The usefulness of ultrasonography in the diagnosis of incomplete tears of the rotator cuff is still controversial. We examined 16 patients (14 males and 2 females) with incomplete tears by ultrasonography and compared those images with our operative findings. Six patients had bursal side tears,9 had articular side tears and 1 had an intratendinous tear. We used a 7.5MHz linear scanner for the ultrasonographic examinations. Ten patients were diagnosed by US: 3 cases had bursal side tears and 7 cases had articular side tears. We could not distinguish between an articular side tear and a small complete tear because of the presence of a wide hypoechoic area. In the 3 patients with a bursal side tear, it was difficult to diagnose the lesion correctly because the bursa was thick and degenerated. A patient with an intratendinous tear was misdiagnosed as having a degenerative change. We noted that tears bebame more difficult to diagnose as the patients aged. Based on these results, we think US is useful for screening patients with incomplete tears of the rotator cuff.
We evaluated postoperative recovery of muscle atrophy in shoulders with rotator cuff tears using MRI. Ten shoulders of 10 patients (avg age 54yrs) were examined. There were 6 full-thickness tears of the supraspinatus and infraspinatus and 4 partial-thickness tears of the supraspinatus. TI-weighted images in sagittal oblique plane at a level 1 cm proximal to the glenoid were used for the measurement of cross-sectional area of the cuff muscles. The cross-sectional area of each muscle was measured using NIH image and normalized by the area of the humeral head. The measurements before and one year after the operation were compared. All cuff muscles showed recovery one year after the operation: 38%±21%(mean±SD)increase in the supraspinatus, 5%±3%in the infraspinatus, 6%±4%in the subscapularis. The degree of recovery was less in full-thickness tears than in partial-thickness tears and less in large tears then in small tears. From these results, we recommend that tears be repaired before muscle atrophy advances too much.
The purpose of this syudy was to clarify the arthroscopic findings characteristic of the glenohumeral joint in patients with multidirectional instability of the shoulder (MDI). We compared the arthroscopic findings in a MDI group with those in a control group without instability. The MDI group consisted of 12 patients (9 females and 3 males), While the control group had 10 patients (7 females and 3 males) The average age of the MDI group was 16.5 years and that of the control group was 17.8years. Arthroscopic assessment was performed in 45°abduction with 3-4 kg of skin traction. The following arthroscopic findings were more common in the MDI group than in the control group; enlargement of the superior recess and rotator interval (83%vs.20%in the control group), ballooning of the dependent pouch (100%vs.50%), a deep gutter under the glenoid fossa (75%vs.0%), hypoplasia of the lower part of the labrum (100%vs.20%), a cord-like and thin middle glenohumeral ligament (MGHL)(93%vs.10%), a lower glenoid attachment site of the anterior inferior glenohumeral ligament (AIGHL) (average3: 30ve.2: 20). However, the superior glenohumeral ligament (SGHL) showed no differences between the two groups. Hill-Sachs lesions of the humeral head (3) and reverse Hill-Sachs lesions (2) were only detected in the MDI group. All of these lesions were small and superficial. In most patients with MDI, capsular enlargement (including rotator interval opening) was observed. In addition, a hypoplastic MGHL, a lower grenoid attachment site of AIGHL, and a hypoplastic labrum were characteristic anatomical variations in MDI.
(Purpose and method) Partial cuff tears have been diagnosed clinically with an arthrography and a subacromial bursography. The purpose of this study was to evaluate the diagnostic values of MRIs of this lesion. We compared the MRIs and the operative findings and assessed the tear size, the localization of the subacromial bursal and long bicepital lesions.59 shoulders of 57 patients with partial cuff tears were scanned on MRIs with a GE Signa Advantage 1.5 T. (Results) In 56 bursal side tears, high signal cuff lesions were observed in all and their tear shapes were easily recognized on T2 weighted images. The other joint sides, intratendinous tears and high signal lesions were confirmed at their portions. We could also validate the subacromial effusion and long bicepital lesions in additional to partial cuff tear lesions. (Conclusion) We concluded that MRIs have a significant diagnostic value. They demonstrated a variety of partial tears and additional pathological lesions.
Introduction: The purpose of this study was to determine the electromyographic activities of the biceps during arm elevation in shoulders with rotator cuff tears and to clarify the relationships between the biceps activities and the isokinetic strength of the shoulder. Methods: Forty shoulders were examined using a dynamic EMG: 18 shoulders with rotator cuff tears and 22 without tears (normal controls). The EMG activities during arm elevation were integrated and expressed as a percentage to the maximum voluntary contraction (% MVC). The isokinetic strengths of IR/ER and Abd/Add were measured in 28 shoulders (10 rotator cuff tears and 18 controls) using a CYBEX or a KIN-COM dynamometer. Results: In the controls, the % MVC of the biceps was always less than 10% during elevation. Of the 18 shoulders with rotator cuff tears,6 shoulders showed increased activities of the biceps(p<0.05, highactivity group), whereas the remaining 12 shoulders showed 10 or 0 less-activities than the controls (low-activity group). Muscle strengths of the high-activity group, low-activity group, and the controls were compared. The high-activity group had the smallest strength and the controls the greatest. The difference between the high-activity group and the controls was significant(p<0.05). Conclusion: The increased EMG activities of the biceps during arm elevation in rotator cuff tears with muscle weakness suggest that the biceps might act as a mover to compensate the shoulder weakness.
The labrum of the shoulder joint plays an important role in shoulder instability. The purpose of this study is to evaluate the usefulness of ultrasonography(US) in the diagnosis of a labrum injury. Materials and methods Four cadaver's shoulder and 10 macerated scapulae were examined to identify the best position for the diagnois of the labrum; that is, the position at which there is no interference from bone structures and the US beam can be directed to the surface of the labrum vertically to obtain a clear US image. On the basis of these results,19 patients with labrum injuries (8 superior and 11 anteroinferior) were examined by US before surgery and the US findings were compared with the operative findings. Results and discussion The anatomical study showed that it was possible to investigate the labrum by US at 4,8-10 and 11 o'clock positions (right alenoid). In the clinical study,4 shoulders with superior labrum injuries (SLAP lesions, types 3 and 4), four with a bony Bankart's lesion and three with a detachment of the anteroinferior labrum were detected by US. From these results, we consider that US is useful in the diagnosis of a labrum injury.
Recently MR arthrography has been proposed as a possible replacement for evaluating shoulders. We investigated the findings of athletic shoulders. One hundred and four patients who had symptoms and sings suggesting shoulder instability underwest MR arthrography with intraarticular Gd-DTPA. Spin echo T1-weighted images were obtained in the axial and oblique coronal planes. Surgical or arthroscopic findings of the glenoid labra were available for 41 patients. Anterior labral tears were diagnosed in 35 out of the 41 by MR arthrography. Anterior labral tears were surgically confirmed in 34of the 35, but not in the other one. Superior labral tears were diagnosed in 8 out of the 41 by MR arthrography. Anterior labral tears were surgically confirmed in 7 of the 8 but not in the other one. We believe MR arthrography is useful in evaluating athletic shoulders, especially indiagnosing superior labral tears.
The purpose of this study was to clarify the mechanism of rotator cuff tears seen in baseball players. Forty baseball players who injured their shoulders through repetitive throwing and underwent shoulder arthroscopy were studied retrospectively using a videotaped arthroscopic tour. They ranged in age from 13 to 48 years (average: 24 years) and were classified into 3 groups according to the rotator cuff findings: articular-side partial rotator cuff tear (APRCT)in Group 1 (29 patients), cuff inflammation only in Group 2 (5 patients), and intact cuff in Group 3 (6 patients). The existence and the site of rotator cuff tears, labral tears and notches of the greater tuberosity were examined in each group. All APRCTs were located around the posterior aspect of the supraspinatus tendon (SSP) and the anterior aspect of the infraspinatus tendon (ISP). Localized splits of the posterior rotator interval were recognized in 5 patients. In most of the other patients in Group 1, the deepest APRCT was also located in the posterior rotator interval. Posterior-superior labral fraying was seen in 22 patients (17/29 in Group 1,0/5 in Group 2, and 5/6 in Group 3). However, posterior labral lesions localized to the superior portion were only recognized in 4 patients in Group 1 and SLAP lesions were combined with this posterior lesion in 5 patients. The remaining 8 patients in Group 1 had labral fraying of the whole posterior portion. A notch of the greater tuberosity around the insertion of the ISP was recognized in 23 players, which showed it had a significant relationship to cuff lesions (21/29 in Group 1,2/5 in Group 2, and 0/6 in Group3). The most significant APRCTs were located around the posterior rotator interval between the SSP and ISP. APRCTs caused by repetitive throwing activity may be initiated by tearing between the SSP and ISP due to an eccentric or shearing force. They were not always associated with posterior-superior labral lesions as predicted by the internal impingement theory.
The relationships between an infraspinatus insertion injury and the functional A-P instability in the throwing motion were evaluated.82 shoulders of 82 men with shoulder pain during throwing motion, aged between 15 and 35 years, were examined. The subjects consisted of 37 shoulders with abnormal findings of the infraspinatus insertion (Group I)and 45 shoulders without an abnormality (Group N). In the cinearthrography, the joint kinetics on axial views were recorded. Using an image analyzing system, the center of the humerl head was measured, and the rotation of the glenohumeral joint was calculated in each position. Group I: The maximum external rotation glenohumeral joint could be seen in 0 degrees of horizontal abduction. The center of the humeral head showed the centripetal motion through to the throwing motion. Group N: MER of GH joint occurred in 10 degrees of HRZ. ABD. Concerning the motion of the humeral head, it could be translated anteriorly in the external rotation and posteriorly in the following internal rotation. The infraspinatus insertion injury was associated with functional anterior-posterior instability of the glenohumeral joint in the throwing motion. We considered that excessive anterior translation occurring with an external rotation might cause stress of the infraspinatus insertion in the following phase.
The thickness of the articular cartilage of the humeral head and that of the glenoid fossa were measured, and their dynamic properties were compared. This study was performed on 22 cadavaric shoulder joints without a rotator cuff tear or macroscopic damage to the cartilage. The humeral head was dissected with a bone cutter along the plane parallel to and that perpendicular to the humeral axis that passes the center of the humeral head; and the glenoid cavity, along the perpendicular plane and the horizontal plane that divides it into 3 equal parts; and the respective cartilages, thickness were measured with a caliper. Then, the gleno-humeral angle formed by the humeral head contacting the glenoid fossa with the intervention of the thickest part of the cartilages was reproduced on the cineradiograms of 30 normal shoulders by elevating and dropping the arm in the sitting position, to measure the gleno-humeral angle. The cartilage of the humeral head was the thickest, i. e., 2.2±0.5mm(p<0.05), at the part in about 10° inferior direction of the humeral axis from the center of the head; and the glenoid articular cartilage, significantly thicker, i. e.,3.5±0.8mm(p<0.01), at the parts in the antero-inferior direction, and also significantly thicker, i. e.,3.5±0.9mm(p<0.01), in the inferior direction. The mean gleno-humeral angle was 77.0±6.8°, which was mostly consistent with the zero position on the cineradiogra ms. The glenoid fossa was markedly varied in thickness from part to part. It may probably be for that reason that the contacting area of the glenoid fossa is more limited than that of the humeral head when the shoulder becomes the joint needing support. The zero position appears to be not only the relaxed position but also the position with the greatest load on the articular surface.
Pathological degeneration of the nerves in the shoulder joints was recognized during investigation of the nerves in the shoulder joint capsules and axillary nerves in human cadavers. Histological features of the nerves were 1)thickening of the perineurium,2)myxoid degeneration in the endoneurium, and 3)the presence of Renaut bodies (RB) interpreted as sequelae of chronic nerve compression. In this study, we estimated the prevalence and clinicopathological significance of RB. Thirty-five shoulder joint capsules were obtained from 20 autops y cases (12 men and 8 women). From the 10 shoulder joints of 5 other cadavers, the axillary portion of the brachial plexus and the shoulder joint capsules were removed en bloc. Ten μm paraffin embedded sections were stained with antibodies against S-100 protein by the ABC method and nerves in the capsule were identified. Sections were selected, based on evidence of nerve degeneration and stained immunohistochemically using antibodies against EMA. Most of the R B were found in the inferior portion of capsules. Existence of RB was recognized in 13of 20 cases. Degenerated nerves were observed on 90 of 1120 slices.32.3% of the degenerated nerves included RB following perineurial thickening. On examination of the axillary nerves, pathologic nerve changes were found only at the teres minor branches in all 10 cases. Some cells in RB were stained by antibody against EMA. It is possible tha t the traction force in addition to the compression might affect the inferior portion of the joint capsules and axillary nerves during shoulder movement because of a high incidence of RB. We speculated that perineurium and perineurial cells seem to be concerned with the formation of RB.
We have seen much of acromio-clavicular joint dislocation, but didn't have established the appropriate method. We have been using a modified Neviaser's procedure for acromio-clavicular joint duislocation. In this study we wish to review the results of the cases performed since 1990. This procedure has been applied on 71 patients since 1990. We evaluated 30 patients (26 males and 4females). The ages at the time of surgery ranged from 16 to 72 years old (36.9 years on average). The post-operative results were evaluated according to kawabe's criteria. The follow-up period ranged from 8 months to 64 months (average 33.4 months). The points of assessment criteria was 86.3 points on average. 53.3% were excellent cases, 26.7% good, 13.3% fair, 6.7% poor. Many patients among the fair or poor case had a reduction in their range of motion, pain and dislocation. X-ray findings showed subluxation or dislocation in 26% of the patients. 70% of the patients were satisfied with their operations. We have been performed a modified Neviaser's procedure with good results. The group of good reposition acquire higher points of assessment criteria than the poor one. Neviaser's procedure satisfies almost all the patients.
The purpose of this study is to compare the outcomes of conservative treatment, a modified Bosworth's operation and a modified Dewar's operation for acromio-clavicular dislocation of grade 3according to Tossy's classification. Forty-seven shoulders of 46 patients (43 males,3 females,22 left shoulders, and 25 right, average age 35.6 years ranging from 12 to 64 years) with a fresh acromio-clavicular dislocation were treated and investigated. We performed conservative treatment in 14 cases, Bosworth's op. in 12 and Dewar's op. in 22. The results were evaluated with the JOA shoulder rating score. The average pain score was 86.7 points in conservative treatment,88 in Bosworth's op. and 91.7 in Dewar's op.. The functional score of every group was more than 90 points, but weakness or easy fatigue was found in 42.9% of the conservative treatment group. The average score of instability was 77.5 in Bosworth's op. and 80 in Dewar's op.. Reduction and stability of the AC joint was better in the Dewar's op. than in the 2 other groups. The re-subluxation rate was 22.7% in the Dewar's op. and 58.3% in Bosworth's op.. Osteoarthrosis of the AC joints was observed in none of the conservative group, in 3 with Bosworth's op. and in 4 of 4 with resection of the disc (100%) and 2 of the 14 without resection of the disc (14.3%) in Dewar's op.. Conservative treatment obtained good results except for residual deformity and weakness. Dewar's op. obtained good reduction, but there were more re-subluxations in the Bosworth's op.. We suposed that only primary repair of the coraco-clavicular ligament was not enough and it was necessary to augment it in order to prevent a re-subluxation and re-dislocation.
Purpose: From 1983 to 1992, we performed modified Cadenat's procedure using a Kirschner wire as a temporal internal fixator for a complete dislocation of the acromioclavicular joint. Since 1993, the Kirschner wire was changed to a Wolter clavicular plate, because the Kirschner wire fixation induced OA changes in the acromioclavicular joint and recovery to the preoperative shoulder ROM was delayed. In this study, we wish to report our experience in the ues of Wolter clavicular plate as temporal internal fixator. Material and methods: Eighteen patients with a complete acromioclavicular dislocation underwent Cadenat's procedure, in which a Wolter clavicular plate was used as a temporal internal fixator in our hospital. Fifteen cases were male and 3 cases were female. The age distributed from 21 to 58years(mean: 36.1 years)at the time of surgery. Results: We used Kawabe's scoring; 17 cases were excellent,1 case was good, with a mean value of 96.0points. A sling was applied for postoperative immobilization for 2.0 weeks. Recovery of shoulder elevation over 135 degrees required 8.5 weeks. As postoperative complication; an acromional fracture occurred in 1 case. Osteoarthritic change occurred in 2 cases. Postoperative subluxation of the acromioclavicular joint occurred 33.3%. Conclusion: As a temporal internal fixator, use of the Wolter clavicular plate revealed more excellent postoperative results than that of a Kirschner wire for a modified Cadenat's procedure. Patients returned to work earlier with a Wolter clavicular plate.
(Purpose) We surgically treated the fractures of distal clavicle (7 cases) and dislocation of the acromioclavicular joint (14 cases) with Wolter clavicular plates. The short-term results were good, and we will report the details here. (Subjects and methods) we operated on seven patients with type II fracture of the distal clavicle (Neer's classification). They were five men and two women whose age ranged from 19 to 75 years with an average of 52.9. The injuries were caused by traffic accidents (4 cases), simple falls (2 cases), and a sports injury (1 case). The mean follow-up period was one year. We also treated 14 patients with type III dislocation of the acromioclavicular joint (Tossy's classification). They were 13 men and woman whose age ranged from 20 to 74 years with an average 41.6. The injuries were caused by traffic accidents (6 cases), simple falls (4 cases), industrial accidents (2 cases), and sports injuries (2 cases). The mean follow-up period was 9 months. In 12 of the 14 cases, the coracoacromial ligament with its bony attachment was resected from the coracoid process, and fixed to the clavicle by an AO-screw according to Neviaser's technique. (Results) In fractures of the distal clavicle, the range motion of the shoulder after the operation was slightly limited; flexion ranged from 125°to 180°with an average of 159°, whereas abduction ranged from 120°to 180°with an average of 157°. In dislocation of the acromioclavicular joint, the range of motion of the shoulder after the operation was comparatively good; flexion and abduction ranged from 120°to180°with an average of 163°. None of the patients(21)had any postoperative weakness, but four of them complained of painful shoulder motion due to a protrusion of the hook part.18 of the 21 cases had a score of over 90 points on the JOA list.
The untreated and over-two-year results of 296 cases (516 joints) of MDI were studied. The influences of age, sex and sporting activity on the onset and the spontaneous recovery were investigated. The incidence of female patients was 1.5 times higher than that of male patients in the 13-34 age bracket. The mean age of the onset in the sporting groups was statistically lower than in the non-sports group (15.4years old in the over-head sports group,16 years old in the other sports group and 21.8 years old in the non-sports group). The correlation between the age of onset and the age when starting a sports was recognized in all the sports the female patients played but it was recognized in only the over-head sports group in male patients. Spontaneous recovery was recognized in 41 joints. In those cases the mean age of the onset was 14.5 years old, and 19 years old in the non-recocery group. The younger the age of the onset is, the higher the incidence of spontaneous recovery is. The incidence of spontaneous recovery in male patients was higher than in female patients. The incidence of spontaneous recovery in the group who discontinued over-head sports was 14.6% and 4.9% in the group who continued it. It was about 14% regardless of continuation or discontinuation of any other sports, but no spontaneous recovery was recognized in the group which changed sports from non-overhead to overhead. There was no spontaneous recovery in cases of type III of Endo's classification and general joint laxity. We conclude as follows. (1) Sex hormones have a great influence on the onset and the spontaneous recovery of MDI. (2)All sports female patients play and the over-head sports male patients play induce the onset of MDI. (3)Over-head sports interfere with the spontaneous recovery of MDI.
[Purpose] There have been the no reports on the correlation between loose shoulder and hypoplasia of the acromion. Morphological appearances and hypoplasia of the acromion were evaluated using the cineradiogram findings. [Subjects] The following subjects were reviewed; 120 loose shoulders (group LS) and 120 normal volunteer shoulders (group N). [Methods] Cineradiography was recorded on a video system and the morphological appearances were classified into three types. Type I is the shape in which the lateral edge of the acromion shows a beak edge and an undeveloped angle. Type II is the shape in which the angle is roundish. Type III is the shape in which the lateral edge is flat and the angle is broad. Clear images were also analyzed. The following measurements were evaluated: 1) the maximum transverse diameter of the acromion 2) the angle between the line under the acromion and the line of the glenoid articular surface (Acromion angle) 3) the angle between the line from the lateral acromion edge to the center of the humeral head and the line of the glenoid articular surface (Acromion Edge angle) 4) the location of the lateral acromion edge [Results] The morphorgical appearances, in group LS, Type I, Type II and Type III were 27.5%,36.7% and 35.8%, respectively. Whereas in group N, Type I, Type II and Type III were 10.8%,29.2% and 60.0%, respectively. There were significant differences between group LS and group N in the transverse diameters, acromion angles and acromion edge angles. The position of the lateral acromion edge tended to be located in the medial-superior site in group LS. [Conclusion] A beak edge and hypoplasia of the acromion were found in looses houlders.
The purpose of this study was to clarify the CT-Arthrographic features of MDI in more detail. Bilateral shoulders in 13 patients with MDI were studied as well as 13 normal shoulders with no laxity as controls. The average age of the MDI patients was 17.9 years and they consisted of two men and 11 women. The average age of the controls was 18.2 years and they consisted of three men and ten women. CT-Arthrography was done by the double contrast method(slice thickness: 5 mm, gap: -2mm). To clarify the characteristic findings on CT-Arthrography, we compared the symptomatic shoulders of the MDI patients with those of the controls. The MDI patients had a flat subchondral bony glenoid, bony hypoplasia of the posteroinferior glenoid rim, and expansion of the capsule and rotator interval. A small Hill-Sachs lesion and reverse Hill-Sachs lesion were also seen in the patients with a traumatic onset. The glenohumeral index and glenoid tilting angle were not significantly different between the two groups. To determine whether these findings were unique to the symptomatic shoulder of the MDI patients or not, we also made a comparison with the asymptomatic side. There were no differences between the symptomatic and asymptomatic sides except for the Hill-Sachs lesion and reverse Hill-Sachs lesion. Not only soft tissue abnormalities but also bony development may be involved in the mechanism of MDI. Since these findings were also in the asymptomatic side of the MDI shoulder, the developmental factor might be thought to be their cause.
We evaluated the findings of MR imaging of patients with subacromial impingement syndrome. We took MR images of 51 patients with subacromial impingement syndrome and examined their high signal intensities of the subacromial bursa, the subdeltoid bursa, and the glenohumeral joint, their cystic changes in the greater tuberosity, their high signal intensity in the rotator cuff, the acromiohumeral interval, and the shapes of the acromion. A high signal intensity of the subacromial bursa was found in 68.6%. A high signal intensity of the subdeltoid bursa was found in 15.7%. A high signal intensity of the glenohumeral joint was found in 31.4%. Cystic changes in the greater tuberosity was found in 51.0%. A high signal intensity in the rotator cuff (an incomplete tear of the rotator cuff) was found in 45.1%. The acromiohumeral interval was 9.69mm (average). The shapes were flat type of the acromion 43.9%, smooth curve type 41.5%, and anterior hook type 14.6%. Statistically there is a close relation between the high signal intensities in the rotator cuff on the bursal side and the cystic changes in the greater tuberosity. The acromiohumeral interval of patients with subacromial impingement syndrome was within the normal limit. Anterior hook type was the fewest of the three types. So“supraspinatus outlet impingement”(written by Neer) was thought to be few.
Purpose: The circadian rhythm in deep body temperature is characterized by a lower temperature at night. The purpose of this study was to analyze the skin temperature of normal shoulders and those with rotator cuff tears (RCTs), and to determine the relationship between the shoulder skin temperature and night pain in shoulders with RCTs. Methods: The subjects were 13 hospitalized patients with RCTs: 12 patients were unilateral and one bilateral. Eight of the 12 contralateral shoulders of unilateral RCTs showed no abnormalities on MRI without any clinical symptoms, and thus were used as normal shoulders. We attached the probe of a TL 72 portable thermometer to the anterior aspect of each shoulder and measured the temperature every 5 minutes from 12: 30 in the afternoon to 9: 30 the next morning. After the moving averages over a one-hour range were calculated, the differences between temperatures at one-hour intervals from 13: 00to 9: 00 were evaluated with an ANOVA. Eight patients reported night pain during the temperature measurements. Results: Both in the normal and RCT shoulders, skin temperatures at night were significantly lower than those during the daytime(p<0.05). Night pain was frequently observed between midnight and early in the morning when the temperature was at its lowest. Conclusion: The shoulder skin temperature of both the normal and RCT shoulders showed a circadian rhythm with a low temperature during the night. Night pain was frequently observed at and around the lowest skin temperature. Low temperature during the night may be related to the occurrence of night pain.
(Purpose)This study was undertaken to obtain more detailed information about the degenerative changes and integrity in the rotator cuff and compared those with operative findings. (Materials and methods)The subjects were 75 patients(79 shoulders)who had underwent shouder sonography before surgery for the rotator cufftears, impingement syndrome, frozen shoulder, shoulder instability or a sport's injury. The age ranged from 17 to 88 years, with a meanage of 59.4 years. There were 120 controls, 120(240 shoulders)people who had had nosymptoms in the shoulder and whose ages ranged from 10 to 92 years, with an average of 57.4 years. Bilateral sonographies using a 7.5 MHz linear phased transducer were performed on all the patients. The findings abnormalities were evaluated. 1) a hizh-echovenicity. 2)a low-echozenicitv between the rotator cuff and the humeral head,3)a low-echgenicity in the rotator cuff,4)irregularity of the rotator cuff, and 5)non-visualization of the rotator cuff. The echogenicity of the rotator cuff was compared with the deltoid muscle was classified 3types. typel: Rotator Cuff>Deltoid. type2: Rotator Cuff=Deltoid. type3: Rotator Cuff<Deltoid. (Results)The complete tears all had abnormalities. All echogenic abnormalities were detected in cases of complete tears while only 1),2)and 4) were found in incomplete tears. There were no echogenic abnormalities in other disorders. The Typel was noted in patients ranging in age from 10 to 40 years, types 2 and 3 in patients from 40 to 90 years. Particularly, those patients of advanced age(>70years)had many more abnormalities. (Conclusion)These date indicate that echogenicity of the rotator cuff and its abnormal findings were observed as being related to the aging development.
The clinical results of rotator cuff surgery were usually satisfactory. However, in some cases, the clinical symptoms recurred after rotator cuff surgery. We wish to present five cases of subcoracoid impingement syndrome after surgery of the rotator cuff tear. Five patients were diagnosed as having subcoracoid impingement syndrome after the surgery for a rotator cuff tear. The average age of the five patients was 66 years (60 to 78 years), All the patients had had Neer's anterior acromioplasty and surgery for a rotator cuff tear (repairs-2, latissimus dorsi transfer-1 and partial resections-2). The tear size of the rotator cuff at the initial surgery was two incomplete and three massive. Subcoracoid impingement syndrome was diagnosed by effective subcoracoid block with 1.5cc of 1% Lidocaine. All the patients had anterior shoulder pain at horizontal flexion, the x-rays revealed a superior migration of the humeral head. CT findings represented a narrowing of the coraco-humeral space. Coracoplasty was performed on three patients, after which, their symptoms disappeared. Intraoperative findings revealed degenerative changes of the subscapularis tendon and anterior of the humeral head in all cases. The coracoacromial ligament was adherent to the deltoid in two cases. Subcoracoid impingement syndrome is one of the important causes of anterior shoulder pain after surgery for a rotator cuff tear.
(Purpose)To clarify the mechanism of suprascapular nerve palsy caused by a ganglion cyst, we examined 9 suprascapular nerve palsy patients who had surgical treatment. (Patients and methods)The patients were 7 males and 2 females with solitary suprascapular nerve palsy. Age at onset, physical examinations, EMG, MRI and the operative findings were evaluated. (Results)The age at onset was from 22 to 54 years old with an average 33.7 years old. Their symptoms were dull pain and pain during movement of their shoulders. There was muscle atrophy of the infraspinatus muscle(ISP)in all the cases and the supraspinatus muscle(SSP)in 6 cases. Abnormal EMG's were found in ISP in all the cases and SSP in 4 cases. According to the MRI, there were ganglion cysts on the spinoglenoid notch with a low intensity on Tl weighted images and high intensity on T2. The high signal intensity of an atrophic ISP in 3 cases on Tl and 6 cases in T2. The ganglion cysts were removed and the inferior transverse scapular ligaments were cut with the posterior approaches. The cysts were gourd spape and constricted with the inferior transverse scapular ligament and the base of the scapular spine. The genglion cysts caused compression of the suprascapular nerve under and medial of the inferior transverse scapular ligament. Ganglion cysts appeared from the labrum-joint capsule complex at the postro-superior part of the glenoid. After the operations, all the patients recovered from their palsy in spite of one recurrence of the ganglion cyst. (Conclusion)Ganglion cysts appeared from the labrum-joint capsule complex, spread into the space under the inf. trans. scapular ligament and caused compression of the suprascapular nerve.
Purpose: The purpose of this study was to clarify the scapular deviation at rest in throwing athletes. Materials and methods: There were nineteen baseball players with a scapular deviation (Group 1) out of 133 patients with a sports injury of the shoulder. They had pictures of their backs with some markings taken while sitting on a chair. The pictures were scanned by computer and the position of the inferior angle of the scapula, the distance from the spine to the medial margin of the scapula and the upward rotation angle of the scapula was measured.20 patients with another shoulder injury (Group 2) and 20 men without any shoulder problems (Group 3) were measured similarly. Results: Group 1: Their mean age was 19.6 years. They had anterior shoulder pain when throwing for months. They had could deviate their scapulas up and laterally on their own. They all had a positive impingement sign. Their scapular deviations recovered as their pain decreased.9 were diagnosed as having impingement syndrome,6 subacromial bursitis and 4 tendinitis of the cuff. The measurements of the scapula were as follows: In Groupl the painful scapula had deviated a mean of 1.5cm up,1.6cm laterally and the upward rotation angle was less than4.3°. Groups 2 and 3 had no lateralizations.53%of baseball players with shoulder injuries showed a scapular deviation. Conclusion: As a scapular deviation was observed in over half of the baseball players with a shoulder injury, we emphasize that a scapular deviation is a significant sign of a throwing injury of the shoulder.
We wish to report on the analysis of arm rotation during abduction of the shoulder.7 normal male's right shoulders were chosen for this study. Their arms were put in braces from their shoulder to their wrist joint in order to keep their elbow in an extended position. An equilateral triangular shaped lead with sides 40mm in length was fixed to the proximal end of these braces with the triangular base parallel to the longitudinal axis of the braces and perpendicular to the horizontal axis of the braces. All the examinations were performed in a sitting position. The subjects were asked to elevate both their arms in the scapular plane and the resting position was considered as the starting point. Right scapulo-humeral rhythms were recorded continuously with an image intensifier, video recorder and computer. The upward rotation angles of the arm at every 10-15 abducted position were calculated with the three edges of the triangle described above. There were individual variations of arm rotations, as well as of the change of rotation in the starting phase. However, after 40 degrees of elevation, the rotation was smooth and increased to 1.0 degrees for each 10 degrees of abduction in 4 subjects and decreased to 1.2 degrees for each 10 degrees of abduction in 3 subjects. From this study, we can easily suggest that an analysis of the arm rotation is useful for patients with a disturbance of the scapulohumeral rhythm.
(Purpose)We wish to report the results of reconstructing massive rotator cuff tears by the McLaughlin procedure or a fascia lata patch grafting. (Patients and methods)Since 1992 we have perfomed the McLaughlin procedure on 4 patients and fascia lata patch grafting on 7 patients to reconstruct massive rotator cuff tears measuring more than 5cm. The mean patient's age was 59 years. The Pre-and postoperative JOA scores were evaluated and the factors contributing to the results were investigated. (Results)The JOA scores of the patients who underwent a McLaughlin procedure averaged 60 points preoperatively and 92 postoperatively. The JOA scores of the patients who underwest a fascia lata patch grafting averaged 58 points preoperatively and 84 postoperatively. All but one patient were satisfied with the results. One patient's old rupture of the long head of the biceps tendon was not reparable and persistent weakness of his shoulder muscle led to unsatisfactory results. In another patient whose long head of the biceps tendon dislocated and was sutured to the rotator cuff, the dynamic electromyograghy demonstrated that the biceps cooperated with the repaired cuff. (Conclusion)The long head of the biceps could play an important role in elevation of the shoulder following repair of a massive cuff tear.
The purpose of this study was to investigate the effects of puming therapy for rotator cuff tears. We reviewed 15 patients treated by pumping therpy (pumping group). Another 15 patients were followed conservatively (conservative group), and 13 patients(medium or small rotator cuff tears) underwent a rotator cuff repairing procedure (repairing group). The clinical outcome of each case was evaluated at pretreatment and at follow-up, using the JOA scores and the improvement ratio of the JOA scores. There was no statistical difference among the three groups in the avarage age. The period from start of each treatment to improvement of symptom was significantly shorter in the pumping group (4.1months) than that of the conservative group (6.3 months)(P<0.05). The total JOA score of the puming group changed from 31.3 (pretreatment) to 67.0 (at follow-up), whereas the changes of the scores in the conservative group and the repairing group were from 34.0 to 62.3, and from 34.0 to 70.6, respectively. The total score of the pumping group (at follow-up) was as same as that of the repairing group. The improvement ratios of the total JOA scores were 73.5(%) in the pumping group,61.9(%) in the conservative group, and 79.4(%) in the repairing group. Although massive tears need repairing, we concluded that the pumping therapy may be a better choice of treatment than conservative therapy for medium or small rotator cuff tears. The maneuver of pumping enlarges the capsule of the shoulder joint and bursa gently. It may also improve the local circulation, and is effective in the improvement of pain, functional ability, and ROM.
We reviewed the cases of 44 patients with 45 tears of the rotator cuff which had been surgically repaired. The average age at the time of operation was 59.8 years(range 40 to 76 years). An anterior acromioplasty was performed on all the cases. McLaughlin's method was used in 34 shoulders, whereas side-to-side suturing was applied in nine, advancement of the supraspinatus in one and a graft of the fascia lata in one. All the patients had an eary rehabilitation program within one week after surgery for their rotator cuff repair, using a continuous cervical epidural anesthesia(CE)or non-steroid anti-inflammatory drugs (NSAIDs). CEs were done pre-, intra-and postoperatively in 41 cases, for 27 of which a CE was also used for rehabilitation for one to three weeks at the longest. In the remaining cases, pain was controled only with NSAIDs. Passive elevation was started within two days to one week, and active elevation within three to four weeks. The postoperative results were assessed according to the scoring system of the Japanese Orthopedic Association(JOA score). The total JOA scores were significantly higher with 65.0 before the operation,81.5 in the third month and 93.1 in the sixth month (p<0.01), and later staying on a plateau with 94.1 in the ninth month,96.0in the twelfth month,94.8 in the eighteenth month and 97.1 in the twenty-fourth mouth after surgery. With the cooperation of anesthesiologists, we performed pain control primarily with CEs and started exercises within one week to obtain favorable results.
The convalescence of those cases with rotator cuff tears treated by McLaughlin' s method were investigated. The results of the operation were evaluated and problems during treatment were discussed. 29 cases (29 shoulders) with rotator cuff tears were operated on. There were 21 men and 8 women aged from 45 to 62 years (average 58.6 years). The 29 cases consisted of 6 small tears,9 medium tears,6 large tears and 8 massive tears. The follow up period was from 1 year to 8 years and 5 months (average 3 years and 7 months). Our indication of operative treatment is based on 3 points. They are 1. under 65 years old,2. the patient's social background (job, ADL, etc.) and 3. severe shoulder pain. The clinical results were evaluated using the JOA score system and questionnaires on the patients satisfaction and problems they had during treatment. The average JOA score improved from 48.5 to 91.6 points.89% of the patients returned to their previous jobs. However,65% of the patients had expected to return to their jobs earlier than they actualy did.73% of the patients answered that the postoperative exercises had been hard. McLaughlin's method based on our qualified indication is useful for rotator cuff tears. But for massive tears, if tight sutures are required, another method should be selected. In order to get the patient's good satisfaction, postoperative care should contain excercises and there should be enough informed consent
Stress X-p in the evaluation of anterio-posterior instability of the shoulder joint with the shoulderpositioning-Telos device was examined because the diagnosis of shoulder instability has not been established. 23 normal male joints without shoulder instability were evaluated. Their ages ranged from 19 to 38years with an average of 26.1 years. The device was positioned with its lower side on the edge of the x-ray table. The patient was seated and his 90° abducted arm (in the scapular plane) was positioned in the device. Shoulder fixation pads were adjusted on the coracoid process and the spine of the scapula. Tho x-ray beam was directed in a 30°angle (frontal plane). For evaluation of anterior instability the pressure support was fixed dorsaly to the shoulder onto its base on the device and the pressure was gradually increased up to 15daN. A pressure support pad was positioned approx.2cm lateral to the edge of the acromion. For the evaluation of posterior instability the pressure support pad was positioned approx.7cm lateral to the edge of the coracoid process. The 60°external rotation of the upper arm was achieved by positioning the lower arm on the“lower arm positioner for 60°”We measured the translation fate of the head. Shoulder 90°abduction⋅neutralrotation. Ant. instability. average 2.98±6.495(SD)% Post. instability. average 3.89±5.43 (SD) % Shoulder 90°abduction⋅60°external rotation. Ait. instability. average 1.17±4.37 (SD) % The shoulder-positioning-Telos device seems to be useful for evaluating shoulder instability.
[Purpose] We treated type 3 acromioclavicular dislocation (Tossy's classification) by a modified Dewar's method, and evaluated the results after follow-up for more than 4 years. [Subjects and methods] Between 1987 and 1992,15 patients with acromioclavicular dislocation were operated on at our department by a modified Dewar's method. Eleven patients (8 men and 3 women) who were followed-up for more than 4 years were studied. Their mean age was 32.2 years. Nine patients had a fresh dislocation and 2 had an old dislocation. Temporary fixation of the acromioclavicular joint with Kirschner wires for 6 weeks was added to the original Dewar's method. Stockinet Velpeau external fixation was applied for 3 weeks, after which Codman's exercises were started. We evaluated the shoulder joint function using the Japanese Orthopaedic Association's (JOA) score and Kawabe's criteria. [Results] The mean follow-up period was 64 months. The mean JOA score was 94.3 points and all 11 patients had an excellent outcome. The mean score for Kawabe's criteria was 91.1 points, with 8 patients rated as excellent and 3 as good. [Conclusion] We treated acromioclavicular dislocation by a modified Dewar's method and achieved good results.
Many treatment options for an acromioclavicular joint dislocation have been proposed in the literature, and which have both merits and demerits, we did a retrospective review of 16 patients who had undergone treatment by coracoacromial ligamentoplasty for an acromioclavicular joint dislocation. The sixteen patients were operated on for acromioclavicular dislocation. The average age was 41.9years(range 19 to 55 years). Thirteen were men, and 3 were women. Seven of the 16 patients were injured in a traffic accident. Six were injured doing sports. Five patients were first seen more than 4weeks after their injury. All the cases but one were considered to be type IV dislocathion according to Rockwood's classification. The remaining case was type V. The operative technique was derived from the Cadenat and involved using a screw to fix the bone tip attached with the coracoacromial ligament to the clavicular end. X-rays during the postoperative period showed residual separation of the acromioclavicular joint in only three cases. But none had any obvious recurrence. Fourteen patients(87.5%)were satisfied with their results. According to Kawabe's scoring system, the results were similar in both acute and chronic cases of acromioclavicular dislocations. Ligamentoplasty employing the coracoacromial ligament gave good operative results in types IV and V acromioclavicular dislocations. The acromioclavicular ligament is ideally suited to perform ligamentoplasty for an acromioclavicular joint dislocation.
(Purpose)Acromioclavicular(A-C)arthrosis is diagnosed with pain of the A-C joint, the existence of an A-C painful arc and osteoarthropathy on radiograph. We examined characteristic MR images useful for the diagnosis of symptomatic A-C arthrosis. (Materials and methods)We studied 15 shoulders in 13 cases with symptomatic A-C arthrosis. There were 11 males and 2 females,7 cases were on the right side and 8 cases on the left, and ranging in age from 24 to 63 years(mean 45 years). Scanning was performed on a GE 1.5-T magnetic imaging system using surface coil. T1-weighted and T2-weighted sequences of all the patients were obtained in the oblique plane along the supraspinatus muscle. (Results)In shoulder radiography, osteoarthropathy was recognized in 4, but decidedly not in the other 11. In the MR images, we recognized hypertrophy of the distal clavicle in 8 and its atrophy in 7. Irregularities of the distal clavicle were seen in all 15 and small subchondral cysts were seen in 7. Swelling of the articular capsule was recognized in 10 and fluid stagnation in the articular capsule existed in 8 of them. (Conclusion)Symptomatic A-C arthrosis was classified into 2 types, one the hypertrophy type and the other the atrophy type had configurations of the distal end of the clavicle in MR images. When comparing the operating findings, there were irregularities and a cyst in the distal clavicle reflecting damages of the disk, the articular cartilage and the subchondral bone. Furthermore, in symptomatic A-C arthrosis, the high incidence of swelling of the articular capsule accompanied by fluid stagnation was confirmed.
We investigated the clinical results of humeral head replacement and the influencing factors affecting the results. Twelve shoulders of 11 patients were followed-up. Six patients were male and 5 patients were female. Humeral head replacement was performed on these patients. The patients' age at operation averaged 56.3 years. The follow-up period ranged from 8 months to 17 years and 8 months (average 4 years 1 month). Preoperative diagnosis was dislocation fracture of the proximal humerus in 6shoulders, non-union in 2 shoulders and avascular necrosis of the humeral head in 4 shoulders. The operative results were evaluated according to the shoulder evaluation sheet of the Japan Orthopaedic Association. (JOA score). The average postoperative JOA score was 69.8 points (46-97 points). The average shoulder elevation was 84.6±39.1°. The roentgenograms showed an inferior subluxation in 4 shoulders. The average points of the JOA scores of 4 shoulders with underlying complications such as other injuries and axillar nerve palsy was 59.5±9.3 points. In 8 shoulders without such complications, the averages of the JOA scores was 74.9±16.4 points. The averages of the elevation angle in shoulders with an inferior subluxation was 56.3±17.9°. The average of the elevation angle in shoulders without an inferior subluxation was 96.3±41.4°. From the results of this study, it can be concluded that the prognosis is poor for patients with underlying complications and an inferior subluxation.
(Purpose)We know about the destruction of a shoulder joint by rheumatoid arthritis(RA), but this report concerns a case which was complicated by a posterior dislocation. (Case)A 73-year-old female underwent treatment for RA in the last decade. In July 1994, she began to have pain in her left shoulder joint and found it difficult to raise her left arm. She consulted a clinic nearby, where she was diagnosed with a posterior dislocation of the left shoulder joint. Then she was referred to our hospital in February 1995. Her left shoulder joint was such that the humeral head contacted with the rear part of the acrmion, and the ROM was significantly limited. The posterior dislocation was confirmed on two-directional X-rays. As conservative therapy led nowhere, we opted for a total shoulder replacement(TSR) in November 1995. Deformity of the humeral head, destruction of the posterior part of the glenoid, and a torn supraspinatus were observed. Her JOA score preoperatively had been 22 but improved to 59 nine months after the operation. (Discussion)Destruction of shoulder joints by RA is common, but no reports have appeared on a pathologic posterior dislocation. There was no traumatic mechanism for this dislocation, thus leading us to consider arthral destruction as being responsible for the posterior dislocation of the shoulder joint. We opted for a TSR as treatment hoping to get rid of the pain and improve ADL.
This report describes the result of shoulder motion measurements in a patient with sternocostoclavicular hyperostosis in whom all the ligamentous structures around the clavicle became ossified during a clinical course of over 20 years. A 59-year-old man visited us in 1995 complaining of pain and limitation of motion in his right shoulder that had been lasting for a couple of years. He first noticed pain and swelling of the right clavicular region at the age of 32.Staphylococcus aureuswas cultured from the right clavicle in 1975. He also had been experiencing repeated low back pain. The laboratory tests in 1995 were positive for CRP and negative for the rheumatoid factor and HLA-B27. The x-rays showed bilateral sternocostoclavicular hyperostosis, ossification of the right coracoclavicular ligament and ankylosis of the right acromioclavicular joint. The motion of the right shoulder was 80°in flextion,15°in extension,30°in abduction,30°in adduction, -5°in external rotation and the right buttock in internal rotation posteriorly. When the arm was elevated in the scapular plane, the rotational arc was 80-90°below 60°of elevation, whereas it decreased to 20°in 70°elevation and 5°in 80°, i. e., maximal elevation. This was most probably because the complete ossification around the clavicle held the scapula unrotated during the arm movement so that, at the arm-trunk angle of 80°, the humerus reached a position equivalent to the 'pivotal position'in a normal shoulder.
There are few reports about a case rotator cuff tear with an intraosseous ganglion. We wish to report two cases here. A 44-year-old man (Case 1) was referred with right shoulder pain to us. There was no history as to the cause. He was suffering from motion pain and nocturnal pain. Shoulder motion was slightly limited. Plain X-ray showed a lytic appearance in the proximal of the humeral head. The MRI is demonstrated a low intensity by T1-weighted images and a high intensity by T2-weighted images. Arthrography revealed a complete cuff tear. A rotator cuff tear with an intraosseous ganglion was diagnosed and operated on. The operative findings showed a 1.5×1.0 cm size supraspinatus tear and an intraosseous ganglion which had transparent jelly contents. The histological finding was an inner layer of fibrous connective tissue without any lining cells. A 48-year-old- man (Case 2) felt pain in his left shoulder when he lifted a heavy object. He complained of moderate rest pain and slight restriction of the ROM of his left shoulder. The MRI findings were similar to case 1. The intraoperative findings were a supraspinatus tear with the intraosseous ganglion in the posterior portion of the greater tuberosity. An intraosseous ganglion of the humeral head is rare and its correlation with the cuff tear was unclear. In both cases, the genesis of the intraosseous ganglion cyst may be related to a long-term impingment between the greater tuberosity of the humerus and the acromion.
Two 14-year-old girls with voluntary dislocations of the shoulder were operated on. They had been suffering from symptoms of instability and we were impressed by their shyness. Their instabilities were multi-directional. Their shoulders' arthroscopes exhibited only a loose capsule and glenohumeral ligament without any bony displasia or osteochondral injuries. They could stop moving and dislocate shoulders voluntarily, after we explained them and their mothers that this motion deteriorates their symptoms. Case 1 inderwent a capsular shift and case 2 an arthroscopic capsulorraphy. The average morbid period was 16 months and their average follow-up period was 10 months. Their average JOA score was 73 points before surgery and 98 points after. There were no further redislocations or complaints of dullness. This ssems a less invasive method to treat patients to control voluntary dislocations.
(case 1) A 75-year-old female with a recurrent shoulder dislocation. As the chronicity of the dislocating increased, so did the difficulties of reduction. There was a compression defect in the articular surface of the humeral head. The humeral head was locked on the rim of the glenoid. Since the humeral head redislocates easily, resection of the humeral head was performed. Three years after surgery she had regained motion as follows: elevation 90°, external rotation 50°, internal rotation to L1. She had pain and a click when she elevated her shoulder. The radiographs showed the humeral head elevated toward the glenoid and made a hinge joint. (case 2) A 76-year-old female with a recurrent shoulder dislocation. Dislocation was impossible to reduct because of a depression fracture of the humeral head. Resection of the humeral head was performed. Five years after surgery she had regained motion as follows: elevation 120°, external rotation 10°, internal rotation to L5. She had no pain. The radiographs showed the interval between the humeral head and the glenoid had become narrow. (case 3) A 47-year-old female with tuberculous arthritis. The humeral head was destructive, so a curettage and resection were performed. Six years after surgery she have regained motion as follows, elevation 110°, external rotation 10°, internal rotation to L5. She had pain and a click in elevation. In the radiographs the humeral head had elevated toward the glenoid and made a hinge joint. Pain relief in elevation was good, but there remained motion pain in the internal rotation. In the radiographs, a year after surgery the edge of the humerus was V-shaped. Two years after surgery, the humerus had made a hinge joint with glenoid. The Shoulder Joint, Vol.21, NA,547-551,1997. (Discussion & Conclusion) In resection of the humeral head, as time passes the elevates upward and makes a hinge joint with the glenoid. After surgery, elevation is good, but rotation is limited. Patients complain of motion pain in internal rotation. Indications should be considered carefully.
Tumoral calcinosis is a rare disorder manifested by a large calcific mass, and associated peripheral nerve damage has been described previously in only one literature. We will report on an axillary nerve palsy caused by periarticular tumoral calcinosis in a patient undergoing hemodialysis. The patient presented himself with a painful mass in the left shoulder, and weakness in joint elevation, which we diagnosed as an axillary nerve palsy. The patient's calcium-phosphorus product in the serum was elevated. Radiographic appearances of the mass was like an amorphous lobulated calcification. The palsy was diagnosed as being caused by the mass, and was treated operatively. The axillary nerve palsy was compressed by the mass, tumoral calcinosis, then the mass was resected. Postoperatively, the nerve function was recovered. The resected mass comprised of a thick connective tissue septa and cavities filled with a dense milky substance. It is important to recognize that tumoral calcinosis may cause a nerve palsy located adjacent to it.
We surveyed the relationship between shoulder pain and the severity of Diabetes Mellitus. Two hundred and seventy-eight out-patients at our diabetic clinics were examined. There were 137 males and 141females aged from 21 to 91 years(mean 62), with an average of treatment of 14 years. They answered questionnaires with a visual scale system on their then present and past shoulder symptoms. We examined the laboratory data on the blood sugar values, HbAlc and the ophthalmic fundus findings. The incidence of present pain in patients on a diet was 18.8%, those taking oral medication-19.4%and those receiving insulin injections was 23.3%. The average blood sugar values and HbAlc were hligher in patients with painful shoulders then in the pain-free ones, though there were no statistical differences in either value. There was a higher incidence of painful shoulders in cases of ophthalmic fundus of proliferative or preproliferative diabetic retinopathy then in those of simple diabetic retinopathy or nondiabetic retinopathy. Eighty-eight patients(31.6%)had a history of shoulder pain at the mean age of 51,11 years after the diabetic treatment. The incidence of past shoulder pain in patients on a diet, taking oral medications and insulin injections was 16.2%,35.0%and 38.5%, and the mean duration of pain of each group was 1.0,2.7 and 3.7 years, respectively. These data may give a hint as to what to anticipate in the prognosis of shoulder pain in diabetic patients.
(Purpose) Shoulder pain is a common complaint of hemodialyzed (HD) patients. But the pathogenesis of such an arthropathy is still poorly understood. We investigated plain X-P, MRI, and the pathological findings in shoulders of HD patients and discussed about the pathogenesis of the their shoulder pain. (Materials and methods) Sixteen patients (29 shoulders) with shoulder pain, who had undergone HD for an average of 14 years, were studied. Their average age was 63 years old. Plain X-P and MRI findings of their shoulders were evaluated and synovial tissue of the subacromial bursa (SAB), which was obtained from a synovectomy of the SAB, was also evaluated. (Results) With the findings of plain X-P, there was only 1 case of definite joint destruction. From the MRI findings, in over half of all the cases, there was glenohumeral synovitis or subacromial bursitis. The rotator cuffs showed a deposition of amyloid and its mean thickness was 5.9 mm. Six patients (7shoulders) underwwent a synovectomy of SAB. In all the cases, we identified a deposition of amyloid in the synovial tissue. (Conclusions) From the MRI findings and pathological findings of synovial tissue, the pathogenesis of shoulder pain in HD patients are amyloid induced synovitis and. rotator cuff tendinitis.
(Purpose) Functional impairment of the shoulder joint is often seen in patients with rheumatoid arthritis (RA), but complaints concerning the acromioclavicular (AC) joint are rare. Still, various changes are observed including joint effusion, synovial proliferation and cartilage destruction. The purpose of this study is to evaluate the changes of the AC joint by ultrasonography and radiography. (Materials and methods) Twelve AC joints of 6 cadavers without RA,2 males and 4 females with a mean age of 85.0 years, were evaluated by ultrasonography and anatomized. Sixty shoulders of 30 patients with RA who visited our institution were evaluated by ultrasonography and radiography. There were 5 males and 25 females with a mean age of 60.0 years (range 28 to 72 years), and with a mean disease duration of 18.0 years (range 1 to 43 years). Changes of the AC joint (narrowing of the joint space, erosion, osteolysis and tapering) were studied by ultrasonograms and radiograms. (Results) In the anatomical observation of cadavers there were 10 shoulders with no change in the AC joint. Narrowing of the AC joint was found in 2 shoulders. Swelling of the AC joint was found in 2shoulders. These findings were confirmed by ultrasonography. On ultrasonograms, there were 11 shoulders with no change in the AC joint. These 11 joints ranged from stage 0 to III radiographically. Narrowing of the AC joint was found in 9 shoulders, AC joints with wide cranial sides and narrow caudal sides were found in 21 shoulders. Most of these 30 shoulders were stage II radiographically. Widening of the AC joint with erosion of the joint surfaces was found in 13 shoulders, most of which were stage II and N. A wide gap between the osteolytic distal end of the clavicle and the acromion was found in 6 shoulders. Swelling and effusion of the AC joint was found in 13 shoulders. As for radiography, changes of the AC joint including narrowing of the joint space, erosion, osteolysis and tapering could be confirmed by ultrasonography. In addition, swelling and effusion of the AC joint could be detected by ultrasonography. Ultrasonography can be useful in evaluating the condition of the AC joint in RA.
The interobserver reliability of the Neer and AO/ASIF classification systems were assessed on the basis of plain radiographs. At least three of four radiograph projections were made; these include an anteroposterior projection, an axillary projection, a scapula lateral projection and a bicepital groove projection of the shoulder. Using the Neer classification system, each fracture was classified into 16types. Using the AO/ASIF classification system, each fracture was classified into 3 types,9 groups and 27 subgroups. Forty-four fractures of the proximal end of the humerus were classified by three shoulder specialists and one orthopaedic resident. Then, kappa coefficients between every possible pair were calculated. The mean kappa coefficient for interobserver reliability of the Neer and AO/ASIF classification systems were 0.547 and 0.378, respectively. Simplification of the Neer and AO/ASIF classification systems, from 16 categories to 6 categories and from 27 categories to 9 categories, respectively, did not significantly improve the interobserver reliability. The mean kappa coefficient of the Neer system was higher than the AO/ASIF system. But both classification systems were difficult to apply in a reliable manner. The differences in classification between each observer may reach a different method of treatment and provide a surgeon with a different estimation of the outcome of that treatment.
Ten patients underwent a hemiarthroplasty for displaced fractures and/or dislocations of the proximal humerus. There were nine women and one man with an average of 73 years. The average patient follow-up was 41 months. Six patients had an acute 4-part fracture and/or dislocation, two had a non-union of the surgical neck, and one had a chronic 2-part posterior fracturedislocation, and the last one osteonecrosis. The average postoperative JOA score was 78.2, range 51 to 96. The average motions were forward elevation,103°; external rotation,28°; and internal rotation to L3. Two failures occurred. One patient had a rotator cuff tear associated with degeneration, the second patient incurred a posterior dislocation spontaneously. Hemiarthroplasy for fractures and/or dislocations of the proximal humerus is technically demanding. While anatomical reattachment of the greater tuberosity, restoration of the lever arm, and enthusiastic postoperative rehabilitation contribute to achieve satisfactory results, it appears that rotator cuff degeneration associated with trauma and aging limits the shoulder function.
The purpose of this study is to investigate MRA findings of initial traumatic anterior dislocation of the shoulder after 4 weeks immobilization, and to clarify the treatment. Twenty-two shoulders with an initial traumatic anterior dislocation were evaluated. There were 17males and 5 females with an average age of 30.6 years(range18`76years). T1 weighted images in the transaxial plane were obtained after injecting 15cc of Gd-DTPA diluted by saline. MRA findings were classified into the following three types. Type I: The ligament-labral complex is detached. Type II: The ligament-labral complex is not detached. Type III: with a bony fragment. The Caspari procedure was performed in 8 cases of Type I with an apprehension sign. There were 14 cases of type I,7 cases of type II and lcase of type III. The average age of type I was 26.4 years and of type II 31.3 years. The percentage with an apprehension sign in type I was 92.9% and in type II 14.3%. The detachment of the ligament-labral complex was confirmed by arthroscopy in 8cases treated by the Caspari procedure. After surgery, the apprehension sign disappeared in all the cases and neither dislocations nor subluxations have reccurred in any of the cases. The ligament-labral complex was detached in 63.6% of initial traumatic anterior dislocations after 4weeks immobilization. Because the apprehension sign is liable to remain in type I, cases of this type should be treated by an arthroscopic Bankart repair, especially when we consider their age and sctivities.
In this study we investigated the pathologies of an initial anterior dislocation of the shoulder by arthroscopy, and reported of the results of an arthroscopic Bankart repair (Caspari's method). Sixteen cases of intial traumatic anterior dislocation of the shoulder were treated. The intra-articulate pathologies of all the cases were investigated, and the Bankart repair was performed using Caspari's method. Arthroscopic examination showed that the AIGHL-labral complex(AIGHLC) was detached from the glenoid rim in all the cases. Twelve (75%) of the patients had inferior displacements of the AIGHLC and 4 (25%) patients had medial displacements. The average Rowe score was 94 points (80-100), and there were no recurrences. In conclusion, detachment of the anterior labrum from the glenoid rim, and inferior and medial displacements of the AIGHLC are thought to be the main lesions of anterior instability. Caspari's method is effective for preventing recurrence because it repairs the Bankart lesion and shifts the AIGHLC.
[Object] Traumatic anterior instability of the shoulder joint has been surgically treated by combined a modified Bristow method and a capsular shift method. The necessity of surgical intervention in the articular capsule is discussed based on the results of the follow-up. [Subjects] This study's subjects consisted of 55 patients with anterior dislocation or subluxation of the shoulder joint with a history of a frank trauma. They were aged 14 to 44 years at the time of surgery ( average 23.2 years). [Method] The 55 patients were operated on by a modified Bristow method combined with a capsular shift method. The results of the treatment were evaluated according to the evaluation criteria of the JOA scores. The pre-operative condition of the capsule was assessed by arthrography and a postradiography CT. [Results] There was no recurrence of a dislocation in any of the patients. The anterior instability of the shoulder joint improved satisfactorily, apprehension signs disappeared in all the patients except two. The mean JOA score markedly improved from 75.9 pre-treatment to 92.1 post-treatment. [Conclusion] The results obtained by the methods under discussion were very satisfactory, patients were only left with a slight limitation of external rotation. We suggest that there is aggressive intervention of the capsule in cases of anterior capsule injury, this treatment is indicated.
(Purpose) The purpose of this study was to evaluate the operative results depending on the external rotation angle at capsulorrhaphy. (Materials & methods) Seventy-seven shoulders(56 men and 21 women)were examined clinically and with CYBEX testing. The minimum follow-up was one year(average 2.7 years)after a modified inferior capsular shift(MICS)procedure. The average age at surgery was 18.7 years. Preoperatively,7shoulders(9%)showed concomitant inferior instability. Capulorrhaphy was performed with the external rotation angle at 10 degrees in 43 shoulders(10-group)and at more than 25 degrees in 34 shoulders(25group). (Result) One recurrence occurred in an epileptic patient(1.5%). External rotations were examined in the anatomical and at 90 degrees abduction positions. The average limitations of external rotation on the operated side in both the 10-and 25-groups in the latter position were 14.8 and 5,0 degrees, which were not statistically different from each other. In the CYBEX testing, the peak torque rations(peak torque of the operated side/peak torque of the non-operated side)were greater in the 25-group than the 10-group in external rotation at both 30 degrees and 90 degrees of abduction(t-test, P<0.01). (Conclusions) MICS procedure was excellent in controlling recurrent anterior instability of the shoulder. However, the postoperative range of external rotation can be increased by an altered rehabilitation program and the position of immobilization.
The purpose of this study was to clarify the relationship between the arthroscopic findings and physical findings in recurrent anterior dislocation or subluxation of the shoulder. Forty-seven shoulders with recurrent anterior dislocation or subluxation were evaluated. There were 34males and 13 females with an average age of 22.4 years (range,15-47 years). The patients were divided into two groups by arthroscopic findings: band type of AIGHL (group A) and membranous type of AIGHL (group B). We statistically evaluated the sex, age, age of initial dislocation, period after initial dislocation, past history of trauma, apprehension test, relocation test, internal and external rotation, Sulcus sign and Bony Bankart. There were significantly differences between group A and group B in sex, period after initial dislocation, past history of trauma, Carter's sign and Sulus sign. The sex, period after initial dislocation, past history of trauma, Carter's sign and Sulcus sign were useful to decide the scopic indication before surgery of a recurrent anterior dislocation or subluxation.