The flexion, scapular abduction and abduction of the arm were studied in 20 normal shoulders by integrated EMG combined with electrogoniometry permitting simultaneous measurement of the elevation angle. The trapezius and supraspinatus muscles and the anterior and middle fibers of the deltoideus muscle showed high activity and such results indicated that those muscles played an important role in elevation of the arm. From the result of the correlation analysis between the calculated work and the integrated EMG activity, it was suspected that the action pattern of the supraspinatus muscle was different from that of other muscles.
a) A new apparatus for measuring the three di mensional motion and the rotation of the shoulder complex has been developed using a personal computer system. b) A new concept of 3D% ROM is introduced. By measuring 3D % ROM, it is possible to evaluate the maximum circumduction of the shoulder complex quantitatively. The normal values of 3D% ROM are more than 38 %. c) In n ormal shoulders, external rotation angle increases rapidly during abduction 90° -135° and with 180° abduction the average external rotation is 96° . With 180° flexion, the average internal rotation is 27° . In painful arc syndrome shoulders, during abduction external rotation increases less than normal shoulders. But during flexion the pattern of internal rotation is similar to normal shoulders.
The function of the rotator cuff in abducting elevation movement of the arm was considered to induce a desirable phase-difference between the humerus and scapula at the abducting elevation movement of the arm.
Although many authors have described the mechanism of shoulder movements, there are little published reports on the stress distribution at the glenohumeral joint in abduction (3). The purpose of this paper is to analyze the glenohumeral stabilizing mechanism for isometric abduction in the “scapular plane” (4) using two-dimensional computer simulation based on Pauwels' stress distribution theory of a concave articular joint (6).
We recommend the new quantitative evaluative method of the degree of infraspinatus muscular atrophy using ultrasonic diagnostic method. We think that this is a useful diagnostic method for the various shoulder disorders with infraspinatus muscular atrophy.
It is a matter of course to search the causes of the pain and the restriction of mobility in shoulder disorders. However, it isn't easy to catch the causes. Therefore we are apt to waste time without getting situation correctly. In order to grasp the situation, we'd also performed some examinations for painful shoulder, and one of them was the arthroscopic observation. By the way, as a method of examination for painful shoulder, arthrography has been generally used. But x-ray examinations were't sufficient to determine the exact lesions in the soft tissue. So we adopted a method with an arthroscope in addition to radiographic examination. It was useful for diagnosis and evaluation of shoulder joint disorders even when there were no typical x-ray findings. In this report, we would demonstrate representative scopic findings and discuss about the indication, still more about the utilization of shoulder arthroscope for painful shoulder.
228 shoulders were divided into the following three groups according to the shoulder instability. GroupI: Suffered from loose shoulder syndrome, which had instability induced by downward traction in both internally and externally rotated position, antero-posterior instability of the humeral head and outward slipping of the humerus in the elevated position(66 joints 41cases). GroupII: Had downward instability in the internally rotated position but they were stable in the externally rotated position(57 joints 52 cases). GroupIII: Were stable in any position(105 joints 99 cases). CT scans were investigated by the following method. A line was drawn from the anterior angle of the glenoid(A) to the posterior angle(B). Then a vertical line was drawn from B to line A-B. The point of intersection of this vertical line and the humeral head was described as C. The angle CAB was named posterior opening angle of the glenohumeral joint(POA). In GroupI it was 23.1±0.7 degrees(mean±standard error). In GroupII it was 16.8±0.5 degrees. In GroupIII it was 12.0±0.3degrees. The application of a “t” test yielded a P value of less than 0.01 for the difference between each group.
Pathological changes of the anatomical structures we recar efully observed and recorded during operative repair in 70 patient s with acute complete acromioclavicular dislocation. We found that t h e coracoclavicular ligament was intact or only partially torn in 25 % of the patients. We s uggest that the radiological Grades and the pathological Stages are considered separately.
Since 1974 we have reconstructed 19 cases of frail shoulder with muscle transfers with favorable results. After thorough consideration of biomechanical aspects a procedure based on dividing the trapezius into 2 parts and anchoring it to the humerus with bone grafts was tried. It has proved to be highly effective.
Inferior subluxation of the humeral head, also known as the “drooping shoulder”, occurs after the development of paralytic states such as hemiplegia or brachial plexus palsy and after injury to the joint capsule or surrounding musculoligamentous structures producing hemarthrosis or fracture of the proximal end of the humerus. The upper extremity is extremely mobile in order to bring its effector organ, the hand, into a position to grasp objects in normal subjects. However, in a total brachial plexus palsy, where the recostructable function is limited because of restrictions in the number of available donor nerves and in the ability of nerves to regenerate, the object of reconstructive surgery will be first of all to provide stability to the joint, and then such mobility as may be possible, given the particular nerve injuries. In this study the recovery after nerve repair was examined by EMG findings and shoulder function in cases of traumatic brachial plexus palsy.
The course of the repair of the rotator cuff rupture has not been fully clarified experimentally in comparison with that of other tendons such as flexor digitorum tendon and Achilles tendon. Revascularization and remodelling of surgically made canine rotator cuff rupture were studied micro angiographically.
Our two cases had so-called weight-bearing shoulder associated with supero-anterior instability of the glenohumeral joint and a tear of rotator cuff. One patient walked with the aid of a crutch and the other, who suffered from paraplegia, used a wheel-chair. The operative findings in these cases showed the torn supraspinatus and subscapularis of the rotator cuff, and the dislocated or subluxated humeral head from these ruptures. We performed the surgical treatment of repair of the torn cuff, anterior acromioplasty and fascial patch method to reinforce the weakened anterior capsular wall. However the postoperative results of these cases were considered to be fair.
In our previous study of 130 bleached skeletal shoulders, we reported the relationship between the slope of the acromion and spur formation on the undersurface of the acromion. There was no significant variation in the slope of the acromion with varing age and degenerative bony change such as pitting on the medial surface of the greater tuberosity was found in older aged specimens. In this study, we investigated cadaver specimens whether spur formation on th e acromion and pitting on the greater tuberosity correlate to the rotator cuff tear not. Fourty eight shoulders in 25 cadaver specimens were investigated. The age of the specimens ranged from 34 to 94 years with a mean of 66 years. Twenty five shoulders out of 48 shoulders had spur formation. There was significant correlation between spur formation and rotator cuff tear. Spur formation and rotator cuff tear were often associated with pitting on the greater tuberosity. The data obtained from the cadaveric study indicated that the degenerative bony chamges such as spur formation and pitting coexisted in the majority cases with rotator cuff tears. We explane the clinical relevance of our finding to be that there was a close relationship between the slope of the acromion and spur formation on the undersurface of the acromion. A rotator cuff tear was frequently associated with spur formation on the acromion. Those results show that the slope of the acromion may be an important factor in the natural history of rotator cuff tear.
The large horizontal tear is one of the big problems in the repair of the rotator cuff tear. This problem, nevertheless, has not been discussed scrupulously. Though they had been repaired by multiple suturing in situ or by resection of the whole affected tendon and advancement, the results were generally poor. The causes of this poor results were thought to be that multiple suturing in situ did not physiologically reconstruct the damaged tendon, and also that the resection left too large defect to repair in an usual manner (Fig.1). Therefore, we have been attempting to observe the fine structure of the horizontal tear and then to reconstruct it into physiological condition according to estimation from the observation. We expected that this method was useful to minimize the resecting portion of the tendon.
We proposed the new acromioplasty for the surgery of the rotator cuff, tears in which the osteotomized acromion was displaced posteriorly to remove an impingement factor. This procedure provided a wide exposure and efficient subacromial decompression with neither weakening of the deltoid muscle nor detachment of the deltoid insertions and allowed an early motion exercise and early regaining of full range of motion, good strength and normal function. The esthetical results were also excellent because of less spreading of the scar and symmetric round contour of the shoulder. The follow-up studies on a group of eighteen patients document the value of this procedure. This approach is most suitable for a surgical repair of retracted massive tears.
We have examined the arthrograms in 164 cases (176 joints) of the frozen shoulder and classified them into 5 types based on the shape of the contrast medium. In the type showing diminution of the inferior pouch, there were many cases in which the range of motion was markedly limited, the capacity of the joint was small, the response to the anesthetic injection to the suprascapular nerve was poor and the period of treatment was long. While in the type showing the normal arthrogram, the improvement rating for the range of motion was high and the period of treatment was short. Although not all the pathologic conditions of the frozen shoulder are visualized, the arthrography may be useful as an auxiliary diagnostic method since it can predict the clinical course to some extent.
The Boytchev procedure was performed in nineteen cases and seventeen of them were followed. In order to simplify the operative procedure, the conjoined tendon was transferred without moving the pectoralis minor. No recurrence occurred, although two patients experienced a feeling of subluxation early in the postoperative period. The limitation in range of motion was slight, except for two patients who had had significant preoperative limitation of external rotation. Six of the patients had temporary nerve complications.
Many operative methods have been reported along with discussions on the etiology for the recurrent anterior dislocation of the shoulder joint. Since 19641,2, we have employed the modified Bristow procedure as the operative method which may be performed on all patients regardless of the etiology of dislocation. Our operative technique is to detach the coracoid process with its attached muscles and to fix it to the neck of the scapula with a screw.
There are many conditions in which the patient complains of shoulder pain. Of these conditions, the shoulder disorders caused by sports are more difficult than might be expected, to diagnose and treat. Shoulder problems where the complaint is pain, in baseball players which involves throwing motions, are espacially difficult to diagnose and treat, when compared to other sports-related problems. This type of painful shoulder, occurring in conditions where the shoulder undergoes maximum loading at high spead, differs from the soreness involved with ordinary shoulder movements such as those occurring in everyday life. Especially in throwing injuries, which are considered to occur as a result of the instability, of the shoulder joint, it is at present almost impossible to make an accurate determination of the intraarticular damage in the glenohumeral joint. Pappas described articulation as follows, the glenohumeral joint is the most mobile in the body. Bony restraint is minimal and further more, the open face of the glenoid fossa is derected anterolaterally, so that the articulation is inherently more stable posteriorly than anteriorly. The surrounding soft tissue provede the elementary restraint against excessive mobility. These tussues are the glenoid lablum, the joint synovium and capsule, the glenohumeral ligaments, and the adjacent muscles, tendons. One of the most important soft tissue stabilizing structures is the glenoid labrum. Recently many authers have noticed that lesser injuries can result in a symptomatic unstable shoulder joint. Instability of the glenohumeral joint presents in many varied and often subtle clinical forms. Excellent research for the subluxation of the shoulder have been by Neer, Rowe, and Rockwood. Unstable glenohumeral joint is classified by Rockwood as follows.
The unstable shoulder is difficult in making a proper diagnosis. Because the objective findings are not clear always on the clinical signs, X-ray appearance and other examination. In order to make diagnosis easier, we divided the'unstable shoulders into two major groups in the pathogenesis (Fig.1). One is the anatomical instability and the other is the functional (3)(6). In the anatomical instability, displacement of the glenohumeral joint can be demonstrable clinically, on the other hand, in the functional instability it cannot be shown clinically although severe shoulder disability is found when the shoulder joint is forced into the definite position such as abduction with external rotation(4)(8). There are many reports on the factors stabilizing the glenohumeral joint, for examples, abnormalities of the subscapular muscles (10), the glenoid labral lesion(3), the capsular elongat1on(5) and the bony defect of the humeral head or the gleno1d. The subscapular deficiency will be excluded in this paper, because it is difficult to show any objective findings of the subscapular muscle before surgery. This factor is still not comprehensive. The glenohumeral joint will be displaced objectively due to the capsular elongation at the stress position, showing the anatomical instability. The glenoid labral lesion including the partial detachment of the capsule will produce severe pain at the forced position, but it will not show the objective displacement of the glenohumeral joint, which is the functional instability.
Inferior instability of the shoulder joint was treated by tra n sfer of the pectoralis major muscle to the inferior angle of the scapula and good results were obtained, especially for the patients complicated with voluntary anterior dislocation. Usefulness of this treatment was confirmed by kinesiological electromyography.
The symptoms of thoracic outlet syndrome sometimes appear in manifestations of those of loose shoulder. It is difficultto divide and acess those manifestations of the two factors. Four cases with these kinds of manifestations are p r e sented and discussed as to their diagnostic and therapeutic problems.
Since 1983, four patients with aggressive giant cell tumor and malignant tumor have undergone an en bloc resection of the tumor and the skeletal reconstruction with a prosthesis and massive bone allograft. In those with malignant tumor, the transfer of the trapezius and the acromion (Bateman) was supplemented following removal of deltoid. The follow-up periods were 9 to 35 months and averaged 21 months. One died of lung metastasis, but there was no recurrence. There was one nonunion. A patient with giant cell tumor had a pain-free shoulder without any difficulty in activity of daily life. Pain-free shoulders with some limitation of daily life activity, especially-active overhead motion were regained in patients with malignant tumor. Although further follow-up periods are required, these observations suggest that the trapezius transfer can, to some extent, substitute for deltoid and that a prosthesis in this procedure is not a passive spacer.
We operated on 16 cases of malignant bone tumor of shoulder girdle. Upper extremity should be preserved in malignant tumor if main artery and nerves are not to invaded. We did reconstructive surgery using prosthesis of humeral head and scapula after wide resection. After operation, survival period was 1 year and 10 months on a varage. Pain was relieved in all cases, range of motion at shoulder was very limited but not so much as to be inconvenient for daily living. Local recurrence was uncommon and appearance of the shoulder was good.
Septic arthritis of the shoulder in infants and children has been reported by Paterson (1970),5 cases, Nelson (1972),10 cases, Colville (1978),5 cases, Toyama (1980),6 cases, Schmidt (1981),9 cases and Otsuka (1983),2 cases (Table I ). However, most of them are short studies, such as by Schmidt for 2 years 2 months, Gillespie 1 year 6 months, Otsuka 1 year 3months. The longest of all was reported by Toyama which was for four years and eight months (Table II). In this paper, we present six cases of which four of them are from Toyama's previous study. The longest follow-up is eleven years and the shortest three and a harf years averaging 7.3 years.
To devise appropriate schedules for the treatment of rheumatoid shoulder, a roentgenographical study was made of the natural courses and the prognoses of shoulder joint destructions in RA patients. Eighty-three definite or classic RA patients, for a total of 166 shoulder joints, were the subjects for this study. For the assessment of shoulder joint destruction, we used X-ray patterns and two parameters: 1) Upward migration index (UMI) showing the distance between the undersurface of the acromion and the center of the humeral head.2) Medial displacement index (MDI) showing the distance between the original glenoid surface and the center of the humeral head. The patterns of joint destruction were classified into five groups: 1) Non-pro g ressive (N) type (n=74) showing only bone atrophy or small erosion even after 15-20 years of RA.2) Hatchet (H)type (n=22) showing marginal erosions but not collapse.3) Collapse (C) type (n=34) showing subchondral cysts followed by collapse.4) Stiff (5) type (n=12) showing osteoarthritic features.5)Mutilating (M) type (n=14) showing mutilating bone destructions. These patterns of joint destruction could be distinguished at 5-10 years of RA. The various prognoses of destruction of t h e shoulder joint were assessed on the basis of UMI and MDI. The following table shows UMI and MDI at 5-10 years of RA. From X-ray findings and these two parameters determined at 5-10 years, we could predict the prognosis of shoulder joint destruction after 15-20 years of RA. This study should prove useful for deciding surgical indication, timing, and prosthetic selection for rheumatoid shoulder. Among patients with rheumatoid arthritis (RA), shoulder joint involvement is not as rare as once thought. However, no therapeutic policy has been established for rheumatoid shoulder. As a first step, knowledge of the natural history of rheumatoid shoulder may help to establish the surgical indication, timing, and prosthetic selection. In this study, the natural history of 166 involved glenohumeral joints in RA patients was studied roentgenographically in order to shed light on the factors involved in the prognosis of this condition.
An operated case of entrapment neuropathy of the axillary nerve in the quadrilateral space is reported. The symptoms, etiology, differential diagnosis and treatment of entrapment neuropathy of the axillary nerve are discussed based on patients treated by the author. This disease must be differentiated without fail when consulting with the patient who complains of shoulder pain. Among patients who complain of pain in the shoulders, sometimes entrapment neuropathy of the axillary nerve is observed. The author experienced operating on both shoulders of a patient with this disease and found one cause to be at the tendinous portion of the long head of the triceps. This paper is to report this case and discuss symptomatology, differential diagnosis and treatment of this disease.