TAKAHASHI, Nobuaki KAWAI ...
2010 Volume 34 Issue 2 Pages
359-362
Published: 2010
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It is difficult to diagnose capsular injuries (CI) with an ordinary apprehension test. We applied a new method of apprehension test on anterior recurrent dislocation of shoulders to evaluate whether the modified apprehension test can distinguish CI or not. Between October 2007 and March 2009, 198 shoulders underwent arthroscopic Bankart repair. Among these, 186 shoulders (141 males, 45 females, average age: 25.7 years old) were underwent a new apprehension test, which assessed apprehension sign (4 grades; none, weak, moderate, strong) from 0 to 180 degrees at abduction by every 30 degrees with patients lying down on a bed. Twenty-seven shoulders had CI at anterior glenohumeral ligaments. There was no statistical difference concerning as age and sex between the two groups. Bony Bankart lesion occurred at low frequency, and attached/attenuated type and negative occured at high frequency on shoulders with CI. Shoulders with CI had significantly high frequency of slight apprehension at 60 degrees and strong apprehension sign at 30 degrees compared with those without CI. Comparing degrees of the most severe apprehension sign within each shoulder, there was no statistical difference between the two groups. The modified apprehension test is a useful method of physical examination for CI.
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Yoshihiro SAKAMOTO, Goro SAKURAI, Tomohisa HASHIUCHI, Yoshiyuki NAKAGA ...
2010 Volume 34 Issue 2 Pages
363-366
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The purpose of this report is to discuss the results of 7 cases of glenoid fracture of the scapula with over 50% bone fragment, which were classified as Ideberg type I and treated with arthroscopy. Seven cases of glenoid fracture of scapula classified as Ideberg type I were treated with arthroscopy from January, 2007 through March, 2009. The average age was 55 years old and there were 2 females and 5 males. We examined whether they had dislocations or not and fragment size, fixed method, and operation time. We also examined the bone union and postoperative results (following JOA score). We used suture anchor and the poly - L - lactic acid pin (following PLLA) as fixed materials. Three cases had dislocations and 4 cases had only bone fractures. The fragment size with dislocation was an average of 57%, and that with only bone fracture was an average of 63%. Three cases were treated with PLLA or PLLA + suture anchor, and 4 cases were treated with only suture anchor. We needed 108 minutes on average for operation time. All cases had bone union and JOA score was an average of 93.8 points. We treated the glenoid fracture by open reduction and fixation with the Delto - pectoral approach in the past, but they were highly invasive methods and several patients fell into contracture. Lately we treated patients by using arthroscopy. It is possible to operate with lower invasion and we got comparatively good results.
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Yuji HATAKEYAMA, Moto KOBAYASHI
2010 Volume 34 Issue 2 Pages
367-370
Published: 2010
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The purpose of this study is to evaluate operative outcomes in sequelae of proximal humeral fractures. Case 1: A 73-year-old female had a lt. proximal humeral surgical neck fracture. 7 weeks post trauma, a radiograph showed delayed union and high potential of nonunion. We classified type 3 of Pascal Boileau's classification. 2 months post trauma, osteosynthesis with plate fixation and an iliac bone grafting was performed. Case 2: A 64-year-old male had a rt. proximal humeral surgical neck fracture. 6 weeks post trauma, a radiograph revealed delayed union and high potential of non union. We classified type 3. 7 weeks post trauma, osteosynthesis with plate fixation and an iliac bone grafting was performed. Case 3: A 77-year-old female had severe lt. shoulder pain and restricted range of motion at 26 years post trauma. A radiograph showed humeral head necrosis, malunion of the greater tuberosity and lesser tuberosity. We classified type 1. Total shoulder arthroplasty (TSA) was performed.
Case 1: 15 months post ope, active elevation: 140 degrees, ER: 40 degrees, IR: T12, JOA score 94 points. X-ray showed bone healing. Case 2: 12 months post ope active elevation: 150 degrees, ER: 60 degrees, IR: T12, JOA score 100 points. X-ray revealed bone healing. Case 3: 1.5 years post ope, active elevation: 120 degrees, ER: 40 degrees, IR: T12 and JOA score 91 points.
Patients with type 3 had good bone union with plate fixation and bone grafting, the patient with type 1 obtained pain relief and functional results with TSA.
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Yoshiyuki MOMONOI, Nariyuki MURA, Daisaku TSURUTA, Toshihiko OGINO, Ya ...
2010 Volume 34 Issue 2 Pages
371-374
Published: 2010
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We reported the relationships between the initial radiogram findings and bone union in surgical neck fractures of the humerus. The purpose of this study was to inspect the relationships between the initial radiogram and bone union and also the shoulder ROM. Between May 2005 and February 2008, 80 humeral surgical neck fractures were treated according to the treatment protocol based on the previous study. When the displacement of the fracture was none and/or less than 1/4 of their diameter in two direction in the initial radiogram, conservative treatment was selected. When the displacement was more than 1/4 in at least one direction in both displaced cases, internal fixation was considered. The relationship of the initial radiogram findings and bone union, ROM and JOA score was examined. More than 90% had bone union in the cases in which their displacement was none or less than 1/4 of their diameter in both the two directions. The mean ROM (flexion, abduction, external rotation) were ; no displacement cases: 136°, 147°, 49°, <1/4 displacement in one direction cases: 115°, 118°, 39°, <1/4 displacement in two direction cases: 109°, 120°, 30°. JOA scores were 88.3pts., 71.2pts., 90pts in each case. When the displacement in both two direction are less than 1/4 at initial radiogram in proximal humeral fractures we can expect bone union. When axis dislocation of the initial radiograms were less than 1/4 in two directions, the bone union rates were more than 90%, and elevation was possible to more than 120 degrees.
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Yohei HARADA, Kenji KASHIWAGI
2010 Volume 34 Issue 2 Pages
375-378
Published: 2010
Released on J-STAGE: September 03, 2010
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The purpose of this study is to evaluate clinical results of internal fixation using Polarus humeral nail for proximal humeral fractures. Thirty shoulders of 30 patients (19 females, 11 males) underwent intramedullary fixation using Polarus humeral nail from September 2004 to January 2009. The mean age was 60 years old (range 18 to 82 years) and the average period of follow up was 13 months (range 6-48 months). According to the AO classification, 5 fractures were classified as A2, 6 as A3, 15 as B1, 1 as B2, 1 as B3 and 2 as C3. We checked radiographic results, JOA score, and the range of shoulder motion. Two patients underwent a second operation because of displacement, and we also used polarus humeral nail for the second surgery. All patients obtained bone union and the mean time for union was 3.7 months. The average of JOA score was 82.1(52-100). The average of shoulder motion was 144 degrees for flexion, 42 degrees for external rotation, L2 for internal rotation. Osteosynthesis of proximal humeral fracture using Polarus humeral nail was a useful procedure. It is important to insert the nail from the top of the humeral head. To prevent cut-out of the greater tuberosity's screws, it is nessesary to combine rotator cuff and screw using suture.
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Atsushi YOSHIDA, Kiyohisa OGAWA, Hiroyasu IKEGAMI, Noboru MATSUMURA, W ...
2010 Volume 34 Issue 2 Pages
379-382
Published: 2010
Released on J-STAGE: September 03, 2010
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Twenty patients with a mean age of 50 years old were treated with corrective osteotomy for the proximal humeral malunions, and were reviewed with a mean follow-up of 20 months. There were two valgus impacted 4-P malunions with greater tuberosity (GT) and lesser tuberosity (LT) osteotomies, three 3-P(GT) malunions with hemiarthroplasty by GT osteotomy, six 3-P(GT) and six 2-P(GT) malunions with GT osteotomy, two 2-P surgical neck (SN) malunions with valgus SN osteotomy, and a 2-P(LT) malunion with LT osteotomy. The initial fracture treatment was conservative in 14 cases and operative in 6 cases. The period from trauma to surgery was 20 months on an average. Postoperatively, pain was improved in 8 cases, and disappeared in 12 cases which included all 2-P(GT) malunions. The range of shoulder elevation was improved in 19 cases, but a 4-P malunion had decreased range of elevation. Bone union was achieved in all cases, but a 4-P malunion with the decreased range of elevation and a 3-P malunion with GT osteotomy were followed by avascular necrosis of the humeral head. Usefulness of the surgery for pain and restricted range of elevation were analyzed by age, initial treatment, period from trauma to surgery, and surgical procedures. Statistical analysis revealed patients under 50 years of age had a higher proportion of disappearance of the pain, and patients with conservative treatment had a higher range of preoperative elevation (p<0.05). Postoperative range of elevation was higher in 2-P(GT) and 2-P(SN), and the improved range of elevation was larger in 2-P(SN) (p<0.05). Corrective osteotomy for proximal humeral malunions is especially effective under 50 years of age, and for 2-P(GT) and 2-P(SN), but osteotomy for 4-P or 3-P malunions has a risk of avascular necrosis of the humeral head.
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Akiyoshi HANDA, Yoshiyasu UCHIYAMA, Hiroyuki HASHIMOTO, Joji MOCHIDA, ...
2010 Volume 34 Issue 2 Pages
383-386
Published: 2010
Released on J-STAGE: September 03, 2010
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Internal fixation of the clavicle can provide immediate rigid stabilization and facilitate early mobilization. The purpose of this study was to compare the clinical outcome between the locked and the nonlocked plate fixation of the mid-shaft clavicle fractures. We examined 24 patients with mid-shaft clavicle fractures who underwent surgical treatments from 2005. They were treated with 12 locked plates (group L) (average age 41.5 years, 2B1 in all cases according to Robinson classification) and 12 nonlocked plates (group N) (average age 43.6 years, 2B1 in 10 cases and 2B2 in 2 cases). Locked and nonlocked plates were fixed with two and three screws in the proximal and distal clavicle, respectively. The final outcome was assessed using the rate of bone union, complications and JOA score. Statistical analysis of data was performed using Mann-Whitney U test. Bone union was achieved in all fractures. Average union time for the mid-shaft clavicle fractures was significantly different between group L (14.8 ± 5 weeks) and group N (23.5 ± 8 weeks). However, JOA score at final follow-up was not significantly different between group L (87.0 points ± 12.3) and group N (89.8 points ± 9.1). There were the same clinical results between locked and nonlocked plates fixation for the mid-shaft clavicle fractures. However, the period of bone union is shorter for locked plate than nonlocked plate. This paper suggested that both plating systems were effective procedures for mid-shaft clavicle fractures.
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Eiji SHIMPUKU, Yoshiyasu UCHIYAMA, Akiyoshi HANDA, Hiroyuki HASHIMOTO, ...
2010 Volume 34 Issue 2 Pages
387-391
Published: 2010
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The purpose is to evaluate postoperative results of a surgical treatment for distal clavicle fractures utilizing the LCP clavicle hook plate (Synthes, inc, West Chester, PA.USA). Seven consecutive patients with fractures of the distal clavicle were treated using CHP. The average age of the patients was 45 (range, 25-67) years old. The mean follow-up period was 11 (range, 7-16) months. Those cases were classified according to Craig classifications; 1 in type I, 1 in type II a, 3 in type II b, and 2 in type VI, respectively. The clinical evaluation was performed using JOA score and the period of the bone fusion. In addition, 3D-CT was performed to determine the subacromial area where CHP was set in the depth or the distance of the bone erosion from the center of the AC joint. The mean JOA score was 95.4 points (range, 90-98) postoperatively. Average period of bony union was 5 months (range, 4-6) radiographically. Two patients suffered from delayed union or cut-out of the acromion. In 3DCT findings, all cases showed bone erosion under the surface of the acromion. Furthermore, the more posterior the position the CHP was set toward, the deeper the bone erosion we detected. (p<0.05, Spearman's rank correction). The data here indicated that the CHP should be set toward the more anterior position beneath the acromion, and reconstructed coracoclavicular ligaments.
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Mitsuko YAMADA, Tetsuo YAMAJI
2010 Volume 34 Issue 2 Pages
393-396
Published: 2010
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In the operation of the proximal humeral fractures in elderly patients, there are some problems due to osteoporosis. Previously we reported the correlation between BMD and the stability of screw fixation about the proximal humeral fracture model. Also we reported regional difference in BMD within the proximal humeral head in cadavers. In this paper we analyzed BMD in the proximal humeral heads of living bodies to confirm regional differences of BMD within the proximal humeral head. BMD of 10 cases, 20 proximal humeral heads (mean age 67.7 yrs.old ) was analyzed by Discovery A ( Discovery A, Hologic Co.). BMD was measured at 4 regions of interest (ROI) ; top of the humeral head(A), the middle of the humeral head(B), surgical neck(C) and the greater tuberosity(D). We analyzed the BMD value at each ROI and compared the dominant side with non-dominant side. Mean BMD ( g/cm
2 )A was 0.48, B 0.35, C 0.29 and D 0.39. There was significant difference between A vs. B, A vs. C, A vs. D and C vs. D (p < 0.05). However there was not a significant difference between the dominant side and the non-dominant side. Our results show that there is a significant difference of BMD is in the proximal humeral head. To get good stability of the screws fixation, the edge of the screw must be inserted just beneath the top of the proximal humeral head.
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Akimoto NIMURA, Teruhiko NAKAGAWA, Yoshitaka TAJIMA, Tomoyuki MOCHIZUK ...
2010 Volume 34 Issue 2 Pages
397-400
Published: 2010
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Previously, we reported that the footprint of the supraspinatus on the greater tuberosity is much smaller than previously believed, and the footprint is actually occupied by a substantial amount of the infraspinatus. The purposes of this study were to analyze our operative outcomes of arthroscopic repair for small and medium rotator cuff tears and to determine retrospectively the locations of tear sites based on our new anatomical concepts. A total of 30 shoulders of patients (13 females, 17 males) underwent arthroscopic cuff repair for small and medium tears from 2007 to 2008. The mean age at surgery and the mean follow-up period were 65 years old (average, 51 to 81) and 10 months (average, 6 to 24),respectively. The distributions of the torn site were analyzed with preoperative magnetic resonance imaging (MRI) using bony landmarks. The clinical outcomes were evaluated using the JOA shoulder score. Based on preoperative MRIs, torn sites of 6 cases were located at the anterior side of the highest impression of greater tuberosity. Torn sites of 21 cases were located from the anterior side of the highest impression to the middle impression, and that of 3 cases were difficult to determine. The average total JOA score improved from 60.7 to 92.4. Based on our new anatomical concepts, the present study showed that infraspinatus tears were included in small and medium tears more than previously described.
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Toshiro ITSUBO, Shigeharu UCHIYAMA, Hiroyuki KATO, Yukihiko HATA, Koui ...
2010 Volume 34 Issue 2 Pages
401-404
Published: 2010
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Previously, we reported that low signal intensity change at a rotator cuff insertion indicated restoration of the rotator cuff after repair at one year postoperatively. Here we report findings in a low signal change group and a no signal change group. We investigated 180 shoulders of 179 patients after rotator cuff repair. We classified the patients into three groups: 109 shoulders with simultaneous rotator cuff low signal intensity changes six months after repair, (6L group); 37 shoulders with simultaneous rotator cuff low signal intensity changes one year after repair (12L group); 34 shoulders with no low signal intensity changes at one year after repair (12H group). UCLA scores were compared between the groups. For configuration evaluation, we estimated thickness of the SSP, ISP, and deltoid muscles, and fatty degeneration of the SSP muscle using Nakagaki's classification. We compared each item at six months and one year postoperatively. Statistical analysis was performed with significance set at 0.05. UCLA scores were more significantly improved at one year postoperatively than at six months (
p<0.01) in all groups. Recovery of the ISP muscle thickness and fatty degeneration were statistically significant in the “6L” group (
p<0.01,
p<0.01, respectively). SSP and Deltoid muscle thickness did not show significant change in any group. Based on these results, we believe that low signal intensity changes show recovery of the rotator cuff itself. Low signal intensity changes can be used as an index to judge clinically the presence of on-site rotator cuff healing.
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Hiroshi YAMAGUCHI, Fuminori KANAYA, Naoki SUENAGA, Naomi OIZUMI
2010 Volume 34 Issue 2 Pages
405-409
Published: 2010
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Chronic rotator cuff tears often involve muscle atrophy and fatty degeneration. It has been reported that the re-tear rate after surgery is relevant to muscle atrophy and fatty degeneration. The purpose of this study is to demonstrate that muscle atrophy and fatty degeneration are improved by successful repair. 24 patients with massive rotator cuff tear were repaired with Surface-holding repair technique. We investigated spuraspinutus and infraspinatus atrophy judged by occupation ratio (=actual occupied area/anatomical occupied area), fatty degeneration judged by Goutallier's classification and repair integrity judged by Sugaya's classification on MRI. We could find improvement from severe preoperative muscle atrophy and fatty degeneration in well repaired shoulders. On the other hand, when re-tear occurred, muscle atrophy and fatty degeneration got worse. Our results suggested that a successful repair may partially reverse muscle atrophy and fatty degeneration.
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Koichi NAKAMURA, Yukihiko HATA, Norio ISHIGAKI, Narumichi MURAKAMI, Hi ...
2010 Volume 34 Issue 2 Pages
411-413
Published: 2010
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We sometimes experienced osteoarthritic (OA) change with cuff tear. However there are few reports about the prevalence, effect of cuff repair and effect on clinical results about OA change with cuff tear. The purpose of this study is to clarify these things by assessing the patients with cuff tear treated by surgery. We studied 234 shoulders, excluding 20 shoulders in which preoperative X-ray image showed OA change equivalent to Gerber's stage 3. We defined shoulders with progression of OA change referring Gerber's classification at 2 year after cuff repair as “Deteriorated group” and those with unchanging of OA change as “Unchanging group”. Inter-group differences were tested for statistical significance according to medical history, tear size and location, and clinical evaluations (range of motion, muscle strength, UCLA score). Deteriorated group included 39 shoulders (17%) and Unchanging group include 195 shoulders (83%). No significant differences were found in medical history between groups. The size of cuff tear in the Deteriorated group was larger than in the Unchanging group (
P<0.05 ). Regarding the location of the tear, there were more tears at the infraspinatus and teres minor tendon in the deteriorated group significantly (
P<0.05 ). Muscle strength and range of motion toward external rotation at first position before surgery were lower in the Deteriorated group (
P<0.05 ). No significant differences were found in UCLA score before surgery. There are no significant differences in clinical evaluations at 2 years after surgery. The causes of progression of OA change after cuff repair were larger tear size and if the tear progressed to the posterior. However, it is supposed that the progression of OA change doesn't affect postoperative clinical results.
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Masafumi GOTOH, Fujio HIGUCHI, Isao SHIRACHI, Yasuhiro MITSUI, Tetsu Y ...
2010 Volume 34 Issue 2 Pages
415-418
Published: 2010
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It is unclear whether the edge of the ruptured rotator cuff tendon is active in healing. We examined procollagen synthesis at this edge, and its association with preoperative clinical parameters and postoperative cuff integrity. Nineteen patients (average age 58 years) with full-thickness rotator cuff rupture were enrolled in the study. The edge of the ruptured tendon was sampled during open rotator cuff surgery. As controls, age-matched rotator cuff tendons with no gross rupture were taken from 5 fresh cadavers. Production of procollagen types I and III was examined by real-time reverse transcription-polymerase chain reaction and Western blot analysis. Using magnetic resonance imaging, postoperative cuff integrity was evaluated by the system of Sugaya's classification and then scored; 5 points for type I to 1 point for type V. mRNA expression of type I and III procollagen at the edges of ruptured rotator cuff tendons was significantly greater than in control tendons (P=0.0097 and 0.0014, respectively). Western blot analysis consistently showed greater production of procollagen types I and III at the edges of ruptured rotator cuff tendons, compared with control tendons. Procollagen-mRNA expression was significantly correlated with postoperative rotator cuff integrity (type I: r = 0.63 with P = 0.04, type III: r = 0.60 with P = 0.03) and period from symptom onset (type I: r = -0.75 with P = 0.0005, type III: r = -0.52 with P = 0.0331), but not with rupture size. In rotator cuff tendon rupture, early surgical intervention may optimize postoperative structural outcome.
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Akemi SUZUKI, Nariyuki MURA, Daisaku TSURUTA, Toshihiko OGINO, Yasuo G ...
2010 Volume 34 Issue 2 Pages
419-421
Published: 2010
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The purpose of this study is to investigate the sports activities after rotator cuff repair. We examined 11 shoulders of 11 patients with rotator cuff tear who participated in sports activities before the operations. There were 9 males and 2 females. The mean age was fifty-five years old. The period from injury to the operation was 3.8 months. We examined the kinds of sports, competition level, operative findings, range of motion, muscle strength of the shoulder, JOA score and the sports activities after the operation. The mean of the follow up periods was 31.7 months. The kinds of sports were golf, baseball, softball, tennis, volleyball, dance and aikido. One patient was competition level and the other 10 were recreational level. Two patients underwent arthroscopic rotator cuff repair, 9 patients underwent mini-open cuff repair. Ten had full-thickness tear and one had bursal-side partial-thickness tear. After the operation, the range of motion and the muscle strength of the shoulder were improved nearly equal to the unaffected side. The mean of the JOA score was 69 points before the operation and that improved 92 point after the operation. Ten patients (91%) could return to previous sports activities, 1 couldn't return to previous sports activities because of renal disease. The middle or old aged patients who participate in sports activities can be expected to return to sports activities after rotator cuff repair.
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Ryohei UCHIDA, Ryuji NISHIMOTO, Tatsuo MAE, Hideyuki KOHDA, Minoru YON ...
2010 Volume 34 Issue 2 Pages
423-426
Published: 2010
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The purpose of this study was to evaluate the effect of patients' age at operation on the clinical results of arthroscopic rotator cuff repairs (ARCR). 24 patients were treated with arthroscopic rotator cuff repair (15 males, 9 females, mean age 62.4) from September 2007 to March 2009 and their postoperative conditions followed-up for more than 6 months. We examined a correlation between the age of patients and clinical outcomes (JOA score, active flexion angle, and active external rotation angle after operation). We also evaluated 11 shoulders of 24 patients on cuff integrity 6 months after operation by MRI.
The average of total JOA score was significantly increased from 56.5 to 85.2 points after ARCR. The average of flexion angle was also significantly increased from 87.5 to 150 degrees. There existed significant correlation between the age of patients and clinical outcomes ( JOA score : r=-0.454, p=0.0304, active flexion angle : r=-0.511, p=0.0098). The correlation between age and cuff integrity was found on MRI as well.
Shimokawa et al reported no significant difference was observed in clinical outcomes of ARCR between in patients 65-years of age or older and in patients younger than 65 years old. Rebuzzi et al reported no correlation between the age of patients and the clinical outcomes. The subjects were divided by their age in these studies, but, in this study, we investigated and found the correlation between the patients' age at operation and some clinical outcomes after ARCR.
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Yoshihiro OHNADA, Dai MATSUMOTO, Kimitaka FUKUDA, Naomi OIZUMI, Hisash ...
2010 Volume 34 Issue 2 Pages
427-430
Published: 2010
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The purpose of this study is to investigate postoperative changes of MRI findings after rotator cuff repair within 1 year and over 1 year. 43 shoulders, which received open repair by a trans-osseous method and acromioplasty, were evaluated with MRI postoperatively within 1 year and over 1 year. 21 males and 22 females were involved; the average age at the operation was 65.1 years. The average follow-up period was 38.6 months. The clinical outcome was evaluated by JOA score. MRI was performed on a 0.5-T system and T2-weighted images were obtained. Intensity of the tendon or the bone-tendon interface is defined as ’high’ when it is as high as joint fluid, as ’low’ when it was the same as the normal tendon, and as ’medium’ when it was between ’high’ and ’low’. At final follow-up, 6 shoulders which showed low within 1 year, showed low continuously. In 21 shoulders which showed medium within 1 year, 19 changed to low at average 20.5 months (90.5%) after repair, 1 remained medium (4.75%), and 1 changed to high (4.75%). In 16 shoulders which showed high first, 4 changed to low at average 36.3 months (25%) after repair, 1 remained medium (6.25%), 11 remained high (68.75%) finally. An average of postoperative JOA score was 93.7 in low, and it was significantly higher than 84.7 in high at final follow-up. 90.5% cases of medium changed to low, compared with 25% cases of high at final follow-up. Therefore, it is suggested that medium of the tendon within 1 year after repair results in a good clinical outcome.
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Mitsuru NAGOSHI, Hiroyuki HASHIZUME, Takahiko HIROOKA, Yasuro OZE, Tak ...
2010 Volume 34 Issue 2 Pages
431-433
Published: 2010
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The purpose of this study was to clarify the clinical and MRI features of irreparable massive rotator cuff tears (MT). Forty-eight patients (27 men, 21 women, average age 68.3yrs) who had been repaired with their MT(over two tendon or 5cm < width) were investigated. Patients were divided into three groups. They were E group (repair easily: 20 cases), SD group (slight difficult; 12 cases), D group (difficult; 16 cases). The differences among the three groups were tested for statistical significance examinations about age, sex, occupation (hard labor), existence of subscapularis (SSC) tendon tear, joint contracture, pre-operative JOAscore, MRI findings (position of cuff stump, fatty degeneration. The fatty degeneration was evaluated according to Goutallier's staging in oblique sagittal plane. Post-operative JOAscores were also investigated. The mean follow-up period was 25.1 months. Statistical study was done using Student's t-test, Kruskal-Wallis test, and χ
2 test. The statistical differences between D group and other groups in the numbers of hard labors and SSC tendon tears was founded. We found the tendency that the age of D group was younger than other groups. In D group there were many cases in which cuff stump existed at the medial side of the joint surface and severe fatty degeneration of SSP and ISP were seen in MRI. JOA score improved in all groups (E; 57.6→92.2, SD 56.8→88.7, D; 52.4→86.3). The position of cuff stump (medial to glenoid) and fatty degeneration of ISP muscle in MRI seemed to be useful for expectation of irreparable cuff tears. The clinical features of irreparable MT were the number of hard labors and the existence of SSC tendon tear. The average age of the irreparable MT group was younger than that of the reparable groups.
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Takahiko HIROOKA, Yasuro OZE, Hiroyuki HASHIZUME, Mitsuru NAGOSHI
2010 Volume 34 Issue 2 Pages
435-440
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The purpose of this study was to investigate the postoperative results of dual-row method, suture bridge method and massive cuff stitch method. The subjects were 23 patients. Surgery was performed in a beach-chair-lying position under general anesthesia. The extended rotator cuff was sufficiently exfoliated even at the coracoid process and the periphery of the spina scapulae. The rotator cuff stump was sutured with the foot print. The subjects were divided into 3 groups with respect to the suture methods: a group in which the dual-row method was employed (DR group, n=10), a group in which the suture bridge method was employed (SB group, n=6), and a group in which the massive cuff stitch method was employed (MC group, n=7). In these patients, we investigated the pain/total JOA scores, shoulder abductor muscle strength, and presence or absence of re-tears on MRI 1 year after surgery. The re-tear percentage in the DR group was slightly higher than in the other 2 groups, although there were no significant differences in any parameter among the 3 groups. In the dual-row method, an anchor was inserted into an area lateral to the greater tubercle of the humerus. Therefore, this led to excessively tense traction and suture of the rotator cuff. The suture bridge method and massive cuff stitch in which the rotator cuff can be sutured at an appropriate tension via medial foot-print positioning may decrease the incidence of recurrent tears.
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Nariyuki MURA, Yasuo GOTO, Yoshiyuki MOMONOI, Isao TAKEI, Daisaku TSUR ...
2010 Volume 34 Issue 2 Pages
441-444
Published: 2010
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It was reported that the postoperative outcome for irreparable rotator cuff tears was inferior to that for reparable tears. The purpose of this study was to clarify the outcome of the patch graft procedure (patch) and the lattissimus dorsi (LD) transfer for the irreparable rotator cuff tears. There were 21 patients, 23 shoulders (male: 20, female: 23) who underwent patch with the long head of biceps or tensor fascia lata or LD for irreparable rotator cuff tears from 1995 to 2008. Patch was done in 16 patients, 17 shoulders and LD was done in 5 patients, 6 shoulders . Pre- and Post-operative JOA scores and shoulder muscle strength, which was tested with Microfet were evaluated. The average age at operation was 64 years (49-87), mean follow- up was 44 months (12-141). JOA score significantly increased from preoperative average of 62.6 (46.5-73.5) points. to postoperative average of 89.1 (76.5-100) points. In LD, preoperative and postoperative, respectively, JOA score was 64.4, 89.2, muscle strength of abductor at 90° abd. was 15.3N, 42.6N, that of abductor at 45° abd. was 34.7N, 79.1N, that of external rotator arm at side was 27.3N, 44.6N, and that of internal rotator was 111.9N, 113.8N. In patch, JOA score was 62.0, 89.0, muscle strength of abductor at 90° abd. was 36.8N, 72.4, that of abductor at 45° abd. was 42.6N, 93.7N, that of external rotator arm at side was 25.5N, 54.9N, and that of internal rotator was 106.6N, 147.6N. Patch and LD might be one of the good options for irreparable rotator cuff tears. However, recovery of shoulder muscle strength after surgery might not be expected so much.
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Hideki ASATO, Hitoshi TERUYA, Fuminori KANAYA
2010 Volume 34 Issue 2 Pages
445-449
Published: 2010
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We reported the results of infraspinatus muscle transfer for massive rotator cuff tear. 17 patients received infraspinatus muscle transfer. There were 13 males and 4 females with an average age of 70 years (55 to 81 years). The patients were affected on the right side (dominant side) except one case. The etiology of the rotator cuff tears was fell down in 6, farm work in 4, sports in 2 and unknown in 5. All patients had rest and motion pain, contracture of the shoulder was not observed and active ROM (a-ROM) was under 60 degrees in 5 cases. The follow up period averaged 17 months (range, 9 to 24 months). A brace with 30 degrees abduction was applied to all patients after surgery, they started passive ROM exercise from the day after surgery. A-ROM exercise without a brace was started from 6 to 8 weeks after surgery. The structural outcome was evaluated with preoperative and postoperative MRI. All patients showed infraspinatus muscle atrophy in preoperative MRI. Shoulder pain disappeared in 8 patients, and improved in 9 cases. The average a-ROM of flexion/abduction/external rotation improved from 94/92/47 to 156/166/44, supraspinatus tests were negative after surgery. The average JOA score significantly improved from 56 to 91. All patients showed no infraspinatus tendon tear after surgery in postoperative MRI. Infraspinatus muscle transfer was an effective method for irreparable massive rotator cuff tear in spite of the presence of infraspinatus muscle atrophy.
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Teruhisa MIHATA, Chisato WATANABE, Mitsuo KINOSHITA, Kunimoto FUKUNISH ...
2010 Volume 34 Issue 2 Pages
451-453
Published: 2010
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We developed a new surgical treatment for irreparable rotator cuff tear, namely arthroscopic superior capsular reconstruction. Our biomechanical study showed that the reconstructed superior capsule can restore superior shoulder stability which is decreased due to irreparable rotator cuff tear. The purpose of this study was to investigate clinical outcomes after arthroscopic superior capsular reconstruction for irreparable rotator cuff tear. A consecutive series of 10 shoulders in 10 patients (6 males and 4 females, average age: 65.4 years) with irreparable rotator cuff tears was evaluated using the rating scale of the Japanese Orthopaedic Association (JOA) scores and active range of motion in shoulder joint at an average of 15.3 months (range, 12 to 18 months) after arthroscopic superior capsular reconstruction with fascia latae. Postoperative integrity of reconstructed shoulder capsule was determined by magnetic resonance imaging. In most patients, active range of motion and JOA score were completely restored. No retear of the reconstructed superior capsule was found in postoperative magnetic resonance imaging. Arthroscopic superior capsular reconstruction is effective option for irreparable rotator cuff tear.
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Yoshiyasu UCHIYAMA, Akiyoshi HANDA, Hiroyuki HASHIMOTO, Joji MOCHIDA, ...
2010 Volume 34 Issue 2 Pages
455-458
Published: 2010
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Irreparable rotator cuff tears (IRCT) have led to a variety of treatment recommendations. The purpose of this retrospective study was to assess the clinical outcomes of partial repair of infraspinatus tendon transfer for IRCT. We reviewed the result of partial repair of IRCT in 19 patients (15 males, 4 females). The mean age at operation was 64 years (53-76), and the mean follow-up period was 22 months (12-45). We performed partial repair of infraspinatus tendon transfer after acromioplasty and synovectomy by mini-open method. The clinical assessment included JOA score, UCLA score and isometric power (abduction and external rotation by degree less than the unaffected side) at final follow-up. In addition, pre- and postoperative (avg. 16 months) fatty degeneration of the rotator cuff musculature was estimated according to the Goutallier grading system. Statistical analysis of data was performed using χ
2 test and Mann-Whitney U test. Significant differences were present between average pre- (53.1 and 16.5) and postoperative (84.9 and 28.0) in JOA and UCLA score, respectively (p<0.01). There were significant differences in isometric powers between pre- (abduction 26.6% and external rotation 35.6%) and postoperative power (53.3 and 58.3%), respectively (p<0.05). Therefore the preoperative average stage of supraspinatus muscle (1.9, range 0-3) progressed more than the postoperative muscle (2.6, range 1-4) (p<0.05). However there were no significant differences in the average stage of infraspinatus muscle between preoperative (1.5, range 0-3) and postoperative (1.8, range 0-3) grading system. Partial repair of IRCT can provide significant clinical and functional improvement. However, postoperative fatty degeneration of supraspinatus musculature progressed more than preoperative, and fatty degeneration of infraspinatus musculature kept preoperative status.
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Hiroyuki SUGAYA, Yoshihiro HAGIWARA, Norimasa TAKAHASHI, Nobuaki KAWAI ...
2010 Volume 34 Issue 2 Pages
459-462
Published: 2010
Released on J-STAGE: September 03, 2010
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To date, reverse shoulder arthroplasty or tendon transfer procedures have been believed to be the preferred treatment options for patients with irreparable massive rotator cuff tears. However, these are relatively invasive and salvage procedure can be very difficult. The purpose of this study is to report the outcomes of arthroscopic patch graft procedure using Teflon felt. Between January 2003 to June 2007, 37 shoulders underwent primary arthroscopic graft procedure using a Teflon felt patch with 3mm thickness. Subjects consist of 31 patients who were able to follow-up for a minimum of 2 years, including 17 males and 14 females with an average age of 64.6 years (range, 33-80). After a tendon mobilization procedure, a Teflon felt patch was introduced to the glenohumeral joint through the standard anterior portal and fixed arthroscopically. Clinical outcomes were evaluated using the JOA and UCLA scores at an average of 40 months (range, 24-72).
The mean postoperative JOA and UCLA score improved significantly to 90.2 and 31.7, respectively. Active forward flexion significantly increased on average from 104 to 158 degrees, with a mean strength increasing from 2.7 to 4.7. In external rotation, strength and ROM demonstrated no significant improvement. On X-rays, 7 out of 21 patients demonstrated bone absorption within 2 years after surgery, however, no progression of absorption was observed more than 2 years after surgery. Further, no patients complained of symptoms related to bone absorption. Arthroscopic graft procedure using Teflon felt patch yielded excellent outcomes in terms of pain relief and flexion strength, and patients' satisfaction was very high. This technique could be an alternative procedure for these difficult patient populations.
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Hirokazu KOBAYASHI, Yukihiko HATA, Norio ISHIGAKI, Kouichi NAKAMURA, N ...
2010 Volume 34 Issue 2 Pages
463-466
Published: 2010
Released on J-STAGE: September 03, 2010
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An association between CRPS ( complex regional pain syndrome ) type 1 and rotator cuff tear has been documented. In this study, we report CRPS type 1 experienced with rotator cuff repair. 183 consecutive shoulders in 179 patients who underwent rotator cuff repair were studied retrospectively. CRPS type 1 was identified in 22 shoulders of 22 patients ( CRPS group ). 161 shoulders were the control group. We compared the clinical history, cuff tear size at operation, range of motion, muscle strength and UCLA scores between the two groups. The symptom rate of CRPS type 1 was 11.7%. The proportion of women in the CRPS group was significantly larger than that in the control group (P <0.05). There was no significance in age at operation, cuff tear by trauma, length of cuff tear, and UCLA score between the two groups. The women's time of development of symptoms was intentionally later, the average of 22 days, than the average of 9 days for a man (P <0.05). There was no significant difference in clinical history, duration of development of the condition and UCLA score between woman and man. However, since it corresponded immediately after development of symptoms, the condition disappeared in an average of seven months. The possibility of development of symptoms in a woman is high, and the case whose symptoms were shown after three weeks after the operation has a risk of the condition being prolonged. CRPS TypeI after Operation with Rotator Cuff Tears did not affect postoperative results.
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Shigekazu UENO, Satoshi MIZUNO, Takayuki DOHKE, Kenji OKAMURA, Toshiak ...
2010 Volume 34 Issue 2 Pages
467-470
Published: 2010
Released on J-STAGE: September 03, 2010
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The aim of this study was to investigate the relation of the morphology of the subacromial spur, and cuff tear size and clinical findings of rotator cuff tears by using three dimensional computed tomography (3DCT). We studied 77 patients (80 shoulders) who had received arthroscopic subacromial decompression with or without arthroscopic rotator cuff repair. The patients were 36 males (39 shoulders) and 41 females (41 shoulders). Mean age at time of surgery was 64.6 years old (range, 36-87 years). We examined the morphology of the subacromial spur, and measured the size with 3DCT, preoperatively. And then, we investigated the relation of the morphology of the spur and patient's age, spur size, cuff tear size, duration of symptoms, clinical outcome (JOA score) and trauma. We classified the morphology of the subacromial spur into the following three types by location, anterior type (type A); 23 shoulders, antero-lateral type (type AL); 17 shoulders and medial type (type M); 40 shoulders. The spur size in type M was significantly biggest of all types. There were significantly more elderly patients in type M. Cuff tear size tended to become larger in type A-L and M than in type A. The spur width is significantly bigger in the complete rotator cuff tear group than the partial thickness tear group. Type M spurs were frequently found in elderly patients and patients with larger cuff tear. Since spur increase in size over time, in many cases, we think that subacromial spur of cuff tear patients progresses from type A to type AL, and then advances to type M last.
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Atsushi YAMAMOTO, Kenji TAKAGISHI, Kouichi OKAMURA, Hitoshi SHITARA, K ...
2010 Volume 34 Issue 2 Pages
471-474
Published: 2010
Released on J-STAGE: September 03, 2010
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The purpose of this study was to investigate the influence of the variance of posture on shoulder pain and rotator cuff tears. A medical checkup was conducted for the residents of a mountain village in Gunma prefecture. The subjects consisted of 525 people including 1050 shoulders; 193 males including 386 shoulders and 332 females including 664 shoulders, with a mean age of 61.9 years old. We took their side view picture in a standing position, and divided them into 5 types according to the classification of Nakatani; normal (type 1), thoracic kyphosis (type 2), lumbar kyphosis (type 3), flat back (type 4), lumbar lordosis (type 5). We examined their background factors, physical examinations and ultrasonographic diagnosis of rotator cuff tear on both shoulders. We elucidated the prevalence of shoulder pain and rotator cuff tears with respect to each variance of posture. Additionally the subjects were divided into 2 groups; namely a Normal group (type 1), and a postural abnormality group (type 2-5). The differences between the 2 groups were evaluated.
The normal type was present in 50.1%, thoracic kyphosis type in 24.6%, lumbar kyphosis type in 4.2%, flat back type in 6.7%, and lumbar lordosis type in 14.5%. Residents having shoulder pain frequently demonstrated thoracic kyphosis, flat back and lumbar lordosis. In addition, residents having rotator cuff tears frequently demonstrated thoracic kyphosis and lumbar kyphosis. The postural abnormality group was most commonly associated with elderly patients, who showed a decreased active forward elevation, a weaker external rotation strength, a positive finding for impingement sign and a decreased QOL. A logistic regression analysis revealed age, gender, present shoulder pain, an active forward elevation and EuroQOL (5 item) to all be significantly associated with an abnormality in the posture of these subjects.
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Hiroyuki NAKAMIZO
2010 Volume 34 Issue 2 Pages
475-478
Published: 2010
Released on J-STAGE: September 03, 2010
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This study was conducted to evaluate clinical and structural characteristics of retorn cuffs after arthroscopic rotator cuff repair (ARCR). 90 complete torn cuffs were treated with arthroscopy. 47 males and 38 females were included. The mean follow-up period was 18 months. The magnetic resonance images (MRI) were taken 6 and 12 months after an operation. The subjects were divided into two groups according to Sugaya's MRI classification: group A (good cuff integrity) and group B (retear). Preoperative and postoperative factors (age, JOA score, intraoperative tension of torn cuff, MRI, etc.) were compared between the two groups. Ten cuffs (11.1%) were re-torn. Postoperative JOA score in group A was 92.9 points, which was significantly higher than in group B (86.8 points). The intraoperative tension of torn cuffs in group A and B were 1.9kg and 3.1kg, respectively. Five shoulders in group B observed stage 3 muscle atrophy according to Goutallier's classification. In almost all cases, muscle atrophy was constant or progressive according to postoperative MRI. ARCR for shoulders with large tear size and more than stage 3 muscle atrophy were considered to be able to improve clinical symptoms, but to be difficult to keep repair integrity.
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Yuji HATAKEYAMA, Moto KOBAYASHI
2010 Volume 34 Issue 2 Pages
479-482
Published: 2010
Released on J-STAGE: September 03, 2010
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The purpose of this study was to evaluate the short term outcome of pectoralis major transfer carried out in three shoulders that had irreparable subscapularis tears. Three patients that underwent pectoralis major transfer between January, 2008 and November, 2008 were used. There were 3 males. The mean age was 62 years old and the average follow-up period was 14.6 months. The mean active flexion was 95° preoperatively, abduction 90°, ER 52°, IR sacrum and the average JOA score was 58.7 points. All patients showed positive lift-off test and belly-press test. All patients had a massive tear of subscapularis, supraspinatus and infraspinatus tendons. Preoperative magnetic resonance imaging revealed retraction of the subscapularis musculotendinous unit to the glenoid and fatty infiltration of the subscapularis muscle of grade IV. The proximal half tendon of pectoralis major muscle was released from its insertion and fixed to the distal aspect of the greater tuberosity using transosseous suture technique. The tendons of supraspinatus and infraspinatus were repaired to the greater tuberosity with suture anchors. The mean active flexion was 153° postoperatively, abduction 137°, ER 67°, IR L4/5 and the average JOA score was 84.7 points.
Lift-off test and belly-press test remained positive in all three patients. Pectoralis major transfer results in improvement for patients with an irreparable subscapularis tear.
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Keizo FURUKAWA, Shiro KAJIYAMA, Toshiyuki SAKIMURA, Masao ETO
2010 Volume 34 Issue 2 Pages
483-485
Published: 2010
Released on J-STAGE: September 03, 2010
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The purpose of this study was to investigate the re-tear rate after arthroscopic rotator cuff repair (ARCR) using bioabsorbable suture anchors using MRI.
We studied 69 patients with 70 shoulders and who underwent ARCR using bioabsorbable suture anchors and had postoperative MRI examinations performed. 53 were males and 17 were females. The average age was 62 years old (38-83 years old) and the average period from ARCR to MRI was 7 months (6-12months). MRI findings were classified according to Sugaya's classification. According to Sugaya's classification, all 4 small tear cases were classified type I or II. 1 of 9 shoulders in incomplete tear cases, 2 of 33 shoulders in medium tear cases, 9 of 19 in large tear cases and 3 of 5 in massive tear cases were classified type IV or V implied complete retear. Retear rate after ARCR was 6.5 % in partial, small and medium tear cases and 50 % in large and massive tear cases.
A high incidence of retear was observed in the large and massive tear shoulders.
ARCR with bioabsorbable anchors is an effective option because the retear rate using bioabsorbable anchors is equal with that using metal anchors.
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Kazuhiko KIKUGAWA, Nobuyoshi OKUHIRA
2010 Volume 34 Issue 2 Pages
487-490
Published: 2010
Released on J-STAGE: September 03, 2010
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We have performed open fascial patch grafting (O method) and arthroscopic fascial patch grafting (A method) for massive rotator cuff tears. The purpose of this study is to evaluate the clinical results of 2 different operative methods. We treated 67 patients with fascial patch grafting for massive rotator cuff tears. A method group was 17 cases (11males, 6 females; mean age 67.8years old). O method group was 27 cases (18 males, 9 females; mean age 62.1years old). Sex, the averaged age at operation, the mean follow up period was not significant in either group. Clinical results were evaluated according to the Japanese Orthopaedic Association score (JOA score). Cuff integrity was evaluated by MRI. The average postoperative JOA score improved from 55.3 to 83.3 in A method, and from 59.4 to 85.3 in O method. There was no significant correlation between postoperative JOA and the 2 different operative methods. Poor result were obtained in 4cases in A method, and 5 cases in O method causing limitation of range of motion and loss of muscle strength. Retear of rotator cuff observed by MRI were 4cases in A method, and 5 cases in O method.
The clinical results of arthroscopic and open fascial patch grafting for massive rotator cuff tears were mostly satisfactory.
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Daisuke NAKAI, Junpei FUJII
2010 Volume 34 Issue 2 Pages
491-494
Published: 2010
Released on J-STAGE: September 03, 2010
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Age is one of the most important factors when we make a decision for the indication of surgery. The purpose of this research is to investigate the clinical features related to generations in arthroscopic rotator cuff repair (ARCR). From August 2005 to July 2008, we performed ARCR in 107 shoulders (71 male,s 36 females). They consisted of 8 shoulders in patients in their twenties and thirties, 11 shoulders in patients in their forties, 28 shoulders in patients in their fifties, 40 shoulders in patients in their sixties and 20 shoulders in patients in their seventies. Among generations in these cases, we compared preoperative factors, intra-operative findings, postoperative rehabilitation, and postoperative clinical results, retrospectively.
As to preoperative factors, patients in their seventies have the lower scoring system of the Japanese Orthopaedic Association (JOA), especially in functional subscore. As to intra-operative findings, there was a significantly high rate of contracture, lower cuff mobility, and delamination in the tear cuff in patients in their seventies. There was no difference as to postoperative rehabilitation. But the patients in their forties tend to have slower recovery of range of motion, so they should have rehabilitation for a longer period.
In the postoperative clinical results, patients in their seventies have significantly lower JOA score (86.5 points) at 12 months postoperatively and a significantly higher re-tear rate (40%) at 6 months, compared to other generations. Our research suggests that the patients younger than 70 years old have an appropriate indication for ARCR generally. On the other hand, it needs considerable decision making for ARCR in the patients older than 70 years old, because they are expected to have lower postoperative clinical results.
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