Forty-nine joints with traumatic acromioclavicular (A-C) dislocation were reviewed, and the influential factors over a long term were studied. The forty-nine joints of 44 males and 2 females were followed-up for an average period of 6 years and 9 months. The average age at the time of injury was 33 years and the types of injury consisted of type 2(26 joints)and type 3(23 joints) as classified by Tossy. The injuries were caused by traffic accidents inflicted by someone else (8 joints), industrial accidents (4 joints) and the others sport's injuries (37 joints). Thirty-nine joints were treated within a week after the injury and the other 10were treated one month or more after. The methods of treatment were conservative (16 joints), a percutaneous fixation by Kirschner wires (15 joints) and a reconstruction of the A-C ligament (17joints). The results of each joint were evaluated clinically and radiologically by both the criterias of the Japanese Orthopaedic Association and Kawabe's scores. The results were compared and analyzed considering the age, the type of dislocation, the method of treatment, the cause of the injury and the time of the initial treatment. In this series, the methods of treatment, the type of dislocation and the delays in the initial treatment were insignificant. However, in these injuries in which the patients had some sort of personal benefit, such as a traffic accident inflicted by someone else or an industrial accident, the results were poorer than those cases, such as sport's injuries. Considering the age factor, the older the patient the poorer the results.
There are various ways of treating complete dislocation of the acromioclavicular joint, both closed and open. We have experienced both Dewar's method and the transference of the coracoacromial ligament(Cadenat's method). In this study we evaluated the postoperative outcome when both methods were used. We used Kawabe's score to evaluate the surgical results in 9 patients who had undergone Dewar's procedure and 14 patients who had been treated by Cadenat's method at out hospital, and followed-up for 6 months or more, and who could be examined in person or interviewed by telephone. When Dewar's method had been used, the outcome was excellent in 6 patients, and good in 3 with an average score of 91.4, whereas when Cadenat's method had been used the results were excellent in 13, and good in 1, with an average score of 96.1. The mean follow-up periods were 10 years and 9 months, and 2 years and 6 months, respectively. All of the patients have returned to their previous jobs, and none have had any problems in terms of ADL. From both an ease of surgical technique standpoint and its postoperative outcome, Cadenat's procedure appears to be the more recommendable of the two.
This report is on three patients who had postoperative bone regeneration at the resected part of the clavicle which caused pain after Weaver's operation. We studied the causes and wish to propose a modification of this operative technique. We operated on 10 patients with an old dislocation of the acromioclaviclar joint. As they experienced continued acromioclaviclar joint pain, Weaver's operation was performed. Postoperatively, we found regeneration of bone at the resected part of the clavicle which was causing pain in three cases. One of the three patients required reresection of the regenerated bone because of persistent pain. The other two patients had spontaneous pain relief. After this experience, we changed our operative technique and started resecting the clavicle end together with the periosteum. Since then, we have not observed any cases with bone regeneration. As bone regeneration causing pain may occur after Weaver's operation, we propose that resected the periosteum, as well as the clavicle end, be resected.
The purpose of this report is to review the results of surgical treatment for fractures of the distal clavicle and decide the most reasonable treatment. This study was composed of 31 patients with unstable fractures of the distal clavicle (Neer's type II fractures). Their average age was 42.3 ranging from 13 to 76. All the patients were divided into 4 types of roentogenogram. Type 1(20 cases): coracoclavicular ligaments are torn and the distal segment is not comminuted. Furthermore, type 1 can be classified into 2 groups depending on the size of the distal segment: a) the large segment is one cm or more, and b) the small segment is less than one cm. Type 2(3 cases): coracoclavicular ligaments are torn and the distal segment is comminuted. Type 3(2 cases): coracoclavicular ligaments are intact and the distal segment is not comminuted. Type 4(6 cases): coracoclavicular ligaments are intact and the distal segment is comminuted. Various operations were peformed, and union was obtained in 30 of the 31 cases. But several problems arose, which were the following: delayed union, a long term immobilization and restriction in the shoulder motion, shoulder contracture, migration or breakage of an instrument, and an operative scar. On the basis of our results, we recommend that type 1 fractures with a large distal segment should be treated by a tension band fixation and not accompanied with an acromioclavicular fixation, type 1 fractures with a small distal segment and type 2 fractures should be treated by a tension band fixation accompanied with an acromioclavicular fixation, type 3 fractures should be treated by a steel wiring fixation, and type 4 fractures should be treated by both a tension band fixation and a steel wiring fixation.
Purpose: Nine cases of reflex sympathetic dystrophy, in brief, RSD, concomitant with rotator cuff tears will be presented here. Patients and methods: Nine cases,5 males and 4 females,68 years old on average, with an age distribution of from 53 to 81 years, consisted of 5 full-thickness and 4concealed rotator cuff tears.5 RSDs followed surgery of the cuff tears 4 RSDs were caused by the cuff tears. Besides a stellate ganglion block and physiotherapy, NSAID and predonine were administered orally. Surgeries were performed in three cases to eliminate the causative lesions of RSDs: 2 cuff repairs and 1 acromioplasty. Results: 4 postoperative RSDs were treated with success.2 cuff repairs and 1 acromioplasty relieved pain in three cases.2 cases are still under treatment. Conclusions: 5 postoperative RSDs occupied 20% of 25 cuff repairs out of the 75 cuff tears which had been treated by us in the past 4 years. RSDs following surgery consisted of 4 full-thickness and 1 concealed tears. Shoulder immobilization after surgery, joint contracture and rehabilitation could develop into RSD. In RSDs caused by 3 concealed and 1 small cuff tears, pain in the cuff rupture which threatened to enlarge might develop into RSD.
When one or more ossification centers of the acromion fail to unite with the body of the scapula it is known as os acromiale. We will report on six cases of rotator cuff tear and discuss the relationship between the occurrence of a cuff tear and os acromiale. All the patients visited our hospitals due to shoulder pain and restriction of motion. Two of them had no episodes of trauma. The diagnosis of a cuff tear was confirmed by arthrography; and roentgenograms showed an osteophyte formation on the undersurface of the acromion. Four of them were treated surgically. On exploration, free movement of os acromiale was recognized and the os acromiales corresponded to the tear site in three cases, there was no movement in the other case but the subscapularis tendon was torn. Os acromiales were removed and the torn cuffs were repaired, and good results were obtained. Two patients were treated conservatively as they suffered less pain. We consider that the movement of os acromiale and osteophyte formation played the roles of pathogenesis of the cuff tear in three cases. But in the case of subscapularis tendon tear, another cause may concern its pathogenesis. It is necessary to treat every case of os acromiale with a radical excision or a partial excision with the fixation of os acromiale.
The purpose of this study is to evaluate the results of arthroscopic surgery for patients with full thickness tears of the rotator cuff. The arthroscopic surgery was composed of debridement of the rotator cuff, synovectomy and lavage of the subacromial bursa and the glenohumeral joint, resection of the coraco-acromial ligament and labral tear, acromioplasty and debridement of the glenohumeral joint. OUr indications for arthroscopic surgery are for a patient, who is over 65 years old, and whose forward flection could be relieved by an injection into the subacromial space with Xy-locaine, but who has had pain which has not subsided with conservative therapy ever a period of more than 6 months. We operated on 8 shoulders with full-thickness rotator cuff tears and investigated 6 shoulders with a minimum 9-month-follow-up. The patients were 3 males and 3 famales, with an age range of from 55 to 76. The average score at follow-up time was 91.6 with a 31.2 gain from the pre-op value (JOA score). Pain relief had improved significantly. Arthroscopic surgery with debridement of the glenohumeral joint was performed on two of the 8 cases. The results of surgery with a debridement of the glenohumeral joint were better than a surgery without one. A patient with a full-thickness rotator cuff tear, who is over 65 years old and has intact forward flection, can obtain good results from arthroscopic surgery.
Since January 1991, eight irreparable, massive rotator cuff tears have been treated with latissimus dorsi and teres major transfers described by Gerber in 1988. Our series consisted of 7 males and a female with an averave age of 63.6 years. There were no neurovascular complications or infections. The average follow-up was 10.5 months(range 3.5 to 21 months). Pain was improved in all the cases. The average active flection was 117.5°; preoperatively and 132.5°; postoperatively. The Japan Orthopaedic Association Shoulder Evaluation Score averaged 66.3 Points preopratively and 76.6 points postoperatively. The synthetic results were excellent in three cases, good in one, fair in one, and poor in the remaining three cases.
(Purpose) We evaluated the postoperative isokinetic muscle strength of patients with a partial tear of the rotator cuff who had undergone repair by either McLaughlin's method or the fascial patch method. Muscle strength following a fascial patch method is generally considered to be inferior to that following McLaughlin's method. (Patients) Seven shoulders of 7 patients who underwent repair by the patch method were evaluated. Their average age was 56.7 years(range,38-67). Nine shoulders of 9 patients who underwent repair by McLaughlin's method were also evaluated. Their average age was 41.6 years(range,17-64). The mean postoperative period was 2.9 years in the patch group, and 1.8 years in the McLaughlin group. (Results) 1) 60 deg. /sec. The average peak torque of the involved shoulder was 89.8% of that of the contralateral shoulder in the patch group and 100.9% in the McLaughlin group. 2) 180 deg. /sec. The average peak torque was 97.4% in the patch group. On the other hand, it was 96.3% in the McLaughlin group. (Conclusion) The xtent of postoperative recovery of muscle strength is at almost the same level after repair by either the McLaughlin or the fascial patch method.
After an operation of the shoulder, it is of great importance to get a large range of motion(ROM)and to relieve pain. In order to achieve these objectives effectively, it is important to start passive ROM exercises as soon as possible after the operation. Since 1989, we have adopted two techniques for obtaining an effective rehabilitation 1. To prevent voluantary contraction during a passive ROM exersise, a relaxation exercise was performed preoperatively. 2. To minimize damage to the deltoid muscle, and to preserve the continuity of the muscle fiber between the trapezius muscle and the deltoid muscle, these muscles were lysed under the periosteum of the acromion. As a result, we can start passive ROM exercise on the first day after an operation. This is effective to gain the ROM of an intermal rotation needed when “Making knot in back” or for “Self hygiene care”.
Various dameges of the shoulder give rise to a rotator cuff lesion. A rehabilitation technique should be selected for a functional pathogenesis. We investigated how to select each exercise. 15 normal shoulders and 20 cases of cuff lesion were studied. The balance of the muscle's activity was analysed electromyographically. From the results, we selected a well?adapted exercise. The rotater cuff had a compensatory function. In those cases which recovered, a well-adapted exercise improved their functional balance. Exercises for the rotator cuff should aim at accelerating the compensatory function or correcting the imbalance of the muscle's activity.
Our Original roentgenographical technique named “Scapula-45” could estimate the function of the glenohumeral and scapulothoracic joints. We took X-ray films under four different condition, which are 0° and 45° elevation in the scapula plane with/without a 3kg weight loading. We could investigate the functional diagnosis of the glenohumeral and scapulothoracic through the four X-ray films. Based on the results of the normal volunteers' X-ray films, X-ray films of each case which had a shoulder problem had its characteristics analysed. The cuff index suggested the relative cuff function and could decide on the capacity of the cuff function, which was confirmed by electromyography. An increased cuff index in the 45° elevation in the scapula plane was seen in 76.6% cases. The activity of their supraspinatus and/or infraspinatus muscle was relatively decreased. There were two types of loose shoulder. Some cases, who had a dull pain and a feeling of instability during their activities, showed an increased cuff index in the 45° elevation in the scapula plane. The remaining cases had no symptoms during their activities and showed a normal cuff index in the 45° elevation in the scapula plane. The scapula index also suggested the function of the scapula.32% of the cased demonstrated a stiff scapula. A decreased scapula index of from 0° to 45° elevation showed pain in motion and/or impingement in the lower elevated level. In conclusion, our originated X-ray technique named “Scapula-45” could make the functional diagnosis which lead to select the adequate treatment.
The range of rotation of the shoulder changes with the three dimensional position of the arm. We measured the range of rotation in various positions of the arm. A magnetic sensor system (3 SPACE TRACKER SYSTEM from McDonnel-Douglas Corp. ) was used to measure the rotation of the shoulder. 1) The subjects were 10 males.2) Six glenohumeral joints of cadavers were used. The rotator cuff was cut, while the capsule was reserved. The range of rotation of the shoulder in normal subjects was largest at 30° elevation and 30° posterior to the frontal plane, while in cadavers it was at 30° elevation in the scapular plane.
The rotational motion pattern accompanying an elevation in various planes was investigated in normal subjects and cadavers. To measure the motion of the shoulder, a magnetic sensor system (3SPACE TRACKER SYSTEM from McDonnell-Douglas Corp. ) was used. Using this device, the three dimensional relative angle of the arm (humerus) to the trunk (scapula) was measured. The starting position was a nutural dropping position and defined as 0° rotation. 1) The subjects were twenty males with normal shoulders. They elevated their arms in 12vertical planes at intervals of 15°. Little rotational motion occurred during the elevations of 60° and 75° anterior to the frontal plane. External rotation occurred during abduction, and internal rotation occurred during flexion. In the scapular plane elevation (30° anterior to the frontal plane), the mean angle of rotation at the maximum elevation was 49° external rotation. 2) Six gleno-humeral joints of cadavers were used. The rotator cuff was cut at the site of the insertion and the capsule was retained. The scapula was fixed on a plate. The humerus was elevated by the investigator's finger in 9 planes at intervals of 15°. The position of the humerus at maximum elevation was on an average 34° anterior to the scapular plane. In the scapular plane elevation, the mean angle of rotation at the maximum elevation was 51° external rotation.
(Purpose) In order to quantitatively define the requirement of adequate protective synergy of the internal and external rotators, we evaluated isokinetic strength during concentric and eccentric activity, in normal shoulders and patients with anterior instability. (Materials & Methods) 15 asymptomatic volunteers,12 patients with anterior instability were evaluated in this study. The isokinetic strength was measured in a standing position, with shoulder in abduction 45°, flextion 30°, using a KIN-COM dynamometer (Chattex Corpo. ). (Results) 1)No patients had any shoulder pain or apprehension during the measurement.2)Eccentric and concentric activity ratios of the shoulder were about 1.2, lower than the other muscles, quandriceps, and the trunk muscles.3)In patients, not only internal rotators but also external rotators decreased during concentric and eccentric activity. (Conclusion) These findings are useful when planning thee pre- and post- operative exercises for patients with anterior shoulder instability.
In some cases of atraumatic shoulder instabilities, spontaneous recovery and a shift of disorders were recognized. From April 1985 to May 1992,4,983 patients (5,401 shoulders) visited the shoulder disorder clinic at Matsudo Orthopaedic Hospital. Among them,196 cases (347 shoulders) were diagnosed as atraumatic shoulder instability. The untreated and over-one-year results of 268shoulders were investigated. The mean age was 20.1 years old ranging from 10 to 41 years old. There were 55 male patients (103 shoulders) and 96 female patients (165 shoulders). The mean follow-up period was 33.1 months ranging from 12 to 83 months.196 shoulders were loose shoulder syndrome. Forty shoulders were voluntary dislocation. Thirty-two shoulders were positional instability. A shift of disorders was recognized in 23 shoulders (8.5%). Seven shoulders deteriorated from loose shoulder syndrome to voluntary dislocation. Four shoulders deteriorated from loose shoulder syndrome to voluntary dislocation and then further to positional instability. Among these four shoulders, one shoulder went back to voluntary dislocation and another one went back to loose shoulder syndrome. Five shoulders deteriorated from loose shoulder syndrome to positional instability. Two shoulders recovered from voluntary dislocation to loose shoulder syndrome. Five shoulders deteriorated from voluntary dislocation to positional instability. Spontaneous recovery was recognized in 24 shoulders. The incidence of spontaneous recovery was 12.6% in male patients and 6.6% in female patients. It was 2.1% in adults and 12.5% in adolescents. The mean recovery age was 16.8 ±2.3 ranging from 13 to 23 years old. The real incidence of spontaneous recovery is supposed to be more than in this research. The incidence of atraumatic shoulder instability is different in each age group. By using the disparity in the incidence of atraumatic shoulder instability of each age group, the practical incidence of spontaneous recovery can be estimated. The incidence of spontaneous recovery in patients whose age is between 14 and 16 years old is supposed to be 19.7% in three years from time of writing and 35.8% in 6 years from then.
Conventionally, much attention has been paid to surgical treatment as therapy for shoulder instability. However not only surgical treatment but also its effectiveness and the limitations of conservative therapy should be studied, and the possibilities of natural healing and the complexities of its pathology should be considered. We carried out strengthening exercises of the rotator muscles in shoulder instability cases. Ten patients 20 joints with inferior instability of the shoulder mostly complained of shoulder disturbance. Isometric exercises of the rotator muscles which were proposed by Dr. Neer, were carried out for 8 weeks, and the physical finding, the stress X-p and the muscular power were evalulated at the start and end of each period over the 8 weeks. The increasing rate of muscular power was significantly larger in the external rotators than that in the internal rotators. An improvement of symptoms was observed in all of the 15 joints with a shoulder disorder. The descending rate of the humeral head by stress X-p improved in 12 of the 15joints in which an increase of more than 10% muscular power in the internal or external rotators was recognized. We consider that an improvement of symptoms and stability can be obtained by strengthening exercises of the rotator muscles in shoulder instability.
We presented a two-directional glenoplasty for the habitual posterior dislocation(positional instability) of the shoulder joint at the 16th JSS annual meeting. A lont-term operative results of habitual posterior dislocationts of the shoulder will be presented. Seven shoulders(seven patients) were operated on by two directional glenoplasty. There were 4 males and 3 females. Their ages at operation ranged from 12 to 35 years(Average: 15 years except for the 35-year-old). The follow-up period was from 2 years and 8 months to 4 years and 7months(Average: 3 years and 6 months). Pain, a sense of instability, and instability had disappeared or were markedly decreased postoperatively. Our two directional glenoplasty obtained good results for a habitual posterior dislocation of the shoulder.
Purpose For non-traumatic instability of the shoulder, we performed inferior capsular shift(ICS) according to the main direction of instability and added a glenoid osteotomy(GO) for dysplasia or retroversion of the glenoid. The purpose of this study is to evaluate the results of our operative intervention. Materials and Methods We evaluated 16 shoulders(14 cases),5 of which were male and 11 female, three shoulders were habitual subluxation(HA) and 13 shoulders inferior and multidirectional instabiliry(I&MDI). The average age at operation was 16.1 years and the average follow-up period was 31.4 months. ICS(anterior approach) was performed on 9 shoulders, ICS(posterior approach) on 2 shoulders, GO and ICS(posterior approach) on 4 shoulders, and GO and ICS(simultaneous anterior and posterior approach) on 1 shoulder. Results The results for 3 shoulders with HS and 9 shoulders with I&MDI, which were mainly 2directional(inferior and anterior or posterior), were good. However the results for 4 shoulders, which had severe three-directional instability, were less favorable except for 1 shoulder on which a simultaneous anterior and posterior approach had been used. In these patients, slipping persisted in a shoulder subjected to the anterior approach, and inferior instability in one subjected to the posterior approach. Conclusion Either the anterior or posterior approach is roughly adequate for one or two directional instability. The degree of instability in three-directional instability is more severe than that in one or two diredctional. Stabilization using a simultaneous anterior and posterior approach for severe three directional instability might not be sufficient, but more preferable than that using either an anterior or posterior approach, because of its residual symptoms.
The purpose of this study is to evaluate the relation of the predisposing osseous factors of recurrent anterior dislocation of the shoulder(RAD) using computed tomography(CT), which made easy and accurate measurement of the gleno-tilting angle(GTA), the humeral retrotorsion angle(HRA) and the glenohumeral index(GI). Between 1985 and 1992, fifty-three shoulders of 50 patients under 40 years of age were diagnosed as RAD and were examined by CT. Their average age was 21(range,15-39). Forty-three patients were male and 7 were female. For the control group,33 shoulders of 21 patients who had no instability were examined. Using a Logitec K-510 digitizer, the GTA, HRA and GI were cauculated from seven points which were mesured at the anterior, posterior and medial edges of the scapula, two maxium diameter points of the humeral head, medial and lateral epicondyle. The involved side group, uninvolved and control groups were compared with t-tests. The GTA, HRA and GI in the involved sides were 0.1°±3.2°,25.3±11.4,59.8 ± 6.4 in the uninvolved were 0.2° ± 2.9°,28.1° ± 12.8°,62.5 ± 6.8 and in the normals were 1.3° ± 4.0°,30.3°±13.2°,61.0±3.9 (mean±SD). The GTA, HRA, GI were insignificant in each group. The authors consider that there are little predisposing osseous factors in RAD, such as the anterior glenoid tilt, humeral retrotorsion or malformation of the glenoid.
Traumatic anterior dislocation of the shoulder was reported, based on CT arthrograms(CTA)and arthroscopic(AS) findings, at the 18th Congress. The present paper deals with the relationship between CTA and redislocation, basing our discussion on the results of the follow-up examinations. The subjects were 40 patients with 40 shoulder joints involved who visited our hospital because of traumatic anterior dislocation of the shoulder. These cases were followed-up by personal examination and telephoned to determine their prognosis. The prognosis could be determined in 33 of the 40 patients. They were divided into a group of 29 patients with anterior dislocation and one of 4 patients with anterior subluxation. The treatment consisted of less than 3 weeks of immobilization(3 patients), more than 3 weeks of immobilization by sling or Desault's bandage(5 patients), and immobilization with our clavicular harness(25 patients). The initial dislocation-to-follow-up intervals ranged from 1 year to 8 years and 3 months(average 4yrs.6 mon. ). As many as 10 patients(33.3%), all under 25 years of age, redislocated. According to Ishikawa's classification of CTA, type III dislocations recurred at a high rate of 75%(6/8). We believe that patients, who are diagnosed by CTA as having a type III or more severe traumatic anterior dislocation of the shoulder, are at a high risk of recurrence.
CT arthrography(CTA) can provide precise quantitative data on intraarticular lesions of the shoulder. We quantified the intraarticular lesions of patients with dislocating or subluxating shoulders using CTA, and attempted to determine the pattern of progression of these lesions. Forty-eight shoulders in 47 patients with recurrent dislocation or subluxation on less than 8occasions were evaluated by bilateral CTA. Thirty-three patients had dislocation and 14 had subluxation. They included 34 males and 13 females, and the average age at injury was 19 years. Using our methods reported at the 18th annual meeting of the Japan Shoulder Society, the width of the attachment of the anterior inferior glenohumeral ligament(AIGHL) to the glenoid rim and the redundancy of this ligament were measured by CTA. The length, width, depth and location of any Hill-Sachs lesions were also determined. Then the correlations of these data with the number of dislocations or subluxations were analyzed. As the number of dislocations or subluxations increased, the attachment of the AIGHL to the glenoid rim became narrower and the Hill-Sachs lesions became wider. However, there were no significant correlations between the number of dislocations or subluxations and the degree of redundancy of the AIGHL or the length, depth, and location of the Hill-Sachs lesions. Since a narrow AIGHL attachment to the glenoid rim on CTA reflects ligament retraction, it was concluded that the AIGHL becomes more retracted as the number of dislocations or subluxations increases. Therefore, early surgical treatment is recommended for traumatic anterior shoulder instability.
Three thousand and four hundred patients who complained of shoulder pain underwent cineradioarthrography from 1982 to 1992. Of those patients, one hundred and eighty-nine shoulders became the subjects to reveal the degree of damaged anteroinferior glenoid edge (=DAGE). The size of the DAGE was measured using the PIAS LA-500 system. A comparative analysis of the horizontal and the vertical lengths of the area was made. Of the one hundred and eighty-nine shoulders with DAGE, one hundred and thirty-five had recurrent dislocation (RDS), twenty-one with Rotator Interval lesion, eighteen with recurrent subluxation, seven with instability, seven with rotator cuff tear, and one with primary dislocation. The mean size of the DAGE in unstable shoulders is smaller than the rest (p<0.05). The horizontal length of the DAGE was longer than its vertical one significantly (p<0.01). A correlation exists between the area of the DAGE and its horizontal length (r= 0.60), and a closer correlation was noted with its vertical length (r=0.71). Of the one hundred and twenty-eight shoulders operated for RDS, the size of the DAGE differ between those with, and without anterior capsular elongation (p<0.01). The former is larger than the latter. No difference was observed regardless of the number of dislocations.
Purpose For the purpose of grasping the pathophysiology before a microscopic examination, we performed MR arthrography(hereinafter abbreviated to MRA) and studied its usefulness in comparison with CT arthrogram(hereinafter abbreviated to CTA) as to whether or not the morphology, qualitative diagnosis and localization of a Bankart lesion can be judged. Method MRAs and CTAs were performed on a total of cases, which are broken down to 14 cases of traumatic anterior instability of the shoulder and 12 cases of traumatic anterior dislocation of the shoulder(first time). MRA was performed using a Toshiba MR T 60A(0.5T) after injecting Gd-DTPA of about 100-fold dilution in accordance with the method of Kumagaya et al. CTA was performed by the double contrast technique. High-position observations were made in the area from the center of the anterior acetabulum to 1/4 beneath the anterior acetabulum. The morphology of the labrum was classified according to Ishikawa's classification, and with MRAs, zlatkin's classification was used to study the morphological diagnosis, the qualitative diagnosis and localization of the labrum. Results When a comparison was made between the MRA and CTA as to the morphology of the labrum in Ishikawa's classification on the high-position observations, similar findings were noted in 24(92.3%) out of 26 cases. As to localization of the labrum, judgement was possible in 23 cases(88.5%) with MRA while it was possible in only 6 cases(23.1%) with CTA. Conclusion MRA, though inferior to CTA in contrast visualization, is free of exposure to radiation and useful for judging a degenerated rupture and localization of the labrum. So MRA can serve as an auxiliary diagnosis before a microscopic examination for the reduction of a Bankart lesion with surgery under a microscope.
The anterior glenoid labrum and capsular insertion were observed on MR images in conditions of joint effusion or injected physiolosical saline with special attention being paid to instability. Forty-seven shoulders of 36 patients were imaged with T2* weighted sequences. The patterns of capsular insertion were divided into 4 major types. The capsule seemed to have some continuity to the labrum in type 1. It's insertion was more medial to the neck of the scapula in type 2 and to a greater extent in type 3. Every case with a glenoid edge fracture or a bony defect was classified into type F. The assesments were done on the images of the mid-glenoid level and of the most inferior level. On the most inferior level of the glenoid,22 of 25 shoulders with traumatic anterior instability (16 dislocations and 9 subluxations) had a type 2,3 or F insertion. There were 11 joints with a type 1 insertion out of 18 contrast cases. Incases of subluxation, there were 2 of type 1 insertion and 3with a normal labrum, and contrarily there were 3 of type 4 insertion and 2 with a large bony defect of the glenoid edge. The joints with a large cuff tear had a type 2 (2 shoulders) or type 3 insertion with a labral defect (1 shoulder). The images of the mid-glenoid level were considered not to be adequate for the assesment, because 14 shoulders of the control group had type 2 or 3 insertions, and the labral changes were less typical on joints with instability. There seemed to be some relations between traumatic anterior instability and the types of capsular insertion, but not in every individual case. Rather severe injury on the anterior aspect of the glenoid seemed to make the reduction easy in some cases, which had been diagnosed as subluxation.
We investigated the following points; 1)pathological differences between a posttraumatic recurrent anterior dislocation and subluxation, and 2)the possibility to distinguish these two disorders by “self-reduction”.85 cases(87 joints) of post-traumatic recurrent anterior dislocation or subluxation of the shoulder joint were divided into two groups: group D, which consisted of 59 cases(60joints) diagnosed as recurrent dislocation and group S, which consisted of 26 cases(27 joints)diagnosed as recurrent subluxation. The history of the dislocation(subluxation), joint laxity measured by the Floating method and the arthroscopic findings of these two groups were compared. The applied force at the initial dislocation(subluxation) and the grade of Hill-Sachs lesion of group D was thought to be more sever than it was in group S on average. Joint laxity was stronger in group S than in group D. About half of this series changed their mode of recurrence from their past history. We would like to conclude that the pathologies of these two disorders overlap each other and that it is impossible to distinguish them by “.self-reduction”. alone.
Purpose Though we obtained good results by modified Boytchev procedure (MVP)(re-dislocation rate 3.5%), a treatment for anterior dislocation of the shulder joint (ARDS) with a large bone defect of the glenoid rim presented poor results. On this study, the indication of MBP with bone graft for the ARDS was presented. Method Sixteen of 115 shoulders on which were performed MBP had a bone defect of the glenoid rim. A bone graft to the glenoid rim was performed on four shoulders. The size of bone defect was determined comparing with the uninvolved side. Results Only MBP was performed on 11 shoulders with under 20% of bone defect. Three of 5 shoulders that had 10-20% of bone defect had inferior instability at the pre-operative state and they felt an apprehension feeling at the follow-up period. Five of 6 shoulders with under 10% of bone defect didn't complain of an apprehension feeling and didn't reveal the positive sign of anterior apprehension test. Only one case that had severe inferior instability complained of an apprehension feeling. MBP with a bone graft was performed on 4 shoulders with over 20% of bone defect, based on our experience with one re-dislocation case with 25% of bone defect. This case re-dislocated one year after the operation without having been relieved of his apprehension feeling. Conclusion 1. Under 10% bone defect: MBP is performed alone. 2.10-20% bone defect: Bone graft is relative indication. 3. Over 20% bone defect: Bone graft should be performed with MBP.
Since 1970 a modified Putti-Platt method for recurrent dislocation and subluxation has been conducted at our hospital. Follow-up studies revealed the clinical results. One hundred and ninety-one cases, involving two hundred and one joints, were evaluated. All the patients were followed-up for at least one year after surgery. The subjects consisted of 149 males and 42 females. There were 105 right shoulder cases and 96 left shoulder cases.175 cases had complete dislocation and 26 had subluxation. The age ranged from 14 to 68 years with an average of 28.2 years. The average follow-up period was over six years. Recurrence, disturbance in daily routines, return to sports activities or occupations, significant pain and range of motion were investigated. No recurrences were noted, but eight patients experienced a subluxation within one year after surgery. External rotation with the arm held at the side ranged from-10 to 80 degrees(mean 31.5 degrees), and from 10 to 110(mean 53.8 degrees) with the arm in a 90 degree-abduction position. External rotation was better, among younger people and those with a higher level of sports activity. The rest of the ROM was not limited.90 percent of the athletes, who had hoped to continue playing, were able to go back to their sports activities. But only 25 percent of the athletes in throwing sports were able to return completely.85 cases complained of varying degrees of pain. But only 5 cases reported significant pain. No complains about daily life were noted among most of the patients. All were able to return to their previous occupations. It has been concluded that modified Putti-Platt procedure is an excellent method, since there were no recurrences and the loss of external rotation was not a functional problem, except in throwing sports.
The long-term results of the modified Bristow's procedure have not been investigated in detail. We have been able to follow up(over 10 years) 23 patients and report the long-term results of this procedure. The 23 patients ranged in age at operation from 16 to 44 years and 16 patients were male and 7 patients female. No dislocations recurred and pain on motion was experienced by 2 patients. Mild limitation of external rotation was seen in 11 patients, which was 10 degrees on average. Return to sports was accomplished by 13 patients,9 of whom played their original sport, while 4enjoyed some other sports. Restriction of external rotation was 8 degrees on average when returning to their original sport and 14 degrees if they did not return to any sports. We recognize that a remarkable limitation of external rotation prevents some athletes from returning to sports. Arthrosis of the shoulder joint was seen in 4 patients, in whom displacement of the screw was observed in 2 and breakage of the screw in 1. We suspect breakage and displacement of the screw to be the cause for arthorosis of the shoulder joint.
Purpose We will report on the postoperative results of du Toit capsulorrhaphy, one of various operations which has been developed to treat traumatic anterior instability of the shoulder, which consists of the reattachment of the capsule and the labrum to the anterior glenoid rim using staples. Patients and Methods Since 1984, we have performed 24 du Toit capsulorrhaphy procedures for anterior recurrent dislocation of the shoulder. We evaluated the following parameters in 18 patients (19 shoulders) who were followed-up for more than one year postoperatively. The average age at the time of procedure was 23 years, and the average follow-up period was 3 years and 1 month. The following paramaters were evaluated: 1)the JOA (Japanese Orthpaedic Association) score,2)stability,3)range of motion,4)athletic activity, and 5)complications. Results The postoperative JOA score was 90.8 compared with 71.6 preoperatively. Recurrence was noted in one patient, and sublaxation in two others. In the 3 patients with instability, the postoperative treatment had been continued for only 2 months, nevertheless external rotation had been limited at less than 30°;. In contrast patients who had done the proper postoperative exercises, had exellent results. The mean range of external rotation was 13.7°; less than that on the contralateral side. With respect to athletic activity, three patients were able to resume their competitive sports'activities, and 6 reported that they could enjoy recreational sports' activities. Staple migration was noted in 4 patients,2 of whom reported a mild related pain. As a major complication, significant damage of the glenohumeral joint due to a penetrated staple was found in one case. Conclusion 1)Of the 18 patients (19 shoulders) who underwent du Toit procedure for anterior shoulder instability, one had a recurrence, two sublaxation and one had a major complication due to a staple.2)Postoperative management influenced the postoperative results.
This report describes our experience of utilizing the STATAK Soft Tissue Attachment Device to attach the capsular extensions to the glenoid rim during a Bankart procedure. We reviewed 15patients (age,16 to 47 years) who had undergone a Bankart repair with this device and were followed-up for over six months. The operative time and the surgical results were compared to those of 17 Bankart operations with the transosseous suture technique. The average operative time was 18 minutes shorter in the STATAK group (83 versus 101minutes). The physicians who used the STATAK felt that this device was particularly effective in patients with a rounded glenoid rim. According to Rowe's scoring system (1979), the surgical results of the STATAK group were asessed as excellent in eight cases, good in four, fair in two, and poor in one. Among the three unsatisfactory results, two patients complained of a recurrence of instability during sports. The X-rays revealed improper placement of the STATAK in these cases. We conclude that the STATAK benefits the surgical technique and the operative time if it is securely inserted into the bone.
We performed a modified Oudard-Iwahara-Yamamoto method (modified 0-I-Y) for recurrent anterior dislocation and recurrent anterior subluxation. We will present the cineradiographical analysis for the stability of the shoulder before and after a modified 0-I-Y. 10 shoulders with recurrent anterior subluxation were examined. Before the operation and between 1 and 2 years after it, we measured the glenohumeral angle and the arm angle at each 50cineradiograms per second during elevation and depression of the arm in the scapular plane. The changes of the glenohumeral angle before the operation showed an irregular curve, and after the operation, they demonstrated a smooth curved line on the graph. Our cineradiographical study could demonstrate an unexpected irregular movement of the glenohumeral joint during shoulder movement in the scapula plane. Our study also suggested that a modified 0-I-Y stabilized the shoulder motion.
The authors evaluated the isokinetic strength(IS) of a recurrent anterior dislocation and subluxation of the shoulder before a modified Bristow's procedure compared with normal individuals and followed the change of IS before the operation, and of 3 months and 6 months after the modified Bristow's procedure. Eight cases of recurrent dislocation and 8 cases of subluxation of the shoulder were examined. There were 16 men and 2 women, whose average age was 20.6 years, ranging from 15 to 32 years. All of their involved sides were the dominant sides. As a control,10 baseball players and 10 soccer players were also examined. The average peak torque per body weight at 90deg/sec and total work per body weight at 180 deg/sec were measured with a LIDO active system in flexion(FL), in extension(EX), in external rotation(ER), and in internal rotation(IR). The average peak torque of the dominant side of the patients was statistically less than the nondominant side by 15% in FL, maybe caused by apprehension. That of the baseball players was statistically greater by 16% in EX and 18% in IR, maybe caused by training. There was no statistical difference between the dominant and nondominant side in the IS of soccer players. Three months after the operation, the average peak torque of the involved side ranged from 55.5%(IR) to 68.4%(ER) compared with before the operation, but after 6 months, they had recovered to 93.9%(FL) and 110%(EX) of their pre-operative states. Total work ranged from 59.4%(IR) to 90.6%(FL) 3 months after the operation, but they had recovered to 88.3%(IR) and 131%(EX),6 months after a modified Bristow's procedure. Three months after a modified Bristow's procedure, the recovery of IS was unsatisfactory for athletic sports, but 6 months later, the IS had recovered to almost its pre-operative state. IS of recurrent dislocation of the shoulder tends to decrease in FL compared with normal individuals, and so, more training of the flexor muscles is necessary.
The muscle strength of recurrent dislocation of the shoulder after Bankart's procedure was evaluated by using a Cybex II, and was compared with that of the non-involved side. The shoulders of 26 patients on whom we had used Bankart's procedure were analysed. The average follow-up interval was 8.1 months(range 5 to 13 months) post-operatively. Isokinetic muscle strength testing of the shoulder was examined by using a Cybex II at the speed of 30 or 60 degrees/second, for flexion, extension, abduction, adduction, internal rotation, and external rotation. The peak torque was measured as a maximum strength and the percentage of the involved/non-involved side was calculated. The muscle strength of the involved side was 83.6% in flexion,93.1% in extension,78.8% in abduction,87.1% in adduction,88.6% in internal rotation, and 73.1% in external rotation. The muscle strength of the involved side was lower in all directions than that of the non-involved side, especially in abduction and external rotation. Then, we examined the correlation between the muscle strength, the number of dislocations, the durations of disease, and the degrees of Bankart's lesion. The muscle strength in abduction and external rotation was significantly lower in the group which consisted of a large number of dislocations, and a long duration of disease. There was no correlation between the muscle strength and the degrees of Bankart's lesion. The muscle strength plays an important role in the stability of the shoulder after surgery. Therefore, Bankart's procedure is recommended to be performed in the early stages of a recurrent dislocation of the shoulder in order to get good results regarding the postoperative muscle strength and stability.