The stapling operation for recurrent dislocation of the shoulder was first described by du Toit in Johannesburg, South Africa in 1956. This operation seems to be a reliable procedure for fixing a detached glenoid labrum, the principal pathological lesion which causes recurrent dislocation. It is technically easier than the Bankart procedure as it is possible to reattach the detached labrum and capsule, as well. A summary of the operative techn i que is as follows. An 8cm incision is made over the deltopectral groove. The short head of the biceps and coracobrachialis are retracted medially. The subscapularis is divided along its fibers and retracted upward and downward. The capsule is incised parallel to the fibers of the subscapularis. After a special humeral head retractor is inserted, the joint is inspected and pathological lesion should be identified. Two staples should be inserted to secure the detached labrum and redundant capsule. Care must be taken so that the staples do not penetrate the articular surface. During the procedure, no tendon or muscle is detached from its origin or insertion. Therefore, postoperative management is easier and early recovery to usual activities can be expected. The authors have performed du Toit procedure on 6 patien t s who had recurrent anterior dislocation of the shoulder. Individual data of the 6 patients were summarized in table 1, and also, the follow-up results were shown in table 2. A few patients felt some dull pain occasionally, but no patients had any redislocations. Most patients resumed their sports activities within 3 to 6 months. Most of the patients had some limitation of external rotation, because the authors were too nervous to recommend that the patients do external rotation exercises soon after surgery. In spite of this limitation, no one complained of any disturbances in performing daily or sports activitties. In summary, du Toit's stapling o peration is directed to repair the pathology of the dislocation. No detachment or transection of the muscles is necessary to perform the procedure, for this reason, early resumption of occupation and sports participation can be expected. The only disadvantage of this procedure is that implantation of metal staples is necessary, and these may loosen, break or require removal. Even though these disadvantages have been taken into consideration, we believe the du Toit capsulorrhaphy is a reliable and useful procedure for recurrent dislocation of the shoulder.
We have used du Toit procedure to treat recurrent anterior dislocations or subluxations of the shoulder joint since 1983. During these five years we have operated 14 men and 2women ranging in age from 16 to 61 years (average age 29.4 years). Their affected sides were right 7, left 8, and both 1. The average operati n g time was 68 minutes (35-90) and the average blood loss was 42.2 grams (10-86). Pathological changes found at operation were as follows: capsule detached 16 shoulders, labrum. detached 5 shoulders, labrum absent-9 shoulders, glenoid rim eroded 8shoulders, and osseous lesions-2 shoulders. We conducted follow up studies of 16 cases. The follow up period was from 7 months to 4 years 9 months (averaging 2 years 11 months). No recurrences were seen and staples were not missing or loosening. External rotations were slightly restricted in 6 cases. We found four patients who complained of pain and instability of the shoulder joint when they instantly changed their motion. All the patients showed no difficulty in carrying out their daily living and returned to social activities. All except one were subjectively satisfied with this procedure.
We perfomed Boytchev's procedure because of its easy technique. In some cases, a moderate amount of joint laxity was recognized. In these cases extraarticular arthrorisis was inadequate, so we performed a modified Bristow's procedure with Protzman's procedure. But these procedures were very complicated. Recently we have devised a modified Boytchev's procedure in which anterior capsular reinforcement can be performed at the same time.
The Boytchev or its modified procedure was performed on twenty-six cases with recurrent anterior dislocation of the shoulder from 1979 to 1986. We evaluated nineteen cases recently on the following points: 1) loss of external rotation,2) non-union of the transferred coracoid process or migration or breakage of the screw,3) nerve disturbance (especially the musculocutaneous nerve) and 4) instability or re-dislocation, with an average follow-up period of 4.9 years. Limitation of the external rotation improved with time and reduced to 20% of full range 10 years after surgery. We had three cases of non-union of the coracoid process, all of which were fixated by a sapphire screw. Nerve disturbance occurred in a high ratio (31.6%). Re-dislocation of the operated shoulder occurred under very strenous force in two cases, which were reduced easily by a closed method. However, another six cases complained of a feeling of instability when throwing or serving. In these cases the roentgenograms displayed large defects of the antero-inferior edge of the glenoid or Hill-Sachs lesion in three cases, and the arthrograms indicated ballooning or detachment of the capsule in two cases. For these reasons, we would like to conclude that the Boytchev procedure should be restricted and used only for cases without any severe instability caused by the capsule or bone.
A review of forty-two cases of the modified Bristow procedure for recurrent anterior shoulder dislocation is presented here. Thirty-five patients were male and seven patients were female. All the patients had the procedure performed laterally. Seven shoulders were on the right and twenty-five shoulders, on the left. The follow-up ranged from seven months to thirteen years and one month, with a mean of four years. In our series the redislocation rate was 2.4 per cent.8 5.7 per cent did not complain of pain and 71.4 per cent had no difficulty in daily living.95.2 per cent were subjectively satisfied with the procedure. The patients were asked to grade their results from 0 to 10 points and the average result, as graded by patients, was 9.2 points. Three patients were incapable of returning to sports activities after the operation because they feared a recurrence. The mean loss of external rotation was 8.7 degrees. The objective results were examined by using the Carter Rowe criteria and the shoulder evaluation sheet of the Jpn. Orthop. Assoc., The results were rated excellent in 73.8 per cent, good in 21.4 per cent, fair in 2.4 per cent and poor in 2.4 per cent using the Rowe criteria. The average point was 95.3 points based on the shoulder evaluation sheet. Roentgenograms before surgery showed Hill-Sacks lesion in 85.7per cent. Bankart lesions were found in 47.6 per cent on the arthrogram and at surgery. Roentgenograms at follow-up revealed that three had broken screw, two had loosened screws, three had fibrous union of transplant and one had a migrated transplant.
The purpose of this paper is to clarify the difference of the arthroscopic pathological findings between recurrent subluxation and classical dislocation, and to report the results of Putti-Platt's procedure. From 1977 to 1987,55 shoulders of 53 cases of recurrent subluxation and dislocation were treated in our department. The average age was 24.0 years (15-56). Twenty-seven shoulders were classified as recurrent transient subluxation (Rowe, C. R.,1981) and 28 shoulders were classical dislocations. Putti-Platt's operation alone was performed on 24 shoulders with subluxations and 22 classical dislocations. In 6 dislocations, glenoplasty was combined with a Putti-Platt operation. The follow-up period ranged from 4 to 96 months (average: 21.1months). In all subluxations, shallow cartilage defects were found at the postero-lateral and intra-articular area between the top of the humeral head and the surgical neck. Notches of classical dislocations (Hill-Sachs' lesion) always had some bone defect which was connected with the surgical neck. At follow-up, the averages of external rotation of recurrent subluxation at 90 degrees and at 0 degrees of abduction were 82.5 degrees and 46.8 degrees, respectively. The average restriction of external rotation was 16.7 degrees in 90 degrees of abduction and 19.6 degrees in 0 degrees of abduction. There were no statistical differences between subluxation and dislocation when we compared the post-operative range of active movement of the shoulder. All the patients who had undergone a Putti-Platt operation, were satisfied with the results. However, competitive athletes complained of decreased throwing ability.
From 1970 to 1987, we have operated on 65 patients with recurrent dislocation of the shoulder. Thirty two patients were treated by the modified Bristow procedure and 15 were treated by the Boytchev procedure. We reported at the 11th Meeting that the Boychev procedure was technically easier than the modified Bristow procedure, but more patients in the Boytchev group complained of difficulty in ADL, decreased ability in sports, and episodes of subluxation. It seemed that the effect of muscular block aimed by Boytchev procedure was insufficient in preventing instability in vigorous sports. Since 1984, we have used the modified Bristow procedure combined with repair of Bankart lesion (Bristow & Bankart procedure) on 17 patients. In this paper, we would like to compare the results of these two procedures. Redislocation occurred in two case of Boytchev's procedure by mild force a nd one case of Bristow & Bankart's procedure by strong force. Subluxation occurred in six cases of the Boytchev group but in none of the Bristow & Bankart group. Forty three per cent of the Boytchev cases and 25 percent of the Bristow & Bankart cases changed or stopped sports due to anxiety. In both procedures, over 85 percent of the patients were satisfied with the results of the operation. We conclude that for daily life activities Boytchev's procedure may be satisfactory, but if we aim to assure that the patient will return to hard or contact sports, Bristow & Bankart procedure seems preferable.
From 1979 until 1987, the Boytchev procedure was performed on twenty-four shoulders of twenty-four patients. They were followed up after a mean observation time of 51.3 months. There were no recurrences except for in one patient, who experienced redislocation due to an unacceptable shoulder position just after surgery. Moreorer, two experienced a feeling of subluxation, but not a complete dislocation, and one had a recurrent subluxation. Nine of the patients had limitation of external rotation. Three o f them were patients who had been treated for rotator cuff rupture with the McLaughlin method combined with the Boytchev procedure and had had significant preoperative limitation of external rotation. In another six patients, the amount of limitation was less than ten degrees, so they felt no inconvenience in their daily activities or sports. Nine of the patients had nerve complica- 'tions; total musculocutaneous nerve palsy was diagnosed in two patients; numbness in the radial side of the forearm in five patients, in the area of the median nerve in one patient, and in both areas in the other. These symptoms almost disappeared in a period ranging from ten days to two years. We believe that careful neurolysis will enable the decrease of postoperative nerve complications. In cases with high penetration of the musculocutaneous nerve to the conjoined tendon, we pass it below only the proximal two thirds of the subscapularis muscle to diminish the tensive force, which acts on the nerve.
Many operative methods have been reported in literature on the recurrent anterior dislocation of the shoulder joint. Conforty presented a paper about the Boytchev procedure with satisfactory results in 1978. From 1979 to 1987, we performed this procedure on 31shoulders of 31 patients with recurrent dislocation of the shoulder in our hospital. They were 24 males and 7 females whose ages ranged from 17 to 45 with an average age of 25.8. In 16of the patients, the right shoulder was affected and in the other 15, the left. The average time interval between the primary traumatic dislocation and the operation was 5.3 years with a mean frequency of recurrent dislocation being 8.8 times. The average operating time was 107minutes and the average blood loss was 113 grams. The main complication after the operation was musculocutaneous nerve palsy in 9 patients (29%), but these symptoms disappeared within six months after the operation. Two patients (6.5%) had recurrent dislocation after the operation and another two patients have experienced a feeling to subluxation but not to complete dislocation. The mean value of limitation in external rotation was 4.5 degrees compared with the unaffected side.
Thirty-nine cases of anterior shoulder instability have been operated on by the modified Boytchev procedure in our university hospital since 1980. In this procedure, the coracoid process to which the conjointed tendon of the short head of the biceps and the coracobrachialis attaches is rerouted posteriorly to the subscaplaris. Thirteen of the thirty four joints were rec u rrent sub-luxation and the others, recurrent luxation. Twenty three cases were male and nine female. The ages at operating time ranged from e ighteen to forty-seven years, and the average was twenty-six years. The follow-up studies showed no dislocations at all after surgery. The range of flexion and abduction of the operated should e r joints were almost normal in all cases, however, lack of range of external rotation remained in almost all cases ranging from 0° to 35° with an average of 17°. Musculocutaneus nerve palsy i s one of the most important problems with this procedure. In our series, we found 9 cases of transient palsy, that is to say, twenty-seven per-cent of all follow-up cases. Therefore, we believe that this modified Boytchev procedure is useful for anterior shoulder instability.
Among a number of procedures to treat recurrent anterior dislocation or subluxation of the shoulder, we have employed the modified Boytchev procedure for the last 13 years. The advantages of this procedure are its easy technique and there is no limitation of external rotation of the shoulder. We have rev i ewed 52 shoulders of 51 cases that were operated by this procedure (Traumatic recurrent dislocation or subluxation: 42 shoulders, Nontraumatic loose shoulder: 10shoulders). Complications following surgery were seen in 5 shoulders: Displacement of the screw: 1. Nonunion of the coracoid process 1. Peripheral nerve paresis: 3 (musculocutaneous nerve 1, median nerve 2). 36 the trauma t ic recurrent dislocation or subluxation cases were followed up, and the following results were obtained. The postoperative follow-up period ranged from 1 and a half years to 13 years 11 months, the average being 5 years and 8 months. 1) No cases complained of shoulder pain or ADL inconven i e nce postoperatively. 2) External rotation limitation was present in 20 shoulders. The average limitation was 8.2 degrees. 3) There were 8 recurrent shoulders (22.2%). The possible causes were preexisting severe Hill-Sachs lesion or postoperative athletic activity.
Boytchev technique has been used in our hospital for the treatment of recurrent anterior shoulder instability since 1979. From 1979 to 1986,65 operations were performed. Single Boytchev procedure had been used for all 36 patients with this disorder until 1982. However, since 1983 we have performed combined operations with Neer's inferior capsular shift on 7cases, complicated with inferior instability and a bone graft to the glenoid on 2 cases, complicated with large bone defects, besides the single use on 20 cases without complications. As results, in the former 36 cases recurrent subluxation occurred with one patient who had 3 complications. Unstable apprehension complaints were noted in 4 cases with inferior instability and in 2 cases with large bone defects. In the latter 29 cases, none had recurrence or apprehension. In the motion range, over half of the cases had limited external rotation of about 15 degrees. Upon returning to social activities, almost all the cases were content. Especially,33 out of 34 cases who preferred returning to sports, did so completely. This procedure is an excellent surgical method, because of its applicability to all cases, relative simplicity in technique, and similarly stable and good results, obtainable by any surgeon.
Multidirectional instability of the shoulder is getting better-known, but is still unknown in diagnosis and treatment. However, its pathogenesis is still unknown, particularly why the shoulder instability causes some functional disability. In order to study the functional disorder of multidirectional instability of the shoulder, we analysed the isokinetic study of those patients using a Cybex II isokinetic exerciser. We selected the patients from our clinical findings, and chose those with an arthrographic abnormality showing the so-called cap shadow on the top of the humeral head. We checked the muscular contraction power at each position of flexion, abduction and extension, and also recorded each contraction curve at the different positions. Consequently, it was found that the muscular contraction power was lower in those patients with multidirectional instability compared with those without the instability, and that the muscular contraction curve produced a different pattern in those with the instability. Therefore, muscular imbalance might cause functional disorder of the sh o ulder in patients with the instability.
Many factors are supposed to concern the instability of the shoulder, such as malformation of the glenoid cavity, capsular disturbance and the scapular incoordination. We investigated the relationship between general joint laxi t y and instability of the shoulder in 77 cases (35 cases with instability and 42 cases without instability). They were all high school athletes. We compare d the two groups and found a high incidence of general joint laxity in those with instability. The clinical features of instability of the shoulder appeared to have been caused by general joint laxity, especially in the male. In most cases (in 80%), we found inferior inst a bility improved by scapular fixation. This result suggests that pectoralis major transfer is an advantageous treatment of unstable shoulders. Other treatments should be considered but our results showed that neither glenoid insufficiency nor joint laxity were significant. We found a high incidence of m ultidirectional instability in the cases with instability of the shoulder. We should examine multidirectional instability in those patients with inferior instability. It is important to clarify the pathogenesis of the instability in the management of shoulder disorders.
We investigated the stablilizing mechanism of the glenohumeral joint which prevents inferior subluxation. We will describe two projects that clarify the functional significance of stabilizing tissues in the approach of shoulders. In the first project, the increment in downward subluxation was measured after anatomical dissection of vertical stabilizing tissues (the coraco-humeral ligament, rotator cuff, rotator interval and anterior capsule) during vertical load condition in different orders in ninety eight fresh shoulder specimens from human autopsies. In the second project, mechanical f orce transducers were installed on the stabilizing tissues (the supraspinatus tendon, coracohumeral ligament and anterior capsule) of eight monkey's fresh shoulder specimens and the stabilizing forces were measured at different vertical loads. This project showed relative restraint provided by shoulder stabilizing tissues during these vertical load conditions. Our results demonstrate d that the coracohumeral ligament and the supraspinatus tendon were most important structures as static and dynamic stabilizers, and closely interacted with each other, in preventing inferior subluxation of the glenohumeral joint.
In order to clarify the pathogenesis of so called loose shoulder, we simulated the shoulder joint using RBSM (Kawai's Rigid Body Sprig Model). We could change the resultant force, the shape of the joint, and Young's modulus. Normal shoulder joints (13 cases,20 joints ) and loose shoulders (9 cases,16 joints) were reviewed in X rays. The difference between these is that the scapulae of the loose shoulder do not abduct more than those of the normal shoulder. This difference is put into a computer for analysis using RBSM. We talked about two typical situations (at 30 degree abduction and 150 degrees). At 30 degree abduction the cont our of the joint was the same in two cases but at 150 degree abduction it was different, the humeral head of the loose shoulder had slipped down from the glenoid. The simulation show ed that at 150 degree abduction there is a great reduction in the raising power of the scapula of a loose shoulder, the capsule is weaker and the resultant force of the humeral head is directed toward the inferior edge of the glenoid. In this paper we will discuss the way to cure loose shoulder.
The present study was performed to look, into the abnormalities of collagen synthesis in joint capsules from patients with loose shoulder. Hydroxyproline was determined to estimate the collagen contents in a neutral salt soluble, acetic acid soluble and insoluble fractions. Insoluble collagen was reduced with NaB3H4. Hydrolysis of the reduced materials was carried out with 3N HC1 for 24h at 110°C in vacuo. Hydrolyzed samples were chromatographed on an Aminex A-5 column with slight modifications. Normal joint capsules of the shoulder joints (ranging from 15 to 45 years of age) were found to contain less collagen compared to other major joints; the amounts of collagen in the tissues were as follows: The shoulder joints; 30-35% per tissue dry weight, the elbow, the hip and knee joints; 80-90%per tissue dry weight. Although there were no significant differences in these values between a normal shoulder and a loose one (8 cases, ranging from 14 to 24 years of age), a significant increase in the amount of neutral salt and acetic acid soluble collagen was observed. Both normal and loose shoulders consisted of mainly type I collagen and of small amounts of type III collagen. Comparative analysis of cross-links of collagen from normal and loose shoulders revealed that collagens from loose shoulders contain more reducible cross-links. These data suggest that joint capsules of loose shoulders produce relatively immature collagen fibers which may partially reflect the clinical features of the disease.
For the last 5 years we have been able to achieve clear images due to the development of double contrast arthro-CTs. However for the last 4 years, when using a positive contrast medium when complications are observed, including pain and sensitivity to iodine, we have switched over to the negative contrast medium with computed tomography (the pneumoarthro-CT method). Since then we have used this method in 55 cases with various disorders of the shoulder joint but in this paper we will report on those cases whose main complaints are dislocation and subluxation. Of these cases,27 out of 42 were induced by trauma so that they had recurrent anterior dislocations and subluxation of which 15 exhibited multidirectional instability. For the former cases we used Bankart's method (Rowe's modified method) and for the latter we used our own modification of Bankart's method plus the inferior capsular shift method. We compared the operative findings and the pneumoarthro-CT findings with regard to changes in the bone, labrum, joint cartilage and peripheral soft tissues. Both the methods' findings agreed with regard to bone lesions, labrum, and scar tissues. However, on close examination, this method well depicted lesions in the labrum, the bucket handle tear, abrasion, defect and complete avulsion, but it did not depict a crack in the base of the labrum (incomplete tear). When we compared the pneumoarthro-CTs and the previously used double contrast arthro-CTs, there was no difference in the depicting power of the afore mentioned structures. Taking into consideration the anoma l y which may be caused by contrast medium and masking, though limited in area, caused by positive contrast medium, one may say that the pneumoarthro-CT is a more effective examination method than the double contrast arthro-CT.
The concept of unknown inferior instability of the shoulder was presented by Endo in 1971, and he called it ‘Loose Shoulder’. Recently, there has been a great deal of interest in multidirectional instability of the shoulder, but its pathogenesis and pathology have not been explained. This instability causes atraumatic dislocation or subluxation. We experienced nine su c h cases from 1985 to 1987. This report presents the management of atraumatic dislocation or subluxation due to multidirectional instabilioy of the shoulder in children. Our cases included five boys and four girls with a mean age of 11.8 years. There were four bilateral cases, three right side cases and two left side cases. Five cases were involuntary and four cases were voluntary. As for the direction of the instability, three cases had anterior and inferior instabilities, two cases, posterior and inferior and four cases, aterior, posterior and inferior. When we suspected the diagnosis to be shoulder instability after regarding the symptoms and performing a physical examination, stress X-rays, double contrast arthrograms and double-contrast arthro-CTs were performed. We planned the management of atraumatic dislocation or subluxation due to multidirectional instability of the shoulder as follows: voluntary cases were chefly treated conservatively. In involuntary cases, we prescribed muscular strengthening exercises of the rotator cuff for the first step. If, after the exercises, the patients were still found to have diflculty in various activities of daily life, surgical treatment was considered. We performed operatious on four shoulders in three cases.
We have determined the effectiveness of muscular strengthening exercises of the rotator muscles for shoulder instability. These exercises are one of the conservative treatments for shoulder instability. As of y et, there have only been a few reports about the effectiveness of this procedure due to lack of data. So we have attemped to clarify this treatment and its effect. In this study, we will report on 11 cases-19 shoulders with inferior and/or multidirectional instability and 3 cases-3 shoulders with recurrent anterior dislocation. All the patients began isometric rehabilitation exercises and followed up using a Cybex machine and a grading system. As a result, we found muscular strengthening exercises to be effective and useful in 75% of the patients with inferior and/or multidirectional instability. Patients with recurrent anterior dislocation also had a good rate of response. However the success and effectiveness of this technique has certain limitations. We should first try muscular strengthening exercises of the rotator muscles in the treatment of shoulder instability.
Psychological factors have seemed to play an important role in voluntary shoulder dislocation. Nevertheless, there are no detailed reports of those who have received psychiatric treatment. We would now like to report the following 4 cases whose shoulder dislocations were caused as a manifestation of psychological factors. Case 1: 28 y. o., female. When the patient was about 16 years old, she dislocated both shoulders by minimal trauma; then, voluntary shoulder dislocation developed. She underwent five operations at a certain hospital from the age of seventeen. As the dislocation had recurred within 6 months postoperatively on each occasion, she visited our clinic. As we recognized split object relations, we told her to have a psychiatric examination. As a result, it became clear that she had a borderline personality disorder and the dislocation was a trend of autoclasia. Case 2: 22 y. o., female. This case is the similar disorder to Case 1, but, just a slight. Case 3: 15 y. o., female. Voluntary shoulder dislocation and pain appeared in her left shoulder two years ago. As her relations with her mother were unnatural, we recommended a psychiatric examination. The result clarified that an adjustment disorder during adolescence existed. Case 4: 23 y. o., female. Two years ago she suffered from traumatic dislocation caused by a traffic accident, and lost her fiance. Then, after she started going out with another man, dislocation of the shoulder began to occur at twilight accompanied by a syncope-like episode. Though it was spontaneously repositioned under general anesthesia, the dislocation occurred again when she came out from under the anesthesia. Therefore, we requested the cooperation of the psychiatric dept.. As a result, she was diagnosed as having hysterical neurosis.
The purpose of this paper is to report the results of non-operatively treated “loose shoulder”, and to discuss the surgical indication for this lesion. Thirty-five consecutive patients,46 shoulder joints with “loose shoulder” were followed up from 1 year and 6 months to 7 years (average 4 years and 2 months). The patients consisted of 14 men and 21 women, and their ages varied from 14 to 67 years, averaging 28.7 years. Their predominant complaints were dull pain around the joint and instability when they were carrying a load, throwing, or working with the arm elevated.26 patients (74%) had tenderness in the rotator interval region and 18 patients (51%) had luxaty of other joints, such as the elbow or wrist joints. The roentgenological findings revealed that 19 joints (41%) had hypoplasia of the glenoid. As a conservative treatment, patients were adviced to rest the involved joint, were injected a steroid locally, and had to avoid carrying a load and so on. At their follow-up consultations,21 patients (60%) had no com plaints of their initial symptoms. Some of them, however, changed their lifestyle or occupations. On the other hand,14 patients (40%) still complained of their initial symptoms. There was an improvement of symptoms in patients with “loose shoulder” caused by a “rotator interval lesion”. But contrarily, patients with “loose shoulder”, caused by joint laxity or hypoplasia of the glenoid, still complained of their initial symptoms. As approximately 60% of the patients with “loose shoulder” showed improvement of their initial symptoms, we conclude that the operative indication for “loose shoulder” should be made carefully and be decided based on the pathognomonic factors.
Twenty seven shoulders involving of twenty three cases of loose shoulder were operated since 1977. In our study, twenty three shoulders could be followed up, and loose shoulders with recurrent dislocation were excluded. Our method of treating loose shoulder has changed in these ten years. Pectoralis minor transfer was performed after applying Gallies procedure, but these two methods could not obtain satisfactory stable shoulder. Following two methods, Neer's inferior capsular shift, pectoralis major muscle transfer and glenoid osteotomy were performed. As the results of our study show, eighteen shoulders in twenty three shoulders could obtain stable shoulder. And fourteen shoulder were satisfactory to sustain their daily life. Of those cases, some were operated upon more than twice. For example, one case was operated four times, but stable shoulder was unobtainable, arthrodesis was finally performed. In one case, right shoulder was provieded with glenoid osteotomy and inferior capsular shift and then left shoulder was dislocated by her own will. In one case, both shoulders were operated and stableness was obtained, but sternoclavicular joint was dislocated by his own will. As a result, it was assumed that a psychiatric factor was concerened in such poor cases.
We have performed surgical operation on 45 cases,10 male and 35 female, diagnosed as loose shoulder. The average age was 19.2 years old and the average follow-up period was 2years and 11 months. There were 6 cases (8 shoulders) which underwent two or more operations.2 cases (4shoulders) had their first operation in our department and 4 cases (4 shoulders) were operated at other hospitals. Glenoid osteotomy had been performed initially in all cases. Enlargement of the anterior recess was observed arthroscopically at the final operation in all cases. We believe this to be the most important factor why the patients' symptoms remained. Their scopic findings at the final operation were the same as those of the other cases at their first operation. As mentioned above, unstable conditions may continue after the first operation in some cases. Our recent opinion is: In case with enlargement of the anterior recess, roentgenographically or arthroscopically, and intensive inferior instability, we will perform an inferior capsular shift or repair the rotator interval. In case with slipping of the humeral head during abduction roentgenographically, we suggest glenoid osteotomy. There may be some cases which may recommended both operative methods at the same time.
Patients with inferior instability of the shoulder joint were treated with a transfer of the pectoralis major muscle to the inferior angle of the scapula. From 1975 to 1982, this operation was performed on 37 shoulders and 32 of these shoulders were followed up. Instability of the shoulder joint had disapperared or was reduced in al m ost all cases, one year after the operation. Shoulder joint pain, feeling of the dislocation and numbness of the extremities had almost decreased entirely, but the dull pain in the shoulder girdle had increased. Roentogenographic studies showed the improvement of the upward rotation angle of the scapula. Electromyographic studies revealed the increased activity of the pectoralis major muscle during abduction motion. The tracking movement capability of the shoulder joint was the same as that of the non-operated side, but activity of the trapezius and the pectoralis major muscle had increased during the movement.
Following the report on “Loose shoulder” by Endo and Takigawa (1971), Neer and Foster (1980) described involuntary inferior and multidirectional instability. Fukuda (1984) classified shoulder instability according to Neer's concept and modes of subluxation and dislocation. This paper presents our long-term operative results for inferior and multidirectional instability (I & MDI) problems based on this classification. Materials and Methods: Twenty-eight shoulders have been o perated on by inferior capsular shift (Neer) since 1981. The follow-up period was from 2 to 6 years (Average: 3years and 9 months). There were 6 males (8 shoulders) and 16 females (20 shoulders). The unilateral involvement was 16 and the bilateral 6. Ages at operation ranged from 13 to 27years (Average: 18.3 years). The cases were classified as follows: The results were assessed using the evaluation system for shoulder diseases established by the JOA.
The shoulder joint is obliged to become unstable in order to get a wide range of motion. The shoulder joint has both instability and strong support of the upper limb. When the balance of instability and support are broken, various clinical signs begin to appear. In 1971, Endo and Takigawa reported their conception of the loose shoulder. We classified this disorder and performed glenoid osteotomy on loose shoulder due to hypoplasia of the glenoid. The purpose of this study is to present the long-term results of these procedures. Between 1970 and 1987, we performed osteotomies on one hundred and forty cases, of which we followed up forty-six cases for more than five years. Results: All the cases except two showed no clinical signs. One case had traumatic anterior dislocation following a fall after surgery, and the other had severe anterior-posterior instability. Hypermobility was almost completely controlled. X-ray examinations showed control of slipping. The biomechanical effects of glenoid osteotomy and the zero position are as follows: 1) To get a new bony fulcrum with increased inclination of the glenoid. 2) To prevent the slipping of the humeral head with bony repair of the postero-inferior margin of the glenoid. 3) To repair the s lack posterior part of the capsule with capsulorraphy. 4) To utilize the range of adduction of scapular movement. 5) A simple and minor surgical procedure. 6) An easy post-operative treatment applying the zero position.
Of all the complaints of pain afflicting man shoulder pain is near the top of the list for both frequency and disability. The shoulder is the focal point for various pain stimuli that may be local or referred.