We reported on bony spur of the acromion and morphological changes of the rotator cuff at the 16th,17th and 19th annual meetings of the Japan Shoulder Society.
The results indicated that some factors which make a small bony spur are physiological impingement and some factors which increase the size of bony spur are clinical or mechanical impingement which is represented in rotator cuff tears (especially the BST, a complete and massive tear).
In this paper we would like to clarify the relationship between the size of bony spur and the term of the symptom.
Our subjects consisited of 142 cases and 144 bony specimens with coraco - acromial ligament which had been obtained by anterior acromioplasty in 52 subacromial impingement syndromes,32partial tears of the rotator cuff (JST10, intertendinous 3, BST19),44 complete tears,12 massive tears,2 subscapularis tendons and 2 rotator intervals.
The age of the patients ranged from 18 to 66 and, averaged 45 years old.
The specimens were examined for the presence of bony spurs of the acromion radiographically and measured.
The results indicated that, there was a correlation between a medium or large sized spur and the term of the symptom.
The above mentionned results take into consideration that a small bony spur is produced by a physiological impingement and the size of the bony spur will increase by adding a clinical or mechanical impingement, which is the result of a disfunction of the rotator cuff. In conclusion, we consider the existence of a vicious cycle between the increase of bony spur and the clinical or mechanical impingement.

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[Purpose] To determine the implications of changes of the peribursal fat plane (FP) on MR imaging (MRI) of patients with subacromial impingement syndrome.
[Materials and Methods] Fifty-three patients who had undergone arthroscopic surgical treatment for subacromial impingement syndrome were studied. All the patients had a good response to subacromial decompression. The mean age at surgery was 33 years (14-64). FP was evaluated in the oblique coronal view, and was classified as follows: a plane visible along the bursal layer on T1-weighted images (T1WI) “Type I”, a signal intensity of the plane on T2^*-weighted images (T2^* WI) were higher than those of T1WI“Type II”, and the plane was not detectable on T1WI “Type III”. Using T2^* WI, type II patients were then classified as having a thin FP (IIn) or a thick FP (Ilk). The bursal findings confirmed at arthroscopic surgery were classified as follows: bursal synovitis (BS), bursal fibrosis (BF), bursal thickening (BT), bursal adhesion (BA). The FP type were compared with the bursal findings.
[Results and Discussion] MRI findings were classified as Type I in 25 shoulders, type II in 23shoulders (IIn in 17, IIk in 6), and type III in 5 shoulders. Bursoscopic findings were synovitis in 27, thickening in 33, fibrosis in 25, adhesion in 25 and normal in 3 shoulders. BT was detected in 71% of Type IIn. BS was found in 83% of Type IIk. BS and a BA were found in 83% of Type III.
[Conclusions] Changes of FP reflect the bursal state, but the presence of an FP does not always mean the subacromial bursa is norma

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The purpose of this study is to clerify the usefulness of ultorasonography (US) in diagnosing an incomplete tear of the rotator cuff.
During the last five years (1988-1993), we performed US on patients who had a shoulder problem. Twenty eight of them underwent surgical repair of the rotator cuff tear suspected by the US. There were 14 shoulders of 13 men and 15 shoulders of 15 women, with an average age of 59.2years.
At surgery, complete cuff tears were confirmed in 23 patients, bursal side tears in four and capsular side tears in two. Standard sonographic examinations were completed using a TOSHIBA 7.5MNz annular array.
Ultrasonographic findings in the bursal side tears showed a thinning of the rotator cuff on the top of greater tuberosity, but no deformations of the junction between the greater tuberosity and the humeral head were observed. The findings in capsular side tears revealed different echogenicities in the rotator cuff, but no deformations of the rorator cuff or greater tuberosity contour were observed. According to the US findings obtained, we classified the developing course of a rotator cuff tear into 2 types; 1) the bursal side tear,2) the capsular side tear.

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[Purpose] We investigated the diagnostic capability of MRI and sonography (US) for partial thickness rotator cuff tears (PTRT).
[Materials and Methods] 11 shoulders of 11 patients including 7 males and 4 females (aged 16 - 70years with an average 37 years) were examined using a Yokogawa RT2800 or ALOKA SSD-650(7.5MH_z probe) along the longitudinal cuff plane, and were imaged with a T2 * sequence along the oblique coronal plane under a 1.0 or 1.5 Tesla Shimadzu superconductive MRI system. In US, a cuff lesion was determined by the hyperechogenicity, the hypoechogenicity and the imhomogeneity of the cuff layer. In MRI, the high intensity region in the cuff was diagnosed as a cuff lesion. PTRT were confirmed at the operation as follows 8 articular surface tears,2 bursal surface tears and one intratendinous tear.
[Results] High intersity regions in MRI were present in 10 out of the 11 shoulders, but in 6 of the 8cases of articular surface tears, the high intensity region was located in the bursal side. In one case of 2 bursal surface tear, the high intensity region was observed in the full thickness layer, and in the case of intratendinous tear, the high intensity region was located within the midlayer of the cuff. The US detected rotator cuff lesions in 10 out of the 11 tears, and classified 3 as hyperechogenicity,4 as hypoechogenicity and 3 as imhomogeneity. [Conclusion] MRI tended to demonstrate a high intensity region in the bursal side in almost all of the cases. The echogenicity of US had no definite tendencies among the types of PTRT in this series. It was difficult to distinguish the location of a PTRT by US and MRI.

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After the repairing of a rotator cuff tear,23 patients (23 shoulders) were assessed by MR images. The age distribution was from 33 to 68 years old (ave.54.4). The followed up time was from 5 months to 9 years (ave.16 months).
Methods
The patients were examined with a Toshiba 0.5 T OR 1.5 T MR imager. The pulse sequences were Ti weight (TR/TE 400/15) and T2 weight (2000/80). The MR images were assessed in the coronal oblique and the axial plane. Then the irregularities, discontinuity, thinning and high signal intensity areas were studied.
Results
Within one year postoperativery, the high signal intensity of bursa' side was seen in 61% and in 20% of patients more tha 1 year after surgery. Irregularitis of the sutured cuff was seen in 33%within 1 year and in 40% over 1 year. The RCT over 3 cm in size revealed a thinning of the cuff. In RCT with a horizontal incomplete tear (imcomplete tears which were sutured layer to layer), a high signal intensity was revealed within the sutured cuff. The sutured cuff stump to the humeral head showed a high signal intensity. One shoulder revealed a reruptured rotator cuff.
Conclusion
Postoperative MRI was useful to assess the repaired rotator cuff.

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We studied the relation between the morphological findings of the supraspinatus muscle on MRI and the moter unit potential (MUP) amplitude in order to evaluate the function of the atrophic supraspinatus muscle in a patient with a cuff tear.
Twenty-three shoulders with cuff tears were scanned in the oblique coronal plane on T1 and T2^*-weighted sequences with a 0.5T unit. We calculated the ratio of the longest width of the supraspinatus muscle belly to the distance from the greater tuberosity to the proximal end of the supraspinatus muscle on a Ti-weighted image, which was termed “Supraspinatus Muscle Belly Rate” and abbreviated as “SMBR”. We classified the degree of appearance of the linear band in the supraspinatus muscle, the variety of signal intensity, irregularity and vagueness of its margin into three grades. We calculated the mean MUP amplitude by means of a needle EMG. Thus we evaluated the function of the supraspinatus muscle by comparing the MUP amplitude with “SMBR”and their morphological grades, because the MUP amplitude were linearly related to the force.
The MUP amplitude had a positive correlation with “SMBR” but a negative correlation with the morphological grades. With atrophy of the supraspinatus muscle belly and an increase in the degree of appearances of the linear band, the variety of signal intensity, irregularity and vagueness of its margin on MRI, the function of the supraspinatus muscle decreased.
We could evaluate the function of the supraspinatus muscle in patients with a cuff tear by analysing its morphological changes on MRL.

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The purpose of this study was to evaluate the MR images of the rotator cuff in postoperative patients with a rotator cuff tear.
Preoperative MRIs were performed on 39 patients with a rotator cuff tear including 31 complete tear and 8 partial tear. Postoperative MRIs were performed on 20 patients 6 months to 4 years and 5 months after.15 of them had postoperative arthrographies. Three were re-operated on. The preoperative MRI findings showed a cuff tear in all except one. The post-operative MRIs, in most cases, showed a very high intensity, to various extents, between the supraspinatus and the acromion and some artifact around the shoulder joint on the fast scans. The postoperative arthrography of the shoulder joint showed a complete rotator cuff tear in 6. The MRI findings on these cases are the presence of a fluid-like high signal intensity on a fast scan that extends through an area of the rotator cuff or the nonvisualization of a portion of the rotator cuff tear. A tluid-like high intensity through the tendons was present in the tendons of the 3 re-oprated on cases. At reoperation these cases revealed two complete cuff tears and one articular side incomplete cuff tear. These findings suggest that MRI could be useful for the postoperative diagnosis of a complete rotator cuff tear.

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We have been using 3 mm-thick Teflon felt for the repair of chronic massive rotator cuff tears (“Teflon Felt Cuff Plasty: TFCP”) successfully Since 1982. This paper will describe the postoperative evaluation of TFCP based on M. R. Is.. The ten shoulders of the 10 patients, who had received TFCP between 1985 and 1992, were imaged with an M. R. (GE: 1.5 T) and shoulder surface ckils.
A low or iso signal area (T1) and an inhomogeneous relatively high signal area (T2) were recognized well in lesion replaced by a TFCP. Degenerative muscular atrophies of the supra- and infraspinatus still remained, but the thickness of the replaced Teflon felt could be recognized over the humeral head.

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We have been using the transacromial approach for the treatment of a massive rupture of the rotator cuff since October 1988. This approach was performed on 11 patients between October 1988to September 1992. All the patients were available for analysis, after a follow-up period that ranged from one to 5.8 years (mean,2.75 years) after the operation. We evaluated the post-operative results using the J. O. A shoulder scoring system. The average J. O. A shoulder score improved from 52.82 points to 92.27 points. The transacromial approach results in minimal damage to the deltoid muscle and provides full exposure of lesions in the subacromial region. We recommend this approach for surgical repair of a massive rotator cuff rupture.

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The procedures for and results of the osteotomy of the acromion accompanying the operation of massive cuff tears were analyzes.
Sixteen osteotomies of the acromion were studied among which,9 were accompanied by a Dubeyre procedure and 7 by a trapezius transfer.
13 right shoulders were involved and 3 cases were left.
There were 15 males and 1 female with an average age of 61 years old.
The methods of osteotomy were divided into 4 groups.
(1),1 osteotomy at the middle of the acromion parallel to the scapular plane (F1).
(2), (1) plus 1 osteotomy perpendicular to the scapular plane (F1S1).
(3),1 osteotomy perpendicular to the scapular plane (S1).
(4),2 osteotomies perpendicular to the scapular plane (S2).
All the osteotomies were reduced and fixed by Kirschner wires.
The tension band wiring technique was performed in 7 cases.
Nine cases of F1 osteotomy resulted in 7 bony unions,1 non-union and 1 unknown. The average periods for union were 3.1 months in thie Debeyre group and 13.7 months in the trapezius transfer group.
Three cases of F1S1 osteotomy resulted in I bony union and 2 non-unions. The period for union was 4.7 months in the trapezius transfer group.
One case of S1 osteotomy accompanied by a trapezius transfer resulted in a bony union within 2.6months.
Three cases of S2 osteotomy resulted in 1 bony union,1 delayed union and 1 non-union. The period for union was 18.1 months in the Debeyre procedure group.
The improvement rate evaluated by the Japanese Orthopaedic Association shoulder score was better in the group with bony union of the acromion than in the group with no bony union.
In conclusion, an F1 osteotomy followed by Kirschner wire fixation with the tension band wiring technique seems to be the most reliable method to get a bony union of an osteotomy of the acromion.

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The isokinetic strength of the internal and external rotator muscles of normal individuals were evaluated in two different test positions.
Ten shoulders of healthy male volunteers were examined. The average peak torque per body weight and average work per body weight at 90 deg/sec. and 180 deg/sec. were measured with a LIDO active system. The test positions were supine with the arm at 0 and 90 deg. abduction and each range of motion was at 45 deg. from the neutral position.
The average peak torque per body weight (N. m /kg) of the external rotator muscles of the dominant arm was the same in both positions, which was 0.36, but that of the internal totator muscles was 0.49 at 90 deg. abduction and 0.42 at 0 deg. abduction, and statistically less at the P>0.05 level of significance. The total work per body weight (J /kg) of the external rotator muscles of the dominant arm was 0.45 in both positions and that of the internal rotator muscles was 0.60 at 0 deg. and 0.55 at 90 deg. abduction, but there were no statistical differences in either position.
The stregth of the internal rotator muscles at 90 deg. abduction was less than at 0 deg. abduction, whereas there was no difference between either of the external rotator muscles. The isokinetic strength of the internal and external rotator muscles produced no definite correlation between each position, which should be discussed separately. However, the 90 deg. abduction position is not ideal for measuring cases with recurrent dislocation of the shoulder due to apprehension of dislocations.

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(Purpose) The purpose of this study was to explore the relationship between the range of motion and work output after a modified Bristow's procedure for recurrent dislocation of the shoulder.
(Patients and methods) 9 patients who underwent a modified Bristow's procedure during 1991 and 1993 had their work output and range of motion of the affected shoulder measured prior to surgery. The same measurements were taken 3,6, and 12 months after surgery.
(Results) The average preoperative range of motion did not differ 12 months after operation in flexion, abduction or internal rotation. On the other hand, the range of external rotation decreased from 54.4 degrees preoperatively to 42.1 degrees 12 months after the operation meaning a loss of 22% of the arc of motion. The average work output during a full arc of motion was 31.1 and 33.2Watts in flexion and abduction preoperatively.12 months postoperatively, the work output was 30.3and 29.2 Watts. The external rotation was 23.4 Watts preoperatively and 30.5 Watts 12 months later.
(Conclusion) 22% of the arc of motion was lost after Modified Bristow's procedure in the external rotation whereas the work output performance was not sacrificed in any of the directions of shoulder movement.

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Modified Bristow's procedure is one of the satisfactory surgeries for a recurrent anterior dislocation, but the muscle strength of internal rotation decreases after it. This study is an attempt investigate the effects of exercise velocity on the rotational muscle strengths of the shoulder after a modified Bristow's procedure. Seventeen patients (2 females,15 males,9 right shoulders,8 left shoulders) were examined. Their mean age at the operation was 25 years (ranging from 18 to 40). The average follow-up period from the operation was 1.2 years. Their dominant side was the right. As a control,10 normal individuals were examined. Using a Kawasaki Heavy Industries Ltd's REHAMATE R -200, the muscle strengths of internal rotation (IR) and external rotation (ER)were measured at 90°shoulder abduction. The range of motion was from IR 45' to ER 45°. The angular testing velocity was 60 deg/sec,120 deg/sec and 180 deg/sec. The isometric muscle strength was measured at IR 45°,0°and ER 45°per 3 sec. In those cases operated on the left side, the peak torque of ERs decreased by 4% at 60 deg/sec,2% at 120 deg/sec and 17% at 180 deg/sec. In those cases operated on the right, the peak torque of ERs decreased by 20%,14% and 6% respectively. The mean torque of ERs decreased at almost the same degrees. The peak torque of IRs operated on the left side decreased by 17% at 60 deg/sec,12% at 120deg/sec and 14% at 180 deg/sec. The peak torque of IRs operated on the right side decreased by 21%,14% and 14% respectively. The mean torque of IRs decreased at almost the same degrees. The isometric muscle strength differed in each group. In conclusion, isokinetic muscle strength tends to diminish more the lower the velocity is.

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We experienced a rare case of posterior dislocation of the acromioclavicular joint caused by a rugby injury. A 27-year-old man fell on his left shoulder with another rugby player on his back. He consulted other clinics but could not relieve his shoulder pain. On the 10th day after injuring himself, he visited our clinic and science institute. At the initial examination, his left shoulder was swollen, painful and restricted in it's range of motion. The dislocation was reduced while he was under general anesthesia on the 14th day after injury.
The acromioclavicular ligament was torn completely but the coracoclavicular ligament was intact. The arm was rested in a Stockinette-velpeau bandage after the operation for 2 weeks and then he started rehabilitation. Now, his shoulder has a full range of motion and he plays rugby at the same level as before. We successfully treated a posterior dislocation of the acromioclavicular joint caused by a rugby injury through surgical treatment.

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Summary
This study is to evaluate whether or not MR imaging of the shoulder after the loading of pitching would improve the diagnostic performance of MRI in the diagnosis of a shoulder injury due to pitching.12 volunteers,6 with throwing pain and 6 without any pain, were examined on a MRI before and after pitching. All the examinations were performed on a 1.5T unit (Signa, GE Medical Systems). Axial T₂^*weighted images and oblique coronal T₂ weighted images were obtained.
The MRIs of the 6 volunteer with throwing pain had 15 abnormal findings, while the MRIs of the others without any pain showed only 9. The amount of fluid in the subacromial bursa or the glenohumeral joint seemed to be somewhat increased (3) or decreased (1) in 4 volunteers whose MRIs were examined after the loading of pitching.
When players complaining of throwing difficulties consult a sports doctor, they may not have pitched for a rather long time. Therefore, an MRI after the loading of pitching may improve the diagnostic ability of throwing injuries of the shoulder.

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The purpose of this study is to estimate the diagnostic value of the local anesthetic throwing test (LA-test) exactly.
Patients: The LA-test was used on 27 athletes (males; 24, females; 3) suffering from shoulder pain in the throwing motion. All the patients were estimated with an arthroscopy and the pathological lesions in the shoulder joint and the subacromial bursa were identified.
Pathological lesions of the subacromial space: The pathological lesions of the subacromial bursa involved inflammation, bursal thickening, and adhesion.
Pathological lesions of the shoulder joints: The pathological lesions of the shoulder joint consisted of the detachment of a bicep and labrum complex, an articular side rotator cuff tear, a posterior labral tear, a Bankart lesion, and an inflammation of the shoulder joint.
Methods of LA testing: The methods of LA-testing were as follows. At first, the patients did a throwing motion about twenty times and the pain of the throwing motion was reproduced. Secondly, an anesthetic (5ml of 1% procaine) with a dye (3ml of 250 isobist) was injected into the subacromial space under a fluoroscope, and the patients threw again about twenty times, and the percent of residual pain compared with the initial pain was asked each patient. Finally, the anesthetic with the dye was injected into the shoulder joint space under the fluoroscope, and the patients threw about twenty times again, and the percentage of the residual pain compared with the initial pain was asked the patient. After these procedures, if more than 30% of the initial pain had been reduced, the LA-test was decided to be effective.
Analyzing procedure: The relationship between the results of the LA-test and the pathological lesions was analyzed, and the diagnostic value of the LA-test was estimated with a diagnostic accuracy and a predictive value.
Results of the subacromial space: The injection into the subacromial bursa was effective in 18patients, and pathological lesions of the subacromial space were recognized in 15 of 18 but not in 3. The injection into the subacromial bursa was not effective in 9 patients, and the pathological lesions of the subacromial space were recognized in 4 of 9 but not in 5. According to these results, the diagnostic accuracy was 74%, and the predictive value was 83%. The local anesthetic throwing test was significant with regard to the subacromial bursa.
Results of the shoulder joint: The injection into the shoulder joint was effective in 13 patients, and pathological lesions of the shoulder joint were recognized in 9 of 13 but not in 4. The injection into the shoulder joint was not effective in 14 patients, and the pathological lesions of the shoulder joint were recognized in 9 of 14 but not in 5. According to these results, the diagnostic accuracy was 48%, and the predictive value was 67%. With regard to the subacromial bursa, the local anesthetic throwing test was not significant.

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A Pyogenous arthritis of the A-C joint is extremely rare. We experienced one case and performed surgical treatment on this case.
(Case and Course) A 50-year-old male fork-lift truck driver. Tenderness and swelling were recognized along the anterior aspect of his shoulder.
Active shoulder elevation was severely limited. As in the plain roentogenograms, destruction of the A-C joint had progressed, a debridement of the A-C joint was performed on Septembers 14th,1992. Two weeks later, the wound had healed and the symptoms improved.
(Conclusion) The A-C joint's functions are not easily disturbed by its resection.
In cases where antibiotics are not so effective, we should perform an operation.

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Snapping scapula is a derangement of the scapulocostal mechanism that results in a distinct thump or snapping sound. We experienced a case of this pathological condition in which cineradiography played a major role to reveal its pathomechanism.
A thirteen-year-old junior high school girl complained of chronic pain and a crepitus when moving her right shoulder girdle. The initial examination revealed an audible crepitus with snapping as the scapula moved across the chest wall. A winging-like motion of the inferior angle of the scapula was also found. Plain X-ray films, CT scans and MRIs showed no abnormal bony changes. But cineradiography pointed out the snapping phenomenon clearly between the superomedial angle of the scapula and the second, third and fourth ribs.
Although the patient was treated conservatively over five months with nonsteroid antiinflammatory drugs, local subscapular injections and physical therapy, no improvement was achieved and she consented to surgery.
At operation, the superomedial angle of the scapula proved to be curved forward slightly and was excised. But as some mild symptoms persisted postoperatively, a partial excision was added nine months after the first operation. The patient made an uneventful recovery and had complete elimination of the crepitus and snapping.
Cineradiography is a useful diagnostic tool to reveal a pathomechanism of snapping scapula.

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(Purpose) Voluntary dislocation of the tendon of the long head of the biceps is extremely rare. Here we will report on this dislocation in one patient.
(Patient) The Patient, a 37-year-old male fell down with his arm extended. Since then, he had a click and pain of the shoulder when he elevated his arm. When he had contracted his biceps with his arm extended and internally rotated, the tendon of the long head of the biceps dislocated from the bicipital groove. By elevating the arm 135 degrees from that position, the tendon reposited with a click and pain. Arthrography showed a dislocation of the tendon of the long head of the biceps. Arthroscopy and a tenodesis of the biceps tendon were performed.
(Conclusion) When observing the shoulder joint of a cadaver, the insertion of the subscapularis tendon was separated into two layers. One was a superficial layer, the other a deep one. Some parts of the superficial layer formed the transverse ligament. So we believe that the tendon of the long head of the biceps is often dislocated accompanying with a tear of the subscapularis tendon.

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We have previously reported on the low echogenic space which existed in the biceps sheaths among the shoulders of disabled patients. The purpose of this study is to delineate if the low echogenic space in the biceps sheath results from intra-articular hydrops and to characterize the low echogenicity found in each shoulder lesion. Three healthy shoulders were examined sonogenically around the space of the biceps tendon and the space between th joint capsule and the humerus head at the axilla. After an intra-articular injection of contrast medium, a low echogenic space around the biceps tendon and an increased space at the axilla were seen. Since then we have considered the low echogenic space of the biceps tendon sheath means an intra-articular effusion of sholder. Patients with pain in the sholder had a low echogenic space with existed in 30% of tenosynvitis of the biceps tendon,17% of the rotator cuff tears and so on. The low echogenicity at the biceps tendon sheath in rotator cuff tears was larger than in other sholder lesion.

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We wish to present our method of internal fixation for proximal humeral fractures. There were 3 patients. Case 1 was a displaced humeral neck fracture with a fragment of greater tuberosity. Case 2 was bilateral humeral neck fractures with fragments of greater tuberosities. Case 3 was a nonunion of a humeral neck fracture 3 years after the trauma had passed. In all the cases, the fractures united.
Our method is to use a Kiintscher nail (6-8mm in diameter,180-210mm in length) for a intramedullary fixation and a wire loop fixation from a hole at the top of the nail to the humeral shaft extramedulary. These wires can stabilize the fragments against any rotational force and the greater tuberosity can be firmly fixed to the humeral head. In addition, a Kiintscher nail can be inserted as deeply as the subacromial without an impingement. Our method is useful in a bilateral case in which conservative therapy has been difficult. We also applied this method to the nonunion case.

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For the past 3 years, we have used the cannulated screw system of ACE Medical in the surgery of 26 shoulders (25 cases). These were 13 cases of modified Bristow's procedure for the recurrent anterior dislocation,2 cases of the coracoid transfer to the clavicle passing through the divided subscapular muscle for the multidirectional instability (Hanamura's procedure),5 cases of humeral proximal end fractures,1 case of the coracoid process fracture and 5 shoulders of 4 cases of rotator cuff tears. In the 5 shoulders of rotator cuff tear, the torn tendons were repaired through the transacromial approach, and then the osteotomized lateral fragment was displaced posteriorly about 1 to 1.5cm for a subacromial decompression and then fixed with the cannulated screws. The retracted torn tendons were advanced and anchored by using this screw system in 2 shoulders.
The cannulated screw system allows for a precise and secure fixation of the bony fragments, which can be simply applied and also time saving for an operation. The other advantages are that a closed reduction and percutanous fixation can be performed with the minimal surgical damage and that the screw has no influence on MR imaging. Arthroscopic labrum repair seems to be the future application of the cannulated screw.

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We wish to report on our experiences of utilizing cannulated screws to transfer an osteotomized coracoid process easily. Eleven patients (11 males; age ranging from 16 to 47 years) who underwent a Bristow's modified procedure and Dewar's procedure were reviewed and followed-up for over four months postoperatively. The Operative procedure is as follows: An anterior incision of the shoulder joint above the coracoid process is made. The deltoid muscle is retracted to expose the conjoined tendon of the short head of the biceps and the coracobrachialis muscle. The coracoid process is osteotomized with a curved osteotome from an anteromedial to a superolateral direction. The osteotomized coracoid tip with its attached muscles is retracted down and medially. The fascia that fans out from the conjoint tendons is divided. Vigorous retraction of the conjoined tendon distally can injure the musculocutaneous nerve. Then a guide wire is drilled into the best position, where the coracoid tip is to be attached. The cannulated screw is placed through the predrilled coracoid tip. The the coracoid tip is fixed with the cannulated screw through a guide wire.
All of the cases recovered well postoperatively, and none of the patients had an apprehension or subluxation. The osteotomized coracoid process was fixed more tightly and easily using cannulated screws rather than conventinal screws. Few complications occurred.
The cannulated screw has benefits as it is an easy procedure for an osteotomized coracoid process transfer. Moreover, the coracoid process is transfered to an accurate position tightly by using the cannulated screw system. Since positive postoperatively, this procedure is especially recommended.

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Our report is of three cases of old anterior dislocation of the shoulder. All the cases were treated conservatively. Nevertheless they had good function of the shoulder.
Case 1. A woman, aged seventy-six years, incurred and susutained a dislocation of the right shoulder three years before. On her first visit to us, she had no pain, nearly normal elevation and full use of her shoulder.
Case 2. A woman, aged seventy-three years, incurred a dislocation of her bilateral shoulders two years before. Four months after closed reductions, she underwent repair of the rotator cuff tear of her right shoulder. Five months after the operation, she visited us because of marked loss of motion. Roentogenograms showed a dislocation of her right shoulder, which manual reduction proved unsuccessful. However, her function improved with only physical therapy.
Case 3. A woman, aged seventy-four years, incurred and sustained a dislocation of her left shoulder with an ipsilateral finger-contracture nine months before. The functions of both her shoulder and fingers got better with physical therapy only.

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We experienced five cases of habitual posterior dislocation of the shoulder joint. All the cases were male and in the dominant hand. The age at the time of the first dislocation ranged from 14 to 22 years. Three cases had no episode of trauma but two had minor ones. The three cases with no episode of trauma had general joint laxity. When they elevated their shoulder at 90 degrees in the internal position, the shoulder dislocated posteriorly. One case had voluntarism. One case had posterior instability and four cases had multi-directionaly instability. On the CT arthrograms, laxity of the posterior capsule was observed in all the cases, and retroversion and hypoplasia of the glenoid in two cases. We performed both a posterior glenoplasty (Scott) and a posterior inferior capsular shift on four cases. At the operation, laxity of the posterior capsule and the infraspinatus tendon were seen in all the cases except these of posterior Bankart lesions. Two years after the operations, there were no recurrences recognized. The results of this operation were satisfactory.

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We have treated several patients who complained of posterior voluntary subluxation of the shoulder. The purpose of this study was to report the outcome of these patients treated with a capsulorrhaphy and bone block.
Three men in their twenties have been followed-up for more than two years since our surgical treatment. One nineteen-year-old woman was just operated on recently. A new posterior approach between the deltoid and triceps lateral head with the arm elevated more than 100 degrees at nearly zero position was selected. This posterior approach to the shoulder is a new one, which we could not find in any textbook. We have tried this approach seven times and have not experienced any damage to either the deltoid muscle or the axillary nerve. This approach is much easier than the deltoid splitting one.
All the patients now have no subluxations, but one patient still complains of slight motion pain and dysfunction of the arm. They were evaluated by the J.O. A. Shoulder Score. The final total scores were 95 95 95 and 82. All the patients are satisfied with our surgical treatment.
We conclude that this new approach is a reasonable way to operate a posterior aspect of the shoulder, especially after an arthroscopy. Our choice to treat these posterior voluntaty subluxation patients of the shoulder with a capsulorrhaphy and bone block seems to be appropriate, now.

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The purpose of this study is to estimate the unstable shoulder with the radiographic technique “Scapula-45”.
56 cases with recurrent anterior dislocation and subluxation of the shoulder and 17 cases with loose shoulder were studied. All cases were estimated with the Scapula-45.
53% of cases with a dislocation and subluxation showed upward displacement of the humeral head at the 45° elevated position. All the cases with a loose shoulder showed a downward displacement of the humeral head with the arm at their side, but 82% of them showed an upward displacement at the 45° elevated position. We selected the “Cuff-Y exercise”to suit each case with an IEMG. With exercise, the humeral head clearly adapted to the glenoid at 45° elevation and the symptoms improved. Further more, the asymptomatic unstable shoulder demonstrated the humeral head had adapted to the glenoid at 45° elevation.
From these results, both indexes of each series of radiograms were parallel to the clinical symptoms and sings. Our original radiographic technique named the “Scapula-45” was a useful method of estimating the shoulder function, objectively.

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The purpose of this study is to evaluate the classification of Bankart lesion on CTA images before arthroscopic surgery.
CTAs and arthroscopes were performed on 18 shoulders (14 males and 4 females, age 15-41, mean 23). The arthroscopic findings were evaluated with Yoned's classification. Two shoulders were clasified as Type 1 Bankart lesion,11 shoulders as Type 2 and 5 as Type 3, respectively. The authors proposed a new classification of Bankart lesion on CTA images as follows; articular surface of the glenoid as Area A (A-0; nothing, A-1; irregularity of the surface, A-2; defect of the surface), IGHL-labral complex as Area B (B -0; nothing, B -1; capsular avulsion with a trigonal shadow, B-2; dotty shadow, B-3; band-like shadow), scapular neck as Area C (C-0; nothing, c-1: bare neck, C-2; displacement of the trigonal shadow) and ossified glenoid as Area D (D-0; nothing, D - 1; fracture of the glenoid rim). The CTA findings were discussed and related to their arthroscopic classifications. Type 1 had the following findings; A-1 (1 shoulder) and D-1(1), Type 2 had A-1 (3 shoulders), A-2(7), B-1(3), B-2(2), B-3(2), C-1(2) and D-1 (3) and Type 3 had A-2(4shoulders), B -3(2) and C-2(2). These results indicated that Type 1 had few findings on CTAs except for A-1 or D-1, B-1 or B-2 suggested Type 2 and Type 3 tended to demonstrate A-2. However, some of Type 2 also had A-2, it was difficult to diagnose Type 3 on CTA images.

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The subacromial bursa seems to be effected by the patological changes of its surrounding tissue because of its anatomical circumstances, and to induce some clinical findings.
We examined sixteen cases that had been operated for rotater cuff tears, and stanined the subacromialbursa obtained at the operation with hematoxylin eosin,. We compared the histopathological changes (papillarychanges, pseudostratification of the lining cell, proliferation of vessels, and hyalinization) with some aspects (age, preoperative duration, or pain, size of tear). Also we examined for the presence of an inflammation, too.
There was no significant correlation between age, preoperative duration, and size of tear to the histopathological changes. But in case with severe pain, a proliferation of vessels was found. There was only one case out of the sixteen with a slight inflammation, and there was no evidence of any inflammation in the others.

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Subacromial impingement includes such disorders as a cuff tear and an impingement syndrome (IS). This report is about the arthroscopic subacromial decompression (ASD) we performed on these patients, their results and indications.
Matenals & methods: 15 cases (10 males & 5 females) were treated with ASD according to Ellman's procedure. Their mean age was 51.3yrs old at surgery (range: 24-78). There were 4 cases of cuff tear with a history of trauma and 11 cases of IS. We examined them clinically with plain Xrays, anthrography and MR imaging, and evaluated the function of their shoulder acciording to the JOA score. Arthroscopy of the glenohumeral joint and the subacromial bursa was performed. Release of the coracoacromial ligament, and abrasion of the anterolateral undersurface of the acromion were done. The postoperative evaluation was carried out at 13.2 mo. mean (range: 2-32)after surgery.
Results & Discussion: The acromial shape was classified according to Bigliani; there were 7cases of both type II and III. Changes of the cuff of Neer's stage II was observed in 8 cases and stage III in 7 cases. The mean value of the JOA score was 70.1 before surgery and 87.0 after. The points on pain had especially improved. ASD is a useful procedure not only for young patients with IS but also for old patients suffering from a cuff tear. Our indications to operate ASD are four followings; a positive impingement sign, a positive block test, reserved cuff function and persistent disability in spite of conservtive treatment for at least 3 months. In addition, we suggest it shoulder be limited to old paients and/or those with less than moderate activity, who are suffering from a stage III of IS or a full-thickness cuff tear.

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[PURPSE] Shoulder arthrography is a simple diagnostic technique for shoulder disorders. We can perform this procedure even on outpatients immediately. Recently shoulder arthrography has been forgotten because of the development of CT-arthrography and MRIs. We experimented with a new technique of shoulder arthrography for a rotator cuff tear using 10% Amidotrizoate (urografin) low density contrast arthrography abbreviated as (LDC-A).
[MATERIALS and METHODS] The LDC medium was made with 3ml of 60% Amidotrizoate and 15ml of 0.5% lidocain. We performed this method on 50 cases of rotator cuff tear, anticipating the bounds of the tear preoperatively. We compared these bounds with the actual tear in open surgery. [RESULTS] 35 shoulders (70%) were well reflected in LDC-A,12 shoulders (24%) were generally, and 3 shoulders (6%) were unknown.
[CONCLUSION] We concluded that a low density contrast arthrography (LDC-A) technique was useful for a rotator cuff tear.

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We tried to clarify what kind of influence the infraspinatus and rotator intervals that are punctured at arthroscopic surgery. We have been performing arthroscopic procedures since 1990 on cases with shoulder disorders. We followed-up and examined by arthrograpy 28 shoulders in 26cases (10 men and 16 women). Their average age was 46.3 years, and the average follow-up term was one year. The postoperative cases were given a routine shoulder clinical examination and a single-arthrography. There were no cases with a rupture of the infraspinatus. Five of the 28shoulders (18%), however, had a rotator interval opening. The periods after surgery in those cases with a rotator interval opening were from 5 months to 28 months. We could not find a relationship between the opening of the rotator interval and the period after surgery. One of the 5 cases had mild pain. But the other 4 cases had almost no pain.
In the five cases (18%) after an arthroscopic procedure, the openings of the rotator interval were demonstrated by arthrography. But they did not have any serious symptoms or dysfunction in their routine daily activities.

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The purpose of this study is to evaluate the results of synovectomy with dialysis arthropathy in the shoulder, and discuss the indications for a synovectomy. We treated the six shoulders of 6patiens with dialysis arthropathy in the shoulder; 4 males and 2 females with the average age of 57years (range,48 to 67 years). The average preoperative period was 9 months and the follow-up period was from 6 months to 45 months (average: 20 months). The average period of hemodialysis was 14.3 years. Open synovectomy was performed on all shoulders. Hemiarthroplasty was performed on one shoulder, which had severe destruction of the humeral head. The operative findings, included severe synovitis of the subacromial bursa, a rotator interval and a long head of the biceps, which were found in all the shoulders. Rice-like body substances in the subacromial bursa and gleno-humeral joint were observed in almost all the shoulders. Complete rotator cuff tears were found in 4 shoulders, and fibrosis of the rotator cuff was found in all of the shoulders. The ROM and function had not improved in any of the cases, but pain score had improved from 4.2points preoperatively to 27.5 points postoperatively in the JOA SCORE, regardless of the operative findings and preoperative period. Open synovectomy was an effective treatment for those patients with dialysis arthropathy.

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(Purpose) The purpose of this study is to evaluate the clinical results of a surgical treatment for posterior shoulder instability, and to discuss the problems of the treatment.
(Patients) 11 patients with posterior shoulder instability treated surgically were reviewed retrospectively.8 of them were male and 3 were female. The mean age at operation was 17 years old (13-22), and the mean follow up after the surgical treatment was 36 months (12-61). The dominant side was treated in 7 patients and the non-dominant side was treated in 4 patients.7 of them had a traumatic episode. All had felt the shoulder pain and 9 had felt a shoulder instability before surgery.
(Surgical treatments) 5 patients were treated with Warren's method, and 3 patients were treated with Tibone's method,2 patients were treated with Neer's method, and the last patient was treated with an arthroscopic stapling technique.
(Methods of evaluation) The clinical results were evaluated about pain, a feeling of subluxation, instability, and post operative sports activities.
(Results) Regarding pain,3 of them felt pain in ADL,4 of them in sports, and 4 of them felt no pain. The feeling of subluxation had improved in 10 cases. In the case of intability,7 of them had improved.3 of the 8 patients who had played a sports before being injured returned to the same sports level, but one of them could not play the same sports.
(Conclusion) The clinical results of the operative treatment were evaluated postoperatively for 11 patients with posterior shoulder subluxation. The pain and feeling of subluxation had improved in almost all the patients.7 of the 11 (66%) had gained posterior stability, ant the rate of return to the same sports activity was 33%.

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We evaluated 27 shoulders (23 patients) that had posterior instability. Ten shoulders (10patients) of the 27 were treated surgically.
There were 12 male and 11 female patients. Nineteen patients were unilateral (dominant: 15, nondominant: 4) and four patients were bilateral involvements. The average age of the patients at the onset of the instability was 17.5 years (range,9 to 36 years). Seventeen shoulders had a recurrent posterior subluxation (when the arm was in flexion and internal rotation, subluxation occurred spontaneously). Three shoulders had a voluntary posterior subluxation (subluxation occurred by muscle contraction alone). Another three shoulders had a recurrent and voluntary posterior subluxation. The initiating cause of the instability was direct trauma or a motor vehicle accident in 5 patients and throwing or playing tennis in 2 patients. Eighteen of the 27 shoulders (66%) had an inferior instability.
In the 10 shoulders (10 patients: 5 male and 5 female) treated surgically, the average age at operation was 21.5 years (range,12 to 36 years), and average follow-up was 5.5 years (range,23months to 10 years). Scott's procedure was carried out in 7 patients, and Kuroda's procedure (two directional glenoplasty) was done in 3 patients.
Results. Three patients (30%) had a recurrence of posterior subluxation (2 of Scott's procedure and 1 of Kuroda's procedure). All these patients were female. The three recurrences occurred at 3years,1 year and 7 months postoperatively. After surgery, another two patients had an impingement syndrome and one patient had an anterior instability. Four patients had excellent results.

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The present study reviews cineradioarthrography of the shoulder following the surgical release of a frozen shoulder.
Fourteen patients who had undergone operative treatment of the frozen shoulder agreed to have a cineradiosrthrography. There were 8 men and 6 women with an average age of 55 years (range 40to 72). The operative procedure included dissection of the coracohumeral ligament and debridement of the rotator interval.
Most of post-operative cineradioarthographies demonstrated reconstitution of an axillary fold and normalization of the scapulohumeral rhythm. These patients have presented a marked improvement in the range of their shoulder motion. The over-all result of the surgical release for the frozen shoulder was satisfactory in thirteen patients (92.8%). The functional results were excellent in four patients, especially these without a subacromial adhesion following the operation.
Post-operative cineradioarthrography may be helpful in the evaluation of the success of the surgical release for a frozen shoulder.

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Arthrography is an indispensable means of examination, and at the same time, it can be effective clinically in the treatment of the shoulder disease. This study was carried out to clarify the effects of the joint distension in the shoulder disease, focused on the obliteration of the subscapuraris bursa. Materials and methods.
A mixture of 10cc contrast medium and 10cc 0.5% of Xylocaine solution is injected into the shoulder joint anteriorly. Under fluorescence, the shoulder joint is moved in all directions while the movement of the dye is carefully observed.
There were 3,792 joints whose arthrographic findings have been recorded on a video tape since 1982. The obliteration of the subscapuraris bursa could be seen in 1706 joints and the joint distension was produced in 639 joints (by fluid pressure 34%, rotation 16%, elevation in the scapular plane 18%, forced abduction and internal rotation 32%).
Results
Pain relief was attained in 69% with tendinitis,62% with RI lesion,39% with a painful and stiff shoulder,33% with tear of the rotator cuff (mainly incomplete tear and partially complete tear with adhesion) and 36% with the other cases.
Relief of symptoms was obtained in 63% of the joints within three months, but it decreased to 32% after three months. (p=0.0002)
There was no relationship between the sex and the age.
Conclusion Joint distension was a useful healing method for the shoulder disease.

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Purpose: This paper is to determine the factors that affect the outcome of manipulation for refractory contracture of the shoulder.
Methods: Fifty-five patients with refractory contracture of the shoulder underwent manipulation under general anesthesia. The average age at manipulation was 53.7 years (range 33-68 years). Thirty-five shoulders were primary contractures and 20 shoulders were secondary contratures after a trauma. The effects of the background parameters (age, sex, side, traumatic onset, occupation, duration of symptoms, previous treatment and complications) on the recovery period were analyzed using a multiple regression analysis.
Results: All the shoulders showed remarkable increases in the range of motion in all directions after manipulation (p <0.0001). The average recovery period was 5.3 months (range 1-18 months). The factors which significantly influenced the recovery period were the traumatic onset (p =0.0210), muscle strength (p =0.0001), and pain (p =0.0059). Among patients with refractory shoulder contracture, those with well-preserved muscle strength, little pain and without a major traumatic onset are the best candidates for manipulation.
Conclusions: Manipulation is an effective procedure for refractory contracture of the shoulder.

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(Purpose) This study was undertaken to elucidate the scapulothoracic rhythm in the unstable shoulder.
(Materials and methods) The subjects consisted of 30 shoulders in 30 cases diagnosed to have unstable shoulders and 30 healthy shoulders of both 30 volunteers. The subjects were asked to elevate their arms actively in the scapular plane and in the sitting position. The joint kinetics in the scapular view and the scapular Y view during the movement were recorded with an image intensifier and video recorder. From the records obtained, images were extracted at every 20°between 10° and 150°. The arm-trunk angle using an image analyzing system, and the change of the rotation angle between the glenoid and the lateral edge of the scapula were measured. The change of the abducted scapulothoracic angle and the scapular backward tilting angle were measured as well.
(Results) (1) The rotation degree in the lateral scapular edge of a normal shoulder is larger than that of an unstable shoulder in the degrees of arm-trunk angles at 110°,130° and 150°. (2) The increasing rate of rotation degree in the lateral scapular edge of the normal shoulder is larger than that of the unstable shoulder in the degrees of arm-trunk angles, from 50° to 110°. (3) The scapular backward tilting angle of the unstable shoulder is larger than that of the normal shoulder in the degrees of arm-trunk angles at 130° and 150°. (4) The increasing rate of the scapular backward tilting angle of the unstable shoulder is larger than that of the normal shoulder in the degrees of armtrunk angles, from 130° to 150°. There are no statical differences between unstable and normal shoulders in the scapular abduction angle and the glenoid rotation angle.
(Conclusion) We suggest that the less the scapular rotation is the more the backward tiling is, at more than 110° of the arm-trunk angle, in an unstable shoulder was caused by slipping phenomenon.

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Spontaneous recovery is recognized in some cases of atraumatic shoulder instability, however, it is impossible to follow-up all the cases without some drop-outs. By using the disparity in the age incidence of atraumatic shoulder instability, the incidence of spontaneous recovery can be estimated. From 1985 to 1993,5,967 patients (6,471 shoulders) visted the shoulder disorder clinic at Matsudo Orthopaedic Hospital. Among them,244 cases (434 shoulders) were diagnosed as atraumatic shoulder instability. The mean age was 19.9, ranging from 7 to 49-years-old. There were 96 male patients (175 shoulders) and 148 females (259 shoulders). To make the number of the mother group joints more than 100, the female cases were divided into 8 groups (less than 14 years old,14-16,17 19,20-22,23-28,29-34,35-40 and over 40's), and the males into 11 groups (less than 13,13-14,15-16,17 -18,19-20,21-24,25 -28,29-32,33 -36,37 -40 and over 40's). The highest incidence in female patients was 43.9% in the 14 to 16-year-old group, then it diminished gradually and decreased rapidly the over 34-year-olds. The peak incidence in the male patients was 25.3% in the 13 and 14-year-old group, then the incidence decreased rapidly and it was less than 10% in the group over 20-year-olds. The incidence of spontaneous recovery of atraumatic shoulder instability can be calculated using the simple formula [Disparity of age incidence] x [Number of the mother group] [Number of atraumatic shoulder instability]. In female patients between the age of 14 and 16-years-old, it was considered to be 13.6% in 3 years and 26.9% in 6 years. In 17 and 19-year-olds, it was 15.4% in 3years and 44.1% in 6 years. In male patients aged 13 and 14 years old, it was considered to be 33.9%in 2 years and 54% in 4 years. In the 15 and 16-year-old group, it was 30.3% in 2 years and 34.5% in 4 years. In the 17 and 18-year-old group, it was 45.3% in 4 years.

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The strengthening of rotator muscles and scapula muscles was effective and useful for multidirectional instability of the shoulder. However, in some cases, they were unable to execute the exercises because of pain, disabling instability or paresthesia in the involved extremity. The purpose of our report is to provide additional information concerning physical therapy for multidirectional instability. Thirty-four patients (53 shoulders) diagnosed as multidirectional instability had been managed coservatively between 1991 and 1993. There were 8 men and 26women with a mean age of 21 years (range 10 to 46 years). The patients exercised for 6 to 8 weeks using a scapula stabilizing band. The peak torque of the internal and external rotator muscles was measured using an isokinetic machine before and after the exercise program. The results were evaluated by a modified Rowe's grading system. All the patients were able to execute the exercise program. In 45 (84.9%) shoulders, the signs and symptoms had improved clinically. The muscular strength had increased more than 20 % in 66.7% of the shoulders. In these cases,93.8% of the shoulders responded to the exercises. Using a scapula stabilizing band, patients who have multidirectional instability of the shoulder can carry out muscular strengthening exercises effectively without any pain or disabling instability.

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Patients with inferior instability of the shoulder joint have been treated with a transfer of the pectoralis major muscle to the inferior angle of the scapula. The purpose of this study was to evaluate the long term prognosis of the results of this procedure.
Thirty-seven cases (43 shoulders) were treated with this procedure from 1975 to 1992.32 cases (37 shoulders) were examined. There were 12 males (14 shoulders) and 20 females (23 shoulders). The average age at the operation was 18 years (14 to 39 years). The follow-up period ranged from 1 to 16 years (average; 6 years 6 months).
The inferior instability of the shoulders were reduced in most of the cases within 5 years after the operation. However, a tendency of inferior instability increased after more than 5 years (average 10 years). Roentogenographic studies showed the improvement of the upward rotation angle of the scapula in most of the cases. After this operation, shoulder joint pain, the feeling of subluxation and dullness of the arm had almost disappeared, but the number of stiff shoulders had rather increased. So a patient whose main complaint is a stiff shoulder should be considered prior to an operation.
85% of the patients were satisfied with the operation, especially these patients with a voluntary dislocation, because of inability to dislocate their shoulders voluntarily.
Pectoralis major transfer is effective for the treatment of patients with inferior instability of the shoulder, whose chief compaint is shoulder pain or dullness of the arm, especially with an accompaning voluntary dislocation.

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Sixty-two shoulders in sixty cases (37 male & 23 females) who were operated on during the period from 1986 to 1992 were examined. The average age at onset was 17.7 y. o.. Trauma was the clue to onset in 55%, and a sport's activity in 76%. A past history of dislocation, subluxation or dead arm syndrome was present in 54 shoulders.7 cases had a long history of a voluntary dislocation. Instability examined without anesthesia was three-dimensional in 26 shoulders, twodimensional in 19 and one-dimensional in 11, where-as all of the shoulders had a two- or threedimensional instability with anesthesia. As for the surgical procedure, a capsule ranging from 1-3 o'clock to 6-9 o'clock was separated, and was sutured (ay.6.6 sutures) again to the glenoid rim or labrum. Forty-three shoulders were followed-up for an ay.29 mos.. Anterior apprehension was positive in 3 shoulders, and posterior in 1. The average limitation of R.O. M. was 8 degrees in elevation,13 in external rotation and one vertebra in internal rotation. One case complained of a resubluxation and one case of dead arm syndrome, and three complained of limitation in A. D. L.. Moreover, thirty patients, thirty-one shoulders operated on over three years ago, were interviewed. Three cases complained of resubluxation, one of dead arm syndrome, and three complained of limitation in A. D. L.. Of the 7 cases with unsatisfactory results,2 had violent trauma and one had the problems with the surgical technique. The other 4 cases had severe arthritic symptoms and a past history of voluntary dislocation bases on psychological disorder, but neither a Bankart's nor Hill-Sachs' lesion. In conclusion, this procedure is effective on most shoulders with symptomatic multidirectional instability. But its usefulness is questionable in cases with a severe arthritic symptom and a long history of voluntary dislocations.

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(Purpose) We investigated the usefulness and limitations of MR imaging for incomplete rotator cuff tears.
(Materials and Methods) 80 patients who had undergone shoulder MRIs before surgery were the subjects of this study. The average age was 39 (14 - 71) years. MRI was perfomed in three directions (oblique corona', oblique sagittal, transverse). Ti weighted images were obtained using a spin-echo sequence and T2 weighted images were obtained using a field-echo sequence. We diagnosed the complete rotator cuff tears by finding the full-thickness high-intensity area in the cuff and the incomplete rotator cuff tears by finding the partial high-intensity area in the cuff. The incomplete tears were classified into joint side tears, bursal side tears and intratendinous tears by the location of the high-intensity area in the cuff. All incomplete tears were classified by using Snyder's classification at the operation.
(Results and Discussion) Of the 80 patients,36 were diagnosed as incomplete rotator cuff tears at the time of surgery. Of these,14 out of the 27 joint-side tears,1 out of 6 the bursal side tear,1 out of the 3 intratendinous tear had been diagnosed correctly by an MRI before surgery. The diagnosis of bursal- side tears was difficult compared with that of joint side tears by MRI. In joint-side tears, the diagnosis of Al and A3 is more difficult than that of A2.
(Conclusion) MR imaging is useful for a joint-side tear but limited for bursal-side tear.

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