We have seen severe contracture of shoulder joints and same of these cases were operated on after three months rehabilitation. We reported on the good results of this operation about one year ago.
A. We observed in op e ration that the rotator cuff was compressed very tightly between the coracoacromial ligament and the head of the humerus when the shoulder joint was abducted more then 80°. On the other hand, the coracoacrominal ligament is found in a different location in monkeys than in human beings.
B.38 operated shoulders and 32 monke y joints are compared and discussed. This exeperimental reseach was carried out at the Institute of Primates, Kyoto University by Dr. Matsumoto.
Conclusion
1. CALig is an embryological structure, which is not needed inz human beings because the coracoid process and scapula are used in human beings.
2. Resection of CALig for frozen shoulders shou l d be considerd as a preferable treatment.

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The pathogenesis of a tear of the rotator cuff in the shoulder has long been a controversial subject.
Codmanc oncluded that cuff tears are degenerative by nature, while Neer stated that 95%of them are caused by impingement and that they start on the bursa' side of the cuff because of the wear and tear of movement of the cuff relative to the acromion.
In 200 specimens from 100 cadavers, we studied the pathological changes on the undersurface of the acromion as associated with tears of the rotator cuff. The ages of the specimens ranged from 38 to 95 (average,72.3 years). There were 104 normal cuffs,69 with incomplete tears and 27 with complete tears.
By roentgenographical and histological analysis we resolved that in specimens with imcomplete cuff tears the acromial undersurface was almost intact. Lesions in the anterior 1/3 of the acromial undersurface were always associated with cuff tears, but not vice versa. We concluded that the pathogenesis of most cuff tears probably is a degenerative process and that extrinsic causes play a secondary role.

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The relations between impingement syndrome of the shoulder and osteophyte around the acromion are described on the bases of three clinical cases.
Two were males, aged 74 and 42 years and one w a s female and 60 years of age. The affected side was dominant right arm in all. The first case had a history of trauma, but the others had a gradual onset of shoulder pain, who had similar osteophyte in contralateral side without any symptoms. Osteophyte appeared in the coracoacromial ligament and was located in the anteromedial portion near the coracoid process. In the first case, only acromioplasty was carried out but the torn rotator cuff was repaired simultanously with the resection of osteophyte in the other two cases. The cuff tear was of full thickness with damage mainly on the bursal side. We found that the osteophyte had encountered a portion of cuff tear in motion. The surface of osteophyte was smooth and covered with a tissue of ligament. Histologicaly, osteophyte consists of ligamentous tissue, fibrous cartilage, calcified cartilage and a bony structure.
The mechanism of the occurrence of osteophyte is unknown, however, it is presumed that impingement is induced by a consequent cuff tear in the development of osteophyte.

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A small spur formation around the antero-lateral part of the acromion is frequently found at operations of rotator cuff tears. It is not clear, however, how much the spurs are concerned with these injuries.
We found, at the o p erations of three cases, considerably large excessive bones around the acromion. These spurs, probably, took part in the occurrence of the rotator cuff tears.

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We evaluated the radiographic findings of the shoulder associated with rotator cuff tearsidentified by arthrography.87 shoulders were investigated.
The age of the cases ranged from 31 to 78 y e a rs with a mean of 56.6 years. The sclerotic changes of greater tuberosity were registered in 38 shoulders (43.7%), sclerotic change and surface irregularity in 36 shoulders (41.4%), cystic changes in 38 shoulders (43.6%), and acromioclavicular joint arthrosis in 27 shoulders (31%).
The bony spur on the undersurface of the acro m in was evaluated, especially the medial pointing bony spur. Medial pointing bony spurs were registered in 17 shoulders (19.5%).
The significance of medial pointing bony spurs in thce pathogenesis of rotator cuff tears was evaluated through operative findings. It appears that medial pointing bony spurs on the undersurface of the acromion may cause ruptures of the supraspinatus tendon.

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Impingement of the rotator cuff beneath the coraco-acromial arch has been recongnized as one of the causes of chronic disability of the shoulder.
The purpose of this study is to investigate the clinical and roentgenographical findings of the cases of impingement syndrome and further evaluate the effect of surgical intervention on recovery after Neer's anterior acromioplasty operation.
51 cases with impingement lesions which w ere operated during the past 10 years were reviewed.
Our series consisted of 43 males and 8 females, with an age range from 21 to 76 years with an average of 50.6 years. All cases were divided into two groups. One was 37 cases with rotator cuff intact, the other was 14 cases with partial rupture of the rotator cuff. The two groups were investigated clinically and roentgenographically.
The average age was 51.0 years in th e group with rotator cuff intact and 50.2 years in the group with partial rupture of the rotator cuff.
All of the patients had severe motion p ain and unbalanced of scapulo-humeral rhythm. Roentgenographically, spur formation at the undersurface of the acromion was the most frequent finding in both groups,5 cases (15.2%) in the group with rotator cuff intact and 4cases (28.6%) in the other group.
According to Wolfgang's system we had excellent functional results after surgical intervention in both groups.

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One cause of shoulder joint pain is friction of the rotator cuff between the coracoacromial ligament (C-A lig. ) and the greater tuberosity of the humerus. In those cases, most surgeons release the C-A lig. by an open operative procedure. Scars of the shoulder area, however, cause anxiety for females and early rehabilitation is restricted by surgical invasion.
If the C-A lig., however, could be safely incised under endoscopic vision, a wide skin incision would not be necessary. Recently, we developed a new operative procedure for subcutaneous C-A lig. release under the Universal Subcutaneous Endoscope (USE). Twentynine patients (23 females and 6 males), or forty-one shoulders, underwent subcutaneous release of the C-A lig. at the Japanese Red Cross Medical Center. The age of the patients ranged from nineteen to sixty-nine years (mean 51.9 years).
The operation is carried out under a local anesth e sia using ten milliliters one percent lidocaine solution, which is applied to the anterior part of the shoulder joint. The USE is then gently inserted between the C-A lig. and the rotator cuff. We observe the C-A lig. and rotator cuff. A retrograde hook knife is introduced along the side of the scope from the previously made skin incision. The C-A lig. is released under complete endoscopic vision. The skin incision is closed with a single stich which completes the operation.
The following day, patients are encouraged to perform gentle active range of motion exercises. Almost all patients reported the disappearance of the spontaneous pain at the shoulder joint and an increased range of shoulder joint motion due to the disappearance of the pain on motion. All of the patients were satisfied with the results of the operation.

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Much is still unknown about the pathogenesis of chronic subacromial impingement syndrome, subacromial decompression (SAD), its surgical therapy is generally said to give favorable clinical results. The purpose of this study is to investigate our clinical results of SAD in shoulder impingement syndrome and to discuss the causes in the unsuccessful cases.24 cases (21 males,3 females) who had been followed for longer than one year (average,24.5 months) after the operation were studied. Complete tears of the rotator cuff were excluded. The average age at surgery was 31.7 years (range,16-66 years), and all cases were operated on the dominant side. The cause was sports injury in 19 cases (79%),15 of which were throwing injuries. The operative procedure of SAD was anterior acromioplasty in 20 cases, and division of coracoacromial ligament only in four cases.19 cases were treated with the open procedure, and five cases bursoscopically. Arthroscopy of the glenohumeral joint was performed simultaneously in all cases, and arthroscopic debridement of intra-articular pathology was carried out in 16 cases. Postoperatively, pain had subjectively improved in 21of 24 shoulders (88%). Pain at rest and with ADL was reduced from 67% of the preoperation to 13% postoperation. However,16 of 24 cases (67%) were allowed to return to their preinjury status. In 15 cases of throwing injuries, five cases including four pitchers did not return to their former level. Among these five unsatisfactory cases, subclinical anterior subluxation or insufficient decompression might be cosidered as a cause in certain cases, but the cause was unknown in some of them, which posed the problem for indication of SAD in throwing injuries (especially pitchers and young people). In cases with severe pain due to bursal side tears of the rotator cuff, the pain tended to remain after SAD, and it seemed necessary to resect and repair the lesion, in addition to SAD.

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Comparative studies of the dysfunction and calcium deposit were done in 160 calcifying tendinitis. Observing the site, the size and the character of the calcium deposit in the roentgenogram, the relationship between the range of motion and the arm elevated angle were analyzed. Calcifying tendinitis is classiffied into three groups depending on the elevated arm angle;
Group A: Under 80 degrees (35 joints)
Group B: From 80 degrees to 12 0 degrees (19 joints)
Group C: Over 120 degrees (106 joints)
The age distribution was nearly the same in the three groups.
Group A: Calcium deposits in the supraspinatus portion were the most, seen in 48.6percent. The area of the deposits was wide, ranging from the rotator cuff to the subacromial bursa (68.6 percent). These deposits were the largest of the three groups.
Group B: The deposits were not only seen in the supraspinatu s and the infraspinatus portion, but also in the subscapularis portion. The area was as wide as in group A.
Group C: 50 percent of the deposits were seen in the infraspinatus and one th i rd were seen in the supraspinatus. They were located mainly in the rotator cuff.
Range of motion: The range of abduction and flexion intended to decrease with limitation of external rotation.
As a conclusion, we consider that there are two causes which provoke the dysfunction of the shoulder; one is subacromial impingement due to large deposits and the other is limitation of external rotation due to pain associated with the inflammation or the outflow of calcium deposits to the subacromial bursa. The latter is the main cause of the dysfunction.
The treatment for subacromial impingement is extirpation of the large dep o sit, but on the other hand, conservative treatment (local injection and traction of the upper limb) takes precedence in bursitis or tendinitis due to calcium deposits.

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The etiology and the site of origin of rotator cuff tears are still open to debate. Neer (1983) stated that 95% of all tears are due to impingement and that consequently tears start at the bursal side secondary to wear and tear. However, clinicopathological data of incomplete bursal side cuff tears have not been clearly demonstrated. The purpose of this paper is to describe the pathogenesis and the role of subacromial impingement of this lesion. Twenty-six cases with incomplete bursal side cuff tears were treated surgically and satisfactory results were obtained in all. Incomplete bursal side cuff tears in our series were divided into two types. The one was caused by long-standing overuse requiring above-horizontal activity, which was associated with severe subacromial bursitis. The tears of this type were mostly present at the bony insertion of the supraspinatus tendon or near the critical portion, and the torn shape was ulcerous-like. The other was caused by direct trauma, which was mostly present at the bony insertion of the supraspinatus tendon, and the shape of the torn cuff site was valvular like. In the specimens of resected acromion by anterior acromioplasty, the slight attritional lesion was evident at the anterior 1/3 acromial undersurface, however, severe pathological changes of the acromial undersurface, which were observed in chronic massive cuff tears, were not observed in either type. Furthermore, no typical pathological changes were confirmed at the acromial undersurface in the type caused by long-standing overuse of the arm. Therefore, we conclude that the subacromial impingement plays a significant role in the progress of this lesion, however, the pathogenesis of most incomplete bursal side cuff tears probably is a degenerative process and a vicious cycle of subacromial impingement subsequently develops.

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In the impingement syndrome, the degenerative change on the undersurface of the acromion are marked in the anterior 1/3 of the acromion. We consider that the spatial position of this anterolateral portion is an important causative factor. The purpose of this report is to show the relationship between the spatial position of the acromion and subacromial impingement.
Materials were 10 cases,15 joints of the impingement group and 7 cases,14 joints of the normal group. To analyse the spatial position of the acromion, the anterolateral point of the acromion was identified by CTscan and plain X-P. Besides the slope of the acromion, the acromion/greater tuberosity ratio and the greater tuberosity/humeral head ratio were investigated.

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Large histologic sections from twelve surgical specimens were studied in order to clarify the pathogenesis of the bursal side rotator cuff tears (BSRCT). The specimen consisted of the bony insertion, the partially torn area and the musculotendinous junction of the supraspinatus tendon. There were eight men and four women with an average age of 48.7 years. Trauma was noted in three shoulders. All patients exhibited clinical evidences of subacromial impingement which were also confirmed at surgery. Histologic sections were stained with hematoxylin & eosin and Azan. All the tears developed from within 1.0 cm of the insertion. The depth of the tears varied from a superficial flap to almost a full thickness tear. Microscopically, the sections demonstrated the following abnormalities in addition to degeneration. At the site of insertion and in the distal stumps, local disruptions of the normal four layers of enthesis and areas of hypervascularity were observed in all. The proximal stumps were rounded, retracted and avascular with abundant chondrocytes. No active repair was noted in the proximal stumps. The pathogenesis of BSRCT appears to be related to a combination of aging and precarious vascularity of the tendon, repeated use of the arm above-horizontal level or injury and most importantly to subacromial tendon impingement.

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OBJECTIVES: In 1972, Neer reported impingement syndrome of the shoulder and the technique of anterior acromioplasty. We report the results of Neer's acromioplasty and arthroscopic decompression for patients with stage II and III impingement syndrome.
MATERIALS and METHODS: In 12 shoulders of 12 impingement syndro m e,10 anterior acromioplasty (Neer) and 2 arthroscopic decompression were performed. Eleven male and one female were involved. The average age was 38 years (range: 24-56). Four shoulders were classified as stage III impingement syndrome. The follow-up period ranged from 3 to 48months (average: 17.3).
RESULTS and DISCUSSION: In 11 patients followed up for 6 months or more, impingement signs were negative at follow-up. All but one who was a semi-professional pitcher, were satisfied with their results. According to the JOA evaluation system of the shoulder, the average score of postoperative improvement was 16 points. No statistical differences were found between stage II impingement syndrome and stage III. Two patients, treated by arthroscopic decompression, seem to have had the advantage of returning to their previous occupations, early.

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We reported 14 cases of chronic subacromial impingement syndrome which were treated surgically and obtained good functional results excluding two cases. Thirteen were male and one was female. The age at surgery ranged from 21 years to 56 years with an average of 38years. The causes of this syndrome were a traffic accident in eight cases, baseball in two cases and four other cases. The duration of complaining of pain and disability ranged from three months to seven years, averaging two years and eleven months.
Some of the chief clinical findings before operation were motion pain which were seen in the fourteen cases, scapula winging seen in six cases and impingement sign seen in twelve cases. We resected the coracoacromial ligament from the inferior aspect of the acromion without osteotomizing acromion. Bursectomy was done when the subacromial bursa showed thickening and adhesion.
The postoperative results were evaluated as good in all patients except two who had shoulder contracture and complained of slight shoulder joint pain on motion.

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The objective of this study was to know whether the coracoacromial ligament division improved shoulder function in patients with chronic subacromial impingement syndrome and to figure out the factors that influenced the surgical outcome. We reviewed 15 patients,9 male and 6 female, who underwent coracoacromial ligament division under local anesthesia after conservative treatment for 3 months or more. None of the patients had subacromial osteophyte or joint stiffness preoperatively. The age at time of operation ranged from 18 to 52. The minimum observation period was 6 months. The pre- and postoperative shoulder function was evaluated using the JOA scoring system.
At follow-up,12 of the 15 patients had improved their shoulder function; the increase in total functional score proved 10 points on average of the 15 patients. The postoperative scores were significantly (p<0.01) higher than those before surgery (Student's paired t-test). The multiple regression analysis revealed that functional improvement was closely related to the presence of preceding trauma, low ROM score preoperatively, a high score in “function”preoperatively and the absence of “concealed tears” of the rotator cuff.

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Attempts were made to treat impingement syndrome (which is marked by severe pain felt on active elevation of the arm) by arthroscopic surgery with the intention of lessening surgical stress and hastening the rehabilitation of patients.
Ten males (11 shoulders) and 1 female (1 shoulder) ranging in age from 16 to 76 years (average age: 46.1 years) underwent this surgical treatment.
Massive tears of the cuff were treated by debri d ment of the soft tissue, responsible for the syndrome, that was formed at the greater tuberosity and subacromial bursa without the intervention of bones of ligaments, with satisfactory results in 3 of 4 cases.
In 2 cases of small tear of the supraspinatus tendon, the edges of the tear were trimmed and A. S. D. was performed.
In one of these 2 cases, the surgical procedure failed to improve the impingement syndrome associated with clicks on motion and, accordingly, the cuff was sutured later.
In all 3 cases of partial rupture of the cuff, arthroscopy revealed a tear of the articular portion of the tendon and treatment was by debridment of the lesion. The results were invariably quite satisfactory in all cases.
A. S. D. was performed on 2 sho u lder joints of 1 patient with stage II, and subacromial debridment was performed on the other patient. The results were gratifying in both cases.
For the impingement syndrome with associated pain in the elderly, arthroscopic o p eration seems to be the treatment of first choice and can be anticipated to prove of great aid in returning the patient early to sports activities.

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The healing process of repaired tendon insertion of the rotator cuff was studied biomechanically up to 24 weeks after operation. The right supraspinatus tendons of twenty-one adult mongrel dogs were repaired by tendon suturing to bone; tendons were transected near the insertion and reattached to the trough cut at the greater tuberosity using 1-Surgilon (experimentals). The left shoulder of each animal was designated as the sham operated control. Another 5 dogs with no surgical interventions were designated as the normal controls.
Tensile testing of failure was performed with supraspinatus tendon-bone units under low strain-rate conditions. The major mode of failure changed from avulsion at 6-12 weeks to tendon disruption at 24 weeks. Increasing load to failure, stiffness and load failure energy were noted for experimentals from 2 to 12 weeks, reaching their plateau after 12 weeks. Mean values of these three parameters reached only 70%∼85% of those of the controls at 24 weeks.

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Objective: It has been reported that the acromiohumeral interval (hereafter referred to as AHI) narrows in rotator cuff tears (RCT). In many cases, however, it does not. In this study we re-examined the clinical significance of the AHI.
Subjects and method: AHI was studied in the f ollowing: normal shoulders, as the control group,55 cases,55 shoulders; RCT (massive: 45·46; complete: 62·64; partial: 51·52), periarthritis: 57·66, and unstable shoulder: 63·85. The AHI was measured as the distance between the humeral head and the under surface of the acromion in a standingposition A-P view (internal and external rotations and neutral position) and scapular Yview.
Results: In normal shoulders the internal rotation AHI was the widest, at 8-16 mm (average 11.3 mm), indicating a significant difference from other roentgenographic directions and measurement values. Concerning the neutal-position measurements in normal shoulders and each disease condition, the AHI was 3-12 mm (average 6.9 mm) for the massive tear group, and this represented the most narrowing found and was significantly different from all of the other groups measured.
Conclusion:
1) The AH I in normal shoulders expands with internal rotation and narrows with external rotation.
2) In AHI measurements, important considerations are consistency of the positioning and the angle of roentgenography, and the most appropriate view is the neutral position.
3) With a roentgenographic method in standing-position, the AHI measu r e ment is clinically significant only in diagnosing a massive RCT.
4) As a diagnostic standard for a massive RCT, an AHI of 6 mm or less is appropriate, but allowances should be made for 52% of false negatives and approximately 18% of false positives.

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If the size of the rotator cuff tear can be predicted, the surgeon can prepare alternatives for the operation. The acromiohumeral interval (AHI) on plain roentgenograms less than 5to 6 mm has been considered a sign of rotator cuff tear.
However, this measurement can vary even in t h e same subject depending on the arm position in which the X-ray is taken. We found that paraplegic patients with rotator cuff tears revealed reproducible AHIs on the antero-posterior projections which were taken with the patients on crutches. This paper discusses the usefulness of a new roentgenographic projection in the rotator cuff tears which we called the “push-up view”.
Materials & Methods: 35 rotator cuff tears were classified in to three groups. Group A consisted of 7 massive rotator cuff tears which were verified operatively, group B,11 massive rotator cuff tears diagnosed arthrographically and group C,17 full thickness supraspinatus tears and incomplete thickness tears verified operatively. The “push-up view”, which was an antero-posterior projection of the bilateral shoulders on a large cassette with the patient in an arm chair lifting himself a little off the seat, was taken in all cases preoperatively. The shoulder bears a load of from one third to one half of the body weight in the “push-up view”. The “push-up AIH”, which was measured on the “push-up view”, was compared with the “standing AHI”, which was measured on conventional antero-posterior projection with the patient standing.
Results: The “standing AHI” and the “push-up AHI” were from 0 to 9 mm, mean value 4.1 mm, and from-8 to 6 mm, mean value 0.8 mm in groups A and B which consisted of massive tears.
The “ standing AHI” and the “push-up AHI” were from 7 to 12 mm, mean value 9.4 mm, and from 6 to 10 mm, mean value 8.4 mm in group C which consisted of small and partial tears.
Discussion: In previous reports, the lowest value of the normal AHI has been discussed, but the positions of the subjects were not clearly described. In our series, “standing AHI” was 7 mm and more in 4/18 (22%) of massive cuff tears. But “push-up AHI” was 6 mm and less in all those cases. In one case of massive tear with rupture of the tendon of the long head of biceps, the “push-up AHI” was 8 mm while the “standing AHI” was 7 mm. It is clear that “standing AHI” does not reflect the conditions of the rotator cuff or the long head of the biceps.
Conclusions: 1. The acromiohumeral interval in a conventional shoulder roentgenogram is unreliable.2. The AHI in the “push-up view” is reproducible and a massive cuff tear is suspected if it is 6 mm or less.3. The “push-up view” is proposed for the screening of massive rotator cuff tears.

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Shoulder arthrography is an important investigative means in studying various softtissue lesions involving the shoulder. However, the accurate size and the area of the lesion are difficult to detect in arthrograms made with conventional screen-films. Since 1985, we have performed glenohumeral arthrography in combination with subacromial bursography on 50 patients with suspected rotator cuff tear, impingement syndrome and/or frozen shoulder, using computed radiography. In the normal shoulder arthrogram, the long head of the biceps is very well outlined and the surfaces of the rotator cuff are smooth and clearly delineated. In impingement syndrome, attritional changes are detected on the bursal surface of the rotator cuff at the critical zone without difficulty. In incomplete thickness tear, the bursal surface around the critical zone appears irregular and rough. Horizontal tear is also clearly visualized. In some cases of full thickness tear, the edge of the torn cuff is demonstrated.
Computed radiography provides much more detailed information about the pathology of the lesion than conventional arthrography, since both soft tissues and bone can be clearly demonstrated by simply changing the desired parameters. This technology permits the preoperative evaluation, not only of the presence of a rotator cuff tear, but also of the accurate extent of the lesion.

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In order to clarify the function of the long head of the biceps brachii as the bicipital gliding mechanism, the morphological and histological changes of the long head in rotator cuff tear were observed at the intra-articular portion and the intertubercular portion.
Materials were 100 shoulder joints of 50 cadavers: 54 joints without cuff te a rs,46 joints with cuff tears.
The morphological study revealed that in the specimens with cuff tears, the bicipital long head was widened and flattened both at the intra-articular portion and at the intertubercular portion, and these pathological changes progressed in accordance with the extension of the cuff tear.
The histological study revealed that in the specimens without cuff tears, the intraarticular portion of the long head was covered with a smooth synovial membrane and the epitendineum consisted of loose connective tissue, and separated a number of bundles of the tendon by the peritendineum. However, in specimens with cuff tears, various pathological changes were found at this portion, such as lack of synovial membrane on the side of the humeral head, inflammation in the synovial membrane on the side of the rotator cuff, hypertrophy of the peritendineum, and a decrease of the bundle of the tendon. On the other hand, at the intertubercular portion, the changes were lack of synovial membrane and abrasion of bundle of the tendon on the side of the humeral head, and inflammation in the synovial membrane on the side of the rotator cuff. There changes were more frequently found in specimens with cuff tear.
We conclude that the long head of the biceps brachii plays a more significant role as a glenohumeral stabilizer, but degenerates more rapidly in the shoulder joints with cuff tears than in those without cuff tears.

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Since Codman's reference to the deep surface tear of the rotator cuff, it has been mentioned in some documents, but, there have been few descriptions of the pathophysiology, diagnosis and treatment of this lesion. Ten patients with non-perforated deep surface cuff tear were treated surgically from 1979. We have tried to elucidate the mechanism, diagnosis and treatment of this lesion. The ages ranged from 36 to 66 years (ave.52yrs. ). Seven patients were men and three patients were women. All patients had definite traumatic histories. Episodes of trauma and typical signs of cuff tear made us suspect the presence of the tear of the rotator cuff. Shoulder arthrogram which showed the pooling shadow in the torn portion of the joint side of the rotator cuff confirmed the non-perforated deep surface cuff tear. The sites were the posterior supraspinatus or the infraspinatus tendon to the greater tuberosity. Operative procedure was excision of the diseased cuff including the superficial layer and anchoring of the cuff edge to the greater tuberosity. Anterior acromioplasty was performed in some cases, and the acromial undersurface revealed bursal tissue defects. It seemed that these pathological changes of the acromial undersurface had been caused by deep surface cuff tears. We conclude that the pathogenesis of most non-perforated tears of the deep surface side are degenerative by nature, and subsequently slight subacromial impingement may occur. The post-operative results were excellent in all, therefore, surgical treatment should be considered in reconstruting the cuff in those cases which have resisted conservative

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The pathogenesis and the possibility of spontaneous healing of incomplete thickness tears have been controversial. The joint side tear is one of the three categories of incomplete thickness tears. We have performed clinical studies of the joint side tear and the following results were obtained.
1) 18 cases of joint side tear excluding rheumatoid arthritis and other inflammatory diseases were treated at Hamamatsu Red Cross Hospital from 1982 to 1988 (15 cases were non-operated and 3 cases were operated).
2) 15 joint side tears occurr e d in the supraspinatus tendons.2 were in the infraspinatus tendons.1 tear extended in both the supraspinatus and infraspinatus tendons.
3) The history of trauma was verified in 6 cases (46%) in the non- o perated group and 2cases (67%) in the operated group. The final evaluation by J.O. A. shoulder scale was 78.2points in the non-operated group and 98.3 in the operated group respectively.
4) Follow-up arthrography in the non-operated group demon s trated the disappearance of the tear portion (3 cases), reduction of the tear portion (1 cases), enlargement of the tear portion (1 case), development of a complete tear (1 case).
5) The prognosis appeared satisfactory when the joint side tear was small and occurred in a young tendon without trauma.

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We have succesfully applied our zero-position functional shoulder orthosis for postoperative management of rotator cuff injuries since 1979. On the basis of the biomechanical concepts of the zero-position and the scapular plane, we recently designed an improved zero-position functional orthosis which is correctly fitted to each person on the so-called “scapular plane”, and would like to report its special features and principle.
The orthosis consists of a pelvic support, an upright bar, an arm s u pport and so on. When a plaster negative was made before an operation, we appointed each person's scapula plane and fixed an upright bar on the pelvic support. But, the orthosis did not often adapt itself to the patient when it was fitted after the operation. Recently we designed a changeable joint, which connects the upright bar to the pelvic support. So it is possible to adjust the orthosis to the scapular plane with individual variations.
The reference plane for shoulder i mmobilization of rotator cuff injuries is the scapular plan, and so it is important to maintain the elevation of the humeroscapular joint on the scapular plane with individual variations and to adjust it gradually, not to keep it at zero-position. For those reasons, our functional shoulder orthosis on the basis of biomechanical concepts of the scapular plane is useful.

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The defects created by the anterior margin of the glenoid in the posterolateral area of the humeral head has been recognized as the dislocation of the shoulder joint. It was well known as the Hill-Sachs notch and was regarded as one of the reasons for recurrent dislocation of the shoulder joint. The defects in the humeral head were demonstrated by internal rotation and Stryker's notch viewer, radiographicaly. Orthographic projections were performed on 15 cases of recurrent dislocation of the shoulder. The patient is supine on the table with a cassette under his shoulder, the humerus is positioned at 135 degrees forward elevation and 15 degrees internal rotation. Without tilting the X-ray beam, it is centered over the humeral head.
The posterolateral notches were positive in 59% of the cases using Stryker's notch viewer, but 88% of the cases were positive using the orthographic projection technique. The orthographic projection was useful in observing the posterolateral notch, because of its high recognition rate. Furthermore, there is no distortion on X-rays and the quantitative analysis of the notches are superior.

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Objective: We experienced a case in which arthroscopic examination of a patient, who had constantly been giving a positive anterior apprehension test, since his sustaining contusion of the shoulder, revealed a pedicled joint mouse, to which the positivity of the test might possibly be attributed.
Case Report: A 20-year-old male sustained a blow on his left shoulder. One week later he experienced a dead arm feeling while batting (a ball). Since then, he experienced several such episodes.
On March 7,1988 he was referred to us, and he constantly gave a positive result in the anterior apprehension tests.
On arthroscopy, the anterior capsular ligaments were intact. However, a pedicled joint mouse was discovered, which had caused his limited movability.
The mouse was removed and the labrum trimmed u nder arthroscopic vision. The patient no longer had a sense of dislocation or click, results were negative and the anterior apprehension test He has since been quite well.

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Two cases of sustained anterior subluxation of the shoulder joint were treated operatively.
Case 1: A 14-year-old girl. On Oct.7th 1985, she noticed pain in her left shoulder after doing chin exercises.
A doctor diagnosed anterior subluxation of the shoolder, and fixed her left arm with a Desarlt bandage. But, she was unable to sustain the reduced position. Then another doctor applied a shoulder spica cast in the abducted position for 3 weeks. After removal of the cast deformity of the left shoulder was recognized. On her first visit to Matsudo orthopaedic hospital on Nov.13th 1985, anterior subluxation of the left shoulder was certified by CT scans. Remarkably multidirectional shoulder instability was also noticed. Reduction was easily obtained by external rotation of the shoulder, but the humeral head displaced forwardly in the dependent position. On Dec.10th 1985, Protzman's and modified Bristow's procedures were performed. After Surgery, the arm was fixed with transarticular pins and a Velpeau bandage for 3 weeks.2 years after surgery, external rotation of the shoulder was 55°, but she had neither disabilities nor anxieties.
Case 2: An 11-year old girl. On June 1987, deformity of the right shoulder appeared without any movent. On her first visit to Matsudo orthopaedic hospital on July 15th 1987, anterior subluxation of the right shoulder was certified. Remarkable outward slipping of the humerus was noticed by roentgenograms taken in the elevated position of the shoulder. It was easily reduced by adduction of the shoulder, but displaced forwardly in the dependent position. On July 30th 1987, a Protzman's a modified Bristow's procedure and a “Rotator interval” repair were performed. After surgery the arm was fixed by transarticular pins and a Velpeau bandage for 3 weeks. One year after surgery, external rotation of the shoulder was 45°, but she, too, had neither disabilities nor anxieties.

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Injury to the shoulder is one of the comon ski injuries. We treated nine cases suffering from recurrent anterior subluxation caused by ski injuries over the past two years. Six patients were men and 3 were women. The right shoulder was injured in 4 patients and the left shoulder in 5 patients. The average age was 25.8 years with a range of 14 to 36 years. Anterior subluxation of the sholder caused by a ski injury is difficult to identify and frequently misdiagnosed. These nine patients had been diagnosed as having some condition other than subluxation and some of them had not been treated correctly. They has all fallen down while skiing. At least 4 patients had experienced a direct blow to the sholder. After injury. they had complained of a “dead arm” when the arm was in an elevated position with external rotation. All the cases had positive anterior apprehension signs. We recognized the slipping out of the humeral head with a click objectively in three cases. Computed arthrotomography and arthroscopy demonstrated that the cause of instability was labral and capsular lesion (Bankart lesion). We belive the reason the injury brought about subluxation rather than dislocation was the different arm position or the different direction of the force. At first, we should treat patients conservatively, since muscle exercises may be effective sometimes. It is important to recognize that traumatic subluxation of the shoulder may occur in ski injuries and frequently leave a dead arm syndrome.

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There are many operative procedures for reccurent anterior dislocation of the shoulder.Between 1970 and 1980, we performed the modified Bristow procedure, and between 1981 and 1984, we used the Boytchev procedure. But the results of both procedures were not always satisfactory with regards to sports abilities.
The above experiences led us t o look for a better and more secure method to reduce unsatisfactory results. Since 1985, we have adopted a procedure in which the Bankart operation and the modified Bristow operation are combined. At the 14th meeting of this society, we reported that the results of this procedure were satisfactory.
The purpose of this paper is to present the details of o ur operative technique of the combined Bankart-Bristow operation, and to report its short-term results.
Twenty-two patients were treated by this procedure, sixteen pat i e nts were male and six female. Their ages ranged from 15 to 36, the average being 22.5 years old. CT arthrograms were done before surgery, and Bankart lesions were observed in all patients. After the operation, three patients' screws broke, which consequently resulted in the nonunion of the grafted coracoid process. One of the patients complained of episodes of subluxation and a second felt his shoulder unstable. So, they were reoperated. Except for these three patients, the results of the combined Bankart-Bristow procedure were satisfactory.

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Many papers have discussed the rate of redislocation after surgery when evaluating procedures for recurrent dislocation of the shoulder. Boytchev or Bristow's procedure, which we used to like to use, is good from this point of view. However, some patients complained of instability during activity. For this reason we have adopted a modfied Bristow procedure combined with a capsulotomy to repair intraarticular lesions.31 patients (32 shoulders), on whom we had undertaken Bristow were followed up for more than six months after surgery and were evaluated before and after surgery to clarify the way to get better stability. Conditions of each structure (bone, cartilage, labrum and capsule) were evaluated by physical findings, x-rays, arthrogram, arthroscopy and operative findings before surgery and discribed as points. On the other hand, postoperative evaluation was done by physical findings, x-ray, and shoulder function during sports.
We would like to conclud e that in the prevention of postoperative instability it is important to be aware of the condition of each intraarticular structure of the shoulder joints preoperatively and to repair them adequately and simultaneously. Our systemic modified Bristow procedure seems to be satisfactory for this.

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Traumatic dislocation of the shoulder joint is a common injury, but irreducible fresh dislocation is very rare. We experienced a case of anterior dislocation of the shoulder which resisted closed reduction soon after the injury and required open reduction. The mechanism of the irreducibility in this case was reported.
A 65-year-old woman fell down on the kitchen floor and hit her right shoulder sustaining anterior dislocation of the right shoulder joint on March 23,1988. One hour after injury the shoulder was manipulated by an orthopedist under local anesthesia, but the dislocation could not be reduced in spite of all attempts including Hippocrates and Kocher procedures.
The radiographs demonstrated a notch formed at the posterolateral site of the humeral head was impacted to the anterior margin of the glenoid fossa.
Open reduction was done 7 days after the injury through the delto-pectral approach. The supraspinatus tendon was massively torn from the insertion of the humeral head. The subscapularis tendon was intact. A fresh compression fracture of about one centimeter in diameter was at the posterolateral portion of the humeral head. Traction according to Hippocrates method caused a slight descent of the humeral head, but raised the tension of the short head of the biceps and coracobrachialis that disturbed reduction by increasing the compactness of the humeral head to the glenoid. External rotation of the humerus as in Kocher's method, caused an unusual bulging of these muscles with the impacted portion acting as the center of rotation. After retracting these muscles medially over the humeral head, reduction was easily obtained by flexion of the humerus. The cause of the irreducibility was thought to be the humeral head impaction to the glenoid which induced high muscle tension on manipulation.

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Although anterior shoulder dislocations may be documented, the basic mechanism involved in the dislocation remains controversial.
We have several patients who fe l l and struck their shoulder on the ground and dislocated it anteriorly. However according to the textbooks, direct force is only rarely the cause of dislocation and we can not find any reports about the mechanism of a dislocation by direct force. We experienced a 17-year-old boy who had a fracture dislocation of the humeral head. We wish to present this case and discuss the mechanism of the dislocation. He was thrown off his motorbike and got injured. In the operation, there was an ecchymosis over the middle portion of the deltoid muscle, which implied the blow was at this point. There was no tear of the cuff muscles, but there was a Bankart lesion. Mild traction toward the lateral direction reduced the dislocation easily. The fragment was fixed stably with a screw. The Bankart lesion was repaired with pull-out sutures. Afterward, he got good results. Discussion: Anatomically the plane of the gleno-humeral joint locates obliquely forward about 30 degrees. Should the compression force come from a more laterall than vertical line of the joint line, the humeral head would be pushed out anteriorly.
Since a scapula is very mobile, a strong direct force and gear effect between the humeral head and the glenoid, move it medially, anteriorly and inferiorly. Anterior dislocation could occur by direct force not only posteriorly, but also laterally. We wish to examine the precise mechanism of the damage for its correct diagnosis and treatment.

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Fixation with Desault bandage for about 3 weeks has generally been used as the method of fixation after reposition of traumatic dislocation of shoulder joints. The inability to use the upper limbs on the affected side causes inconvenience in daily life and many patients, themselves, remove the fixation when this method is employed. Taking this into consideration, we devised a fixation method using a modified clavicular harness with a pad and used it clinically.
The subjects are 404 cases of traumatic anterior dislocation of shoulder joints, which were treated at our hospital, the Ishiuchi-Maruyama Skiing Ground Clinic and the Nozawa Hot Spring Skiing Ground Clinic from December,1982 to April,1987. Of these,194 cases had initial dislocations. These cases were subjected to direct examination and investigation on the prognosis by questionaire.
Of these 194 cases of inital dislocation,104 cases responded to the questionaire. There were 58 cases of Desault bandage,39 cases of modified clavicular harness and 7 other cases. The proportion of re-dislocation was 15.5%, (9 out of 58 cases) in the Desault bandage group and 5.1%, (2 out of 39 cases) in the group of modified clavicular harness. The latter proved a superior method in the prevention of re-dislocation.

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Traumatic posterior dislocation and fracture-dislocation of the shoulder are rare. It is very difficult, not only to diagnose them, but also to determine the optimal treatment methods. In cases of dislocation, we performe manual reduction and use a sling in neutral position for three weeks. In cases of fracture-dislocation, in principle, we perform either manual reduction or open reduction of dislocation by a posterior approach witiout ORIF of fractures, and begin physical therapy within a week. We conducted this study with the objective of considering the validity of this method.
The subjects of this study w e r e two dislocation cases and four fractuse-dislocation cases. The ages ranged from 23 to 46 years. The causes of injury were a traffic accident in five cases and a skiing accident in one. The fracture-dislocation cases were two 2-part fracture and two 3-part fracture cases. The two dislocation cases were manually reduced within 24 hours. In the fracture-dislocation cases, however, diagnosis of two cases was delayed, so that they underwent open reduction 14 days after the injury. While a case had complications of brachial plexus palsy and a Monteggia fracture had joint contracture, the other cases showed satisfactory recovery without any hindrance to daily life.
There is no established view on the treatment of tra u matic posterior fracture-dislocation. For fresh cases, we attempt traction and/or manual reduction at first. However, for cases in which manual reduction has failed, or cases in which diagnosis was delayed, we reduce the dislocation operatively without ORIF of fracture. Within a week after reduction, pendulum exrcises are started. This method of treatment is advantageous in that it is easy, and produces stable satisfactory results without further destroying the gliding mechanism.

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The present study was undertaken to investigate the histological and histochemical characteristics of the deltoid and major pectoral muscles in the normal shoulder, the loose shoulder and recurrent dislocation of the anterior shoulder joint for the better understanding of the pathophysiology of these diseases.
1. Human deltoid and major pectoral muscles were obtained from 7 cases with the loose shoulder (age 14 to 22), and 14 cases with recurrent dislocation of the anterior shoulder joint (age 17 to 48). As a control, deltoid and major pectoral muscles were also obtained from 8autopsy cases (age 17 to 73) within a few hours after their death.
2. All the samples were frozen in isopentane, and cool e d in liquid nitrogen. Cryosections were stained with hematoxylin-eosin, Gomori-trichrome, oil-red 0, NADH-TR and myosin ATPase (pH 9.4,4.6,4.3).
3. In all muscles of the lo o se shoulder and recurrent dislocation of the anterior shoulder joint, there were marked variations of fiber size and endomysial fibrosis as compared with normal shoulders.
4. A ll muscles, particularly in the loose shoulder, showed predominance of type 1 fiber and atrophy of type 2 fiber.
5. The grades of histological and histochemical abnormalities correlated approximately with the clinical features in the loose shoulder and recurrent dislocation of the anterior shoulder joint

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The present study was undertaken to investigate the biochemical characteristics of collagen in deltoid and major pectoral muscles in the normal shoulder, the loose shoulder and the recurrent anterior shoulder dislocation.
1. Collagen was extracted f rom human deltoid and major pectoral muscles in 8 cases with immediately after the accidental death (ranging from 12 to 73 years old),7 cases with loose shoulder (14 to 22 years old) and 14 cases with recurrent anterior shoulder dislocation (15 to 54 years old).
2. The amo u nts of collagen in all muscle tissues were about 1% of the wet weight of the tissue.
3. All muscles consisted of mainly type I collagen and of small amounts of type III collagen.
4. The soluble collagen was richer in the loose shoulder and the recurrent shoulder dislocation than in the normal shoulder.
5. Amounts of reducible cross-linkings were abundant in the loose shoulder and the recurrent anterior shoulder dislocation, but they were scarce in the normal shoulder.
6. These data suggest that collagen in muscles of the loose shoulder an d the recurrent anterior shoulder dislocation has relatively immature collagen fibers compared with normal shoulders; these data may approximately reflect the clinical features of the disease.

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In most cases with multidirectional instabilities of shoulder joints, it seems unable to identify the causative factors or secondary lesions, which makes radical surgical approaches for this kind of instability very difficult. In this paper we report on a new dynamic suspension operation from which satisfactory results were obtained.
The coracoid process with conjoined tendo n s of the short head and coracobrachial muscle was transferred superiorly to the clavicle so as to pull up the humerus. This coracoid transfer was combined with other procedures, such as the shortening of the long head, reconstruction of the coracohumeral ligament with the coracoacromial ligament transfer and the Putti-Platt procedure.
The most rigid stability was obtained when we combined operations of the coracoid transfer passed through the subscapularis and the shortening of the long head.
If the coracoid is passed through the horizontal slit made in the upper one third of the subscapular muscle, the lower part of the subscapularis will serve as a muscular buttress to prevent anterior dislocation, and the upper part does not allow the humeral head to slip posteriorly or laterally as the arm is elevated. The long head acts as a guide rope to lead the humeral head toward the center of the glenoid fossa, and its loosening, in fact, as observed in all cases arthroscopically, will enhance multidirectional instability. The tightened long head efficiently prevents lateral slipping with the shoulder in abduction. The merit of this operation is that the anterior approach can be applied also to the posterior instability as described above.

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Over the years, loose shoulder syndrome has been treated by several procedures. Between 1978 and 1985,30 patients with 32 shoulders involved were treated by glenoid osteotomy. Their ages ranged from 14 to 33 years with an average of 22.1 years. Patients were usualy disabled by pain in activity. Instability of the shoulder joint was a common feature in all. The results were evaluated after an average length of follow-up of 6.4 years. In every instance, X-ray confirmation of instability was demonstrated with the arm elevated, and the degree of slipping of the humeral head beyond the glenoid was measured both preoperatively and postoperatively. Clinical findings showed good results in twenty-three cases (77 percent) with displasia of the posterior margin of the glenoid.
Seven cases (23 percent) with general joint laxity showed poor results.
Postoperatively X-ray examination showed effectively the control of the tendency to slip by the bony reconstitution of the posterior-inferior margin of the glenoid in all.
Glenoid osteotomy for loose shoulder should be done for patients with dy splasia of the posterior-inferior glenoid found by X-ray in A-P view and with the arm elevated on axillary view.

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