The holmium YAG laser (Ho: YAG) has the ability to coagulate, to ablate and to resect both soft tissue and bone by one handpiece and its effect on arthroscopic subacromial decompression (ASD) was investigated. ASD was performed on five patients with a rotator cuff tear using the said Ho: YAG. Their mean age at surgery was 60 years. The arthroscope was inserted to the subacromial bursa and debridement of the ruptured rotator cuff, release of the coracoacromial ligament and resection of the anterolateral undersurface of the acromion were done using a Ho: YAG. The postoperative follow-up period averaged 7 months. The Ho: YAG was noted to be quite effective for the control of bleeding without need of vasoconstrictive irrigation fluids. The shoulder score evaluated by the Japanese Orthopaedic Association shoulder scoring system was averaged to be 69 before surgery and 85 after. ASD with a Ho: YAG was concluded to be a treatment of choice for a rotator cuff tear.
We have treated dialysis arthropathy by arthroscopic debridement (AD) in the following cases: (1) patients whose shoulder arthralgia was severe even at rest, and caused impairment in sleeping and (2) patients whose shoulder arthralgia during dialysis was so severe that dialysis could not be fully accomplished. AD was performed on 13 shoulders of 10 patients (2 shoulders of a male and 11 shoulders of 9females). The ages of the patients ranged from 47 to 78 years (mean: 59.1). The period from the start of dialysis to surgery ranged from 14to 21 years (mean: 16.6). Plain X-rays revealed small cystic lesions of the humeral head in all cases. In all cases, arthrography disclosed marked irregularities on the articular surface, suggesting synovitis, and the T2 weighted MRI showed fluid accumulation in the joint and the SAB. Intra articular and SAB debridement were carried out. After AD, the pain during dealysis disappeared completely in all cases, and nocturnal pain disappeared almost completely, allowing the patients to sleep well at night. The average JOA score for all cases, which was 65.5before surgery, was 84.5 after, when assessed 1-13 months (mean: 5.6)after surgery. AD for the treatmrnt of dialysis shoulder yielded good results. The patients were highly satisfied with the surgical results. Since AD does not cause great stress, it is especially appropriate for patients on hemodialysis, because they are susceptible to infection and their wounds take a long time to heal. Another great advantage of this surgery lies in that it can be repeated years later. Patients on chronic hemodialysis who complain of shoulder pain will enjoy great benefits from this surgery.
We evaluated the usefulness of an arthroscopic debridement of superior glenoid labral tears. 15patients were treated by arthroscopic debridement of superior labral lesions. There were 12 males and 3 females. The average age at the time of surgery was 19. 9 years, with a range from 14 to 31years old. All the cases were injured in sport's activities and 4 cases had a history of major or minor trauma. We excluded the cases which had a clinical joint instability or other lesions in the gleno-humeral j joint. 13cases had Snyder's type 2 lesion and 2 cases had a type 3 lesion. 9 cases had significant symptomatic relief and returned to their sports. However, 6 cases had remaining symtoms and 2 of the 6 cases had required an additional subacromial decompression. A superior glenoid labral tear is diagnosed by arthroscopy. It is difficult to explain how the lesion affected the symtom. Wesuspect from our results that an arthroscopic debridement is not a good enough treatment.
To clarify the clinical effectiveness of arthroscopic treatment for painful Bennett lesions, we retrospectively studied 6 baseball players. None of them responded to conservative treatment and the mean duration of symptoms before operation was 28 months (12-36). The mean age at operation was 26 years (17-42) and the mean follow-up period was 23 months (12-36). The only consistent physical finding was tenderness over the posteroinferior glenoid region. Posterior pain on forced forward elevation and on forced abduction/external rotation of the shoulder was observed in 3 patients each. Two patients had slight posterior and inferior laxity. The local anesthetic throwing test under fluoroscopic control was performed in all patients before arthroscopy. After this test, all the patients could throw with significant pain relief. Bulging of the posteroinferior glenoid labrum was observed in all the patients arthroscopically. All the patients underwent arthroscopic removal of the Bennett lesion. In the last 3 patients, we performed a reattachment of the glenoid labrum using suture anchors or a capsular repair by the suture punch technique. Associated lesions were detachment of the superior glenoid labrum in 3 cases and an articular-side partial rotator cuff tear in two. These lesions were partially debrided. At 2-3 months, throwing was started and a return to preinjury or vigorous throwing activity was allowed at 6 months. At follow-up, all the patients noted a reduction of both tenderness and throwing pain, but pain-free throwing was achieved in 4 only. All the patients could continue to play baseball, and 5 of them returned to their preinjury performance level. Therefore, the overall success rate was 83% (5/6). Thus, arthroscopic treatment of painful Bennett lesions achieves a successful outcome. In addition, a positive local anesthetic throwing test is a good indication for this procedure.
The purpose of this study is to analyses the three dimensional movement of the glenoid and the gleno-humeral joint in the habitual posterior dislocation of the shoulder. 5 male and 6 female patients with habitual posterior dislocation were examined. The magnetic sensor system was used for measuring. The magnetic field generating source was fixed to the sternum, and sensors were fixed to the lateral epicondyle of the humerus and to the spina scapulae. Elevation was measured in the sagittal plane, the scapular plane and the frontal plane. The elevation time was 5 seconds. The gleno-humeral joint with inferior instability decreased in the elevation angle at the initial stage of movement. The glenoid in the sagittal plane did not face the plane of flexion during the initial 90°. Incoordination of the scapula and the humerus was one of the causes of posterior shoulder instability.
Introduction Traumatic posterior dislocation and fracture-dislocation of the shoulder joint are rare, and when they are overlooked, treatmetn is very difficult. We wish to present 4 cases surgically treated, who obtained good results. Materials and Methods The subjects were 1 dislocation case and 3 fracture-dislocation cases. All the cases were male and their ages ranged from 20 to 29 years. The cause of injury were traffic accidents in all the cases. The fracture-dislocation were all 2-part fractures in Neer's classification. One dislocation and 1 fracture-dislocation case were manually reduced. Two fracture-dislocation cases underwent osteosynthesis 6 or 11 days after the injury. As 1 fracture-dislocation was overlooked, he underwent open reduction and osteosynthesis 40 days after the injury. One dislocation case felt apprehension of the shoulder movement, so that he underwent a glenoid osteotomy. The follow-up period ranged from 8 to 43months. Results The postoperative JOA score ranged from 90 to 100 points. The radiographies showed no abnormal signs. As the prognosis of an old case with a long time follow-up is uncertain, we would like to emphasize that early diagnosis and treatment are important.
To clarify the usefulness of our method of treatment consisting of either manual or open reduction of a dislocation without O. R. I. F. of fractures followed by early physiotherapy, clinical cases were analyzed. The subjects were eleven shoulders of eleven cases (eight men, three women)treated in the past twelve years, whose ages ranged from 20 to 53 y. o.. Their clinical findings, treatment course and functional results were investigated. The cause of their injuries was a traffic accident for eight cases, a fall for two and an epileptic cnvulsion for one. They were one 1-p. fx., six 2-p. fx. and four 3-p. fx. according to Neer's classification. In seven cases, diagnosis was delayed, ranging from 3 to 23 days. Reduction was obtained by persistent traction in one case, by manual traction in two and by an operation in eight. After the reduction, all but one fragment had not been displaced over 10mm. In one of the 10 cases followed over 1 year, the collapse of the humeral head caused by aseptic necrosis developed. The other cases gained excellent recovery of their joint function. In conclusion, the proposed method of treatment is advantageous in that it produces stable satisfactory results without further destroying the gliding mechanism and disturbing the blood supply, unless the fractured humeral head is completely displaced.
Purpose Early rehabilitation for rotator cuff repair is necessary to prevent joint contracture, muscle atrophy or reflex sympathetic dystrophy. Recently, we carried out early rehabilitation under cervical continuous epidural anesthesia (CCEA). The purpose of this study is to evaluate the value of CCEA on rotator cuff repair. Materials and Methods 39 patients were operated on without CCEA (group non-CCEA). They consisted of 25 males and 14 females whose average age was 60.6 years. At the operation, we found complete tears of the rotator cuff in 32 cases and incomplete tears in 7 cases.19 patients were operated on under CCEA (group CCEA). They consisted of 14 males and 5 females whose average age was 61.8 years. At the operation, we found complete tears of rotator cuff in 14 cases and incomplete tears in 5 cases. These two groups were examined and evaluated by the Japanese Orthopaedic Association (JOA)score before surgery,3 months after surgery and 6 months after surgery. Results Before surgery, the average JOA score was 58.1 for group non-CCEA and 56.5 for group CCEA. At 3 months after surgery, the average JOA score was 76.5 for group non-CCEA and 83.6 for group CCEA. At 6 months after surgery, the average JOA score was 89.7 for group non-CCEA and 92.1 for group CCEA. Conclusion CCEA facilitates an early rehabilitation for rotator cuff repair. As a result, the rehabilitation period gets shorter and good results are obtained earlier.
The purpose of this study is to investigate the joint position sense of the shoulder in groups of patients with rotator cuff tears and normal individuals. Materials and Method This study group consisted of twenty patients with rotator cuff tears, proved by arthrography. Their mean age was 63.4 years. Twenty normal healthy male volunteers were chosen as controls. Their mean age was 25.4 years. The position sense was tested by setting the upper limb at the 45 or 90-degree-abductedp osition. When the abductedp ositionw as reached, the subjectw as blindfoldeda nd asked to concentrate on this position. The upper limb was left in the tested position for five seconds. A first photograph was taken from the back with a fixed camera. Returning to the starting position, t he subject reproducedt he arm at the 45(90) degrees abducted position. A second photograph was taken from the back. This process was repeated three times on bilateral shoulders of all the subjects. The differences between the first and the second abducted positions of the upperlimb were measured on the photographs. Results and Discussion There was a signficant correlation between the affected side of the rotator cuff tear group and the control group at the 45-degree-abductedp osition (p<0.001). But at the 90 degree-abducted position, there was no significant difference. In cases of rotator cuff tear, the proprioceptivei nformationw as thought to be disturbed.
The diagnostic value of ultrasonography for rotator cuff tears is still controversial. This study is a prospective evaluation of the clinical usefulness of shoulder sonography. One hundred and thirteen patients suspected of having rotator cuff tears underwent sonography of their shoulders before arthrography and then underwent surgery. Three different ultrasonographic machines were used with a 7.5 MHz transducer. In twenty-nine of thirty-five patients with a complete rotator cuff tear (82.3%), signs of rotator cuff tear were detected ultrasonographically. The sensitivity of one system was significantly lower than that of the others. In nineteen patients with a partial cuff tear, three of nine with a bursal side tear, three of five with an intratendinous tear and three of five with an articular side tear were revealed. One machine was not available to detect incomplete rotator cuff tears. Six of fifty-nine cases without a rotator cuff tear were false positive. There were no significant differences on the false positive among the three machines used. To make a more accurate diagnosis of a rotator cuff tear ultrasonographically, an adequate machine, as well as considerable experience seem to be needed.
Purpose We studied the relation between the morphological findings of the supraspinatus muscle on MRI and its elongation length in order to evaluate the elasticity of the atrophic supraspinatus muscle in a patient with a cuff tear. Materials and Methods Twenty 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, which was termed“Supraspinatus Muscle Belly Ratio”and abbreviated it as “SMBR”. We classified the appearance of a linear band and the degree of the retracted tendon fiber in the supraspinatus muscle into three grades. Thus we compared the elongation length of the supraspinatus muscle at surgery with the length of cuff defect, “SMBR” and their morphological grades. Results The elongation length had a negative correlation with the degree of retracted tendon fiber but no correlation with the length of cuff defect, SMBR and appearance of linear band. Conclusion We could evaluate the elasticity of the supraspinatus muscle in patients with a cuff tear by analyzing the degree of retracted tendon fiber on MRI.
Purpose To semiquantify synovial changes in painful shoulder lesions using dynamic magnetic resonance imaging. Patients and Methods Patients with full-thickness rotator cuff tear (n=13), frozen shoulder (n=18) and subacromial impingement syndrome (n=8) were studied together with healthy volunteers (n=3). All the patients gave informed consent before the imaging. Using a 1.5-tesla MR unit, gradient echo images (TR 45-50ms/TE 9-10ms, flip angle 40-50) of the shoulder were acquired in the scapular plane before and after intravenous administration of Gd-DTPA (0.1mmol/kg). The enhancement ratio was calculated in the glenohumeral joint (GHJ) and the subacromial bursa (SAB). Results The enhacement ratio in cuff tear and in frozen shoulder was significantly greater than that of normal shoulders. The GHJ and SAB were nearly equally enhanced in the shoulders with torn cuff, while frozen shoulder showed greater enhancement in GHJ than in SAB. Subacromial impingement syndrome showed greater enhacement in SAB, although the data varied among the shoulders examined. Conclusion Dynamic MR imaging substantiates the regional variety in synovial changes in shoulder joint disorders.
The diagnostic value of MRI for the incomplete rotator cuff tears is still controversial. We assessed the effectiveness of MRI in surgical cases. Twenty-four cases of incomplete cuff tears including 13 joint sides,9 bursal sides and 2intratendinous tears were confirmed at surgery. T1-and T2-weighted images of these patients obtained preoperatively, the oblique coronal and sagittal planes in 1.5T MR system, were compared retrospectively with the surgical findings. In 13 joint side tears, high signal lesions on T2 were present in 8 and slightly increased signal lesions were found in 5. In 9 bursal side tears, high signal lesions were evident in 2, while they were not recognized in 3 cases which were classified as grade 1 lesions of Ozaki. High signal lesions were found in all 2 intratendinous tears. In order to detect incomplete rotator cuff tears on MR imaging, it is necessary that the tears penetrate into the tendons more than half of their depth.
Previously only a few cases of isolated subscapularis tendon rupture have been reported on. The prupose of this study is to clarify the clinical features of this tendon injuty. Six shoulders (only male, age 46-57, average 50, right 4, left 2) were examined. The mechanism of the injury, the imaging studies, the operative findings and the clinical results (JOA score) were evaluated. The mechanism of the injury was direct force on the tendon in two patients, excessive extensionexternal rotation in two, eccentric contraction in one, and the contusion on the back of the shoulder in one. On ultrasonogram the rupture was observed in three patients. An abnormal pooling of medium in the subscapular bursa was observed in three patients on scapular Y view of the arthrogram. CT-arthrogram, MR imaging, and arthroscopy revealed the rupture respectively. The subscapularis tendons degenerated in all the patients. The ruptured tendons were repaired using a pull-out technique in all the patients. In one patient the clavicular part of the pectoris major was translated. The dislocations of the tendon of the long head of the biceps were associated with the rupture in three patients. These were reduced in two patients and we performed a tenodesis on one. The case of tenodesis needed a reoperation. The average JAO score was 75.2 points preoperatively and improved to 87.7 points postoperatively. It is difficult to determine a definitive diagnosis, but this surgical repair provided a good clinical outcome. The degeneration of the tendon, observed in all the patients, was suggested to be impingment between the lesser tuberosity and the coracoid process.
Purpose: The purpose of this study was to investigate the results of arthroscopically assisted rotator cuff repair. Materials and Methods: Fifty-one patients (52 joints) were studied at more than 6 months postoperatively. The mean age at operation was 57.3 years (range: 32-79) and the mean duration of follow up was 15.7 months (range: 6-20). The procedure was as follows. First, arthroscopic examination of the glenohumeral joint and subacromial bursa was performed and the size, location, and repairability of the tear were determined. Then the edges of the tear and any coexisting glenohumeral lesions were debrided. Next, arthroscopic subacromial decompression was performed, followed by repair of the cuff by splitting the deltoid muscle fibers bluntly about 4cm in line with the anterolateral arthroscopy portal. The torn cuff was repaired according to McLaughlin's method or using side-to-side suture and the deltoid muscle fascia was never detached from the acromion. Postoperative rehabilitation: Passive elevation exercises were usually started the day after surgery and assisted active elevation in the 2nd week. Cuff strengthening exercises were strated in the 8th week. Results: All patients had supraspinatus tears, including 45 complete tears and 7 partial tears (Snyder's A4 and B4). There were small tears (<1 cm) in 7 cases, medium tears (1-3 cm) in 25cases, and large tears (3-5 cm) in 20 cases. Suture method: McLaughlin's repair was used in 43 cases and side-to-side suture in 9 cases. Concomitant lesions: There was a labral tears in 14 joints and synovitis in 20 joints. Using the JOA system, the total score improved from an average of 59.4points (range: 40-78) preoperatively to of 87.7 points postoperatively (range: 55-100). The average pain score improved significantly from 7.2 to 25.3 points. Discussion: Arthroscopically assisted rotator cuff pepair offers the following advantages.1) The extent of pathology in the glenohumeral joint can be correctly determined (size, location, and repairability of the tear).2) Treatment of coexisting glenohumeral pathology is possible.3)Arthroscopic subacromial decompression can be done to avoid detaching the deltoid from the acromion. This makes early rehabilitation possible and reduces postoperative pain because there is less soft tissue damage.
Purpose The purpose of this study is to recognize the effect of exercise for cuff muscles using EMG. Materials and Methods 5 healthy young men, aged from 17 to 29 yrs., were examined. The "resisted external rotation"exercise for the infraspinatus muscle was estimated. The Cuff-Y exercise with a yellow Thera-Band and F. W. Jobe's strengthening exercise with a 1.5kg weight were compared. During the exercises, the infraspinatus, the supraspinatus, the deltoid, and the middle fiber of the trapezius were examined with EMG. The EMG was recorded continuously from the beginning for 5 minutes. Results The exercise withe the yellow Thera-Band could dominate the activity of the infraspinatus muscle compared to other muscles. As for the exercises with a 1.5kg weight, it was difficult to keep the activity of the infraspinatus advantageous and the 5 volunteers demonstrated five different patterns of muscle activity. Furthermore, the relative activity of the infraspinatus gradually decreased with time. Conclusion Exercises for cuff muscles should be carried out to keep the dominant activity of the targeted muscle compared to other muscles. The setting of the load and time limit both failed and the purpose of the exercise could not be attained.
Ultrasonographic evaluation of the humeral proximal epiphyseal plate was performed on two cases (11 and 12 year old males) of little league shoulder. The purpose of this study is to attempt to classify the stages of this lesion using ultrasonographic findings. On ultrasonography, damage to the cartilage was evaluated in the short axis view which is parallel to the epiphyseal plate. The ultrasonographic image of the normal epiphyseal plate of the contralateral side demonstrated an homogeneous medium echogenicity. In the acute stage of the injury, island-like high echogenic spots were observed. The echogenicity of the island-like bright spots change to rather low with time. Finary, the ultrasonographic image of the cartilage returned to its homogeneous medium echogenicity. These results were classified into the following 4 groups: (Acute stage) Period when high echogenic island-like spots in the cartilage are confirmed. (Initial repair stage) Period when decrease in echogenicity of island-like spots is observed. (Final repair stage) Period when low echogenic island-like spots are confirmed. (Healing stage) Period when homogeneous medium echogenicity was observed. We permited resumption of throwing / pitching activity at the final repair stage and excellent courses without any kinesalgia were confirmed.
The authors evaluated the sonographic findings in the normal rotator cuff and compared them with the rotator cuff tears. The subjects were 200 volunteers (167 males and 33 females) with normal healthy shoulders ranging in age from 15 to 88 years (mean 44.3 years) and 100 patients (74 males and 26 females)with rotator cuff tears ranging in age from 28 to 92 years (mean 60.3 years). Ultrasonography was performed with a 7.5 MHz linear scanner and examined with the shape of the bursal surface (concave, flat, convex), the change of thickness of the cuff (The distance between the subacromial bursa and the humeral head=DSH), echogenicity and homogeneity of the cuff layer, nonvisualization of the cuff, and irregularity of the greater tuberosity. A concaved shape of the bursal surface was not observed in any case. The DSH of the normal cuff was 6.2±0.9mm and constant in the under 70-years-olds and there was only one case with less than 4mm of DSH, but the DSH gradually decreased over 70. The echogenicity in normal rotator cuffs were lower than the long head of the biceps and higher than the deltoid muscle and tended to get lower with aging, that were iso (45%) and semi-high (55%) echo. In all the cases the rotator cuff was visible. Irregularity of the greater tuberosity was seldom seen in the young. The DSH of the normal rotator cuff was constant under 70 years, and so, a DSH is useful to diagnose a massive rotator cuff tear, if the DSH is less than 4mm. The low echo area is a most specific finding for a rotator cuff tear, because there were no low echo areas in the normal rotator cuffs. But ecogenicity of the normal cuff layer tends to get lower with aging, careful examination is necessary for diagnosis as rotator cuff tears.
We made a comparative study between the arthrographic findings and the maximum length of the tear in rotator cuff tears. Thirty-eight cases with complete rotator cuff tears that had been operated on were evaluated. We classified the arthrografic findings into four groups by Hamada's classification. group A; the articular cartilage of the humeral head and the subacromial bursa were not continuous in any projection group B; continious only in the external rotation group C; continious in the external rotation and neutral group D; continious in the external, neutral and internal rotation The operative findings were classified depending on the size of the tears every 1cm. We evaluated them in scapular Y view, too. Groups A, B and D were well correlated as to size of the tear. Cases of groups A and B had the tendency to be less than 2cm. Cases of group D had the tendency to be more than 4cm. But there was no tendency in the size of the tears in group C. In the scapular Y view results, the rotator cuffs were not seen but the subacromial bursa was seen on cartilage of the humeral head had tended to be more than 4cm. The other tendencies were not present. Arthrography was considered to be useful for evaluating the size of tears as a conventional and simple method. But for a more accurate evaluation, othere methods are needed.
Purpose The purpose of this study is to evaluate the charactoristics of MR imaging in small complete and incomplete tears of the rotator cuff, comparing them with our operative findings. Materials and Methods Forty cases were surgically diagnosed to have small complete tears of the rotator cuff (twenty cases) or incomplete tears of the rotator cuff (ten busal-side tears, three intratendinous tears and seven joint-side tears). T2-weighted images were obtained along the oblique coronal plane in a 0.2T MR system (HITACHI MRP20). Results and Conclusion High signal lesions were observed in nineteen of the twenty small complete tears and six of the ten bursal-side tears at the anterior insertion of the supraspinatous tendon. Middle signal lesions were present in one of the twenty small complete tears, four of the ten bursal-side tears, all of the three intratendinous tears and five of the seven joint-side tears at the critical portion of the supraspinatou tendon.
The purpose of this study was to investigate the occurrence of and the state of the throwing shoulder in high school baseball pitchers. Eighty active baseball pitchers from 22 high schools were evaluated at our institute; 65 were right-handed and 15 were left-handed. (1) A questionnaire inquiring about their history of shoulder disorders. (2) Evaluation of shoulders regarding general joint hypermobility, shoulder ROM, shoulder joint loosening and instability, as well as of some diagnostic tests. (3) X-ray examination in the AP view, Bennett view and scapula-Y view. The data were evaluated statistically using a paired t-test, Fisher's exact probability test and chi-square test for independence employed. Thirty-nine of the players had experienced shoulder pain during pitching and 13% had shoulder pain at the time of the study. General joint hypermobility was found in 11% of the players. An increase of the anterior displacement of the humeral head was detected in 33% of these in the throwing side and 45% in the opposite side, whereas the increase of the inferior displacement was observed in 15% and 15%, respectively. The relocation test of the throwing side was positive in 8%of the shoulders. The impingement sign was observed in 11% and Yergason test was positive in 6%. Sixteen percent of the shoulders showed tenderness on the posterior site of the GH joints. In three cases, roentgenographic abnormalities were found. According to these results, general joint hypermobility and shoulder joint looseness were not risk factors of shoulder pain during pitching among high school students. The relocation test was highly sensitive to detect shoulder pain at the time of throwing.
Purpose The purpose of this study was to investigate the glenohumeral movement in throwing motion by using cineradiography, particularly from the cocked up phase to the ball release phase in the horizontal plane. Materials and Methods The subjects were 48 shoulders in 48 baseball players who had throwing pain relieved by distension arthrography and 35 healthy shoulders in 42 volunteers. In the sitting position, they went through the throwing motion from the cocked up phase to the follow-through phase and usually finished the whole throwing phase in 6 seconds. The axial view of the glenohumeral joint during the whole phase of throwing was observed with the aid of an image intensifier and recorded on a video tape. The motion was analysed with an image analyzing system. From the records obtained, images were reviewed at every 10 degrees between 40 degrees and 150 degrees by measuring the glenohumeral angle. A coordinate axis was determined and the center of the humeral head was obtained. Results The center of the humeral head moved posterior to the line bisecting the width of the glenoid and tended to translate its position concentrically at the phase of abduction in the horizontal plane and moves its position eccentrically from 20 degrees of adduction in normal shoulders. In pathological shoulders on the other hand, the anterior translation occurred in both adduction and abduction and significant eccentric translations were also observed from 30 degrees of adduction to 60 degrees of abduction in the horizontal plane. Conclusion Throwing motion disorders of the shoulder are associated with anterior and eccentric shifts of the humeral head.
Purpose The purpose of this study was to collect information about osteopenia in several parts of the shoulder joint from a series of individuals suffering from periarthritis of the shoulder. The BMD (Bone mineral density) was measured with a DEXA (Dual energy X-ray absorptiometray). Materials and methods In 30 cases of periarthritis of the shoulder,16 men and 14 women, the BMD of the shoulder joint was evaluated. The measurements were made of the head of the humerus, the greater tubercle of the humerus, the surgical neck of the humerus, and the neck of the scapula. The average age of the male patients was 58.4 years and 59.5 years for the females. The reference cases,9 men and 9women, randomly selected from people (range,24-62) without any history of disease in the shoulder joints, had their BMD measured. Results In the reference cases, the greater tubercle and female surgical neck, of the handedness, contained more mineral than did the contralateral one. Only in the cases of the women with periarthritis of the shoulder, the proxymal humerus of affected side, had less mineral than did the contralateral one. At the neck of the scapula, there were no significant differences in any of the cases. Conclusion The degree of osteopenia associated with periarthritis of the shoulder was significant in the proximal humerus of females.
(Purpose) Neurogenic disorders such as brachial neuritis are well known as causes of non-traumatic shoulder paralysis. But it is often difficult to distinguish such diseases from cervical disc herniation. Weperformed clinical and electrophysiological examinations on such cases of shoulder paralysis. (Materials and methods) From 1991to February 1994, EMGs and clinical examinations were performed on 11 cases of paralytic shoulder. The patients were 9 males and 2 females. Their average age was 49.2 years and the average follow-up period was 14.1 months. Clinically, presymptoms, muscle atrophy, weakness of muscle strength and sensory disturbance were evaluated. EMGs and SEPs were performed on all the cases and MRI of the cervical spine or shoulder arthrography was performed on some cases. (Results) 4 cases had presymptoms like a common cold. Active shoulder elevation was impossible in 8cases. On EMG, there were 9 cases of neurogenic change in the deltoid muscle. All the cases recovered their active shoulder elevation spontaneously within from 1 to 8 months (average 3.8months). Clinical diagnosis were 7 cases of brachial neuritis,3 cases of cervical disc herniation and 1 case of cervical myeropathy. (Conclusion) There are some differences in the therapies and prognoses of the neurogenic disorders which cause the nontraumatic shoulder paralysis. So it is important to diagnose these disorders electrophysiolosically at an early stage of the disease.
We wish to present a tabulation of the shoulder joint disorders we encountered in the last two years. The degenerative Changes in the rotator cuff which consist of a wide variety of diseases, which we consider important to differentiate. The subjects were 406 outpatients with shoulder joint disorders. In cases of impingement syndrome, elevation disturbance without contracture, impingement signs and the impingement test were used as a diagnostic criteria. Frozen shouldrs were taken into account only in cases with contracture. There were 170 cases (average age of 57.3) of the impingement syndrome. Rotator cuff tears were observed in 23 of the cases resistant to treatment. There were 77 cases (average age of 58.5) with a frozen shoulder. There were 55 cases (average age of 64.2) of rotator cuff tear or 78 cases when the 23 cases were corrected from the impingement syndrome were included. Then there were 36 cases (average age of 55.2) of calcified tendinitis, 10 cases (average age of 49.8) of bicipital tendinitis and 8 cases (average age of 71.5) of osteoarthrosis of the shoulder joint. There were 50 other cases. The findings of a survey on the patients' backgrounds revealed the existence in many cases with the impingement syndrome and the rotator cuff tear to be among farm and blue-collar workers and that of many cases with calcified tendinitis among females. When treating an impingement syndrome and a rotator cuff tear, we limited the patients' work and encouraged rest. Kinetic therapy was the basic therapy for a frozen shoulder. Steroid injections into the subacromial bursa proved efficacious in cases of impingement syndrome. Attention ought to be paid to the advance of degenerative changes in the rotator cuff and the existence of its tears. Conservative therapy was not satisfactory enough for more than half of the cases with a rotator cuff tear, and about one third of all the cases required surgery. Satisfactory results were obtained with steroid injections into the subacromial bursa for calcified tendinitis.
The purpose of this study was to evaluate the results of arthroscopic surgery for massive rotator cuff tears. Arthroscopic surgery was carried out on massive rotator cuff tears on six patients including two males and four females aged 71to 86with an average of 77years. Arthroscopic subacromial decompression (ASD) was performed on three patients and arthroscopic subacromial debridement (DB) on three. The patients were evaluated pre and postoperatively on the JOA shoulder rating scale (JOAS). In all of the six patients minor improvement on the JOAS was obtained (from 62.0 to 66.7 in the three patients treated by ASD, from 55.3to 60.3in the three by DB). Five out of the six patients had a relatively improved rating for pain (from 10.8to 15.0). Almost no improvement was obtained in the ratings for function, range of motion, roentgengrams and stability. In one of the three patients treated by ASD, the humeral head had shifted to the superior and he was dissatisfied because his shoulder pain had not decreased after surgery. Three of the six patients had suffered from recurrent hydrarthrosis preoperatively and they were satisfied because their hydrarthrosis had disappeared postoperatively (one was treated by ASD, two by DB). It was concluded that arthroscopic subacromial dasridement was effective in the treatment of a massive rotator cuff tear in older patients with chronic hydrarthrosis and pain.
Purpose It was difficult to repair a massive rotator cuff tear, so at first, we tried to apply the arthroscopic debridement on older cases with a massive rotator cuff tear. In this report, we evaluated the effects and problems of this method. Patients There were 19 cases (20 shoulders) with massive rotator cuff tears.11 males and 8 females were in the group, with the right shoulder involved in 14 cases, the left in 4 cases and both in one case. The average age was 70 years (range: 55-82). The average follow-up duration was 17.5 months (540 months). Treatments We did an arthroscopic observation, after which we carried out an arthroscopic debridement. One day after the debridement, early passive motion exercises were started, and one week after the debridement, active motion exercises started. After the treatment, all the patients were evaluated using the JOA shoulder score. Results In the JOA score, the average score at preoperation was 50.6, at discharge time 67.7 and at followup time 67.4. The average scores at discharge and follow-up time were significantly better than that at preoperation. However, in 7 cases shoulder pain recurred and 6 cases without any, could not elevate their arms even after surgery. But,14 cases were satisfied with the results anyway.5 cases were unsatisfied.4 of these 5 cases were treated with open surgical repair, and 3 cases recovered. Conclusion Arthroscopic debridement is one of the useful first-aid treatments for inactive older cases with massive rotator cuff tears, but limited. Some patients need second cuff repair operations.
[Purpose] We performed the reconstruction of 3 cases of rotator cuff injury with dried allogenic fascia lata (DAFL). We could not repair the injury by McLaughlin's method for these patients. We will present our methods here and the results of the functional evaluation. [Patients and Methods] All of the three patients were males and they were aged 45 years,50 years and 66 years. We exposed the lesions by Henry's method and performed an acromion plasty. Then we pulled out the edge of the tendon and resected the degenerated portion. We subsequently found that it was extremely difficult to repair a tendon by McLaughlin's method. We made anchoring tunnels in both the tendon and the greater tuberosity of the humerus. We then used DAFL to fill the tendinous defect. We passed the DAFL both anchoring tunnels and overlapped it. Then we fixed it firmly in 90°abduction. All 3 patients were placed in zero position for one day after the operation and we also applied a shoulder abduction brace from two days to 6 weeks postoperationally. The patients started horizontal flexion and extension exercises with a brace from 3 weeks postoperationally. We evaluated the function of the shoulder joint using the Japanese Orthopaedic Association's (JOA)score. [Results] We followed the three patients up for 9 to 13 months. Their JOA scores were 95,92 and 84 points respectively. No complications occurred. [Conclusion]We achieved a good result using this material.
(Purpose) In this study, the results of a fascia lata patch grafting for a massive rotator cuff tear were evaluated. (Materials and Methods) Between 1990and 1993,46 cases of rotator cuff tear were treated operatively. Of these patients, fascia lata patch grafting was performed on 8 patients with a massive rotator cuff tear. There were 7 males and 1 female. The mean age was 59.8 years. All the patients were examined directly, and evaluated by the J. O. A. score. Reoperations were performed on 3 cases. (Results) The post operative J. O. A. scores were more then 90 points in 4 cases,82 points in 1 case, but the other 3 cases had less than 60 points. Failure of the tendon-bone healing on a bony trough were recognized in all the reoperated cases. The reoperated cases were unable to gain good strength of abduction, finally. (Conclusion) Results of fascia lata patch grafting for a massive rotator cuff tear were not stable. There were two problems, tendon-bone healing in the bony trough and the post-operative management.
In the operative treatment of a rotator cuff tear, cuff repair and subacromial decompression are performed in our hospitals. In a cuff repair, in spite of making an adequate release of the cuff and capsule, the defect remains in some cases. For these cases, a Gore Tex Patch is used. In this paper, the clinical results of a cuff repair with a Gore Tex Patch were reported and the role of the patch was studied. (Materials and methods) From 1989, nineteen patients with twenty involved shoulders underwent a cuff repair with a Gore Tex Patch. Thirteen patients were men and six were women. The average age at the operation was 59.1 years old (44-75). The mean follow up period was 28 months (1-5 years). The chief complaint before operation was pain with restriction of ROM in 18 of the 20 shoulders, restriction of ROM in 2 of the 20. About the size of the tear,5 of them were massive tear,11 were large or middle tear, and 4 were small or incomplete tear with severe degeneration. The size of the patch was less than 2 cm in diameter in 9 patients (small patch group) and over 2 cm in 11 patients (large patch group). The clinical results were evaluated with the JOA shoulder scoring system and the abduction strength at 90-degree abduction. The relationship between the clinical results and the size of patch was analyzed. (Results) The average pre and post operative JOA score were each 56.7 and 85.6 points. In the JOA score, the pain score improved most from 9.0 to 27.5 points and the other scores did not improve significantly. With regard to the relationship between the JOA score and the size of patch, there was no significant relationship apparently. Regarding the post operative abduction strength, the average strength of all patients was 3.2kg. The relationship between the abduction strength and the size of patch, the average abduction stength of the small patch group was 6.0kg and that of the large patch group was 1.6kg. There was a significant relationship between the size of the patch and the post operative abduction strength.383 The Shoulder Joint, Vol.19, No.2,383 388,1995. The clinical results of a cuff repair with a Gore Tex Patchare satisfactory, especially pain has improved. In cases repaired with a small patch, the good abduction strength can be expected.
Purpose The purpose of this study is to evaluate the results of conservative and operative treatments for massive rotator cuff tears. Patients and Methods Ten patients,9 men and 5 women of a mean age of 71, were treated conservatively and followedup for 3.7 years on the average (Group I ). These patients were of Grade 4 arthrogram of Hamada's arthrographic classification. Twenty patients,17 men and 3 women, comprised the operative group which had cuff tears of more than 5.0 cm in the longest dimension (Group II). The mean age at operation was 63 years. Anterior acromioplasty was performed in all the cases. The additional procedures were tenorrhaphies (tendon to bone) in 14, fascia grafts in 4 and Bush's procedure in 2. The mean follow-up period was 3.1 years. The results were assessed by the JOA score. The muscle strength was evaluated by Cybex in 9 operated patients. Results The JOA score in Group I increased from 52.9 to 71.7, while in Group II from a preoperative 50.1 to 85.3. More pain relief was obtained in Group II than Group I, especially motion pain. Muscle stength and range of motion had recovered more in Group II than in Group I at follow-up. There was no statistically significant difference of age factor for the end results of those above 70years of age between Goup I and Group II. Reasonable operative results were obtained within one year after the symptom started. There was no statistically significant difference of JOA score between a water-tight and non-water-tight closure. There was a statisticil difference of JOA score between a ruptured and non-ruptured LHB. The peak torque ratio recovered gradually as time elapsed postoperatively.389 The Shoulder Joint, Vol.19, No.2,389 - 395,1995. Conclusion Although the two groups were not entirely comparable, pain relief, range of motion and muscle strength recovered more favorably in the operated group than in the conservatively treated one. Reasonable operative results may be expected if done within one year after the symptoms had started. The mode of closure did not affect the end result. Those with an intact long head of the biceps branchii did better in both groups than did those without. Most patients treated conservatively were limiting the ADL by themselves. If at all possible, a massive cuff tear should be treated operatively.
Patients with a rotator cuff tear are usually treated by McLaughlin's procedure along with a partial leteral acromionectomy and resection of the coraco-acromial ligament in our hospital. The purpose of this study is to evaluate the results of the surgical treatment for patients with a massive rotator cuff tear. 97 shoulders were followed-up for from 6 months to 12 years (average 3 years 7 months). There were 81 males and 12 females with an average age of 54 years. 33 shoulders had massive tears and 64 shoulders were other than massive. McLaughlin's procedure was performed on 93 shoulders and patch graft procedures were done on the rest of the 4 patients with a massive tear. We evaluated the post-operative results of the massive tear group and the other group according to the shoulder evaluation sheet of the Japanese Orthopaedic Asociation (JOA score), and then compared them. The average JOA score of the massive tear group was 89. 3±8. 9 points and that of the other group was 93.4±6.1 points. There was a statistically significant difference between the two grooups. There was no correlation between the preoperative JOA score and the post-operative JOA score in both groups. However massive tear group showed a significant increase of JOA score as the length of the post-operative period increased. All but one patient with a patch graft showed good results. From this study, it can be concluded that satisfactory results can be obtained with most massive tears by using McLaughlin's procedure along with partial lateral acromionectomy and resection of the coraco-acromial ligament. Furthermore, in some circumstances a patch graft is usuful.
Forty-three shoulders with massive rotator cuff tears were operated on during the 22 years from 1972. We reviewed the 29 cases(20 males,9 females, age range 47∼76 years, mean: 62 years)which could not be repaired by McLaughlin's procedure. The postoperative follow-up period ranged from 1 year to 19 years(mean: 101 months). The surgical procedures were as follows: supraspinatus advancement (Debeyre),12 cases; deltoid-rotator cuff suture,6 cases; trapezius transfer,8 cases; tuberculum majus transfer,3 cases. The results were evaluated by the JOA score. A total score of >90 was evaluated as excellent,80-89 as good,70-79 as fair, and <69 as poor. We obtained the following results. (1) supraspinatus advancement: excellent 4, good 7, fair 1. This procedure was applied in the cases in which the cuff edges could only be pulled out a little bit and could not be reinserted into humeral head. (2) deltoid-rotator cuff suture: excellent 2, good 2, fair 1, poor 1. Sufficient abductor strength could not be obtained in those patients with severe deltoid atrophy. (3) trapezius transfer: excellent 2, good 4, fair 2. This procedure was used in cases of global tears in which tendinous portion could not be detected in the cuff edges and the humeral head was completely exposed. (4) tuberculum majus transfer: excellent 1, good 2. This is a method which covers the torn cuff by anteriorly transferring the teres minor insertion together with the bone. In order to obtain satisfactory results in the surgical treatment of massive rotator cuff tears, it is important to select repair procedures according to the condition of the edges of the torn cuff.
Very large tears of the rotator cuff may be irreparable. Several reconstruction methods have been reported. We have performed the Latissimus Dorsi (LD) transfer described by Gerber (1988)for the treatment of irreparable massive rotator cuff tears. Since 1991,13 shoulders in 11 cases with a irreparable massive rotator cuff tear have been treated with LD transfer. They consist of 10 males and a female with an average age of 64 years (range 49 to 81 years). An average follow-up is 25 months. These cases were evaluated by JOA shoulder score and EMG analysis. Pain was improved in all cases. Active flexion averaged 104°preoperatively and 139°(range 50°to 180°)postoperatively. There were no complication. JOA shoulder score averaged 60 points preoperatively and 79 points postoperatively. Electromyographic analysis revealed that transfered LD was acting more with the abducted arm than the arm at the side. On flexion, apparent contraction was observed over 900° The LD transfer relieves pain and aids functional recovery of the shoulder with massive rotator cuff tear. This procedure may act as not only rapair of the cuff but also reconstruction of the shoulder function.
Reconstruction of the rotator cuff in patients with a massive tear of this structure is difficult. We determined the prognosis of patients who underwent modified Debeyre's operation for a massive tear of rotator cuff. Between 1984 and 1992, twenty-three patients (23 shoulders) with massive rotator cuff tear were treated surgically using a modified Debeyre's operation. There were 16 males and 7 females, ranging in age from 43 to 76 years (mean: 58 years). The right shoulder was affected in 18 patients, and the left shoulder in 5. The dominant side shoulder was affected in 18 patients. All the patients were evaluated by the JOA shoulder rating score (JOA score). There were 5 patients with excellent results (21.7%),12 with good results (52.2%),1 with a fair result (4.4%) and 6 failures. The average JOA score was 56.8 pre-operatively. The therapeutic results in 18 patients without a re-rupture of the rotator cuff were excellent or good, the mean points being 87.8 post-operatively. Six patients (26.1% of all patients) suffered a re-rupture. In these cases, the therapeutic score was 53 points pre-operatively and 60 points post-operatively. All of the six patients had persistent pain and weakness on external rotation. Eight cases including 2 without a re-rupture demonstrated no recovery. The six re-rupture cases included 2 severe degenerations of the rotator cuff,3 failures of rehabilitation and 1 infection. A modified Debeyre's operation for a massive tear of the rotator cuff is a good method for reconstructing the shoulder, especially elevation and external rotation, and there are few complications. The evaluation of the cuff degeneration and a proper rehabilitation program are important for the success of this operation.
We have repaired 130 chronic cuff tear cases. which could not be repaired conventionally, using Marlex mesh or Teflon felt from 1980. Seven shoulders showed a transient subacromial effusion and 4 patients who had been operated on in other hospitals were reoperated on. This paper describes the indications and limits of this procedure for repairing massive cuff tears retrospeculatively based on clinical results and postoperative MRIs. In the present study,45 shoulders were evaluated by the new JOA score and 34 shoulders had satisfactory functional results. Twenty-one shoulders were imaged postoperatively with an MR. Thirteen had a low or relatively high signal area (T2) at the placed lesion but 8 showed a high intensigy lesion (T2). The operative findings, the factors which caused the unsatisfactory results, were vascularity of the greater tubercle. osteoporotic humeral head and severe degenerative residual cuff tissues. We concluded that vascularity of the greater tubercle and the quality of a torn cuff end effects the results of this lesion.
The MRI test has been used in recent years for diagnosing shoulder joint diseases, and its usefulnesses have been reported elsewhere. We have developed on MRI test of the subacromial bursa infusing in concurrently using an anesthetic locally mixed with Gd-DTPA. Accordingly, we will an assess its usefulness here. The subjects were 33 shoulders in 14 males and 18 females, totaling 32. Their ages ranged from 14 to 78 (average 54). The clinical diagnosis made were rotator cuff tendinitis in 13 cases, a rotator cuff tear in 15 cases and 5 baseball shoulders. Before the MRI test we injected physiological saline of which there was 1% xylocain and Gd-DTPA into the subacromialbursa. The results of the MRI diagnosis were 12 cases of rotator cuff tear,15 cases of rotator cuff degeneration and 6 normal cases out of the 33 cases. Of the 7 cases in whom an arthrography had been carried out on the shoulder joint, a rotator cuff tear was confirmed in 5 cases by both the MRI diagnosis and the arthrographic findings. In cases of a painful shoulder joint disease, there are occasions when no patients remain restful during the MRI testing and the images fall into disarray because of which insufficient information can be obtained. A detailed diagnosis could be made if the patients were kept resting using a subacromial bursa blocking. This diagnosis may be more accurate because of the roentgenographic effects of Gd-DTPA