The purpose of this research was to clarify the causes of numbness and pain by traction of the upper limbs. We stretched the nerves in the upper limbs of rats by utilizing the flail of the shoulder girdle, and measured the blood flow of the brachial plexus and the median nerve. The model animals,32 wistar rats, were inserted with steel lines to the radius and ulna. These steel lines were drawn in the direction of a shoulder abduction of 80 degrees. A decrease and recovery of the blood flow were measured using the hydrogen gas clearance method.
The blood flow of the subepineural space in the brachial plexus decreases sharply in conditions with looseness of the plexus.
The blood flow of the intrafuniculuse in the brachial plexus decreases like a straight line in those states without looseness of the plexus. The blood flow of the subepineural space in the median nerve decrease like a straight line, too. The decrease rate of the subepineural space was sharper than that of the intrafuniculuse. As for the recovery rate, there was no significant difference in either site.
One of the factor that causes nervous and functional imbalance with a slight traction is a sharp reduction of the blood flow in the subepineural space of the brachial plexus.

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Purpose
Biceps labrum complex (BLC) lesions most commonly occur during sports activities in which the arm is frequently held in an overhead position. Among the available literature there are few histological studies about BLC. The purpose of this study was to demonstrate the anatomy of BLC and its attachment to the glenoid and to evaluate the results of our treatment for BLC lesions.
Materials and Methods
Anatomical Study: Sixty shoulders from 30 cadavers were studied. We recorded the appearance of the glenoid labrum and the LHB. Then, we removed the glenoid process from the scapula leaving all of the capsular insertion intact. Sections were each cut along the cornal plane and along the sagittal plane at 200-300 p m thickness on a rotary milling saw, and then ground to a 20 p m thickness. The sections were stained with Cole's hematoxylin and eosin and examined via light and polarized light microscopy.
Clinical Cases:
Thirty shoulders of 29 patients with BLC lesions underwent arthroscopic debridement of the superior labrum.
Results
Anatomical Study: The LHB inserted directly to the superior glenoid and its attachment extended to the middle of the posterior glenoid. The LHB was firmly attached to the superior glenoid from the edge of the glenoid rim. The attachment was gradually loose toward the middle of the posterior glenoid. The LHB was attached to a large surface of the glenoid.
Clinical Cases:
All patients were able to return to competitive sports.
Discussions
Based on our anatomical study, the LHB has a larger attachment area on the glenoid than had been previously reported. Therefore, we believe debridement of the superior labrum for BLC lesions preserves the LHB functions.

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肩関節唇は肉眼的にも部位によりその形態,付着様式に相違があり,反復性肩関節脱臼など種々の肩関節疾患と関連すると考える.今回我々は系統解剖用屍体よりの15肩を用いて,関節唇の形状と関節縁付着部の形態を観察し,特に割面での微細線維構築について検討した.光顕的に,関節唇は関節包と関節窩の間に存在する狭いバンドで,部位によりその形状や軟骨,骨性関節窩への付着に差が見られた.走査電顕による観察では肩関節唇は3層より成り,主に外力に対する緩衝機構の役割を持つと考えられた.

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An incomplete thickness tear of the supraspinatus tendon includes the on - going process to a complete tear. It is essential to clarify the normal fiber arrangements of the tendon to explain the progressive mechanism of an incomplete tear. We studied 24 cadaveric supraspinatus tendons stereoscopically and histologically to clarify their threedimensional fibrous structure and the correlation to the coracohumeral ligament and to the infraspinatus tendon. The thick fibers in the anterior portion of the supraspinatus tendon were compactly double - layered, superficial and deep layers, and gradually intertwined each other toward the insertion. The superficial fibers ran longitudinally and the deep fibers transversely or obliquely. The outermost thin transverse fibers, enveloping the entire tendon just like a lateral “U” toward the posterior direction, were continuous from the deep layer of the tendon itself. On the contrary, the thin fibers in the middle and posterior portions branched over and were partly interlaced with the infraspinatus tendon. They were also dispersed toward the insertion and were intervened by the infraspinatus tendon fibers at a right angle, especially in the critical portion. The deep layer and the joint capsule had little fibrous communication near the insertion. Therefore, in contrast with the compact structure in the anterior portion of the supraspinatus tendon, the dispersion and stratification in the critical portion appear to produce the intra-tendinous shear stress, which may partly explain its vulnerability.

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The pathogenesis of rotator cuff lesions of the shoulder is still controvertial. The authors investigated mechanoreceptors in the rotator cuff in order to claify the role of proprioceptors in the shoulder joint.
[Materials and Method]
Fifteen pieces of the rotator cuff were obtained at the time of surgery of four cases of partial thickness tears and eleven cases of full thickness tears of the rotator cuff.
The specimens were stained in bulk using Gairns' modified gold chloride stain. Then the sections were studied by microscope.
[Results and Discussion] The rotator cuff proved to have a neural network. There were four different types of mechanoreceptors identified in the rotator cuff. They were Pacinian corpuscles, Ruffini receptors, Golgi tendon organ-like receptors and free nerve endings. In the cases of massive complete rotator cuff tears, they decreased in number. Mechanoreceptors in the rotator cuff are thought to be related to the proprioception of the shoulder joint.

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Torn supraspinatus tendons are expected to have a healing ability like the flexor tendons'. Synthesis of procollagen α1 type I is one of the most important factors in tendon healing. In order to localize cells where type I procollagen synthesis is high in torn supraspinatus tendons, the in situ hybridization technique was applied. Proximal stumps of torn supraspinatus tendons were obtained, fixed in 10% buffered formalin, embedded in paraffin, and sectioned at 6 μ m. A 22 mer oligonucleotide probe was synthesized for sequences coding human procollagen α1 (I) messenger RNA (mRNA). The probe was labelled with digoxigenin, and the probe-mRNA hybrids were visualized enzymatically using NBT and BCIP as the substrate. With the probe, the procollagen α 1 (I) mRNA was clearly observed in the tenocytes, undifferentiated mesenchymal cells at the proximal edges of torn supraspinatus tendons which had ruptured less than 4 months before. In the torn supraspinatus tendons which had ruptured 4 months and more before surgery, the procollagenα1 (I) positive cells were detected at the bursal side of the tendon and near the intratendinous extension rather than the proximal edge. However, they were not consistently observed in the vicinity of the intratendinous extension and not clearly observed in the fibroblasts of the subacrominal bursa. Therefore, the torn supraspinatus tendons were supposed to have an intrinsic healing ability rather than an extrinsic form. As the intratendinous extension did not constantly have a healing ability, this kind of rupture should be debrided before suturing at time of operation.

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Purpose
The purpose of this study is to estimate the normal rotator cuff function with IEMG.
Methods
40s houlders of 20 normal cases were studied. We selected the muscles at each motion and estimated these functions with IEMG.
Results
The IEMG activity of the supraspinatus and trapezius muscles was shown with the arm at the side and these activities increased with the load. The IEMG actitity of the deltoidus, supraspinatus and trapezius muscles increased during elevation in the scapular plane. But the infraspinatus did not demonstrate any remarkable activity. The IEMG activity of the supraspinatus, deltoideus and biceps brachii muscles increased with the load at 45° elevated position in the scapula plane. The IEMG activity of the biceps brachii in external rotation was higher than that in the neutral position at 45° elevated position. The regression coefficients between the torque and IEMG activity of the supraspinatus, deltoideus and biceps brachii muscles were higher than the infraspinatus. The ratio of IEMG activity of the supraspinatus to deltoideus at 45 ° elevated position was almost 2: 1irrespective of the load. In these cases with shoulder disorder, the correlation of the IEMG between the supraspinatus and the deltoideus changed. We consider this condition is to be imbalance between the inner and outer muscles.

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The gleno-humeral rhythm in the raising of the arm is well known and very important in clinical practice. Where other movements of the arm are concerned, however, we have been likely to neglect the scapular motion because of the wide range and large freedom of the gleno-humeral motion and the difficulties in dealing with analyzing the scapular motion. Using X-ray computed tomography (CT), we have so far measured the degrees of spinal rotation and scapular inclination to the thorax, and found that the range of spinal rotation is only on average 24 degrees at the level between the sacrum and upper thoracic spines, and that the degree of adduction and abduction is on average 53 degrees. Thus, the importance of scapular motion has been suggested. The present study was performed to confirm the presence of gleno-humeral rhythm on the horizontal plane as well.
Method and result
Two healthy male subjects were requested to extend and flex their arms at the horizontal level to study the scapular motion associated with such motion of the arm by using the NAC VICON threedimensional computed motion analyzer. The scapular spine was marked with two K-wires inserted under local anesthesia. We found that the scapular as about from 40 to 50 degrees when the arm is moved horizontally from a maximally flexed position to a maximally extended position.
Discussion
When analyzing the upper extremities in other movements, other than raiing the arm in sports have been studied. In the majority of such studies, however, the scapular and clavicular motions have rarely been taken into account. We confirmed the presence of gleno-humeral rhythm during the horizontal motion of the arm. At present, we are further analyzing scapular and clavicular motion using this VICON computed analyzer in the throwing and various other motions.

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Accessory nerve pasly and long thoracic nerve palsy are common causes of a winged scapula. This study was designed to examine the three-dimensional movement of the scapula in them.
Six accessory nerve palsy patients and five long thoracic nerve palsy patients were examined.
The active arm elevation was allowed in both the sagittal and scapular planes. Eight points were determined as marking points of the spine, the sternum, the clavicle, the scapula and the humerus which were identified every thirty degrees. These were recorded on three VCRs. A threedimensional analysis system (ARIEL^TM) was employed. The affected and unaffected sides were measured before and after therapy, when possible.
In patients with accessory nerve palsy, the scapula (glenoid cavity) rotated downward (the downward rotation) in the early phase of arm elevation in the scapular plane. At the same time, the subscapular fossa tilted upward (the upward tilt) and the subscapular fossa tilted medially. In patients with long thoracic nerve palsy, on the other hand, the downward rotation and the upward tilt of the scapula were marked by a forward flexion. When the paralysis was restored, the scapular movement changed to a similar pattern to that of the unaffected side. This method is useful for the quantitative evaluation of the abnormality and the improvement of accessory nerve palsy and long thoracic nerve palsy.

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Although numerous reports on image analysis during pitching have been published, quite a few studies have established a clinically applicable method for image analysis. To identify the causes of “baseball shoulder” in clinical cases, it is essential to accurately assess shoulder movement during pitching. In this report, we analyzed the shoulder motion in pitching in cases of baseball players with Bennett's lesion.
The throwing motion was recorded in four amateur baseball players ranging in age from 18 to 28years. All the players had Bennett's lesion but pain had been relieved. The throwing motion was videotaped from two directions with high-speed video cameras. And the rotation of the upper arm was recorded from the shoulder with a small video camera. The recorded images were expressed on a spherical model. Using a telemeter-type electromyograph, the activity of the biceps muscle and the triceps muscle were measured during pitching. Analysis of the latitudinal, longitudinal and rotational, angles yielded the findings that each individual subject has his specific shoulder motion. There were no significant differences between the Bennett's lesion group and the control group. The electromyographic analysis showed the activity of the triceps muscle from the acceleration phase to the follow-through phase.

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The purpose of this study is to define the mechanical cause of the loose shoulder by using a twodimensional rigid body spring model. Mechanical models of the glenohumeral joint were formulated based on radiographic studies of normal shoulders and loose shoulders.
In O degree of abduction the mechanical stress of the lower end of the glenoid increased and the humeral head shifted to the inferomedial direction. In 30 to 90 degrees of abduction, the results of the loose shoulder were not so different from those of the normal shoulder. In 120 degrees of abduction, the mechanical stress at the lower portion of the glenoid increased and the humeral head tended to displace downward in the loose shoulder. In the late phase of abduction, the direction of the loading vector was on the lower portion of the glenoid and the humeral head tended to be displaced laterally from the glenoid.
In the loose shoulder, the glenoid rolling down mechanism deteriorated and the displacement of the humeral head outward from the inferior portion of the glenoid cavity was remarkable.

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Many baseball players experience shoulder pain. One of the causes of shoulder disorder is related to the instability of the shoulder joint. This condition was investigated and the relationship between shoulder joint instability and general joint laxity was examined.
(1) We interviewed and examined 68 university baseball players.
(2) Sixty-one (89.7%) of the patients had experienced shoulder pain. Particularly those players with more than ten years practice complained more than the others.
(3) We observed the tendency that the internal rotation of the throwing arm shoulder had decreased, and on the other hand the external rotation of the same side had increased.
(4) This suggested that there exist two types of instability of the shoulder joint. The first is attributable to general joint laxity and the second solely to a joint's laxity.
(5) Players with a greater range of rotation, especially in internal rotation, experienced instability of the shoulder joint.
(6) Manual examination can overlook a throwing arm shoulder's instability in players. There could possibly be more cases with this instability than is thought.

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We believe we become familiar with throwing arm for an accurate diagnosis. Physical examinations were performed on Seventy collegiate baseball players (31 pitchers and 39 position players). The rotation measurements were made with the patients supine and the shoulder at 90°abduction to eliminate the effect of scapulothoracic motion. They demonstrated 14° more external rotation and 18° less internal rotation compared with the nondominant shoulder. The anterior drawer test (ADT), posterior drawer test (PDT) and the Sulcus sign were carried out upright with the elbow at the side. The ADT was positive in 8 (11.4%), the PDT in 10 (14.3%), and the Scicus sign in 25 (35.7%). Hawkins's impingement sign was noted in 10 (14.3%).
Those players who showed a positive PDT had significant increases in their external rotations (20 degrees or more). On the other hand, those who showed positive impingement signs had significant decreases in their internal rotations compared with their nondominant shoulders.

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<Purpose> The purpose of this study was to investigate the strength of the glenoid labrum and capsule.
<Materials and method> 15 shoulders of fresh cadavers were used for this study.6 of them were the right side and the rest of the 9 were the left side. Their ages ranged from fifty-five to eightyeight years. There were 6 males and 3 females. We determined the anterior, inferior and posterior portion of the labrum and capsule as the 3,6 and 9 o'clock position, respectively. The labrum and capsle were cut in 5mm width pieces. After fixing the glenoid, each respective piece of labrum and capsule was strained. We measured the applied force which detached the labrum from the glenoid.
<Results> The 4 o'clock position was comparatively weaker than any other position, irrespective of the age or sex of the cadaver.
<Conclusion> We conclude that the anterior-inferior portion of the glenoid is weaker than any other portion.

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Purpose
The purpose of this study was to classify cuff dysfunctions concerned in variable shoulder disorders using roentgenograms, physical examinations, and EMGs.
Methods and methods
There were 200 randomly sampled cases with shoulder disorders out of 500 cases. They were diagnosed clinically from roentgenograms, physical examinations, and other techniques. They were also diagnosed functionally using the “Scapula-45” and EMGs. Treatment was selected based on the functional diagnosis.
Results
In group A, the cuff could not fully work because of a dysfunction of a surrounding structure in spite of normal cuff function, and in group B there was a true dysfunction of the cuff muscles. From the clinical results, it was important to choose a conservative or surgical treatment in order to exhibit good cuff function. Group A, consisted of apparent dysfunction of the rotator cuff, including scapulo-thoracic dysfunciton, anatomical damage of the cuff function such as Bankart's lesion, and severe inflammations. In group B, there was real cuff dysfunction, including imbalance between the inner muscles and outer muscles, decreased reaction of cuff function depending on the load, and full thickness cuff tears. Improvement of the cuff fuction, clinical signs and symptoms was a deciding factor in selecting treatment when the clinical results and the cuff function are not parallel, we should treat other structures such as the scapulo-thoracic or anatomical damage of stability of the shoulder joint. A remarkable improvement in the clinical results and functional diagnosis were due to the selection of treatment.
Conclusion
The rotator cuff is an important stabilizing mechanism in shoulder function. The functional diagnosis of the rotator cuff is significant in selecting proper treatment.

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The purpose of this study is to examine a correlation between the displacement the of glenohumeral joint and rotator cuff tear, and to clarify the mechanism of stabilizing pattern in the shoulder.
Forty-five cases (46 joints) of rotator cuff tears were evaluated. They were all identified during surgery. (27 shoulders with a massive tear, and 19 with full thickness tear of supraspinatus tendon)As a control,55 normal joints were used.
The subjects were examined with the humerus in external rotation and in neutral position. They were evaluated through a Scapular-Y view and axial view cineradiographically using a PIAS LA-500 system.
The centers of the humeral head had shifted to the supero-posterior position in many cases of cuff tear. Posterior migration was recognized at the neutral position. At 45 degrees external rotation, there were no significant differences between the cuff tear group and the control group. There was a correlation found between the degrees of displacement and the existence of joint contracture in massive tears.
These data suggest that the rotator cuff has a concentric force, which becomes a bony fulcrum at the acromion.

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We have reported the results of the treatment of 38 bone tumors (13 benign,14 malignant,5metastatic and 6 tumor-like conditions) and 30 soft tissue tumors (20 benign,8 malignant and 2metastatic) around the shoulder for the past 20 years. A marginal resection was performed on almost all benign bone tumors with no recurrences. There was a prosthetic replacement performed after the resection of one giant cell tumor. In the cases of malignant bone tumor, limb-salvage operations were performed on 4 chondrosarcomas, while a fore quarter amputation was needed in one extensive case. All four osteosarcomas which had occurred at the proximal humeri were dead within 2 years after the forequarter amputations. All benign soft tissue tumors, except 2 desmoids, had no recurrences after the marginal resections. Four malignant soft tissue tumors out of 8 cases with various pathologies died of pulmonary metastasis.
We also assessed the functions of the upper limbs of 3 bone tumors of the proximal humeri with prosthetic replacements after a wide resection, but without any deltoid or rotator cuff reconstructions. The functions of their upper limbs were poor with frail shoulders postoperatively. Thus, we conclude, that arthrodesis of the shoulder may be recommended for those cases with extensive bone resection with insufficient soft tissue reconstructions.

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Massive bone defects after excision of proximal humeral malignant bone tumors were reconstructed by using frozen or autoclaved allografts. The purpose of this study is to evaluate these postoperative results.
Reconstruction with an intercalary allograft and prosthesis was performed on five proximal humeral bone tumoirs. Two of these were men and three women, the age at operation was from 18to 42, and the average postoperative follow-up period was 22.8 months. One of the five was diagnosed as osteosarcoma, two a chondrosarcoma, and two as aggressive giant cell tumors. Wide resection or marginal excision with the soft tissues intact was perfonmed, and the remaining soft tissues were reattached to the allografts.
No local recurrences or prosthetic loosenings were evident, and the incorporation at the host graft junction was obtained 7 to 9 months after surgery. In Enneking's evaluation system, three cases were rated as good, one fair, and one poor. The JOA scores were from 40 to 77 points, with a mean 57 points, and the more intact the soft tissues remained, the higher the shoulder function was. Shoulder function after reconstruction was affected by the tumor's extent and the amount of soft tissues preserved. Reconstruction using an allograft with a prosthesis acts as a spacer in the preservation of the elbow and finger function, and is a viable attachement of the remaining muscles and tendons. Therefore, it seems to be more beneficial for the restoration of shoulder function than any other reconstruction procedures.

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The purpose of this report is to evaluate the results of treatment for fractures of the scapula with associated injuries. This study was composed of 123 patients (130 fractures). One hundred and seven were males and 16 were fenales. Their average age was 44.8 ranging from 3 to 84. The fractures were divided into four types as follows; scapular body: 54 cases, scapular neck: 40 cases, coracoid process: 18 cases, acromion or scapular spine: 18 cases. Seven cases had fractures in more than one location. Eighty-one of the 123 cases (66%) had assoceated injuries. Ninety-four cases were treated conservatively and 29 cases surgically. The results of the treatment were evaluated by the J.O.A.score.
The results of cases without any nerve injuries were judged as excellent (mean score of conservative cases: 92.3 points, surgical cases: 97.1 poinys). Cases with nerve injuries had poor results (mean score of the conservative cases: 80.3 points, surgical cases: 85.7 points).
An association between scapular fractures and fractures of the ribs is common. In those cases, a pneumothorax may not develop immediately after a traumatic episide, but it may occur after a few days. An acromioclavicular dislocation is apt to be associated with a fracture of the coracoid process, in which case, surgical treatment is indicated. A displaced fracture of the scapular neck associated with a clavicular fracture on the same side is unstable, in which case, surgical treatment is indicated. A rotator cuff tear is apt to be associated with a fracture of the scapular body or but it is often overlooked, Associated nerve injuries have a great inflvence on the results. It is important to examine an associated nerve imjury and to start rehabilitation as soon as possible. neck, very

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Purpose
This report is on the usefulness of ultrasonography in diagnosing a minimally displaced fracture of the greater tuberosity of the humerus.
Patients and methods
Since January 1993, we have diagnosed 10 patients with isolated and minimally displaced fractures of the greater tuberosity fo the humerus. Three of the patients were in their twenties, and 7patients were between 45 and 68 years old. Four patients were treated with initial immobilization and early motion. The others have no immobilization. We evaluated their radiograms and ultrasonograms (7.5MHz probe)
Results
Ultrasonography demonstrated this fracture as a discontinuity of the cortex medial to the greater tuberosity and one of the lateral to the bicipital groove. In six out of the 10 cases, fractures of the greater tuberosity were confirmed ultrasonographically, while radiographic evidence was not clear. In two cases, displacements had developed, while the arm had been suspended in a sling. They had pain on motion for 6 months. In these cases, ultrasonography revealed a large low echo area lateral to the biceps tendon initially and a subacromial impingement 3 months after the injury.
Conclusion
1) Some patients with an isolated and minimally displaced fracture of the greater tuberosity of the humerus could develop it further dispite wearing a sling, and a large low echo area lateral to the biceps tendon was revealed ultrasonographically in these cases.2) Ultrasonography was effective in diagnosing this fracture.

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We have treated proximal humeral fractures using Neer's prosthesis according to Neer's indication, and reviewed the results.
33 cases who were operated on from 1980 to 1993 were available for follow-up examination. These patients consisted of 1 male and 32 females, whose ages ranged from 47 to 88 years old (69years old on average). One anatomical neck fracture-dislocation, six 3-part fracture-dislocations, seven 4-part fractures and nineteen 4-part fracture-dislocations were classified according to Neer's system. The average period of time between injury and surgery was 9 days, and ranged from 1 day to 24 days, all prosthesis were inserted without cement. The follow-up term after operation ranged from 4 months to 12 years and 5 months (6 years and 8 months on average). They were evaluated with the Neer scoring system.
The results were excellent in 6 cases, satisfactory in 16 cases, unsatisfactory in 6 cases, while 5cases ended in failure. Relief of pain was favorable in almost all the cases, but the ROM of the external rotation was especially restricted in almost all the cases. The factors of failure results were advanced age above 70 years, late operation 2 weeks after injury, poor cooperation with rehabilitation due to dementia, axillary nerve palsy, loosening of the prosthesis due to osteoporosis and arthrosis of the glenoidal cavity.
Needless to say, rotator cuff repair and post-operative therapy are important. The most significant factors associated with the results are the post-operative immobilization position, arthrosis of the glenoidal cavity and bone atrophy of the humerus especially in older patients, and we should cope with these factors.

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Nineteen patient with displaced proximal fractures and fracture-dislocations underwent prosthetic arthroplastics from 1982 to 1993. The results of prosthetic arthroplasty in 15 patients on whom a follow-up study could be made more than one year after surgery were evaluated by the J. O. A. score.
These patients consisted of 4 males and 11 females whose age at operation ranged from 43 to 82years. The follow-up term after the operation ranged from one year and 2 mouths to 10 years and 6months. According to Neer's classification of these patients,3 elder patients had a 3-part fracturedislocation,10 patients had a 4-part fracture-dislocation and 2 elder patients had a non-union of the surgical neck. As for the inserted prosthesis, there were 12 Neer types and 3 PSS types.
The results of the prosthetic arthroplasties in 15 patients are as follows: excellent in 2, good in 5, fair 5 and poor in 3. The average of the total score was 76 points. A remakable relief of pain was observed with an average of 26 points. Function scored an average of 14 points and an improvement of ADL was obtained. However, while the improvement of ADL was obtained, the improvement of ROM was unsatisfactory with an average of 15 points. In the radiographic findings, the wear of the articular cartilage was observed in 4 patients (33%) operated upon with a Neer's prosthesis but none in those patients with a PSS prosthesis.
To improve the results of a prosthetic arthroplsty, the follwing are very important: (1) Early operation after injury, (2)Preservation of the anterior fibers of the deltoid, (3)Anchoring of the greater and lesser tuberosities, and (4)Early systematic rehabilitation.

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Purpose: Postoperative complications to prosthetic arthroplasties of the shoulder, using ceramic-toplastic glenohumeral units produced by us in 1973 and revised modular-typed units will be reported on here.
Methods: Prosthetic arthroplasties were performed on 40 fresh and 12 old fractures,6 osteoarthritis,16 rheumatoid arthritis,3 avascular necrosis, and 5 miscellaneous lesions.
Results: Infection ensued from one old and two fresh fractures, which had had their prostheses removed, resulting in flail shoulders. Dislocations occurred postoperatively in a neglected posterior one, a rheumatoid shoulder and an unstable shoulder. The former two required open reduction, while the latter was converted to an arthrodesis but was infected. Posterior dislocation after surgery for an old 4-part fracture was acceptable because there was slight pain. Broken pieces of wire fixing both tuberosities were surgically taken out in two out of seven cases. A migrating screw from an osteotomized coracoid process was removed. Breakage of the ceramic-made stems, subacromial impingement, ectopic ossification, pseudoarthrosis and reflex sympathetic dystrophy arose in 3,7,5,2,3, cases respectively but without need of surgery.
Conclusion: Old traumas and rheumatoid shoulders chiefly account for the complications, thirteen of which required surgery.

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A modified Dewar's method has been used for type 3 (Tossy's classification) acromioclavicular joint dislocation in 92 patients since 1979 in our department. This paper reviews the therapeutic results obtained by this method on our patients. The therapeutic results were evaluated using the evaluation criteria of Kawabe et al. in 55 patients who could be interviewed personally or by questionnaire. The therapeutic results were “good” or “excellent” in 45 of 47 fresh cases and 5 of 8old cases. The X-ray findings showed evidence of residual subluxation of several m m in about 30%of the patients, but the degree of subluxation did not necessarily correlate with the subjective complaints. Our method can be regarded as a useful treatment modality, because it produces stable therapeutic results and greatly satisfies patients.

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The presence of a Bankart's lesion in a recurrent dislocation of the shoulder is considered an important factor in the development of recurrent shoulder instability. We collected the data from direct observations of the Bankart's lesion intraoperatively to analyze the CT arthrogram findings. In this study, there were 38 patients (38 shoulders) treated for recurrent dislocation of the shoulder during the years 1987 through 1992. There were 32 men and six women and the average age of the patients at operation was 23.4 years old (range 14-43). Roentgenographic examination was done on all patients preoperatively.
Arthrography was done by the double-contrast method, using 2.5 ml 76% Amidotrizo Na meglumine and 2.5 ml 1% Lidocaine and 15 ml of air. An arthrogram with computed tomography (CT arthrogram) was used to show a Bankart's lesion.
There was a significant correlation between the extent of the Bankart's lesion determined by the CT arthrogram before operation and that of the glenoid labrum. The correlation between the condition of the glenoid cartilage and the extent of the Bankart's lesion was also calculated, but there was no significant correlation. The detachment and rupture of the joint capsule was observed in some CT arthrograms. It seems possible for a CT arthrogram to determine the extent of a Bankart's lesion before operation.

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The diagnostic capabilities of MRI to depict the Bankart lesion were evaluated by comparing the images with CT arthrograms (CTA) and arthroscopic findings.
Twenty-nine shoulders with traumatic anterior instability (TAI) including 26 recurrent cases and 19 shoulders without any complaints (control group) were imaged with T2^* sequences using either a 1.0 or 1.5 tesla superconductive MRI system (Shimadzu). A saline solution or xylocaine (infusion)had been injected in before imaging of 11 TAI and 10 control shoulders. Two shoulders were imaged within 14 days after a recent dislocation (early cases). Both a CT arthrography and an arthroscope were done subsequently in every TAI cases.
An MR arthrogram was obtained with an injected infusion (in 11 of the TAI cases and 10 control groups) or a joint effusion (in 2 early cases). The Bankart lesions were assessed based on two categories, such as the labral morphological changes (including types AL, AR, AF, DL, VL and VF)and the changes of the signal intensity (including types S and I) on the anterior labral portion. In the control group, the anterior labrum had few signals and a triangular outline. The MR arthrograms of the TAI group showed morphological changes in twelve of thirteen shoulders, which reflected well their arthroscopic findings, such as labral avulsion, fractures of glenoid edge, a vanishing labrum or a bony defect. The last one withour any abnormal changes on the MR arthrogram was arthroscopically confirmed to have no Bankart lesion. Abnormal signals were obtained only in front of the conventional MR images without an infusion or joint effusion, and none of them had morphological changes. On conventional MR images (16 shoulders), the arthroscopic findings could not be determined from the MR findings except in type AL (4 shoulders), AF (2 shoulders) and VF (1 shoulder). The CTA revealed bony chages well, but labral avulsion seemed more like vanishing labrum in 3 cases, a slight dent in 1 and normal in 1. Labral changes were pointed out more correctly on MR arthrogram than on CTAs. MRI, MR arthrograms in particular, were very useful for detecting the Bankart lesion.

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We investigated the use of MR imaging in the diagnosis of shoulder instability. Fifty-two patients who had symptoms and signs suggesting shoulder instability underwent MR imaging with and without intraarticular Gd-DTPA. Spin echo Ti-weighted images and FISP images were obtained in the axial plane in a 1.5-T MR system. Surgical findings of the glenoid labra were available in all the 52 patients. Labral tears were diagnosed in 40 out of the 52 patients. Labral tears were diagnosed in 40 out of the 52 by MR imaging.
Labral tears were surgically confirmed in 37 of the 40, but not in the other three. The labrum was diagnosed as being normal in 12 of the 52 by MR imaging. Detachment of the labra were surgically confirmed in two of the 12, but not found in the other 10. We believe MR imaging with intraaarticular Gd-DAPA could clearly visualyze labral tears.

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Purpose: To compare MR arthrographic images of Bankart's lesions with arthroscopic findings.
Patients and Methods: Twenty-Eight shoulders with recurrent anterior dislocation or subluxation and 3 shoulders with initial anterior dislocation were evaluated as a dislocation group. There were 26 males and 4 females with an average age of 23 years (range,14-44 years). Five normal volunteers were also evaluated as a control group. Ti weighted images in the transaxial plane were obtained afrer injecting 10ml of Gd-DTPA diluted by saline (1: 100). All the shoulders in the dislocation group underwent arthroscopic repair. The MR images were compared with the arthroscopic findings.
Results: The inferior glenohumeral ligament was detected as a cord-like structure separated from the capsule in 3 out of 5 normal shoulders, while it was detected as a structure attached to the capsule in dislocated shoulders. In the dislocation group, MR images of the labrum were classified into four: Grade 1, normal; Grade 2, labral tear or detachment; Grade 3, displaced labrum; Grade 4, no labrum detected.
MR arthrographic images of the labral lesions correlated significantly with the arthroscopic findings (r =0.664, p <0.0001).
Discussion: When performing arthroscopic repair of a Bankart's lesion, the detached labrum needs to be well identified. The results of this study indicate that the extent of the labral damage can be evaluated preoperatively using MR arthrography.
Conclusion: MR arthrography clearly visualizes a labral lesion, which is helpful in determining operative indications.

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In the present study, the recurrence fo traumatic anterior dislocation of the shoulder was investigated on the basis of the MR anthrogram obtained soon after injury.
After an intra-articular injection of Gd-DTPA, MR arthrography was performed on 32 shoulder joints.
The patients consisted of 25 males and 7 females ranging in age from 15 to 80 years, with an average age of 31.7 years. the period from injury to examination ranged from 8 to 29 days, with an average of 26.3 days. The Bankart lesions were assessed according to our grading system, as Types Na, Nb, 1a, 1b,2 and 3.
Five elderly patients, aged at least 60 years old, had no Bankart's lesions. However, they did have extensive Hill-Sachs lesions or rotator cuff tears. Twenty-five patients aged 15 to 37 years had positive Bankart lesions. Of these 25 patients,24 were classified as Type 1a and 1b.
From these findings we determined that the nature of shoulder joint damage at dislocation varies with age and that Bankart lesions is uncommon in the elderly.

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Patients with superior labrum injury have vague complaints such as elevation pain, instability, and a catching sensation in the shoulder. Definite diagnosis is quite difficult without arthroscopy and treatment is also difficult but has successfully been carried out, as descrebed below.
9 patients who had been diagnosed with superior labrum injury were the subjects of this study. The average age was 24.3 (16-31) years. Seven patients complained of pain on shoulder elevation,4, of a sensation of instabilety and 2, of a catching sensation. We were able to confirm the detachment of the superior labrum from the glenoid in five of the nine cases by pre-operative CT arthrogram.
Arthroscopic debridement was performed in 1 case, arthroscopic stapling in 2 cases, arthroscopic multiple suturing (Caspari's method) in 4 cases, and resection of a buckethandle tear in 2 cases. According to Synder's classification,1 case had type 1 SLAP lesion,6 had type 2, and 2 had type 3 at the operation. Elevation pain disappeared completely in 6 cases, the sensation of instability disappeared in 3 cases, and the click, in both cases. We believe that arthroscopic treatment is useful for a superior labrum injury.

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We wish to report the results of arthroscopic Bankart's suturing repair usign a Grasping Siticher System on 8 cases of recurrent anterior shoulder instability without signs of general ligamentous laxity.
This system was manufactured by the Arthrex company [Germany] and we advanced the inferior glenohumeral ligament complex to the previously abraded glenoid neck using a Cannulated Grasping Stitcher safely and the transglenoid suture was completed using a Percutaneous Knot Pusher. We reviewed 8 patients [6 males and 2 females, whose ages ranged from 16 to 28 years] and a follow-up period of more than one year postoperatively. After the operation, one patient felt some dull pain occasionally and one had recurrence of subluxasion. Postoperatively, the anterior apprehension sign was positive in one. The mean range of external rotation was 7° less than on the unenvolved side.
No complications occured in this series. We concluded that arthroscopic Bankart's repair [the Arthrex Grasping Stitcher System] was an effective procedure for a non-collision athlete.

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The authors evaluated the results of arthroscopic staple capsulorrhaphy (ASC) for initial traumatic anterior instability of the shoulder and discussed the problems of ASC.
This study involved 17 shoulders of 17 patients,13 males and 4 females, ranging in age from 13 to 42 years (mean 24 years), who were followed up for over 1 year after ASC had been performed for initial traumatic anterior instability. There were 12 patients with inital dislocations,5 initial subluxations,8 right shoulders,9 left shoulders and 8 of dominant shoulders.
The arthroscopic findings of the patients were categorized into 4 types and 2 subtypes in type 2, type 3 and type 4 according to Yoneda's classification. ASC using a ligamentous and capsular repair system (Instrument Maker Inc. ) was performed on patients with type 1, type 2 and type 3. Strict immobilization postoperatively was recommended for the first 3 weeks. At 3 to 12 months after surgery, arthoscopic re-examination and subsequent extraction of the staples were performed. We evaluated the results of this procedure on the JOA shoulder rating scale (JOA score). The postoperative follow-up period was 12 to 57 months (mean 25 months).
Positive apprehension sign persisted in 1 patient each of type 2n and 3a, accounted for 11.7% of all patients, and subluxation recurred postoperatively in 1 patient of type 2n, and accounted for 5.9%of all patients. The average point of JOA score was 91.4 postoperatively, there were 12 patients with over 90 points,3 with over 85 points and 2 with under 84 points. Twelve of the 17 patients who underwent an arhtroscopic re-examination showed repaired inferior gleno-humeral ligaments by arthroscopy with the 1 remaining patient showing an re-subluxation. The complications associated with this surgery included loosening of the staple in 1 patient and cutting out of the AIGHL in another.
We expect this procedure will prevent the recurrence of an initial dislocation and subluxation.

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The results of arthroscopic Bankart's suture repair (Craig Morgan's technique) are classified in this report. Fourteen patients who had recurrent anterior shoulder instability were treated operatively with arthroscopic Bankart's suture repair (Morgan's technique).10 patients were men and 4 patients were women, whose average age at operation was 23.5 years (range 17-36 years), and postoperative follow-up averaged 18.3 months(range 6-32 months). Our indications for an arthroscopic Bankart's suture repaire were: 1). The number of episodes of dislocation or subluxation are less than 10 times.2). There is no loss glenoid bone stock.3). The patients are relatively young.4). The patients are involved in neither a contact sport or hard labor.5). There is no multidirectional instability present. We performed Craig Morgan's technique (transglenoid absorbable suturing technique) depending on these indications.
At arthroscopy, it was noted that all 14 patients had a Bankart's lesion. A Hill-Sachs lesion was detected in 6 cases. All the cases had an anterior apprehension sign preoperatively. The preoperative JOA score was 81.4 points and improved 15 points up to 96.1 points postoperatively. After the operation, the apprehension sign disappeared in 12/14 cases. The recurrence rate was 1/14,7.1%. No complications (infections or neurologic injuries) occurred in this series.
Arthroscopic Bankart's suture technique proved to be a useful technique for recurrent anterior shoulder instability when performed according to the proper indications.

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Purpose: To determine the sporting activities, clinical features, and types of labral tears in patients responding well to the surgical treatment of glenoid labral tears.
Materials and methods: Thirty-three shoulders in 33 athletes who had no clinical positional instability of the glenohumerala joint were studied retrospectively. The mean age ata operation was 21.1 years (range: 14-48 years) and the mean duration of follow-up was 58 months (range: 2680 months). Nineteen patients (58%) had a history of major or minor trauma (sudden onset). Twenty-six patients were found to have a labral detachment,3 had a labral flap tear, and 4 had mixed lesions. The operative procedure was arthroscopic debridement of glenoid labral tears in 11patients and arthroscopic/open repair in 22 patients (stapling in 18 and suturing in 4).
Results: There was a significant improvement of symptoms in 70% of the patients. The success rates for repair of the anterior labral detachment and superior labral detachment were 88% and 75%, respectively. Patients with a history of trauma showed a relatively high success rate, while patients with throwing injuries generally had a poor outcome. From a review of individual cases, associated subcromial impingement syndrome, joint laxity, and asymptomatic small labral tears were considered to be the possible causes of failure.
Conclusion: Patients without a throwing shoulder, with a “ sudden onset” injyury, without glenohumeral joint laxity or subacromial impingement, and with a large labral tear can be expected to have a good outcome.

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Although recurrent subluxations are diagnosed with the presence of a marked self-reduction, there are still many vague points in the pathology of recurrent dislocation and subluxation. In this study, we examined the pathology of recurrent dislocation and subluxation.
We evaluated 21 joints with recurrent anterior dislocation and 33 joints with recurrent anterior subluxation, which had been examined as follows: physical findings, plain and stress X-ps, MRIs, arthroscopic findings, and findings at operation. In the dislocation group, the extent of the injury to the labrum was small, but the degree of the injury varied. In the subluxation group, a large injury to the labrum or an ossific Bankart was observed without any inferior instability, and a small detachment of the labrum with inferior instability was, too. The differences in the pathology of recurrent dislocation and subluxations were confirmed. We suggest that every the subluxation varies with every inferior instability.

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[Purpose] The purpose of this study was to evaluate the results of the Putti-Platt and a new modified method combined with the Bankart and the Bristow procedures.
[Patients and Methods] From 1986,35 Putti-Platt procedures,4 modified procedures combined with the Bankart and the Bristow methods and 2 Bankart's operations alone were performed.33 males and 6 females were involved. The ages ranged from 13 to 60 (avg.: 23.3). The follow-up period ranged from 6 to 39 months.
[Results] All the cases were evaluated as excellent. Postoperative scores ranged from 90 to 100points with an average of 97.0 points on the shoulder scoring system of the Japanese Orthopedic Association. In all the cases, no re-dislocation or subluxation had occurred for 12 months, postoperatively. At 12 and 13 months after the operation, however, a transient subluxation occurred in 2 competitive athletes. After 4 weeks fixation and rehabilitation, they could return to their original sports with a stable shoulder. Compared with the unaffected side, the range of external rotation at 90 abduction was limited with an average of 13.5 in the Putti-Platt group and 5.8of the modified procedures combined with a Bankart and Bristow method group.
[Conclusion] The results of the Putti-Platt procedures were evaluated as excellent. However, for competitive athletes in contact and throwing sports, a modified procedure combined with a Bankart and a Bristow method showed excellent results.

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We perfomed a modified Oudard-Iwahara-Yamamoto method on recurrent shoulder dislocations. This operation consists of grafting a bone chip of 5.5 × 1.5 × 1.5cm in to the coracoid and conjoint tendons. We observed the condition of the absorption of the grafted bone continuously.
There were 140 cases of which 89 were male (95 joints) and female (51 joints) examined. We measured the grafted bone in ratio with the length of the grafted bone to the glenoid. Their survival rate was calculated and comparied with the rate just after the opration as 100%.
The mean survival rate at 1 year was less than 75% in 77 joints, from 75% to 85% in 48 joints, and over 85% in 21 joints. Over a 2 year follow-up, there were fewer cases demonstrating progress of the absorptions.
The survival rate of a grafted bone using our modfied method was excellent compared to the original technique. We believe this surgical technique will act as a stabilizing mechanism for a long term.

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[Purpose] We measured the muscle strength of the shoulder in patients after a modified Bristow operation and compared it with the strength of the intact side.
[Subjects] The subjects were 14 right-handed men who underwent a modified Bristow operation and could be directly examined. The patients were 16 - 30 years old (mean 20.1) at the time of surgery.
[Methods] Internal and external rotator strength was measured in the standing position using a Cybex 340 to examine the following: 1) The angle of occurrence of the peak torque,2) the peak torque,3) maximum work, and 4) the ratios of the injured shoulder values to those of the intact shoulder. Twenty right-handed men,17-34 years old (mean 23.8), without shoulder disorders were used as the controls, and each measurement was performed 5 times.
[Results] The results of the Smirnoff-Grubbs rejection test confirmed that the measurements were reproducible. A peak internal rotation torque was observed slightly externally, and that of an external rotation was observed slightly internally. The peak torque of internal rotation was reduced 4 months postoperatively, and had not recovered to its preoperative value even 6 months postoperatively, however; it was greater than the preoperative value one year postoperatively. Since the subjects returned to their athletic activities 6 months postoperatively, the muscle strength was assumed to have been greater than its preoperative value at this point in time, however, this suggests that it is difficult to evaluate the time to return on the basis of muscle strength alone.
The peak external rotation torque was only slightly reduced 4 months postoperatively, and was still slightly greater than the preoperative value 6 months postoperatively. It became approximately the same as the the preoperative value one year postoperatively. There seemed to be only a slight postoperative influence on external rotator strength because of the absence of surgical stress on the muscle strength of an external rotation. [Conclusions] Measurements were performed on 20 healthy subjects, and their reproducibility was confirmed. The peak torque of internal rotation was observed slightly externally, while that of external rotation was observed slightly internally. The internal rotator strength was greater than the preoperative value and the value of the intact shoulder one year postoperatively. The muscle strength of external rotation was only slightly reduced after surgery.

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[Purpose] We investigated the micromovement of shoulder motion using cineradiography. The unstable shoulder demonstrated a skid slip, the causes of which we will report.
[Patients and Method] Ten healthy volunteers,10 recurrent anterior dislocations,10 rec. ant. subluxations and 10 loose shoulders were examined. Each cineradiogram measured the glenohumeral angle, the arm angle and the scapula angle. Then we studied our original X-Ray methods: [Scapula 45] and EMG activities.
[Results] The skid slip was present in the shoulder motion of unstable shoulders. In cases of poor scpula motion, the relative ratio between the suprasupinatus and the deltoid decreased. In the Fscpula45J, the cuff index that reflected the relative cuff function demonstrated the cuff dysfunction. After treatment, the skid slip disappeared from the shoulder motion and the cuff function improved.
[Conclusion] The mechanical stress of a skid slip seems to be factor of symptoms. The skid slip is caused by a relative dysfunction of the cuff miscle and the scapula motion.

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[Purpose]
Shoulder disorders caused by multi-directional instability of the shoulder joint are common in the young, but rare in the elderly (over 50 years old). The purpose of this study was to define the clinical features of the elderly cases.
[Patients and Clinical Findings]
There were 6 cases (over 50years old) with shoulder disorders caused by multi-directional instability of the shoulder.3 males and 3 females were involved. The average age was 58.3 years (range: 50-74).
No cuff tears were present in the arthrographies and/or arthroscopies in any of the cases. Two cases had symptoms of cuff tendinitis with a positive impingement sign. The other 4 cases had symptoms and signs of a shoulder contracture on one side. Three of them had severe contractures (frozen shoulders).
[Treatment and Results]
All the cases with multi-directional instability of the shoulder joint were treated conservatively (muscular strengthening exercises etc.). Two cases with cuff tendinitis, one with mild shoulder contracture and one with a frozen shoulder recovered conservatively. Two cases with a frozen shoulder in the other side were treated with arthroscopic synovectomy and manipulation. After treatment, the range of motion of the shoulder joints improved, but recurred the instability and its symptoms recurred.
[Conclusion]The clinical features of elderly cases with multi-directional instability of the shoulder joints were different from those of young cases. Few young cases have symptoms and signs of shoulder contracture, but the elderly have many.

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