The collagen fibrils of rotator cuffs were analyzed quantitatively from the transmission electron microscopic photographs.
(Materials and methods) Specimens of rotator cuffs were obtained from 22 patients aged 44 to 81 who had undergone surgery. Eighteen cases of rotator cuff tear (massive 7, large 4, medium 6 and small 1)and 4 cases of non-tear (fracture 2, calcium deposit 1 and impingement 1) were available. In the rotator cuff tear cases, the biopsies from the superficial and deep layers of the proximal stump(PS&PD), distal stump(D) and non-torn site(N) were performed. In the non-tear cases, biopsies from the superficial and deep layers(SL&DL) were carried out. Collagen fibrils were magnified 150.000 times by electron microscope. Quantitative analysis of the collagen fibrils were performed using a personal computer: the fibril diameter, the occupied area percentages (the sum of each fibril area/total area X 100 %) and the fibril density (the number of fibrils per square micro-meter).
(Results) The average diameter: PS 50nm, PD 45nm, D 44nm, N 48nm, SL 68nm and DL 59nm. In PS, unimodal diameter distributions (small diameter peak at 50 nm) were observed in 13 of 18 cases (72%). In SL, bimodal diameter distributions (small diameter peak at 50 nm and large diameter peak at 120 nm) were observed in 3 of 4 cases(75%), The average occupied area percentages: PS 48%, PD 44%, D 43%, N 54%, SL 53% and DL 46%. The average densities: PS 172, PD 208, D 193, N 208, SL 113 and DL 143.
(Conclusion) In both the rotator cuff tear group and the non-tear group, the average diameters of collagen fibrils were larger in the superficial layers than in the deep layers. The mass-average diameter of collagen fibrils in non-tear cases was larger than that in the tear cases. The non-tear cases have bimodal distributions which are made up of large and small diameter fibrils. On the other hand, the tear cases have unimodal distributions which are made up of small diameter fibrils. In tear cases, the large diameter fibrils may become small because the tensile stress decreases.

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The puropose of this study was to investigate the relation between the morphology of the acromion and the spur at the antero-inferior surface of the acromion. This investigation was performed on 268scapular dry bone specimens. These specimens of 107 males and 34 females were used. Their ages ranged from 20 to 83 years with an average of 57 years. The presence of spurs of the acromion were identified. All the acromions were classified as type I (flat), type II (curved) or type III (hooked) as described by Bigliani et al. The slope of the acromion was measured in all the spcimens, as well.
Spur at the antero-inferior surface was seen in 129 acromions(48.1% ). Almost all the spurs were located in the anterior one third of the acromion. In all the specimens, eighty-six acromions(32.1%)were type I, one hundred and thirty-nine(51.9%)were type II and forty-three(16.0%)were type III. The type of acromion was not related to whether there was the presence of a spur or not. The average slope of all the acromions was 47±8°, that of the acromions with a spur was 44±7°and that of the acromions without a spur was 50±8°. There was a significant difference between the slope of an acromions with a spur and one without a spur. From this study, we conclude that the type of acromion had no relation to a subacromial impingement and the flattened slope of the acromion might be one of the causes of a subacromial impingement.

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The operative findings of 12 patients with bilateral ratator cuff tears were reviewed to find out the characteristics of the tears. All the patients were men aged from 37 to 69 (mean 55) years. Six cases were heavy labourers and the others were engaged in sedentary work.
The macroscopic findings of the torn stumps were investigated. The presence of a traumatic history, the duration between the onset of the symptoms and the operations and the shapes of the acromions were also evaluated.
Results
Three cases had significant traumas in bilateral shoulders and three cases had them unilaterally. The other six cases had atraumatic onsets of symptoms. Both acromions were identical in shape in 11cases, and classified as Bigliani's type 2 (curved) in 10 cases, and type 1 (flat) in one case. The intraoperative findings showed bilateral incomplete tears in three cases, bilateral small tears in five cases and bilateral large tears in one case. The other two cases had different sizes of complete tears. The torn stumps of six cases were studied histologically. Most of them demonstrated similar findings in both the degenerative and reactive changes in bilateral shoulders.
Conclusion
There were similarities in both types of tears and histologic findings in bilateral rotator cuff tears.

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The purpose of this study was to determine the relationship between the glenoid osteophytes and superior translation of the humeral head during arm elevation in shoulders with rotator cuff tears. The inferior margin of the glenoid was observed on A-P x-rays of 52 shoulders (14 normal controls,9 partialthickness tears and 27 full-thickness tears), and the incidence and shapes of the osteophyte were examined. Next, A-P x-rays with the arm at 0°and 45°of abduction in the scapular plane were taken. The superior translation of the humeral heads were measured by digitizing the reference points. Hooktype osteophytes were observed more in shoulders with full-thickness tears than in the other groups. There were no significant differences in the superior translation of the humeral heads among the three groups. The superior translation in shoulders with hook type osteophytes was significantly larger than those with sharpening-type and elongation-type osteophyes (p<0.05). The superior translation of the humeral head observed in shoulders with rotator cuff tears seems to be related to be formation of hook-type osteophytes at the inferior portion of the glenoid.

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(purpose)
The description of incomplete rotator cuff tears using arthrography seems to be difficult. The purpose of this study is to evaluate the diagnostic value of cine radioarthrography.
(Materials and methods)
The subjects consisted of eighty shoulders of 80 patients who had been diagnosed as incomplete rotator cuff tears clinically; consisting of 62 males and 18 females, ranging in age from 16 to 75years(average,51.7 years).
The types of tears were 70 shoulders with articular side tears,8 with intratendinous tears and 2 with bursal side tears.
The arthrographic findings were compared to the surgical findings retrospectively.
(Results)
Fifty-five shoulders,68.7% showed pooling of the contrast medium in the rotator cuff and 25 shoulders,31.2% showed leakage to the subacromial bursa. In articular side tears,50 shoulders had pooling and 20 had leakage, in intratendinous tears,5 shoulders had pooling and 3 shoulders leakage, and in the bursal side tears,2 shoulders had leakage.
(Conclusion)
1) The findings of leakage to the subacromial bursa in 25 shoulders could represent the existence of a microperforation even in an incomplete rotator cuff tear.
2) It was suggested that cine-radioarthrography could be useful and necessory for the diagnosis of an incomplete rotator cuff tear.

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Forty consecutive patients (average age,54 years) who underwent surgery for rotator cuff tendinopathy between June 1994 and June 1996 were studied to determine physical findings characteristic to partial-thickness tears of the rotator cuff. There were 19 full-thickness tears,15 partial-thickness tears (3 articular side,6 bursal side,4 intratendinous, and 2 combined), and 6 tendinitis. The evaluated findings were: pain (motion pain, rest pain, and night pain), muscle atrophy (deltoid and infraspinatus), tenderness (greater tuberosity, lesser tuberosity, intertubercular groove, coracoid process, infraspinatus, and acromioclavicular joint), the range of motion (flexion, abduction, internal rotation, and external rotation), impingement signs (Neer and Hawkins), supraspinatus test, external rotation strength, and lift-off test. Among these findings, significant differences were observed in the following: 1) atrophy of the infraspinatus,2)strength in the supraspinatus test, and 3) strength in external rotation. Atrophy of the infraspinatus was more commonly observed in full-thickness tears (79%) than in the partial-thickness tears (7%) and tendinitis (33%)(p=0.0010). Normal strength in the supraspinatus test and in external rotation were less frequently observed in full-thickness tears (0%,11%, respectively) than in the partialthickness tears (33%,53%) and tendinitis (67%,50%)(p=0.0028, p=0.0070). From these results, we conclude that the characteristic physical findings of partial-thickness tears are less atrophy of the infraspinatus and better preserved strength than in full-thickness tears. These findings, however, are similar to those observed in tendinitis, which makes it difficult to differentiate partial-thickness tears from tendinitis.

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(Purpose)The purpose of this study is to evaluate the sonographic diagnosis of subacromial impingement syndrome (SIS) e. g. subacromial bursitis and/or tendinitis (Grade I) and incomplete rotator cuff tears(Grade II).
(Materials and methods)83 cases of SIS were operated on from 1994 to 1996 after a sonographic examination using a Toshiba SSA-250A with a 7.5 MHz by the same staff member. There were 24 Grade I, 20 Grade II(8 bursal-side tears; BT,4 intratendinous tears; I T, and 8 joint-side tears; JT), and 39 Grade III (complete rotator cuff tears)lesions. The diagnostic criteria for Grade I were a thickend cuff tendon and/or fluid collection in the bursa, and for Grade II, surface irregularity and/or echogenic material in the cuff tendon. At operation, palpations, color tests and a trial tenotomy were variously employed to confirm any concealed pathology. Comparisons were made between the preoperative sonograms and operative findings.
(Results)In Grade I lesions, the sensitivity was 41.7%, specificity,80%, positive predictive value,71.4%and accuracy,59.1%. In Grade II lesions, consisting of BT, It and JT, the sensitivities were 75%,50% and 12.5% respectively, specificies,80.6%,85% and 94.4%, the positive predictive values.46.2%,25% and 33.3%, and accuracies,79.5%,81.8% and 79.5%.
(Discussion)This is the first report on the sonographic diagnostic rate concerning the BT, IT, and JT separately. The sonographic diagnosis of IT was effective.
(Summary)1) Sonographic findings in subacromial bursitis, tendinitis and incomplete rotator cuff tears were compaired with the operative findings.2)The accuracy of the sonographic diagnosis was 59.1% in Grade I lesions and 79.5% in BT,81.8% in IT and 79.5% in JT.3) Sonographic screening of IT was useful in deciding on a trial tenotomy.

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(Purpose)In this study we investigated the role, the usefulness and limitation of ultrasonography in detecting incomplete rotator cuff tears.
(Materials and methods)The subjects were 70 patients (73 shoulders) who had undergone shoulder sonography prior to surgery and arthroscopy. Their ages ranged from 17 to 88 years, with a mean age of 58.6 years. Bilateral sonography was performed on all the patients using a 7.5 MHz linear phased transducer and the measurments were taken in both the long and short axis scans. Bilateral ultrasonographies were performed before a double contrast arthrogram of the symptomatic side. If a complete rotator cuff tear was not diagnosed by the arthrogram, the ultrasonography was performed again. We called this method“enhanced ultrasonography”. We diagnosed a complete rotator cuff tear by finding nonvisualization, defects and thinning of<4mm and an incomplete tear by finding defects, thinning and a high echogenic region.
(Results and Discussion)18 out of 74 cases of incomplete tears were surgically comfirmed. Of these,7 of the 11 joint-side tears,1 of the 2 of the intratendinous tear,1 of the 2 intratendinous tears and 1 of the 5 bursal-side tears were diagnosed by ultrasonography. With enhanced ultrasonography, the diagnosis rate of joint-side tears was 86% (6 out of 7 joint-side tears). The diagnosis of bursal-side tears and intratendinous tears was difficult compared with that of joint-side tears. Enhanced ultrasonography may be useful for the diagnosis of incomplete rotator cuff joint-side tears.

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Sonographic findings in partial thickness tears of the rotator cuff of the shoulder were compared with operative findings.
The subjects were 45 patients(32 males and 12 females)with partial thickness tears of the rotator cuff ranging in age from 15 to 75 years(mean 39.2 years)who underwent operation after sonographic examination. The injuries were bursal side tear in 20 shoulders, articular side tear in 20, and intratendinous tear in 5.
Ultrasonography(US)was performed with a 7.5-MHz linear scanner. Measurements were made in both long and short axis scans. The changes in the echogenicity of the rotator cuff layer were evaluated and classified into 4 types: typel(homogeneous), type2 (high-echoic), type3(low-echoic), and type4 (heterogeneous). Type2,3, and 4 changes were regarded as signs of tear.
Thirty shoulders(66.7%)of 45 shoulders were positive in ultrasonography. Of which 11(55%)were positive in 20 shoulders with bursal tear,14(70%)of 20 shoulders with articular side tear, and all in 5 shoulders with intratendinous tear. Eight shoulders of 13 of grade I of Snyder's classification were positive (61.5%),13(72.2%)in 18 of the grade II, and 10(90.9%)of 11 shoulders of grade III and IV.
Ultrasonography was useful in screening of tears and degeneration of the rotator cuff, but discrimination between partial tear and complete tear was diificult.

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Many authors have reported that anterior dislocations of the shoulder are often associated with rotator cuff tears in older patients. After manual reduction, some patients complain of pain and functional disability. If conservative treatment is not effective, there are two operative methods. One is a rotator cuff tear repair alone, and the other is repairing a cuff tear together with a Bankart lesion. Usually, we operated a cuff repair alone in such cases. The purpose of this study is to assess our operative cases retrospectively, and to clarify the indications for and limits of a cuff repair.
15 patients with no axillary nerve palsy were operated on. They consisted of nine males and six females with an average age of 65 years. The rotator cuff was repaired alone in all the cases except one(Case 3). The clinical results were evaluated according to JOA score and discussed with respect to the size of the tear, the exsistence of a Bankart and Hill-Sachs lesion, whether recurrent or not, the stabiity and reductional sensation at manual reduction.
The average preoperative JOA score was 46 points and the postoperative one was 86 points. Three cases redislocated. Case 1 and case 3 redislocated in some everyday motion, but Case 2 fell. There were nine cases of a small tear of the supraspinatus, two of which (Case 1 and Case 3)redislocated. A Bankart lesion was found in seven cases, five of them had a supraspinatus tear only, and a Hill-Sachs lesion was found in seven. In five recurrent cases, only one (Case 3)dislocated again. Case 1 and Case 3 had poor reductional sensations at manual reduction.
In summary, repair of the cuff alone is almost sufficient in the older cases. Two of the redislocated cases; case 1 and case 3, which a small tear and a poor reductional sensation, can imply that an anterior capsular mechanism is associated, and a Bankart repair is sometimes needed.

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There is no consensus of the surgical method for a massive rotator cuff tear that can not be repaired by McLaughlin's procedure. We performed reconstructive surgery with a tuberculum majus transfer (Tm transfer) as reported by Paavolainen in such cases.
During the 7 years since 1989, we performed a Tm Transfer on 7 patients, of whom 6 (5 males and 1 female) were observed for 1 year or more and included in this study. The right side was affected in 5 patients and the left side in the other one. The age of the patients at the time of surgery was 47-76years (mean,62.8 years). The follow-up period was 13-86 months (mean,42 months). The massive cuff tear was complicated by a glenoid fracture of the scapula in case 1 and by a rupture of the long head of the biceps brachii in case 2.
Tm transfers alone were performed on 2 patients. Tm transfer was combined with a supraspinatus advancement (Debeyre) in 3 and with a trapezius transfer (Mikasa) in 1. In the patient with a glenoid fracture, osteosynthesis of the glenoid fracture was performed in combination with a modified Bristow's procedure. The postoperative results according to the JOA score and X-ray films were evaluated for these patients.
The mean JOA score before surgery was 44.2 points but markedly improved to 90.3 after surgery: pain, from 12.4 to 28.8; function, from 6.3 to 19.8; range of motion, from 11 to 22.7. The mean acromiohumeral interval increased from 7.4mm before the operation to 10.8mm after it.
We recommend the use of the rotator cuff itself in reconstructive surgery of massive cuff tears. The teres minor is often preserved even in a massive tear, and a Tm transfer using this muscle is useful.

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The manage ment of the deltoid in a rotator cuff repair is still controversial. The purpose of this study was to analyse the functional recovery of the deltoid by using surface EMG.43 shoulders of 43 patients with a rotator cuff repair were examined before and 2 months after surgery. There were 32 males and 11 females, ranging in age from 33 to 78 years(mean: 59.02 years). Surface EMGs were measured in the deltoid(anterior, middle and posterior fiber). Each muscle activity was recorded under the maximum isometric contraction for five seconds. A computer system managed the described data and calculated the integrated EMG. All the subjects underwent an acromioplasty and they were then divided into two groups according to the management of the deltoid, group A consisted of 29 patients with a nondetached the deltoid, group B consisted of 14 patients with a detached deltoid. In the reattachment of the deltoid, the muscle fiber was jerked up to the acromion in order to give the muscle a favorable tension.
All three fibers showed excellent recovery after surgery compared with before. The percentage of recovery rate(after surgery/before surgery%)indicated 140.11% in the anterior fiber,152.71% in the middle fiber,124.92% in the posterior fiber.
There was no statistical difference between group A and group B (p<0.05)in the percentage of recovery rate of the detachment of the deltoid.
In a cuff repair, a lot of factors such as age, sex, size of cuff tear and morbidiy period influence the surgical results. However, the recovery of the detached deltoid had the same reasonable results as the recovery of a non-detached deltoid on condition that the muscle fiber was tense.

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Neural end organs in the human shoulder joint capsule were observed under a light microscope. The specimens were stained by an immunohistochemical method with the anti-protein gene product 9.5.
Three distinct neural end organs were identified: free nerve endings, Ruffini corpsules and Golgi tendon organ like-receptors.
Free nerve endings, which may function as pain receptors, were distributed widely in the capsule. Spray formed Ruffini corpuscles were distributed widely in the capsule. Spray formed Ruffini corpuscles were sporadically recognized in the fibrous layer. Golgi tendon organ like receptors, which were arranged like plaques side by side, were often located in the boundary zone between the fibrous layer and outside of the capsule.
It is of great interest that Golgi tendon organ like-receptors often exist in the anterior part of the joint capsule, suggesting that these proprioceptive receptors are related to the shoulder joint stabilizing mechannism.

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(purpose)Shoulder pain occuring in patients on long-term hemodialysis is very severe during hemodialysis and sleeping at night, and is a characteristic finding not observed in other diseases. We performed arthroscopic debridements on those cases with good results. However, the cases of this pain has not been confirmed. To clarify the mechanism of this pain, we histologically examined tissue specimens obtained during surgery.
(Materials and methods)Specimens of the synovium and cartilage were obtained from the glenohumeral joint(GH-j) and subacromial bursa(SAB) at the time of arthroscopic debridement. These specimens were stained with Congo-red, and the localization of the amyloid was evaluated by polarizing microscopy. Nerve cells were examined by S-100 staining and vascular hyperplasia by a α-smooth muscle actin(α-SMA)staining.
(Results)Amyloid was present in the synovium, on the sinovial surface, and on the cartilage suface. In the synovium, there was no increase in the number of nerve cells. The blood vessels in the synovium had deceased. These findings were similarly observed in the GH-j and SAB.
(Conclusion)No increase was observed in the nerve cells in the synovium, and the number of blood vessels was decreased. However, the disappearance of pain after a synovectomy and debridement suggests that amyloid deposition in the synovium and on the cartilage surface trigger pain.

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(Purpose) We reported that the patterns of shoulder joint destruction in RA could be classified into 5groups: Non-progressive(N), Erosive(E), Osteoarthritis-like(O), Collapse(C), and Mutilating(M) types. The natural course of progression and the prognosis differ for each of the 5 types, and can be classified between 5-10 years after the onset of RA. This classification is helpful in planning treatment for a RA shoulder. In this study, the results of arthroscopic synovectomy for rheumatoid shoulder joints were assessed separately for each shoulder joint destruction pattern, and compared.
(Patients and methods) Arthroscopic synovectomy was performed on 15 shoulders of 13 RA patients. The subjects were 10 females and 3 males, the average patients age was 51 years, and the average disease duration was 11.1 years. When these 15 shoulders were classified by pattern of destruction,8 joints were considered E type and 7 joints N type. Among the Japan Orthopedic Association shoulder scoring systems, pain, function and the ROM scoring systems were used for pre-and post-operative estimates. The average duration of follow-up was 9.3 months.
(Results) Overall pre- and post-operative scores were 36.6 and 62.2 in the N group and 39.7 and 49.7 in the E group, respectively. Improvement of the overall score was significantly higher in the N group than in the E group. Pain, function and ROM were improved in both the N and E groups postoperatively, and the improvement of ROM was significantly higher in the N group than in the Egroup.
(Conclusion) We performed arthroscopic synovectomy of the shoulder joint for less destructive types, such as the N and E types. Although the follow-up periods were short, the results were good. Especially, the results of arthroscopic synovectomy for N type shoulders were good, showing improvement of not only pain but also the ROM.

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Nonunion of the surgical neck of the humerus which is underlain by osteoporosis in many cases, often challenges treatment. In this report, we evaluated the results of treatment by the operative procedures.
We studied 7 shoulders of 7 patients who were treated by the operative procedures for nonunions of the surgical neck of the humerus in the 9-year-period of from 1985 to 1994. They included 3 males and 4 females aged from 34 to 76 years(average60). The mean initial treatment-to-surgery interval was 9months(range 2 months to 1 year and 10 months). Autogenous bone grafting was carried out on all the patients, using a 95 angle plate in 2 patients and K-wires with tension band wiring in 5 patients.
Good union was obtained in all the patients, the mean period to union being 5 months(range 4 to months). None of them experienced any pain in their day to day activities, and they all returned to their pre-injury occupations or their full range of normal activity. But it took them 6 months to 1 year and 10 months(average 11 months)to restore their maximum range of montion. The patients were left with some restriction of motion, compared with the intact side.
If such on immobilization can be accomplished that a firm fixation, especially in rotation, is achieved, the prognosis would be rather favorable. Therefore, operative procedures should first be considered when a nonunion of the surgical neck of the humerus is encountered instead of hemiarthroplasy.

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The purpose of this study is to examine the effects of conservative treatment of initial traumatic anterior dislocation of the shoulder.
Materials and methods: From December 1985 to April 1995,527 patients with traumatic anterior dislocation of the shoulder were initially treated at Zao hospital. Questionnaires about the history of the dislocation, glenohumeral joint stability, immobilization time and other factors were sent to them by mail in December 1995. Then the frequency of instability, the relevant prognostic factors and the effects of immobilization after the initial dislocation were statistically analyzed.
Results: Three hundred and twenty-four patients answered the questionnaire, including 176 with initial dislocation. One hundred and fourteen (65%) had no instability, while 62 (35%) had instability (44 with a redislocation and 18 with an apprehension of dislocation) at an average follow-up of 50 months after the initial dislocation. Shoulder instability was present at the follow-up in 65% of 20 patients under 20years of age. The rate decreased to 40% in 102 patients aged 20 to 29 years, and was only 4% in 24 patients over the age of 40. The rate was 55% in 29 patients with less than 1 week of immobilization, but decreased to 23% in 89 patients with more than 3 weeks of immobilization. The rate in 20 patients with a greater tuberosity fracture was significantly low (5%). We also assessed the incidence of shoulder instability in relation to both age and immobilization time in patients without a greater tuberosity fracture. More than 3 weeks of immobilization was not such an effective treatment for patients under 20years of age, but effective for patients over 20.
Conclusion: The age at the time of the initial dislocation, the presence of a greater tuberosity fracture and the immobilization time were significant determinants of shoulder instability after an initial dislocation. More than 3 weeks of immobilization was not such an effective treatment for patients under 20years of age, but effective for patients over that age.

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Five macaca mulattas were our subjects, and we conducted examinations of their scapular movements with elevations of the upper extremities in the scapular plane and flexion-extentions in the horizontal plane using radiography and a video camera. As a result of the examinations we recognized coordinated movements of the scapula of the upper arms, known as the gleno-humeral rhythm, in both motions. We have already suggested that a gleno-humeral rhythm exists in all of the various movements of the upper extremities in our previous motion analysis of human scapulas, at that time, we used on X-ray CT or VICON for the horizontal flexion-extention of the shoulder joint. A comparative anatomy, shows that both the Monkey family and the genus Homo have similar structures. The results of this present report support this, and further confirm that the scapula and the clavicle's movements are always co-ordinated with the upper arm. The trend is usually to ignore the movement of the scapula except for in the elevation of the shoulder joint, and consider the scapula to be fixed to the truncus. That is probably because; it is difficult to distinguish the movement of the scapula from that of the truncus; clinically there are a very limited number of impairments and opportunities for therapy of scapulo-thoracic joints; there is no precise and simple, easy way to analyze the movements of the scapula; and therefore, interscapulo-thoracic muscles should be omitted. However, we suggest here that we should take the movement of the scapula into consideration with regards to sports activities or the mechanism of impairments since this scapulo-thoracic joint originally has a considerably large ROM and an important function.

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(Purpose)
The degeneration of the rotator cuff increases with aging. Reports of rotator cuff tears of both sides are, however, limited in number. The purpose of this study is to elucidate the abnormal findings of asymptomatic contralateral shoulders on MRI in patients with rotator cuff tears.
(Materials and methods)
MRIs of 108 asymptomatic shoulders were evaluated to determine the prevalence of findings consistent with tears. The findings were analyzed regard to age, the episode of traumas, the tear types of the affected side and the occupations. The patients consisted of 65 males and 43 females with an average age of 58 years(32 to 87). A 1.5T MRI was utilized to obtain an oblique coronal plane imaging.
(Result)
Forty-two cases(39% )had tears in the supraspinatus tendons of the asymptomatic side. The incidence of cuff tears was 15% in patients under 60 years and 66% in those over 60. Tears were seen in 11% of forty-six cases who had traumatic episodes, and 60% of sixty-two cases who had no traumas in the affected side. In relation to the tear types of the affected side, the incidence of tears were as follows: 32%full-thickness tears,20% bursal side tears,14% intratendinous tears and 0% articular side tears in patients under 60 years. They were 73%,50%,33% and 63% respectively in patients over 60. Sedentary workers had a higher rate of tears than manual laborers.
(Conclusions)
When a patient over 60 years has a full-thickness tear on one side withont any traumatic episode, the existence of an asymptomatic tear in the contralateral shoulder should be considered.

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Introduction: The supraspinatus tendon attaches to the superior facet and the superior half of the middle facet, whereas the infraspinatus tendon attaches to the entire middle facet, making an overlap between these tendons. Therefore, it seems possible to identify the tendons involved in a tear judging from these facets. The purpose of this study was to differentiate the superior and middle facets on MRI. Materials and methods: Forty-two symptomatic shoulders of 40 patients without a bony spur or defect of the greater tuberosity on plane roentgenograms were enrolled in this study. T1 weighted images in the coronal oblique were obtained using a 0.5-T imager(Yokokawa Medical System RESONA: FOV 17cm, matrix 224×256,5.0 mm thickness/1.0 mm slice gap). The angle between the long axis of the humerus and the superior margin of the greater tuberosity (H-GT angle) were measured and the effect of the rotation of the humerus on H-GT angle was studied using cadaver shoulders.
Results and discussion: The greater tuberosity was visible in 5.1±0.9 slices (avg±SD), H-GT angle of the superior facet was 82.4±8.1°in the anterior 2.1±0.8 slices, and H-GT angle of the middle facet was 58.0±12.0°. H-GT angles of the superior facet and middle facet became closer in external rotation (74.9±9.9°,79.7±3.8°, respectively), and became apart in neutral (83.0±7.5°,58.0±12.0°), and internal rotations (82.5±9.0°,52.2±9.3°). Therefore, neutral and internal rotations seem to be desirable in identifying these facets on MRI.
Conclusion: The superior and middle facets, useful landmarks in localizing rotator cuff tears, can be identified on MRI, especially with the arm in neutral and internal rotations.

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This study was designed to evaluate the value of MR imaging compared with arthro-bursography for incomplete tears of the rotator cuff and to classify the post-operative MRI findings of an incomplete tear. Pre-operative MRI were taken on 42 shoulders and we applied arthro-bursography to 99 shoulders. The pre-operateve MRI findings were classified into complete and incomplete tears which were classified into 3 patterns; high signal of the bursal side of the tendon, intratendinous high signal and high signal of the articular side of the tendon. The post-operative MRI findings were classified into 4 types; Typel-homogeneous pattern, Type2a-partial intratendinous high signal pattern, Type2b-intratendinous high signal pattern in almost all slices of the sutured area, Type3-high signal at the suture site of the bone groove. Sensitivity and specificity of the MRI in incomplete tear cases were 78.6% and 89.7%, respectively. The diagnosis rate of the MRI, especially in the intratendinous tear, was higher than arthrobursography. There was no correlation between post-operative MRI findings and the clinical results. The intratendinous high signal patterns of the MRI at the suture site, which were seen at 6 months postop., tend to become lower in patients with a 1 year or longer follow-up.

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(Purpose) MRI is very useful for the diagnosis of the rotator cuff tear. However, in cases of incomplete tears it is sometimes controvertible. In this study, we studied the accuracy of MRI's. in the diagnosis of full thickness and incomplete tears. We also compared the MRI findings with the operative findings in the assessment of the size of the rotator cuff tear.
(Materials and methods)75 patients who underwent MRI investigation before operation were chosen for this study. There were 69 males and 6 females, ranging from 18 to 80 years(mean: 54.4 years). MRIs were taken with a 1.5T superconductive system with a shoulder surface coil. MRGRT2-weighted images were recorded in the coronal oblique and sagittal oblique planes. A complete tear was diagnosed when a full thickness high intensity was observed in the rotator cuff, whereas a partial high intensity of the rotator cuff was considered as an incomplete tear. The size of the tear was measured in both MRI planes. We compared the size of the cuff tear in the MRI findings with the operative findings.
(Results) The operative findings confirmed complete tears in 59 patients, incomplete tears in 10 patients and no definite tear in 6 patients. On the other hand, MEI's showed complete tears in 54 patients, incomplete tears in 17 patients and impingiment syndrome in 4 patients. MRI demonstrated 89.8% sensitivity,90.5% specificity and 90.7% accuracy in the diagnosis of a complete tear. In the cases of incomplete tear, they were 90.8%,90.5%,88.0%, respectively. A linear regression analysis showed an excorrelation between the MRI assesment and the size of the tear revealed at operation on both planes.
(Conclusion) MRIs provided very useful pre-operative information on rotator cuff tears. In cases of complete tears, the size can easily be determined pre-operatively by an MRI. However, in a few cases of incomplete tears, there were hard to differentiate from the very small tears or the degenerative changes of the rotator cuff.

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We invenstigated the diagnostic capability of MRI for a partial thickness rotator cuff tear. Eighteen shoulders of 18 patients including 14 males (aged 16-71 years with an average 39 years) were scanned in the oblique coronal plane with a 1.0T superconductive MR imager (Shimadzu). T2*-weghted images were available for all of the 18 shoulders and T2-weighted images for 13 shoulders. The diagnoses were confirmed during arthroscopy and/or open surgery. The area of high signal intensity on the image was compared to the location of the tear, which meant the articular surface, the bursal surface or the inside of the rotator cuff. All the shoulders had a high signal intensity area in the rotator cuff both T2*-weighted and T2-weighted images. The location of the tear was pointed out accurately in only 6 out of the 18 shoulders (33%) on T2*-weighted images and in 6 out of 13 shoulders (46%) on T2-weighted images. MRIs did not satisfactorily point out the location of a tear, but was very sensitive to the presof a partial rotator cuff tear. In addition, T2*-weighted images showed the severity and extent of the degeneration and/or inflammation of the rotator cuff. So we believe that MRI is a useful and noninvasive screening method for the indication of arthroscopy and in deciding the surgical treatments.

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The diagnostic value of MRI for incomplete rotator cuff tears is still controversial. We assessed the effectiveness and limits of MRIs retrospectively in surgical cases.
Fifty-five shoulders of 53 cases of incomplete cuff tears including 22 joint sides,28 bursal sides and 5intratendinous tears which were confirmed at surgery. The oblique coronal and saggital planes of T1and T2-weighted images with a 1.5T MR system were obtained preoperatively and compaired with the intraoperative findings.
In the 22 joint side tears, high intensity signals and mderate intensity signals on T2WI were found in 14 cases and in 7 cases respectively, but they were not recognized in one patient with a depth less than one fourth of the tendon thickness(sensitivity: 95%). In the 28 bursal side tears. those signals were found in 17 and 4 cases. The 7 erosive types failed to be diagnosed(sensitivity: 75%), All 5 intratendinous tears showed the high signals(sensitivity: 100%).
For detecting incomplete rotator cuff tears on MR imagings, the lesions must penetrate more than one fourth of the thickness into the tendons.

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(Purpose) The purpose of this study is to clarify the character of magnetic resonance imaging (MRI)of a bursal side partial rotator cuff tear.
(Patients and methods) Thirteen patients (13 shoulders) who had been diagnosed as bursal side partial rotator cuff tear at operation were studied. By Comparison, we investigated 40 shoulders, diagnosed as complete rotator cuff tear, articular side partial rotator cuff tear or subacromial bursitis. MRIs were taken in three directions (oblique coronal, oblique sagittal and transverse). T1 weighted images were obtained using a spin-echo sequence and the T2*weighted ones using a gradient-echo sequence.
(Results) Of the 13 shoulders with a bursal side partial rotator cuff tear, six (46%) had a full-thickness high-intensity area, four (31%) had a bursal side partial high-intensity area and three (23%) had no high-intensity area in the cuff on T2*weighted images. The size of the high-intensity area was under 12mm at the oblique coronal plane. Six shoulders with a full-thickness high-intensity area in the cuff at MRI had a deep type bursal side partial rotator cuff tear. Eleven shoulders (85%) had subacromial bursal effusion. There was no gleno-humeral joint effusion in any of the shoulders.
(Conclusion) MRI of bursal side partial rotator cuff tear has a full-thickness or a bursal side partial high-intensity area in the cuff, subacromial bursal effusion and no gleno-humeral joint effusion.

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Using a VICON system, we conducted a movement analysis of the scapula during pitching motion with two adult males (right-handed). There were a total of seven places where markers were set on the subjects. Three markers were set on the truncus: two on the thoracic vertebrae spinous process and one on the superior border of the sternum. Every two maykers were set to the upper right arm and the scapula, and to the scapula, and two K-wires were inserted into the scapular spine. The results showed a large movement of the scapula, over 30°against the truncus in three planes during a pitching motion which did not involve the stepping forward action. Such a movement was co-ordinated with the movement of the upper arm. Generally speaking, rotator cuffs or gleno-humeral joints tend to be impaired by the pitching motion. Until now, we considered fixing the scapula to the truncus during a pitching motion. However, the results of this present report show that we should consider the scapula as not being fixed to the truncus. Furthermore, we should consider that a decrease in ROM of the scapula may cause an increase in the load onto the gleno-humeral joint. Hence, we suggest that it is important to evaluate ROM of the scapula and the function of the scapulo-thoracic joint as a“pitching motion with less possibility of causing impairment”.

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Exercise in water is used in early rehabilitation programs after shoulder surgery. However, there is no literature on the muscle activities during rehabilitation programs in water. The purpose of this study is to analyze the electromyographic (EMG) activities during static exercise in water and on land. The EMG activities of the rotator cuff muscles were obtained from eight volunteers. Static exercises in ten positions were studied: with 0°,30°,60°and 90°of shoulder flexion and abduction, and three positions of shoulder rotation at 0°abduction. The EMG signals were low-pass filtered, full-wave rectified and integrated for 5 sec. Moreover, the EMG activities were quantified as a percentage of the maximum manual muscle test (% MMT). All the EMG activities in water were very few about 1-11%and decreased when comparing them with those on the ground. In particular, of all the exercises, the supraspinatus activity remarkedly decreased in water. The activity levels of the subscapularis muscle during internal rotation was conspicuously high.
These results suggest that early rehabilitatio n in water after a rotator cuff repair is safe. However, the rotation of a shoulder adduction should be avoided when a subscapularis muscle has been repaired.

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The purpose of this study was to clarify the role of the biceps brachii in the shoulder joint. Ten dominant shoulders of healthy men were studied. The average age was 21.5 yrs. The subjects were sitting and wearing an elbow brace locked in neutral forearm rotation. The peak torque was measured by a Kin-Com AP during isometric flexion and abduction of the shoulder. The electromyographic signals were recorded with surface electrodes from the LHB and the SHB with an NEC Multitelemeter System. The elbow was in 0°flexion and loaded with 30% MVC(peak torque), and EMG signals were collected at twelve different arm positions, which were arm flexion or abduction of 45°,90°and 135°in external or internal rotation. The elbow was then flexed of 90°. The signals were analyzed with respect to the IEMG. Each IEMG value was divided by the IEMG value of the MVC, which was expressed as %MVC. The signal levels increased for each externally rotated position in both heads at an increasing angle of flexion or abduction. The EMG level increased at external rotation in each elevated position. Higher activity was found in the LHB when the arm was medially rotated than in the SHB. Both heads of the biceps brachii are always active during an arm flexion or abduction. We suggest that the biceps brachii could act as a dynamic stabilizer of the humeral head.

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[Purpose] We studied the angular velocities of the trunk and upper extremities using a 3D analyzing system to analyse the throwing motion.
[Materials and methods] Ninety best pitches, which 34 baseball pitchers(14 professionals,5 semiprofessionals,15 high school players) threw, were examined. The throwing motions were recorded by two NAC high speed videos. The angular velocities between the two shoulders and the upper arms(shoulders), between the upper arms and the fore-arms (elbows), the fore-arms and balls(wrists), between the two shoulders and the pelvis (trunks) were calculated. Measurements were taken of the acceleration phase and the follow through phase.
[Results] The angular velocities of the trunk showed first the peak level during from 10% to 30% of the acceleration phase. Then, the peak levels of angular velocities successively improved in the shoulder (from 40% to 60%), the elbow and the wrist (from 80% to 100%).
In the follow through phase, the angular velocities of the shoulder increased again right after the ball release.
[Discussion] The throwing motion is based on the rotation in the throwing plane. According to our results, the rotational energy transferred smoothly from the proximal to the distal parts of the body, as shown in the changing peak levels of the angular velocities. We believe that pain or fatigue prevent an efficient energy transmission and this strain results in a throwing injury.

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(Purpose)We studied the treatment of little league shoulder clinically and radiographically. (Materials and methods)We examined 43 shoulders to compare the clinical findings with the widening of the proximal humeral epiphyseal plates radiographically.
(Results)The healing time when there was a restriction i n throwing, was on average within 3 months for the 1mm widening group and within 6 months on average for the 2-4mm widening group.
(Conclusion)There should be a connection between coaches, trainers and doctors, which do es not always mean there has to be a long discontinuance of throwing until radiographical healing.

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(Purpose)We Studied the diagnosis and surgical management of suprascapular nerve entrapment neuropathy in athletes.
(Materials and methods)Eighteen patients with infraspinatus muscle atrophy were studied. Fourteen were men and 4 women. Their mean age was 27 (range 14 to 40) years. The diagnosis was confirmed by physical and electromyographic examinations. As an ancillary test, MRIs of the shoulder joint were obtained. Those patients with rotator cuff tear were excluded from this study.
(Results)Electromyographic examinations showed an abnormality in 8 patients. Two of them had isolated paralysis of the infraspinatus muscle. We operated on 4 patients with suprascapular nerve entrapment. We performed a release of the superior scapular transverse ligament on 2 patients with paralysis of the supraspinatus and infraspinatus muscles, a shaving of the spinoglenoid notch on a patient with isolated paralysis of the infraspinatus muscle and removed the ganglion cyst in 1. All the patients had good results, however, they needed 1 or 2 years to recover from paralysis.
(Conclusion)Early diagnosis and treatment are important for the management of suprascapular nerve entrapment neuropathy in athletes.

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We routinely prescribe a strength training program of the shoulder muscles for injured athletes, which consists in, after elevating the arm to the zero position, flexing and extending the elbow in the scapular plane grasping a rubber band, which offers a suitable resistance to the movement. This method is effective in our clinical experience.
We evaluated the work of the rotator-cuff muscles in this training through MRI(relaxation time of T2), and the purpose of this paper is to show our results. Two kinds of exercises were evaluated: the scapular plane exercise (described above), and the rotational exercise in which the athletes stretch the rubber band from the abduction-external rotation position to the elbow extended-internal rotation position. We examined the differences in strength and the relaxation time of T2 of the rotator-cuff muscles, before and after the exercise. In this experiment, ten healthy volunteers exercised until the“very, very hard level”in the Rating of Perceived Exertion. Results; The strength of abduction and external rotation was decreased after the exercise. After the scapular plane exercise, the relaxation time of T2 increased on a nerage from 30.4 ms to 34.0±2.0 at the supraspinatus (p<0.01), from 30.6 ms to 33.6 ms at the infraspinatus (p<0.01),31. O ms to 34.2 ms at the subscapularis (p<0.05).
After the rotational exercise, the results were from 31.1 ms to 33.6 ms at the supraspinatus (p<0.05), from 31.3 ms to 32.9 ms at the infraspinatus (ns),29.8 ms to 38.1 ms at the subscapularis (p<0.01). MRI suggested an excessive load at the subscapularis in the rotational exercise, but in our training, the load was divided evenly between the three rotator muscles.
Clinically, patients suffering from shoulder pain can perform this training immediately without pain. The training exercises can be modified to simulate pitching or other movements. We consider this training a good way to treat sports-related shoulder injuries.

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(Purpose)
Injuries to the superior labrum of the shoulder called SLAP lesions are often successfully managed with arthroscopic treatment. This study presents the postoperative results of the cases of arthroscopic debridement only for SLAP lesions.
(Materials and methods)
23 patients could not reflect when doing the exercises for the rotator cuff muscles and mobilization of the shoulder joint, and had SLAP lesions at the time of arthroscopy. There were 15 males and 8 females in this study. The average age at the time of surgery was 23 years, with a range of from 16 to 29 years old. The torn and frayed labral tissue was debrided back to the intact labrum with a motorized shaver vial in all cases. The postoperative follow-up average was 27 months (15-38 months).
(Results)
SLAP lesion was classified by Snyder's classification of lesions. The findings were classified as follows: Type I: 13 cases, Type II: 10 cases, Type III: 1 case and Type IV 2 cases. The mean JOA scores were as follows: (preoperative/postoperative) Type I: 86.2/96.6, Type II: 82.1/91.6, Type III: 88/100 Type IV: 89/100.
(Conclusion)
Type II means that the superior labrum and attached biceps tendon were stripped off the underlying glenoid. Many authors were said that it is necessary to promote healing of the avulsed labrum to the underlying bone. However our technique for these cases were debrided back to the intact labrum. The results of this study are sufficient enough to warrant a debridement in a labrum lesion that could enhance stability.

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[Purpose] Until 1992 we had been performing modified Phemistef's procedure and coraco-clavicular ligament reconstruction with an artificial ligament for acromioclavicular dislocations. Since 1993 we have been employing modified Cadenat's procedures. The purpose of this study was to evaluate these three different procedures for acromioclavicular dislocations.
[Materials and methods] This study involved 25 patients with a mean age at surgery of 34.6 years (range 15-76). A modified Phemister's procedure was performed on 10 patients and a coraco-clavicular ligament reconstruction with an artificial ligament was performed on 6 patients. Nine patients were treated with a modified Cadenat's procedure.
[Results] At the final follow-up, the radiographic evaluations showed 5 residual subluxations of the 10 patients treated with a modified Phemister's procedure, and 4 residual subluxations and 1 dislocation of the 9 patients treated with a modified Cadenat's procedure. In six patients treated with a coracoclavicular ligament reconstruction with an artificial ligament, three patients showed subluxations and 2 patients showed dislocations. Using Kawabe's rating system, clinical results were excellent in 13 patients (52%), good in 7 patients (28%), fair in 5 patients (20%). The differences in these three different procedures were not significant.
[Conclusion] Modified Phemister's procedures and modified Cadenat's procedures for acromioclavicular dislocations showed satisfactory results in both radiographic evaluations and clinical results. Coracoclavicular ligament reconstructions with an artificial ligament showed poor results radiographically, and did not seem to lead to any unsatisfactory clinical outcomes.

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(Purpose) We used Wolter clavicular plates for the surgical treatment of injury of the acromioclavicular lesion. This study introduces the technique, examines the postoperative results, and reports on the usefulness of this method.
(Materials and methods) Twenty-eight patients with injury of the acromioclavicular lesion who had been treated between September 1992 and June 1996 were used for this study. The subjects consisted of 25 males and 3 females, aged from 17-62, of whom 14 were injured on the right side and 14 on the left. Of the 28 patients,16 were classified as acromioclavicular dislocation of Toss's grade III,10 as distal end clavicle fractures, I as acromioclavicular dislocation with a coracoid process fracture, and I as a distal end clavicle fracture with an avulsion fracture of the coraco-clavicular ligament.
(Results) The patients conditions were followed-up over a period ranging from 9 months to 3 years and 8 months after the operation. The average Japan Orthopaedic Association's shoulder score was superior at 93.4 points at the time of evaluation. The results were thus excellent.
(Conclusion) Wolter clavicular plates are superior in the following three aspects. Firstly, unlike the Kirschner wire, Wolter clavicular plates, do not damage the acromioclavicular joint. Secondly, they firmly fix the acromioclavicular joint by leverage. Lastly, they enable the shoulder joint to be elevated by 140 degrees or more even during fixation with the plate due to their structure that does not restrict rotation of the clavicle.

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(Purpose) Instability may cause impingement lesions. However, the category of M. D. I. has not been examined yet.
(Materials and Methods) 218 shoulders of 200 patients who had a loose shoulder were investigated.127shoulders underwent conservative treatment, and glenoid osteotomy was performed on 91 shoulders. The range of motion and the painful arc were measured in the motion of anterior elevation, lataral elevation, posterior elevation, horizontal adduction, horizontal abduction and internal and external rotations in the horizontal plane.
(Results) The percentages of pain appearance rate with each motion indicated 18.1%, 28.3%, 18.9%, 21.3%, 22.8%, 22.0%, 26.0% in the non-operative group and 24.3%, 23.1%, 25.3%, 20.9%, 22.0%, 31.9%, 19.8% in the operative group. Each value decreased to 5.5%, 6.6%, 4.4%, 3.3%, 5.5%, 13.2%, 8.8% post-operatively. The arthrograms of each subject did not detect any rotator cuff tears.
(Discussion) The painful arc in the motions of internal and external rotation in the horizontal plane and the motion of horizontal adduction look similar to the impingement sign advocatedby Neer and Howkins. According to our results, between 20% and 30% of the patients with a loose shoulder showed a positive, impingement sign. However, the rate of the painful arc in other motions indicated the same level as the rate of impingement sign which could detect a subacromial impingement lesion. In addition, no cuff tears could represent any actual subacrimial friction. On the other hand, glenoid osteotomy made the glenoid articular surface tilt anteriorly and superiorly. Although the effect of this tilting may cause a subacromial impingement, the rate of impingement decreased after surgery. Therefore, in a loose shoulder, the impingement sign does not always imply the existance of a subacromial impingement. Improvement of instability, not a subacromial decompression should be the advocated treatment for this painful arc.

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We studied the relationship between fatty degeneration in the supraspinatus muscle following a rotator cuff tear and the degree of muscle atrophy, retracted tendon dissecting 22 supraspinatus muscles from 41 cadavers averaging 74.1 years of age. Eighteen shoulders had a supraspinatus tendon tear. The transverse sections of the supraspinatus muscle were made at the proximal end of the scapular notch. The tendon fiber areas were stained red, the muscle fiber areas were stained yellow by the van Gieson method, the fatty degenerative areas were stained orange red by the Sudan 3 method and then measured quantitatively using a computer color image analysis system. There were few fatty degenerative changes in the supraspinatus muscles associated with normal cuffs and they did not correlate with age. But there were many areas of fatty degenerative change, mainly around the tendon fibers and the vessels, in the supraspinatus muscles associated with cuff tears. The fatty degeneration in the supraspinatus muscle following a cuff tear was associated with the degree of retraction of the tendon fiber rather than muscle atrophy. Such fatty degeneration is considered to reduce the remaining function of the supraspinatus muscle with a cuff tear and cause a bad prognosis after repairing a torn cuff.

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[Purpose] Cuff tear arthropathy is the most famous complication of massive rotator cuff tears. In this report, we would like to study and discuss the other complicatons associated with massive rotator cuff tears, and their pathogenesis.
[Patients] We treated 19 cases with complications associated with a massive rotator cuff tear. There were 3 shoulders with cuff tear arthropathy,3 with recurrent intraarticular bleeding,4 with a spontaneous rupture of the deltoid muscle,1 with intraarticular bleeding and, a spontaneous rupture of the deltoid muscle, and 11 with osteoarthritis of the glenohumeral joint.6 males and 13 females were in the group, with the right shoulder involved in 15 cases, the left in 1 case and the both in 3 cases. The average age was 73.7 years (range: 59-88).
[Diagnostic Methods] We investigated there complications using many kinds of diagnostic methods. MRI is one of the best methods to determine the diagnosis of there complications. MRI demonstrated a rupture of the deltoid muscle and intaarticular bleeding clearly.
[Conclusion] There are many kinds of complications associated with a massive rotator cuff tear. The instabilities and weakness of the shoulder joints due to massive rotator cuff tears are the most important factors of the occurrence of these complications. The best prevention is a repair of the rotator cuff, which needs a careful follow-up.

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Purpose
We compared several isometric strengths in order to clarify the reliability of Microfet. Materials and Methods
(Study1) Ten normal subjects
participated in this study. We measured the shoulder isometric strength of,
1) flexion at 90 degrees of flexion,
2) external rotation at 90 degrees abduction, with examinee placed supine, and,
3) abduction at 45 degrees abduction,
4) abduction at 30 degrees abduction and maximally internal rotation, with placed sitting.
(Study2) Six normal subjects
participated in this study. We measured shoulder isometric strength of,
1) flexion at 90 degrees flexion,
2) external rotation at 90 degrees abduction, with placed supine, and
3) flexion at 90 degrees flexion,
4) external rotation at the arm at sibe, with placed sitting. In study 1, we applied the fixation with strapping to all measurements.
In study 2, we applied the fixation to measurements used Cybex, whereas no fixation to Microfet.
Results
1) There ws a high relationship between the two measurements.
2) strength measured by Microfet was significantly greater than that measured by Cybex.
3) Coefficient of variation was no significant difference between the two devices except flexion measured by Microfet with placed supine.
Conclusion
We concluded that Microfet was a clinically useful device to evaluate shoulder isometric strength.

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(Introduction) Shoulder surgeons often perform osteotomy of the tip of the coracoid process to expose the shoulder joint and stabilize the tip to its original position. To fix this firmly, it is important to make a hole in the center of the coracoid before the osteotomy. Because of the coraco-acromial ligament, the teres minor and the conjoined tendon attached to the coracoid process, it is difficult to define the direction and thickness of the coracoid process. We have developed a drill guide to ease the was to make a hole in the center of the coracoid process.
(Method) In 80 shoulder x-rays, the length of the coracoid process was measured in the axial view and its thickness was measured in the antero-posterior view in the fully elevated position. There were 48males and 32 females, ranging from 17 to 39 years old (average 23.4).
(Results) The average length of the coracoid process was 3.7cm and its average thickness was 0.88cm. A drill guide was made based on these data.
(Configuration of the drill guide) The drill guide has a hook and a drill sleeve that slants toward the hook. The distance between the drill sleeve and the hook can be changed from 20 to 60 mm. In order to make a hole in the coradoid process, the hook of the drill guide is placed on the bottom of the process and the drill sleeve is lengthened to the top of the process. A surgeon does not need to hold the drill guide, because the drill guide has a locking system which holds the coracoid process.
(Conclusion) We can drill a hole easily in the center of the coracoid process using this drill guide.

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Purpose
The association of the cervical spine with periarthritis of the shoulder was considered even when there was no obvious radiculopathy observed. Hence, the following examination was performed.
Subjects
The Subjects were 74 patients who were diagnosed with periarthritis of the shoulder. They consisted of 24 men and 50 women, aged from 36 to 75 years (mean 56.1). Each patient was confirmed to be free of obvious causes of shoulder pain such as arthropathic changes, calcification and complete rotator cuff tears. Moreover, patients who had cervical pain or numbness of the upper limbs abnormalities on neurological examinations such as tendon reflex and nerve root irritation test were excluded from this study.
Methods
The anteroposterior diameter of the spinal cacal and the range of motion of the cervical spine were measured from the roentgenogram of the cervical spine. Such parameters were also measured in 54 volunteers who had no history of pain or numbness of the upper limbs(27 men and 27 women, mean age 52.9), and the values obtained were used as the control.
Results
The anteroposterior diameters of the spinal canal were narrower than these in the control group at the levels of C5, C6 and C7 (p<0.05).
The range of motion of the cervical spine tended to be less in the periarthritis group than that in the control group at the level of C2-3 (p=0.06).
Discussion
It is well known that the narrower the spinal canal, the more the disorder of the spinal cord. However we assume that even in a case with no obvious radiculopathy, the cervical apine appears to be involved in periarthritis of the shoulder. Further considerations are required.

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(Materials and methods) Thirty-five shoulder MRI images of 19 RA patients were evaluated. From the MRI images, the thickness of the rotator cuff(supraspinatus: SSP, infraspinatus: ISP, and subscapularis: SBS)was measured, and the cuff tears, the pannus formation and the joint destruction were also observed. The MRI images of 15 normal shoulders were examined as the control.
(Results) A rotator cuff tear was recognized in 4 of the 35 shoulder MRI images. These shoulders were then eliminated from further studies. According to the bone destruction and the pannus formation, the RA shoulders were classified into three groups. A shoulder without a pannus formation or bone destruction was classified as group A(n=5), that with a pannus formation but without any bone destruction was classified as group B(n=16), and that with a pannus formation and a bone destruction was classified as group C(n=10). In group A, the mean thickness of the SSP was 5.29±0.47mm, that of the ISP was 3.08±0.59mm, and that of the SBS was 4.49±0.39mm. No tendons of group A were significantly thinner than the normal tendons. In group B, the mean thickness of the SSP was 3.30±1.28mm, that of the ISP was 3.14±0.80mm, and that of the SBS was 4.55±0.69mm. The SSP tendons of group B were significantly thinner than the normal SSP tendon. In group C, the mean thickness of the SSP was 2.05±0.79mm, that of the ISP was 2.08±0.84mm, and that of the SBS was 3.06±1.29mm. All the tendons of group C were thinner than the normal tendons.
(Summary)The characteristic rotator cuff changes of an RA shoulder were the thinning of rotator cuffs. The thinning of the cuff was mainly seen in the SSP in the early pannus formation stage (Group B), but spread all over the cuff in the joint destruction stage(Group C).

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Although many authors continue to recommend primary operative treatment for an unstable type of distal clavicular fracture because of a high incidence of nonunion and residual shoulder disability associated with non-operative treatment, there are many reports of asymptomatic nonunions resulting from the operative treatment. Our 73 patients with a fresh distal clavicular fracture were reviewed on an average 3 years after their injuries. There were 21 undislocated Craig Type I fractures,39 dislocated Type II fractures,2 intraarticular Type III fractures and 11 dislocated Type V three-part fractures. The patients'age at trauma was 41(16-86)years.20 Type I,13 Type II,2 Type III and 6 Type V fractures were treated non-operatively, and the remainder underwent primary operative treatment. At follow-up,71 shoulders were asymptomatic.2 shoulders of Type II and Type III had moderate pain; no patient had a severe, residual shoulder disability. There were 8 nonunions resulting form 6 Type II (5 had nonoperative treatment)and 2Type V (one had non-operative treatment),7 of these were asymptomatic. The symptomatic nonunion resulting from non-operative treatment was Type II, whose displacement of the proximal clavicle was not superior but just posterior, like Rockwood Type IV acromioclavicular dislocation with a posterior displacement of the clavicular end, and had residual hypermobility of the proximal clavicle. We conclude that an unstable type of this fracture has coracoclavicular ligament injury of various degrees, and the functional healing of this ligament can be acquired even by non-operative treatment to some degree, and is usually followed by a bone union. Even if it is not followed, nonunions with coracoclavicular stability are asymptomatic. The objects of this treatment are a coracoclavicular ligament injury, and the stickiness the bone union gets can be followed by residual disability.

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The purpose of this study is to clarify the factors which advance an initial shoulder dislocation to a recurrent shoulder dislocation using MR imaging.
Eighty-nine shoulders of 82 patients with traumatic anterior dislocations (40 shoulders of initial dislocations,49 shoulders of recurrent dislocations) were examined. The patients with an initial dislocation were checked upon redislocation and instability and given a personal examination or answered a questionnaire on the telephone. Twenty initial dislocations that had been treated conservatively and had observed for over 6 months were divided into two groups. The shoulders of group R were young patients (<30 years old) without a fracture or cuff tear. The shoulders of group N were older patients (>30 years old), with a fracture of the greater tuberosity of the humerus or with a cuff tear, The axial sections of T2* weighted or 3D-STAGE images were obtained using a superconductive MR imager (Shimadzu). The differences of Bankart lesions between the initial and recurrent dislocations were evaluated using Horii's classifications.
Among the initial dislocations, there were 37 out of 40 shoulders in grade 1 with a distinct labrum (92.5%). Of the recurrent dislocations, there were 32 out of 49 (65.3%). There was a statistical difference between the two groups (P<0.01). In R group, all the shoulders with a detached Bankart lesion (>2 mm; 5 shoulders) had a feeling of instability. But only one of four shoulders with an undetached Bankart lesion (<2mm) had it. There was a statistical difference between the two groups (P<0.05)too.
We speculate that an initial dislocation with a detached Bankart lesion (>2mm) will advance to a recurrent dislocation.

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There has been no difinitive treatment for habitual posterior dislocation of the shoulder. The purpose of this study was to evaluate the clinical results of the glenoid osteotomy combined with the posterior capsulorrhaphy for patients with habitual posterior dislocation of the shoulder. There were 5 men and 3 women with an average age at operation of 21 years(range,15-45 years), totally eight shoulders in 8 patients. All of the patients had a positive sulcus sign indicating an inferior looseness in addition remarkable posterior instability. The patients who had remarkable anterior instability(loose shoulder)and could dislocate their shoulders voluntarily were excluded from this study.
An osteotomy was performed so that the atticular surface of the glenoid inclined both anteriorly and superiorly. A bone block taken from the iliac crest, was trimmed to be about 20°wedge-shaped and to extend to the posterior edge of the glenoid and was used for all the patients. The mean follow-up period after surgery was 4.5 years(range,1.4-9.8 years)
Two patients did not improve their posterior instability postoperatively, one had a general joint laxity and the other had an insufficient corrective angle of the glenoid by osteotomy. The other six patients improved their posterior instability and were satisfied with the results. A subacromial impingement occured in one but was successfully managed with an arthroscopic subacromial decompression. So, patient selection and proper surgical techniques seem to be the key factors for successful results.
In conclusion, a glenoid osteotomy combined with posterior capsulorrhaphy was effective for habitual posterior dislocation of the shoulders.

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