The purpose of this paper is to investigate whether the interscalene brachial plexus block is of use or not for the surgery of the shoulder.
Eighteen cases,16 men and 2 w omen, were reviewed. The age at the surgery ranged from 22 to 79 years old with the average of 45, and the operation time from 34 to 125 minutes with the average of 84. The operative procedures included the internal fixation of clavicle fractures (4 patients), plasty of the acromioclavicular joint (3 patients), rotator cuff repair (2 patients), and Bankart operation (2patients). A single shot of 20 mililiters of local anesthetic (10 ml of lidocaine plus 10 ml of bupivacaine 20 ml of lidocaine, or 20 ml of mepivacaine) was injected into the interscalene space according to the technic of Winnie (1970).
The result was that this method a fforded adequate anesthesia throughout the operative procedure in 15 of 18 patients, of whom 10 were completely free from pain. Three patients were inadequately anesthetized. No major complications were noted, although Homer phenomenon appeared in two patients and hoarseness in one. The authors have concluded that the interscalene brachial plexus block is a safe and secure method of anesthesia for the surgery of the shoulder, since a single shot of 20 ml of local anesthetic can provide adequate analgesia around the shoulder with high rate of success and with low rate of remarkable complication.

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Normal movement of the shoulder depends on the acromioclavicular ligament and the coracoclavicular ligament supporting the acromioclavicular joint.
Complete dislocation of the acromioclavicular join t has been treated by the Weaver's method, which includes removal of the lateral end of the clavicle. This may not be good for the function of the shoulder, but there is little trouble in the function of the operated shoulder.
To discover why there is little trouble, we carried out a roentgenogra h ic study using Freedman's and Poppen's methods.
Regression lines for predicting glen ohumeral angle (θGH) and scapulothoracic angle (θST)from arm angle (θArm) were calculated.
Our data differed very little from the findings of Freedman's and Poppen's data.
We don't find out remodeling of the lateral end of the clavicle in roentgenograms.

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We operated the dislocation of acromioclavicular joint in 35 cases during the past 14 years. Our series consisted of 32 male and 3 female, age ranged from 19 to 56 years with the means of 32 years,19 were left side and 16 were right side. Thirty-two were Tossy's type III and 3 were type II. The causes of injuries were traffic accidents (15 cases), sports injuries (13 cases) and others.
We divided our series into 3 groups depending upon the injury time. A: Operat i on was indicated within 2 weeks after injury. B: from 2 weeks to 6 weeks. C: over 6 weeks. The surgical prosedures were follows: 1. modified Phemister's method (A: 6 cases).2. percutaneal multiple pinning (A: 1case).3. reconstruction of coracoclavicular ligament with vascular prosthesis (A: 13 cases, B: 2cases and C: 3 cases), with palmaris longus (A: 1 case) and Vargas method (A: 1 case).4. Neviaser-Yamamoto's method (B: 1 case).5. resection of the distal end of the clavicule (C: 2 cases).
Results: we would like to discuss the post operative results on the 4 cases of modified Phemister's method (former groupe) and the 9 cases of vascular prosthesis method (latter group). These cases were operated within 2 weeks and followed up over 1 year. Pain subsided completely in the 3 cases of former group and 8 cases of latter group. There was no case which had restricted joint mobility after the operation. On the radiological observation, bone resorption of the clavicule, due to the prosthesis, were recognized in all cases of the latter group. But these findings did not always correlate with the post operative results. Re-dislocation of the A-C joint was found in the two cases of latter group, which also did not correlate with the clinical symptoms.

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Complete dislocation of the acromioclavicular joint usually accompanies tears of the acromioclavicular and coracoclavicular ligments. This injury should be treated sargically. We have used modified Weaver's procedure to reduct dislocation of the acromioclavicular joint since 1982.
15cases were followed postoperatively. Time of follow-up ranged from four months to 37 months with an average of 16 months. All of cases were divided into two groups by two different procedures. One is the case with which were fixed the acromioclavicular joint by two Kirschner's wires, and added transfer of the coracoacromial ligament to the clavicular (modified Weaver's procedure ( I )). Another is the cases with which were fixed the clavicula to the spina of the scapula by Kirschner's and added bony suture of the coracoacromial ligament to the clavicula (modified Weaver's procedure (II)). Eight males and two females were trested by modified Weaver's procedure (II), and five by modified Weaver's procedure (II ). Postoperative results were evaluated by means of Kawabe's. scores. Of ten, which were treated by modified Weaver's procedure ( I ), nine were excellent, and one fair. On the other hand, of five, which were treated by modified Weaver's procedure (II), four were excellent, and one good.
Roentgenologically, the acromioclavicular joint was completely reducted in eight, and subluxated in seven.
The results between two groups were almost clinically and roentgenologically same. However, we should recomend modified Weaver's procedure (II) for dislocation of the acromioclavicular joint. On comparison with these two procedure, we believe that modified Weaver's procedure (II). will not destroy the acromioclavicular joint, further and be sure to keep the joint reducted after operation.

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The present case of subacromial brusitis of rheumatoid arthritis (RA) was very difficult to make a diagnosis. It was commonly mistaken for a tumor, because it looked like a large soft tissue tumor, there was no local inflammation, it's content couldn't be aspirated and plain radiograms showed no specific signs.
(Cas e Report) A 41-year old man who was suffering from RA for 10 years had a large mass on his shoulder. The mass had no inflammatory sign. It's margin was not well defined. There was no adhesion to the skin. Active and passive shoulder joint motion was not limited. Plain radiograms showed a shadow of a soft tissue mass. Computed tomogram showed a homogeneous mass. So it was suspected of a soft tissue tumor. But surgical exploration of the shoulder revealed a very large subacromial bursa which was filled with jelly like substance of 450 grams. Histologic examination of the bursal membrane showed changes of chronic inflammation. Because the clinical and histological features showed it to be rheumatoid bursitis except that there was no villous formation in microscopic sections, we made a diagnosis of subacromial bursitis of RA.
In this manner, when you appraise a patient with RA who has larg e shoulder swelling, you had better remind not only a soft tissue tumor but subacromial bursitis also.

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Knowledge of the natural history of rheumatoid shoulder may help to establish the operative indication and the selection of surgical techniques. So, serial radiological study of glenohumeral joints in rheumatoid arthritis (RA) patients was carried out to know the fates of the destructions.
83 patients,166 shoulder joints, aged 25 to 83 years (mean age 55.5 years) with definit e or classical RA according to the American Rheumatism Association criteria were studied. The duration of disease ranged from 5 to 39 years (mean 15.3 years).
To study the pattern of glenohumeral joint destruction, the following radiological changes were evaluated; bony atrophy, subchondral sclerosis, marginal erosion of the humeral head (HH), subchondral cyst, collapse of the HH, joint space narrowing, bony spur, mutilating change and so on. And to observe the pattern of the progression, the radiological grading from Larsen's method was used in the present study.
Consequently, after the disease period of 10 to 15 years, the fates of rheumatoid shoulders were classified into five types by the pattern of destruction and progression as follows: Non-progressive type; no apparent erosive change was seen. Erosive type; extensive marginal erosion of HH led to joint destnlction. Collapse type; collapse at the site of subchondral cysts of HH led to severe destruction. Stiff type; Osteoarthritis-like change was seen and normal anatomical structure was spared. Mutilating type; resorptive change rapidly occured.
Thus, the fates of rheumatoid Shoulders can be predicted based on these five types.

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The avascular necrosis of the humeral head is less common than the femoral head necrosis. The objectives of this study are to examine the clinical and radiological features of the avascular necrosis of the humeral head and to define the relation ship to the femoral head necrosis.
Eighty-five patients, who were diagnosed the femoral or humeral head necrosis, were examined.
The average age of the patients was 43.2 years, ranging from 18 to 79 years. The femoral and humeral head were affected indivisually in seve n ty-four and two patients, respectively. Nine patients were affected both heads. Five patients of these humeral head necrosis (8 shoulders) had corticosteroid therapy and four patients (8 shoulders) had been taking excessive alcohol. In the other two patients (2 shoulders), the pathogenic factor was unknown. Six patients (8 shoulders) of these eleven patients complained pain and eight patients (13 shoulders) had limited shoulder motion. According to the report of the Medical Research Council (1966), eighteen shoulders and the affected hips were classified radiographically, as group I (normal articular surface), group II (deformed articular surface) and group III (osteoarthritis). In the eighteen shoulders of the humeral head necrosis,37.5 % of group I had clinical symptoms. In the eighty-three hips of the femoral head necrosis,77.4 % of group I had severe pain and/or limited motion of the hip joint.
The 22 % of the patients with the femoral head necrosis, which area was involved 50 % or more, were simultaneously showed humeral head necrosis. However, no humeral head necrosis was found in the patients with the femoral head necrosis which area was 50 % or less.
The avascular necrosis of the humeral head is asymptomatic in the early stage and tend to be overlooked. Therefore, in the cases of the femoral head necrosis with the large necrotic area, the careful examinations should be performed on the shoulder and the other joints.

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In 1972, Neer II noted that the slope of the acromion of the scapula may play an important role in development of the impingement syndrome of the shoulder joint. This study was undertaken to know the relationship between the slope of the acromion and rotator cuff impingement.
65 intact bleached skeletal bones,130 shoulders (65 right shoulders,65 le f t shoulders) which have been stored in the Department of Anatomy (Section 2), Sapporo Medical College were used. The age and sex of these specimens were clearly known. The undersurface of the acromion and the greater tuberosity of the humeral head were observed to know whether degenerative changes such as a spur formation was present or not. At the same time, the slope of the acromion in the scapular plane was determined.
There was significant variation in the slope of the acromion. Degenerative changes on the undersurface of the acromion located in anterior one-third of the acromion. The incidence of degenerative changes in the undersurface of the acromion increased in accordance with flattening of the slope of the acromion.There was no difference in the slope of the acromion by age, but the incidence of degenerative changes on undersurface of the acromion increased by age. The degenerative changes on the greater tuberosity occured more frequently in the aged shoulders.
These results suggest that the flattened slope of the acromion may be a c ause of subacromial impingement between the anterior part of the acromion and the greater tuberosity. And repetitiv, e stress of subacromial impingement by aging may result in the degenerative change on the undei-surface of the acromion. We think that with growth in the degenerative changes on the undersurface of the acromion, rotator cuff tear may occur, then the degenerative change on the greater tuberosity may appear.

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Many radiological findings have been known as the signs of long-standing rotator cuff tear. But no sign has been noted for the relatively fresh rotator cuff tear. The purpose of this paper is to introduce the new roentgenographic sign, which has not been recognized. This new sign is the localized radiolucency of the humeral head under the area of rotator cuff tear, which appears in early stage.
I had sixty one cases with rotator cuff tear during recent one and a half years. In twenty nine cases of them, the localization and size of tear were determined at operation, and in thirty-two cases from arthrographic findings. The history of violent trauma, the arthrographic findings and new sign were investigated.
Thirty one cases had the obvious history of violent trauma. Of them, twelve cases had the localized radiolucency. Of thirty cases without the history of violent trauma, four cases had the new sign. The remarkable pooling of dye was seen arthrographically in twenty four cases, of which eleven presented the new sign. Of twelve cases with the history of violent trauma and the new sign, nine presented the pooling of dye.
As a result, roentgenograms of the patients with the history of violent trauma frequently showed the localized radiolucency of humeral head under rotator cuff tear. The parhogenesis of this new signs are discussed.

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No Literature has been found so far to determine the reliability of each symptomatology in making diagnosis of rotator cuff tears. In order to clarify this relationship, we have examined those who are over 40 years of age complaining of shoulder pain with references to the followings;
1. crepitus on elevation
2. subacromial effusion
3. narrowed acromio-humeral interval on x-ray(<7mm)
4. weekness of abduction(<MMT3)
5. history of trauma
6. disturbance of elevation(>4months)
7. motion pain(> 6months)
8. atrophy of infraspinatus
9. drop arm sign
10. painful arc
128 cases were examined since May 1984 to August 1985, in which 64 were male and 64 female. Arthrography was performed in 82 (64 %). Rotator cuff tear was diagnosed in 48 cases (59 %).
In those 82 cases, crepitus on elevation was noticed in 41 cases, in which 27 (66 %) showed r o tator cuff tears. Similarly, the incidences of rotator cuff tear with reference to the above described items are,2) 15/17 (88 %),3) 12/14 (86 %),4) 10/18 (61 %),5) 19/27 (70 %),6) 11/28 (39 %),7) 18/27 (67 %),8) 29/45 (64 %).
Drop arm sign and painful arc were noticed in the cases that showed no contracture. The incidence of the former is 7/10 (70 %) and the latter is 18/27 (67 %).
The triad of symptomatology for the rotator cuff tear hav e been considered as 1) pain,2)crepitus, and 3) motion pain. However, the reverse is not always true. Based on our studies, the triad for the screening of rotator cuff tear is advocated as 1) subacromial effusion,2) narrowed acromiohumeral interval on x-ray ( <7mm),3) history of trauma in order of reliability.

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A rare case of an anterior redislocation of the shoulder joint occurred after repair of the rotator cuff was reported.
The case was a 68-year-old woman, who suffered from the anterior dislocation of her right shoulder one month previously. She came to our hospital because she could not lift her arm even after the manual reduction of the shoulder joint. She could not flex her shoulder beyound 30 degree in spite of the lack of contracture and drop arm sign was positive. The plain film of the shoulder showed shortening of the acromiohumeral interval, osteoarthritis of the acromioclavicular joint and osteophyte formation of both the acromion and the greater tuberosity. Our diagnosis was rotator cuff injury and was confirmed by the arthrogram.
A massive rupture of the supraspina tus tendon was found at the surgery and suturing of the cuff to the greater tuberosity was performed under some tension. Her right shoulder was maintained in 110 degree abducted position with a brace for 6 weeks and was thereafter lowered gradually.
Redislocation of the head was found at 5 months postoperatively and the imm e diate manual reduction failed. The reduction was also impossible at the surgery because of the softening of the humeral head and the tightness of the rotator cuff. The repaired cuff remained intact. Resection arthroplasty was done and 5 months after the second operation she found no difficulties but in washing her hair.
Not only the weakness of the anterior elements but also the tightness of the rotator cuff was thought to play an important role in redislocation in this case. To prevent redislocation after repair of the rotator cuff, it seems to be advisable to perform repair of the cuff and stabilization of the anterior elements at the same time.

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The physiological function of the coracohumeral ligament commonly known is to act as a brake from any excessive external rotation of the glenohumeral joint. Any other function is not definitely known. Recently we have studied two cases of massive rotator cuff tear where the coracohumeral ligament was found left over and bridging over the tear. From these experiences we discuss here on the possible functions of the coracohumeral ligament previously not reported.
Case 1: A 43-year-old man fell froma height on August 2,1984. The arthrograms indicated massive rotator cuff tear in the right shoulder. On January 16,1985, an operation was performed. We found that the supraspinatus tendon and anterior half of the infraspinatus tendon were completely torn. An intratendinous horizontal tear was also located in the posterior half of the infraspinatus tendon. The deep layer of the subscapularis tendon had been avulsed with a bone fragment (18 x 8mm )from the lessor tuberosity. The coracohumeral ligament was found bridging this tear, partially covering the distal intra-articular part of the long head of the biceps.
Case 2: A 73-year-old man fell from a stepladder and sustain e d a bruise on his right shoulder on December 19,1984. The arthrograms showed massive rotator cuff tear. On February 28,1985, the operation was done. The supraspinatus tendon, infraspinatus tendon and rotator interval were completely torn. The coracohumeral ligament was found bridging the tear and covering a part of the long head of the biceps.
In the two cases m entioned above, the coracohumeral ligament extended over the distal intraarticular part of the long head of the biceps where it was exposed to stress from the coracoacromial arch. We conclude here that the coracohumeral ligament protects the bicipital tendon from mechanical stresses.
Furthermore, it seems that the coracohumeral ligament has an influence over the size of a rotator cuff tear. Given that a chronic subacromial impingement is one of reasons for a rotator cuff tear, the wearing area would occur in the supraspinatus tendon and the region where the long head of the biceps enters into the bicipital groove. Although this concept will explain the reason why the supraspinatus tendon is most susceptible to rotator cuff tears, it will not explain why a tear with the long head of the biceps exposed is rare.
We suppose that the coracohumer all igament blocks the forward extension of the rotator cuff tear. Therefore, we would emphasize on the following two functions of the coracohumeral ligament apart from its function to work as a brake when excessive external rotation occurs:
1) To protect the distal intra-articular part of the long head of the biceps.
2) To prevent forward extention of a rotator cuff tear.

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In ruptures of rotator cuff, the supraspinatus tendon frequently is retracted, especially in so massive tear and repair difficult to achieve without excessive tention. For such case, the techinique of supraspinatus advancement, patch graft or muscle transfer may be useful. Trapezius muscle transfer has been performed for such five cases of which four are male and one is female, ages ranged from 47 years to 59 years. Affected sides are 3 in right,2 in left. Following observation was confirmed for more than 7 months postoperativeally. The postoperative results were evaluated according to the criteria of wolfgang (1974).
The results were excellent in 2 cases, good in 2 cases, and fair in one case. Most postoperative impairment of A. D. L. were the restriction of the R.O. M. and weakness of lifting and holding.
Indication of this procedure are the massive tear of the rotator cuff which cannot be anticipated to achieve the sufficient function of supraspinatus muscle.

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We would like to discuss and report on the results of non-operative complete tears of the rotator cuff which were diagnosed by both clinical findings and arthrography. Fifty consective patients with rotator cuff tears were assessed when the patients were first seen at Iwaki Kyoritsu General Hospital, the patients were subsequently followed up.
4 of the 50 patients were lost to follo w -up. These consisted of 25 men and 21 women, varying in age from forty-one to seventy-seven years, average age being 62.5.
34 of the patients had rotator cuff tears of the right shoulder,10 had the left shoulder and 2bilateral.17 of the cases were due to trauma, while 31 were atraumatic.
Clinical findings at the initial visit showed night pain in 29 shoulders, pain on motion in 40s, weakness in 36s, contracture in 12s, crepitus in 19s, and limitation of ROM in 15s.
At follow-up 15 patients complained of night pain in the affected shoulder,29 complained of pain on motion,23 of disability of ADL.22 of the patients examined were engaged in work.
16 patients did not complain of pain, limitation of ROM and disability of ADL.
Their characteristic points were
1 atraumatic as history.
2 no limitation of ROM and contracture at first visiting.
3 wide and spacious subacromial bursa and joint capacity at arthrographic findings.

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Methods of reduction of anterior dislocations of the shoulder have commonly used the Kocher or Hippocratic maneuvers.
Many surgeons had prefered the Kocher leverage technique, but recently some authors have not recommended their use because of the possibility of increasing damage to the capsule, soft tissues and injuring the axillary vessels and the brachial plexus. While Milch recommended the forward elevation maneuvers for reduction of anterior dislocations of the shoulder as the simple and safe techniques.
Twenty cases were performed with the forward elevation maneuver for the shoulder dislocation in our hospitals. The patients are placed in a supine position on the examining table, intravenous and intramuscular medication are not required. The patients are instructed to relax as much as possible while the maneuver is performed, the arm is very slowly and gently abducted untill 90 degrees.
The horizontal adduction on the 90 degrees plane is applied to 90 degrees flextion position, forward flexion is continued untill reduction is carryed out. Nineteen of 20 cases were obtained complete reduction without assistants and anesthesia by this techniques, another one case was needed the muscle relaxant due to severe pain.

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We have treated an old unreduced posterior dislocation of the left shoulder joint associated with large impression fracture of the humeral head. A 52-year-old man fell down and injured his left shoulder. He was diagnosed as having a 3 part fracture of the humeral head. At that time, however, a posterior dislocation was overlooked. Although bone union was completed, motion pain and restriction of both external rotation and abduction persisted for 10 months. A posterior dislocation of humeral head was revealed by an axial x-ray film. His left shoulder was posteriorly dislocated and associated with about a 45 % bone defect of the anteromedial aspect of the humeral head. The posterior edge of glenoid rim was locked in the bone defect of the humeral head. Open reduction was performed, but redislocation occured easily with 20 degrees of internal rotation of the humeral shaft during the operation. Iliac cortical bone grafting was performed on the posterior rim of the glenoid to prevent redislocation. At present, active ROM of the affected shoulder is as follows: flexion,110degrees, extention,40 degrees, abduction,80 degrees, external rotation,55 degrees and internal rotation,20 degrees. According to Neer, in a case of posterior dislocation of humeral head associated with a 20 % ?40 % bone defect of the humeral head, the modified Mclaughlin procedure is the recommended method to prevent redislocation. However, in such a case as ours, in which subscapular muscle and anterior capsule of the shoulder joint is damaged extensively, posterior bone block operation might be the alternative procedure for prevention of shoulder dislocation.

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Follow-up study was performed in the cases of fractures and fracture-dislocations of the proximal part of the humerus and old shoulder dislocations in which different methods of surgical treatments were made. Nineteen shoulders of eighteen cases consisted of thirteen cases of fracturedislocations; four cases of two-part, two of three-part, six of four-part and one case accompanied with glenoid fracture and three cases of proximal humeral fractures; two two-part fractures and one three-part were examined. Moreover, three cases of old traumatic shoulder dislocations treated by open reduction were also analysed. Patient's age at operation ranged from nineteen to seventy-nine years old,53.1 years on the average. The patients had been followed for from six months to fourteen years and nine months; the average period of follow-up after operation was five years and two months. Internal fixation with screws or Kirschner wires was attempted in eight cases, replacement of the humeral head with Neer's type of prosthesis in folk, resection arthroplasty in five cases. In two cases of old shoulder dislocations open reduction and Bristow's operation was made.
The results of treatment was assessed according to Neer's criteria for eval u ation although an item of anatomy (10 units) was omitted from the criteria because the result had to be compared among the different methods of surgical treatment. Therefore, full score became 90 points; 35 points of pain,30 of function and 25 of range in motion.
The average points was 67.5 in the group of internal fixation which was the highest score among the four groups,61.5 in the prosthesis,49.4 in the resection arthroplasty and 66.5 in the open reduction and Bristow's operation for old shoulder dislocations. The total points in the group of prosthesis had become increasing in recent cases. The fact would be attributable mainly to the minimal detachment of the deltoid muscle by using long delto-pectoral approach advocated by Neer. On the other hand, worse results in the resection arthroplasty was caused by its restriction of range in motion.

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Eight fractures of the scapular glenoid in eight patients were studied clinically and roentgenographically.
Six were male and two were female.
The age at injury ranged from 13 to 76 years with an average of 37 years.
The mechanism of injury was a traffic accident in six cases a sports in one and a fall in one.
The severe displacement of the fragment was seen in one patient, moderate in four patients and slightly in three patients.
All patients w ere treated conservatively. Five patients were treated with a sling and bast band from three to five weeks, two patients were treated with a bed rest only, and one patient was treated with a traction on lateral position for five weeks.
Bony union occured in all patients with good augment.
Clinical results were evaluated as good in all patients except two who had shoulder contructure and complainted slight shoulder joint pain on motion.

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We are reporting four cases of the glenoid fracture which were treated surgically and obtained a good functional result.
Case 1 & 2: tr a nsverse fracture of the glenoid fossa. The initial radiograph showed a large inferior fragment markedly displaced inferiorly. Through the posterior approach between the infraspinatus and the teres minor the capsule was incised transversely. The inferior fragment was reduced and fixed with two screws. After immobilization in a sling for three weeks the range ofmotion exercise was started. There is no restriction of motion postoperatively.
Case 3 & 4: fracture of the anterior glenoid rim. These two cases were operated for not only a displaced fragment but also anterior instability. Through the delto-pectoral approach the displaced fragment was reduced and fixed with a screw and the capsule was reattached to the refreshed glenoid rim. Postoperatively no instability is found.
In the transverse or oblique fractu r e of the glenoid fossa obtaining congruency and stable fixation and early active exercise will give a good result. The posterior approach is preferrable to the anterior for the adequate exposure. The anterior glonoid rim fracure should be considered "fracture -dislocation" so that it necessitates congruency and stability. Intraoperatively we found the labrum and capsule stuck to the displaced fragment but detached from the rim above and below the fragment. This fact suggests to us the accurate reduction of the fragment makes the labrum intimate with the rim and “anterior capsular machanism” repaired anatomically.

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We examined 41 cases of the scapula fractures to know the prognosis (the average follow up period: 6 months).
Patients & Methods:
The cases consist 34 Males and 6 females and their age is from 13 to 67 mean is 35.9 years old. Concerned with the affected side, the left side is 24 cases, the right side is 15 cases and the both sides is one. We have classified the fracture types after Jinnaka, the trunk types 21, cervical types 15, combined types (including the former cases) 7 cases. Therapy:
Only 4 cases are operated and the rest of the cases are treated conservatively, for example, the traction, ABD cast, Desault bandage and so on.
Prognosis is better than we expected, but a few cases suffer from the pain or limitation of ROM. There is no cases of the paralysis nor nonunion.

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The purpose of this operation is to control anteroinferior instability of the shoulder. We operated on a 19-year-oldm ale with voluntarya nterior (sub)l uxation of the shoulder. The operative procedure is as follows.
Make a cur v ed incisiona long the deltopectoralg roove to the acromion. Detacht he anterior fibers of the deltoid muscle from the clavicle and expose the coracoacromial ligament from the coracoid process to the tip of the acromion. Resect the coracoid process partially at the insertion of the ligament and transfer it to the lesser tuberosity of the humerus. After fixation the fragment with a screw, repair the incised subscapularis attachment, and then suture the isolated muscles (the short head of the biceps musclea nd the coracobrachiaml uscle) to the coracoclavicularli gamentor to the coracoid stump. The clinicalc ourse for 2 years and 4 months after the operation is satisfactciry. The voluntary (sub) luxation and the instability of the shoulder have been well controlled now. We think this method is applied to the “loose shoulder” with severe anteroinferior instability.

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We examined and discussed for relation between primary traumatic anteriro shoulder dislocation and recurrent anterior shoulder dislocation. As the result, the incidence of recurrent dislocation was a high rate in young patients. Contrary, it was the small number of recurrences in old patients. We discuss the reason of small number of recurrences in old patients and report the prognosis of recurrent dislocation. Total 458 cases were obtained information through a questionnaire for primary traumatic dislocation and recurrent dislocation.
Answers were 134 cases of primary traumatic dislocation and 138 cases of recurrent dislocation. We took some cases physical examination about range of motion, instability and roentgenographic study. In 15 per cent of the patients, the dislocation recurred.
The incidence of recurrent dislocation of the shoulder was 34 per cent before 30 years of age, but 2 per cent after age 50. There was no incidence of recurrence for the group of 5 weeks immobilization or more. Various phases of trauma in relation to dislocations were reviewed. Usually the greater the initial injury, the lower was the incidence of recurrence.
In recurrent dislocation group, before 30 yea r s of age of the patient at the time of primary deslocation was 85 per cent, and 4 cases after 50 years of age had all huge Hill-Sachs lision. From our figures, patients had dislocated easily decreased the incidence of dislocation year by year.

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Five cases of recurrent anterior dislocation of the shoulder in the aged are presented.
Case 1 A 75-year-old female dislocated her right shoulder at age 70. She sought medical attention because of recurrences of dislocation. X-ray revealed a huge posterolateral notch and arthrogram demonstrated massive cuff tear. After Magnuson-Stack procedure and tenorrhaphy, she has had no dislocations.
Case 2 A 67-year-old female fell and dislocated her right shoulder when she was at age 57. Since then, multiple dislocations have recurred. X-ray demonstrated anterior dislocation with a huge posterolateral notch. Arthrogram following reduction, revealed rotator cuff tear. After Magnuson-Stack procedure, she has had no complaints.
Case 3 A 75-year-old male hit a nd dislocated his right shoulder. Despite adequate reduction and fixation, recurrent dislocation became apparent. Arthrogram revealed a posterolateral notch and massive cuff tear. After Bankart procedure, no recurrence was noted until his death four yeras later.
Based on our experience, recurrent anterior dislocation of the shoulder in the aged is charac t e rized as follows:
1. The primary dislocation occurred after middle age.
2. The posterolateral notch is usually huge probably due to osteoporosis.
3. The incidence of concomitant rotator cuff tears in high. S ince the dislocation occurred so easily in ADL, that surgery is recommended unless contraindicated. In surgery, the limitation in external rotation against the huge posterolateral notch is mandatory and adequate cuff repair is desirable.

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Seven cases in which the modified Bristow procedure was performed for recurrent anterior subluxation of the shoulder were reviewed. The purpose of this study is to present the long-term results of these procedures.
MATERIALS AND METHODS
Seven out of eig h t patients, who underwent the modified Bristow procedure for recurrent anterior subluxation between 1970 and 1980, were able to return for evaluation. Three patients were men and 4 were women. The right shoulder was operated on in 5 patients and the left shoulder in 2 patients. The average age at the time of surgery was 21 yerars and 9 months with a range of 16to 25 years. Three patients had no specific traumatic episode and were engaged in sports activity, such as tennis or volleyball.
Five out of seven patients had only anterior instability, but the others had anterior and inferior instability, or so-called loose shoulder. All patients were treated with a modified Bristow procedure that consisted of fixing the bone block with a screw.
RESULTS
Follow-up time of seven patients averaged 124 months ranging from 60 to 190 months. All patients have not had the so-called dead-arm syndrome after surgery. None of these patients had a positive anterior apprehension test, but one patient who had had anterior and inferior instability had a positive inferior apprehension test. There were no pain in sports or work in 5 patients.
Three patients had a limitation in the range of motion of external rotation, which was 19° with the range from 15 to 22°. Five patients had no limitation in sports or overhead work. The results were: four, excellent; two, good; and one, fair. Five patients were satisfied with the result subjectively,
CONCLUSION
A modified Bristow procedure, which is easily done by the anterior axillary spproach, has the effectiveness in preventing recurrent anterior subluxation in our study.

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Post-operative complications of modified Bristow, original Boytchev and modified Boytchev procedures are talked in this paper. There are thirty-three cases, including sixteen modified Bristow, ten original Boytchev and seven modified Boychev, twenty-six males and seven females. Ages ranged from fifteen to thirty-nine when operated, averaged 23.9. Sixteen cases of modified Bristow con sisted of six cases of this procedure without capsulotomy and eight with capsulotomy in which the capsule was repaired when needed.
We are going t o talk about following points,1) Post-opereaive dislocation,2) Limitation of external rotation,3) Troubles about implants,4) Complications of the musculocutaneous nerve,5)Disfiguring scar of skin incision.
(Results) 1) There were two cases of recurrence after repair which suffered violent force when playing baseball or football. We had also one case of subluxation after repir without any sp ecial episode, which capsule had been too loose for modified Bristow without capsulotomy, treat ed by Bankart procedure subsequently.2) Limitation of external rotation was decreasing with time to about 30 % one year after surgery.3) Breakdown of implants were seen in three of ten cases in which special sapphire screw for shoulder were used Loosening of the screw was seen in one case in which ?the length of the screw was too short. Another case in which the length of the screw was too long to catch the muscle posteriorly was cut its tip.4) Six cases of seventeen of Boytchev procedures had some degree of disturbance about musculocutaneous nerve but it tended to disappear with ti me passing.5) Disfiguring scar of the skin incision was seen in three cases severly. Anterior axill ary incision is required especially when woman.

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Many procedures have been devised for recurrent anterior dislocation of the shoulder. In our hospital, the Oudard-Jinnaka has been the most frequently performed operation since 1937. The present report is that of our experience with the procedure. From 1953 to 1985, we did a total of twenty one Oudard-Jinnaka procedures for the anterior instability excluding the multidirectional instability and the recurrent anterior subluxation at our department. A follow-up was undertaken of nineteen patients. The age of the patients ranged from sixteen to thirty-eight years and averaged twenty-three years at the time of the operation. Fourteen procedures were done in male patients and 5, in female. They were followed for one to thirty two years. The average follow-up was twelve years. Four of the nineteen patients redislocated their shoulders from four months to nineteen years after operation. One was operated on again using the same procedure because of detachment of the tip of the coracoid process, which had been recognized shortly after the initial operation. They had no recurrences during the ensuing years. Redislocation occurred in one of fifteen patients in whom the bone graft was longer than 3 cm as indicated in the manual. In shoulders in which the bone graft was shorter than 2.5 cm, the incidence of redislocation was significantly increased.

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There are many operations for recurrent anterior dislocation of the glenohumeral joint. Oudard-Iwahara procedure is one of them and we would like to describe the cause on absorption of the implant bone in coracoid process at post-operation.
In 24 years since 1961 to 1985, we have 88 cases 88 joints by this procedure and have inquired into 72 cases 72 joints that post-operation passed more than one year and could follow up results. About each case, we have mesured the size of the implant bone on the plain X-ray gram that has been taken at post-operation and observed a state of absorption of the implant bone. We have thought of the cause on absorption of the implant bone, for example, times of dislocation of the glenohumeral joint at befor-operation and taking a rest from post-operation or playing sports, and compared them with degrees of absorption of the implant bone.
As a result, in all cases, absorption of the implant bone has been found and no case that the implant bone absorbed completely.
In almost cases it h a d begun to be absorbed within two years, and in very little cases had gone in absorption of the implant bone more than two years passed.

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There are many kinds of therapeutic methods for recurrent anterior dislocation of the shoulder. In these methods, Putti-Platt's procedure, which was described by Osmond-Clarke in 1948, is simple in its operative technique and good in its results. However, the restriction of external rotation causes certain problems in the patient's A. D. L. after operation.
Since the opening of our hospital in 1978 unti l Oct.1984, the Putti-Platt's procedure has been used on patients with recurrent anterior dislocation of the shoulder. Follow-up period is on the average of 2 years and 7 months (from 1 year to 4 years and 2 months). No redislocation occurred in any cases.
The purpose of this paper is to report the short term results and to consider means to prevent redislocation. The anterior barrier of the subscapular muscle plays the main role in the prevention of redislocation.
There are some differences between the preoperative glenoidal shape and postoperative one in the roentogenographic film. The lateral facing ratio (height/width) of the glenoid is larger postoperatively than preoperatively. So, the lateral facing of the glenoid (scapular extension) seems to play a minor role in the prevention of redislocation of the shoulder.

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In 1978, we reported the results of the Putti-Platt operation for 88 shoulders with recurrent anterior dislocation. One of the conclusions was that excessive “double-breasting” for the patients with large bone defects of the glenoid should be avoided because of the postoperative restriction of external rotation. According to this conclusion, we have devised combined procedure of the glenoplasty and the Putti-Platt operation. In this study, short-term results and operative details were discussed. From 1981 to 1985, this procedure has been performed on five shoulders of four cases. All the cases involved male subjects. An average age of the patients at the time of operation was twenty three years. Deltopectral approach was used. Close by the articular surface, anterior part of the glenoid neck was osteotomized intra-capsullary on the sagital plane and tilted posteriory with bone chisel. Then, iliac bone was wedged in a gap parallel to the articular surface as outer surface of the iliac crest making a new glenoid cavity. Finally, anterior capsule and subscapularis was doublebreasted same way as the Putti-Platt operaation. Post-operatively, no recurrence was occured and grafted iliac bone was united within 8 weeks. Averages of range of active motion were 158° of flexion,173° of abduction and 81° of external rotation in abduction at the time of follow-up. In three cases, CT with double contrast arthrogram showed newly formed glenoid rims and articular surfaces which were covred by soft tissue with same density as cartilage. Congruency of the newly formed glenoid was good in three shoulders followed 1 year or more.

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