The purpose of this study was to clarify the significance of notches of the greater tuberosity (GT notches) in the shoulders of baseball players. [Materials and Methods] Forty-nine beseball players who had injured their shoulders through repetitive throwing and had undergone shoulder arthroscopy were studied retrospectively. A videotaped arthroscopic tour of the shoulder was performed. They ranged in age from 14 to 48 years (average: 23 years). The locations and sizes of the GT notches were determined from the arthroscopic recordings. Then the relationships between the GT notches and several other factors were examined, such as the history of their playing baseball, the history of their pitching, the gleno-humeral joint laxity and the ROM on examination under anesthesia, the location, depth and width of articular-side partial rotator cuff tears (APRCTs), the existence of a posterior rotator interval (post. RI) tear between the supraspinatus tendon (SSP) and the infraspinatus tendon (ISP), and tearing of the postero-superior labrum. Statistical analyses were done using the chi-square test. [Results] The formation of GT notches was recognized in 32 shoulders (65%). They all existed at the insertion of the ISP facing the post. RI, and they extended more caudally (ISP side) as they became larger. Therefore, they were classified into 4 groups according to their size: Group 1: no notch (17shoulders), Group 2: small notches restricted to the post. RI (12 shoulders), Group 3: medium notches smaller than a 1/4 of the ISP insertion (11 shoulders), Group 4: large notches larger than a 1/4 of the ISP insertion (9 shoulders). The existence of APRCTs strongly correlated with the formation of GT notches (p<0.001). The width and depth of the APRCT also significantly influenced the size of the GT notch (p<0.001). The other factors showed no significant influence on the formation of GT notches. [Discussion and Conclusion] The formation of GT notches seen in throwing shoulders is strongly correlated with the existence of APRCTs. When a GT notch is recognized in a plain X-ray, the size of the notch is thought to be an important sign suggesting the severity of the APRCT.
We once reported on the histopathology of the subacromial bursa associated with rotator cuff tears. The purpose of this study is to compare the histopathology of the subacromial bursa (SAB) with the intraarticural synovium (IAS) associated with complete tears. Biopsy specimens of both SAB and IAS were obtained from 30 shoulders (30 patients) who had undergone surgery for complete rotator cuff tears. There were 8 females and 22 males with a mean age of 59.2 years. ranging from 40 to 70 years. They were stained with H. E. and observed microscopically. In 13 of the shoulders the pathological conditions of the IAS were much the same as those of the SAB. The others were a little different. Complete rupture of the rotator cuff causes a bursitis, and an inflammation of the subacromial bursa. In this study we compared the SAB with the IAS, and found some instances with much more inflammed conditions in the joint cavities than in the subacromial bursa. Pathological conditions not only of the subacromial bursa but also of the gleno-humeral joint cavity were considered to contribute to the symptoms of shoulders associated with cuff treas.
In order to evaluate the residual disabilities caused by chronic acromioclavicular (A-C) dislocations,14 Judo athletes (7 cases of Grade II and 7 cases of Grade III) injuries were reviewed. Clinical examinations and isokinetic muscle strength of internal/external rotation and of flexion/extension in the supine position were examined. In Grade II, there were no clinical symptoms or differences in isokinetic muscle strength between the involved and uninvolved sides. In Grade III,4 cases had motion pain and 3 cases felt weakness in Judo practice. In Grade III the A-C joints, the directions of instability were horizontal as well as vertical. Work magnitudes of extension (60 deg/sec) and those of external rotation at 30° abduction (60 and 120 deg/sec)were less in the involved side than those in the uninvolved sides. Isokinetic muscle strength of extension and external rotation at 30° abduction (60 deg/sec) in Grade III was smaller than that in Grade II. Characteristically, the involved side of Grade III cases had less power than the uninvolved side in flexion/extension above the horizontal level. In Grade III, the torn A-C capsular and coracoclavicular ligaments produce more unstable A-C joints than in Grade II. During an arm elevation above the horizontal level, more than 3/4 of a clavicle rotation occurs and is controlled by the trapezoid ligament. Unstable A-C joint causes an unstable scapula, leading to muscle weakness of the shoulder, especially in flexion/extension above the horizontal level. The current study showed that the Grade III had patterns in the flexion/extension which were different in the involved and uninvolved sides. This could explain why there is weakness above the horizontal level in Grade III injuries. Therefore, an operation is recommended for Grade III A-C injuries of Judo athletes.
Introduction. We examined 3 cases of a cannulated cancellous screw fixation for a coracoid process fracture associated with an acromioclavicular joint dislocation. Method. Before an operation, the two directional image intensifiers should be ensured. The coracoid process is exposed by the deltopectoral approach. The A-C joint is repositioned and fixed by two Kirschner wires. A guide pin checks the direction of the image intensifier and is inserted into the base of the coracoid process. After a cannulated drilling and tapping, a 4.0 mm cannulated cancellous screw is inserted. The average operation time is 64 minutes and the average blood loss is 50g. Postoperatively, a Velpeau's bandage was applied for 4 weeks, then sling immobilization for 2 weeks more and the K-wires were removed 6 weeks after the surgery. Results.4 months after surgery,2 cases had full motion of their shoulders and good alignment of their A-C joints. Now 2 months after the operation case 3 was still exercising. Conclusion. It is difficult to reinsert a screw into the coracoid process, because of its anatomy. Our method performs the appropriate internal fixation of the screw inserting it along the guide pin and insured by images. The direction of the guide pin was 40 degrees cephalad and 20 degrees medial. If the screw is inserted in the wrong direction, it causes a neurovascular injury. We should ensure the two directions of the guide pin using an image intensifier.
To evalutate operating treatment of the double lesion of SLAP and rotator cuff tear (RCT). (Materials and Results) Of the 270 patients who underwent a rotator cuff repair, nine patients with both a SLAP lesion (Type2) and a RCT were studied. The average age of the patients was 54.9 years and they consisted of nine men and two women. The RCT included five complete tears, one arthro-side partial tear, one intratendinous RCT, one rotator interval tear and one bursal side partial tear. An arthroscopic assisted rotator cuff repair was performed in all RCT cases. In the cases of a SLAP lesion, five cases were treated using a debridement, one case a suture anchor and one case the Caspari method, and two cases had no treatment. Almost all of the cases were satisfied with their operational treatment, independent of the different treatment for SLAP lesion. (Conclusion) A SLAP lesion with a RCT can sometimes be overlooked because it is masked by the symptoms from RCT. In our short term results, it is no differance in the results of the treatment for SLAP lesion. But considering its mechanizm, a patient with obvious symptoms of a SLAP lesion or a young active patient may need accurate repair.
[Purpose] We wish to report a case of unstable shoulder with suprascapular nerve sntrapment due to a gandlion. [Statement and methods] The case was a 53-year-old-female who had had an episode of dislocation of her left shoulder in her teens. She visited our hospital complaining of pain and dullness. Plain radiograms revealed an inferior subluxation and a free body in her left shoulder. The physicalexamination the sulcus sign was positive. MRIs revealed a high intensive mass at the spinoglenoid notch in the T2 weighted images. EMGs revealed a reinnervation of the supraspinatus and infraspinatus muscles. The patient was treated with release of the suprascapular nerve, resection of the ganglion on spinoglenoid notch, removal of the freebody, sturing of the subscapular muscle to the rotator inteval. [Results] Clinical symptoms were disappeared 1.5 year after and she had recovered her grip power. The patient has no problems in her daily life and shi is satisfied with the results. [Conclusion] We successfully treated an inferior unstable shoulder due to entraoment neuropathy caused by a ganglion.
Disruptions of lateral capsule are seldom observed in recurrent anterior dislocation of the shoulder joint, and complications by rotator cuff tears in young adulthood are extremely rare. The patient was a 30-year-old-male who at 25 years of age fell while snowboarding and suffered a severe blow to the anterolateral aspect of his left shoulder. ROM was limited by pain for a month. After this, subluxations occurred 12 times. Preoperatively, there was a 35 degree limitation of motion in both elevation and external rotations. The drop arm sign and the initial abduction test were negative. An air-contrast CT and A/G revealed flow of air and contrast medium in the subacromial and subcoracid bursa. Intaroperatively, the anterior joint capsule-labrum junction area was found to be normal, but the joint capsule was torn on the head side, and it was displaced to ward the axilla and retracted. Because of the retraction of the capsule, it was repaired with an homologous lyophilized dura mater. A complete tear of the supraspinatus tendon was observed, and it was reattached. Two years after, ROM slightly restricted, but there have been no problems in terms of activities of daily living, and a dislocation has not recurred. Very careful preoperative exploration is required because, even in young persons, recurrent anterior dislocation caused by a powerful external force is sometimes associated with rotator cuff tears or joint capsule tears on the head side. Since retraction of joint capsule tears on the head side can occur, plans for surgery must be devised with a means of dealing with this in mind.
The purpose of this study was to evaluate the factors influencing the size of a Hill-Sachs lesion in traumatic anterior instability of the shoulder. Forty-one shoulders with traumatic anterior instability of the shoulder were evaluated. There were 31 males and 10 females with an average age of 25.7 years (range,14-48 years).We measured the size of the Hill-Sachs lesion by axial and coronal MRA images. The patients were divided into two groups by the size of their Hill-Sachs lesion: Group A with a size smaller than the mean size, Group B with a size larger than the mean size. We statistically evaluated sex, past history of trauma, age at initial dislocation, times of dislocation, period after initial dislocation, the Carter sign, the Sulcus sign, anterior and posterior instability, external rotation and epilepsy. There were significant differences between Group A and Group B in the number of times of the dislocation and period after the initial dislocation.
The residual function of the supraspinatus muscle in patients with a torn rotator cuff was studied in comparing the architecture by Magnetic Resonance Imaging with motor unit potential amplitudes on electromyograms.
Recently, we have chosen an arthroscopic subacromial decompression (ASD) for old patients with a complete rotator cuff tear. (Purpose) The purpose of this study was to investigate the outcome of an ASD for a complete rotator cuff tear, and to compare the ASD and cuff repairs which were performed under the same operative indications. (Materials and Methods) Indications for an operation were major pain that interefered with daily life activities, and there was a functional cuff tear and the patient's activity was low. We have reviewed 14cases treated with an ASD (ASD group) and 25 cases treated with a cuff repair (repair group). The mean age of each group was 71.8 years (range 51-81) (ASD group) and 67.3 years (range 61-80) (repair group), the mean follow up period was 11.4 months (ASD group) and 14.8 months (repair group). preand postoperative JOA scores were evaluated. (Results) The mean JOA scores (ASD group/repair group) were as follows: ROM (19.8/20.8), function (9.6/10.0), pain (5.8/5.8), total (54.6/56.6) preoperatively, and ROM (27.5/28.4), function (16.6/18.6), pain (29.1/29.0) postoperatively. When we studied the JOA scores, each group had improved postoperatively and there was no significant difference. (Conclusion) ASD for old patients with a complete rotator cuff tear was effective.
The purpose of this study was to clarify the CT arthrographic findings of a normal shoulder in more detail. Ninety-four normal shoulders were studied. The average age was 22.4 years and they consisted of 69 men and 25 women. A CT arthrography was undertaken using the double contrast method (slice thickness: 5mm, gap: -2mm). The CT arthrographic findings in this study were as follows: 1) trapped air sign,2) detachment of the anteroinferior glenoid labrum,3) thickness of the labrum,4)the glenoid tilting angle(GTA) of bony and the labral. The thickness of the labrum was classified into 3 types: good, normal and poor. We then partitioned the glenoid into 6 portions, studied the thickness of each portion. The statistical evaluations were done using the t-test. The results were as follows: 1) Three (3.2%) shoulder had a trapped air sign.2) No detachment of the anteroinferior glenoid labrum.3) Forty-two shoulders were all good at each portion with regard to thickness of the labrum.38 shoulders were normal at the anterosuperior portion and good at the other portions.14 shoulders had other patterns.4) Bony GTA at the superior portion was 9.0±3.9, middle 2.7±1.9 and inferior 1.9±2.0. In contrast the labral GTA at the superior 6.5±4.1, middle 2.3±1.9 and inferior 2.7±1.9. The thickness of the labrum at the anterosuperior portion correlated to the labral GTA at the superior portion. In conclusion, three (3.2%) out of 94 normal shoulders had a trapped air sign in the CT arthrographies. There was no detachment of the anteroinferior glenoid labrum. The thickness of the anterosuperior labrum varied normally.
We investigated the use of MR arthrography in diagnosing glenoid labral tears including SLAP lesions. One hundred and forty-four patients who had symptoms and signs suggesting shoulder insrability underwent WR arthrography with intraarticular Gd DTPA, Spin echo Ti-weighted images were obtained in the axial and oblique coronal plane. Surgical or arthroscopic findings of the glenoid labra were available in 48 patients. Anterior labral tears were diagnosed in 40 out of the 48 by MR arthrographies. Anterior labral tears were surgically confirmed in 39 of the 40, but not in the orther one. SLAP lesions were diagnosed in 11 out of the 48 by MR arthrography. SLAP lesions were surgically confirmed in 9 but not in the other two. We think MR arthrography is useful in evaluating, glenoid labral tears, including SLAP lesions.
We examined the Telos shoulder fixation pad, because fixation of the shoulder was insufficient. We improved the fixation pad. The diameter of the improved pad (new pad) was 58mm, and of the similar pad (old pad) was 44mm. The subjects consisted of 15 male shoulders. Their average age was 35.6 years. The subjects were seated and their 90°abducted arm was positioned in the device. A shoulder fixation pad was adjusted on the coracoid process and the supine of the scapula. A pressure support pad was fixed dorsaly and positioned 2cm lateral to the edge of the acromion. The pressure was increased to 15kg. The subjects were evaluated with their shoulder at 90°abduction, neutral and 60°external rotation with both pads. We measured the anterior convexity angle and the anterior transrotation rate of the head. The neutral rotation The angle with the old pad was 39°average and new pad was 36°average. The anterior transrotation rate was with the old pad was 4.4% average and the new pad was 5.3% average.60°external rotation. The angle with the old pad was 41°average and the pad was 36°average. The anterior transrotation rate with the old pad was 1.7% average and new pad was 3.2% average. Fixation of the shoulder improved with new pad.
We investigated the CT and MR imaging (MRI) features of painful Bennett lesions of a throwing shoulder. Group P consisted of 13 baseball players who were diagnosed as having painful Bennett lesions, while group N was 9 players with Bennett lesions and throwing shoulder pain caused by other lesions based on physical findings and the block test.The following items were evaluated; episode, operative findings; size, location, shape of ossification on CT and MRI findings. The average age at onset of group P was 25 years and that of group N was 19 years. The average duration of playing baseball in group P was 14 years and that in group N was 9 years. Using CTs, we classified the Bennett lesions as the beak type, the thickning type, and the tusk type. The tusk type was more common in group P (8 patients: 61%) than in group N (2 patients; 22%). On MRI,7 patients (6 tusk type and 1 thickning type) in group P showed a linear high intensity area in the low intensity osteophyte. We detected instability of the osteophyte at operation in 5 of them. No patients in group N showed this on MRI. In conclusion, the tusk type on CTs and a linear high intensity area within the osteophyte on MRIs was common in painful Bennett lesions. This finding reveals an occult fracture of the osteophyte.
We wish to report on a baseball player who developed a Bennett lesion associated with bony proliferation of the greater tuberosity. This patient had started playing baseball at the age of 8 years, and played as pitcher from the age of 14 but later as a second-baseman because of his right shoulder pain described below. He felt subluxation in his right shoulder when he throws with all his strength at the age of 20. Since then this symptom repeated itself so that he could not throw a ball. When he first visited us at the age of 24years, he complained of pain in the posterior aspect of the right shoulder in the cocking phase, but at first he had felt pain in the follow-through phase. The X-rays and CTs showed bony proliferation on the posteroinferior glenoid rim (Bennett lesion) and a small bony proliferation at the greater tuberosity. One and a half years later he felt pain in the cocking and acceleration phase in addition to the follow-through phase of throwing at the age of 26 years. The X-rays and CTs revealed, not only an enlarged Bennett lesion, but also an enlarged bony proliferation at the greater tuberosity. We operated on this patient, and resected the extruded bone of the glenoid and the greater tuberosity. He is now under our observation.
The range of motion (ROM) after conservative treatment of a contracture of the shoulder was compared with arthrographic measurements. This study was conducted on 23 shoulders treated conservatively and whose maximum flexion angle was 20 degrees less than that of the opposite shoulder. The age of the patients ranged from 53 to 68 years (average; 59.5). ROM was recorded prior to and after treatment with regard to flexion, abduction, internal rotation and external rotation. Then on the ar thrograms, the size of the anterior, inferior and posterior pouches and the distance between the coracoid process and the greater tuberosity, were measured prior to and after treatment. Furthermore, the correlation between ROM and measurements on arthrograms was examined. The measurements on arthrograms were shown as percentages of the diameter of the humeral head. There was a significant improvement of ROM with regard to flexion, abduction, external rotation in the pendulous position and interal rotation in the 90-degree-abduction position after conservative therapy. A significant extension of the anterior. pouch was observed on the arthrograms. There was a significant increase of the distance between the coracoid process and the greater tuberosity on the X-ray films. Therefore, if arthroscopic treatment is selected for contracture of the shoulder, it should include releases of the antero-inferior capsule, the coraco-acromial ligament and the coraco-humeral ligament.
(Purpose) The purpose of this study was to evaluate the value of MR Arthrography (MRA) in detecting labral tears of the shoulder. (Materials and Methods) MRAs were performed on 20 shoulders with labral tears before arthroscopic surgery. There were 19 males and one female. Their ages ranged from 16 to 28 years. All the males were baseball players, and the female was a volleyball player. None of the patients recalled any episode of a major trauma. MRIs (T2 weighted, axial and oblique coronal sequence) were performed immediately after arthrography. We evaluated the labral tears of our MRA findings, and compared them with the arthroscopic findings. (Results) Arthroscopically, labral tears were observed in 36 sites of 20 shoulders. In 26 of them (72%), labral tears were detected with MRA. There was a variety of sites of tears. Twenty cases revealed a posterior tear,14: a superior, and 2: an anterior. Positive MRA findings were shown in 16 of 20(80%)posterior tears,8 Of 14 (57%) superior tears, and 2 of 2(100%)anterior tears. A false positive was only found in 2 sites of the superior labrum. There was no significant difference between the diagnostic rate of labral tears with a detachment and those without. (Conclusion)MRI is a valuable imaging tool to detect, not only anterior tears but also posterior and superior labral tears.
The long head of biceps and the Biceps tendon/Labrum Complex (BLC), dysfunction of which as a result of trauma or throwing injuries is the one of the important compornent for shoulder instability. This study compares and examines BLC froms obtained by MR arthrography with those obtained by arthroscopy. The MR arthrography conducted by our department,68 of which were subjected to arthroscopy. The patients were aged 14 to 70. For MR arthrography, Gd-DTPA of about 100-fold dilution, or a total of 20 ml contrast medium were injected into the G-H joint and a T1 weighted coronal view was evaluated. A case was diagnosed BLC lesion positive, if BLC avulsion or dislocation as indicated by clear inward invasion of contrast medium from the glenoid cartilage rim was observed. A case was considered negative for BLC lesion, if the findings appeared to be normal or only degenerative lesions, or if no invasion by contrast medium was observed. In arthroscopic diagnosis, cases where avulsion or instability was confirmed by probing 3 mm or more from the glenoid of the BLC labrum were taken to be positive. MRA yielded 20 positive cases of BLC lesion,14 of which were avulsion type and 6 dislocation type. There were 41 negative cases.7 cases proved to be difficult to diagnose by MRA. The arthroscopic findings yielded 17 positive and 41 negative cases. For both diagnostic methods, sensitivity was 63.6%, specificity 86.8%, and accuracy 78.3%. MRA is considered to be effective as a preoperative supporting diagnosis for findings BLC lesions. It is considered to be important in the future to study an imaging method and a scanning position that allow a more accurate diagnosis.
A comparative study on SLAP lesions between the MR arthrographic and arthroscopic examination findings was performed. 17 shoulders of 16 patients diagnosed as a SLAP lesion by arthroscopy were examined using MR arthrographies (MRAs). All the patients were males and there were 12 right shoulders,4 left shoulders and one bilateral shoulders. The average age was 22 years (range,16-32). Eight patients were baseball players. Five shoulders had only a SLAP lesion, and 12 shoulders had combined injuries (8 recurrent dislocations or subluxations,1 initial dislocation,1 Bennett's lesion,2 subacromial impingement syndromes). All the cases were diagnosed as SLAP lesion by MRA. Thirteen shoulders were type2 (Snyder's classification)and 4 shoulders were type3 by arthroscopic examination. All the type2 cases could be diagnosed before arthroscopy by MRAs. However, type3 could be diagnosed before arthroscopy in only 1of the 4 cases by MRA. So it was difficult to distinguish between type2 and type3 by MRA. Among the type2, the detached superior labrums were sutured in 3, stapled in 1 and there were debridements in 9. In all the type3 cases, bucket-handle tears were resected. MRA was useful in diagnosing a SLAP lesion injury, but it was difficult to distinguish between type2and type3 by MRAs.
Shoulder arthropathy induced by dialysis-related amyloidosis is one of the most fequent lesions that occur in long-term heamodialysis patients. A chief complaint of patients was severe shoulder pain during dialysis and at night. The pain increased when patients were lying down and decreased when they were sitting or standing. We performed surgery on these patients using three different methods and evaluated the results. Twenty men (26 shoulders) and 33 women (42 shoulders) who had been having dialysis for an average of 16.7 years were operated on. Their average age was 56.7 years. Endoscopic coracoacromial ligament release (ECLR) was performed on 67 shoulders. Arthroscopic synovectomy (AS) was conducted on four shoulders for which ECLR was not effective. Total arthroplasty (TSA) was performed on one shoulder with severe joint destruction. We evaluated the results according to the JOA score. The average JOA improved from 62.3 to 89.2 after ECLR and from 61.2 to 80.2 after AS, and from 53.5 to 88.5 after TSA. The shoulder pain was relieved by ECLR in 91% of the patients. Various changes occurred in the bone and soft tissue around the shoulder of long-term hemodialysis patients. We determined that the main cause of shoulder pain in these instances was the increase of subacromial pressure induced by the amyloid deposit in the subacromial bursa and rotator cuff. ECLR is a useful method for these cases. We called lesion “hemodialysis subacromial syndrome”to differentiate it from other shoulder abnormalities caused by amyloidosis. This lesion is the major type of shoulder arthropathy induced by dialysis-related amyloidosis. Other methods are necessary when ECLR is not effective. When severe proliferation of the synovium or granulation tissue is evident in the gleno-humeral joint under MRI, AS should be conducted. When there is advanced gleno-humeral joint destruction, TSA should be indicated.
Radiographic changes occurred in 3 shoulders after injections of 0.5%pyoctanine solution for an intraoperative color arthrography. Case 1: A 65-year-old man with a rotator cuff tear was operated on in 1991. A full-thickness tear was found by an intraoperative color arthrography. Two years later, he felt pain in his right shoulder again. A total shoulder arthroplasty was done in 1996. Case 2: An acromioplasty was performed on a 56-years-old woman with subacromial bursitis in June 1992. The absence of a full-thickness tear was confirmed by a color arthrography. In 1995, she felt right shoulder pain again, and a total shoulder arthroplasty was performed. Case 3: In July 1993, a 47-year-old woman felt some right shoulder pain after a fall on her right hand. She was operated on for a full-thickness cuff tear in September 1993. A tear site was identified by a color arthrography. Although she felt no pain for 3 years after the operation, she developed motion pain in her right shoulder in October 1996. Her pain was partially relieved by medication. Findings of these patients were compared with those of 5 patients with primary osteoarthritis (OA) of the shoulder. In pyoctanine arthropathy, plain radiographs showed a joint space narrowing, and subchondral bone atrophy. Peripheral osteophytes which were seen in OA at the inferior margin of the joint were not evident in the arthropathy. On T1-weighted MR images, small round areas with iso-signal-intensity to muscle were detected in the subchondral bone of the arthropathy joint. They showed high-signal intensity on T2-weighted images. Such findings were not found in OA shoulders. Histologic sections showed dominant cartilaginous destruction replaced by granulation in the arthropathy joints. These findings suggested different pathogenesis of pyoctanine arthropathy from that of OA shoulders.
Sensory nerve endings in the coracoacromial ligament and in the periligamentous bursal tissue were observed under a light microscope. The specimens were immunohistochemically stained with a protein gene product 9.5 (PGP9.5) and Calcitonin-Gene Related Peptide (CGRP). Two distinct nerve endings (Ruffini corpuscles and free nerve endings ) were identified in the periligamentous bursal tissue with PGP9.5. CGRP positive nerve fibers were similarly stained with PGP9.5 except those around vessels and Ruffini corpuscles. The results of the quantitative analysis of nerve fibers showed that in each staining method the average density on the coracoidal side of the coracoacromial ligament and periligamentous bursal tissue resected from patients with a rotator cuff tear was higher than that on the acromial side. it is of great interest that the average nerve density on the coracoidal side was higher than that on the acromial side with each staining method, which suggests that not only free nerve endings on the acromial side but also those on the coracoidal side must be involved in the pain of rotator cuff tears.
In clarifying a relation between a systemic hyperostosis and an acromial spur, sixty macerated whole body skeletons were studied. Criteria for judging the presence of spurs was determined to be a minimum length of 3 mm. Spur formation at eight different extra-spinal skeletal bones (16 spots in all)were measured bilaterally. Additionally the morphological features of acromial spurs were classified. The average ratio of spur presence(>3mm)was found to be at each of the following locations: acromicn 35.0%; olecranon 3.4%; iliac crest 16.7%; pubis 3.3%; ischium 9.2%; ilium at sacro-iliac joint 18.3%; patella 6.5 %; and calcaneus 1.0 %, respectively. Comparative study on paired acromial spur in both length and morphological classification demonstrated statistically significant symmetry. Giant spur(>4mm)at bilateral acromions and systemic hyperostosis(when the sum of the spur presence in each individual was five or more ), were categorized. In the cases of bilateral acromions, three cases out of six were also associated with the cases of systemic hyperostoisis. Impingement and overuse have been usually recognized as supposed preceeding factors in acromial spurs. However, we would like to propose two additional possibilities. The first is associated in cases in which an acromial spur is just a local finding seen in the systemic hyperostosis, or diffuse idiopathic systemic hyperostosis ( D I S H ). It seems that half the cases with giant spur at bilateral acromion are thought to be influenced by D I S H. The second possibility is based on the findings that paired acromial spurs are confirmed to be so similar that the main preceeding factors can be construed to be intrinsic rather than acquired impingement or overuse. Therefore the pathogensis of acromial spur was investigated utilizing macerated skeletons. In addition to previously recognized factors, intrinsic factors were revealed to be significant.
The purpose of this study was to detertmine the relationship between the rotator cuff tears and degeneration of the glenoid, and the relationship between the morphology of the osteophytes and degeneration of the glenoid. Materials and Methods: 35 shoulders (19 shoulders without rotator cuff tears,8shoulders with partial-thickness tears, and 8 shoulders with full-thickness tears) among 86 cadaveric shoulders (average age 77 years) were observed in 8 portions of the glenoid margin using soft X rays, then the shapes of the glenoid osteophyte were separated into the following four types-the round type, the sharp rype, the elongation type, and the hook type. The degeneration of the cartilage of the glenoid and labrum were histologically observed in 8 portions of the glenoid. Degenerative changes of the cartilage were observed significantly higher around the inferior portion of the glenoid than other portions (p<0.001), and were observed significantly higher in those with full-thickness tears than with partialthickness tears (p<0.0001). Degenerative changes of the cartilage were observed significantly higher in the hook type osteophyte group than other groups (p<0.0001). The same results were observed in the labrum. Degenerative changes of the cartilage and labrum in the inferior portion of the glenoid seem to be related to the rotator cuff tears, and seem to be related to the hook type osteophyte.
[Purpose] We measured the bone mineral contents (BMC) of the proximal humerus and greater tuberosity of the humerus in patients with a shoulder disease and normal subjects. We also investigated loss of BMC in a frozen shoulder and cuff tear, and the changes of BMC after an operation. [Materials] 28 patients with a unilateral shoulder disease included 13 cases of cuff tear and 15 cases of frozen shoulder. There were 22 males and 6 females. The average age of the patients was 58.2 years old, and we also investigated 58 normal subjects. [Methods] The BMC was measured by dual energy X-ray absorptiometry (DEXA). We settled %BMC (%BMC: BMC of the disordered side/BMC of the ordered side). [Results] in normal subjects, the BMC of the greater tuberosity was higher in the dominant hand. But in subjects over 40 years old, there was no difference on either side. In patients with a cuff tear, the BMC decreased only on the greater tuberosity (%BMC: 83.4). In patients with a frozen shoulder, the BMC decreased both on the greater tuberosity (%BMC: 83.0) and proximal humerus (%BMC: 83.4). The BMC of the operated shoulder became closer to the ordered shoulder. In patients with the dominant hand, the %BMC of the greater tuberosity was 89.5, and that of the proximal humerus was 92.5. On the other hand, in patients with the non-dominant hand, the %BMC of the greater tuberosity was 76.3, and the %BMC of the proximal humerus was 79.3. There was a difinite decrease of BMC in patients with the non-dominant hand. [Conclusion] We figured that there was a difference between loss of BMC in a shoulder with a rotator cuff tear and loss of BMC in a frozen shoulder. The BMC of the proximal humerus increased after treatment.
We examined the relationship between arteriosclerosis and nerve degeneration in shoulder joint capsules. We obtained 6 shoulder joint capsules including 3 cadavers with diabetes mellitus in life. The capsules were fixed in formalin solution and each capsule was cut into 32 slices. Each slice was embedded in paraffin and 10 pt μm sections were cut. The arteries in the shoulder joint capsule were examined histologically using EVG staining for internal elastic lamina. Quantitative measurements were performed on the percent stenosis in the luminal area. In both the DM and control group, the percent stenosis in the luminal area demonstrated a significant increase in the posterior to the posteroinferior portion of the capsule. In the DM group, the percent stenosis was significantly higher than that in the control group in the inferior portion of the capsule. The capsular portion demonstrated a high percent of luminal stenosis of arteries was also significantly larger in the DM group than in the control group. Although no correlation between the severity of degenerated nerve and the percent of stenosis of arteries, the percent of stenosis tended to be higher in the DM group than in the control group in any of the severities of the nerve degeneration. This present study showed that nerve degeneration does not seem to be directly associated with luminal stenosis of the arteries. However, we hypothesized that the severity of nerve degeneration might be correlated with the degree of luminal stenosis of the arteries.
The bursal-side layer could have higher a healing ability than the joint-side layer in the absence of a subacromial impingement. Hamada et al. reported that the procollagen α1 type 1 positive cells were abundantly detected even in long-standing tears. They suggested the possibility that partialthickness tears could continue tearing after the initial trauma
We have employed the modified Bristow procedure for recurrent anterior sh oulder dislocations at our institutes. The purpose of this report was to give the clinical results. Thirty-one shoulders of 30 patients were followed-up. Nineteen patients were male. The average age at operation was 24.5 years. Nineteen shoulders were dominant. The average follow-up was 3.5 years. The objetive results were examined by using the JOA shoulder evaluation sheets and Rowe's. No patient had a redislocation of the shoulder, but 5 patients had positive anterior apprehension tests. None of the patients were dissatisfied with ADL. The mean limitation of ER with arm at the side was 15.7 degrees, and ER at 90-degrees abduction was 12.1 degrees. The average point were 94.7 based on the JOA, and 87.7 based on Rowe's. Roentgenograms at follow-up revealed a broken screw in 1 case, Ioosening screws in 2 cases, and nonunions of the transferred coracoid processes in 2 cases. Twenty-eight cases (93.3%) had 90 points or more using the JOA. Twenty-eight cases (93.3%) had overall successful using Rowe's.
Since 1967, we have carried out modified Bristow procedure for the treatment of recurrent anterior shoulder dislocation. The purpose of this report was to investigate the clinical results of this procedure. 80 shoulders of 79 patients were followed-up.65 patients were male and 14 patients were fe male. The right shoulder was affected in 42 cases and the rest of the 38 shoulders were on the left side. The follow-up period ranged from one year to 17 years and one month, with a mean of five years and nine months. The objective results were examined according to the shoulder evaluation sheet of the Japanese Orthopaedic Association (JOA) and also by the Carter Rowe's criteria. The average JOA score was 94.5 points. JOA score ranged from 95 to 100 in sisty one shoulders (76.2%), from 90 to 94 points were observed in 23 shoulders (28.8%), from 85 to 89 were seen in 4 shoulders (5.0%) and the rest 5 shoulder (6.3%) had below 84 points. Rowe's criteria had excellent results for 76.2%, good for 13.7%, fair for 3.8% and poor for 6.3%. In our series, four (5.0%) of the shoulders redislocated and one (1.3%) had two subjective episodes of subluxation after surgery. The mean loss of external rotation was 10.4 degrees. Radiographic findings revealed loosening of the screw in five cases, breakage in six cases, bending in two cases, migration in one case. The modified Bristow procedure, a s described above, in an effective operation for achieving shoulder stability while prevening recurrent anterior dislocation.
[Purpose] We have performed a follow-up study to clarify the validity of a modified inferior capsular shift for recurrent shoulder subluxations and recurrent shoulder dislocations (hereafter RSSL and RSD). [Materials and Methods] Since 1982,59 shoulders of 59 patients with RSSL and RSD were operated on by modified inferior capsular shifts. Among them,31 patients including 7 patients with RSSL 24 with SDL were examined directly by the author. Each had more than 1 year follow-up period and the average was 5 years. Twenty four patients were males and 11 were females. The right shoulder was involved in 20 shoulders and the left in 11. The dominant shoulder was involved in 19 patients. A Bankart lesion was demonstrated in 29 shoulders and a general joint laxity in 10 patients. Physical and radiological examinations were performed and questionnaires answered. [Results] There were no re-dislocations but there was a positive apprehension sign in 4 patients. Loss of external rotation was 8 degrees on average. The follow-up radiograms demonstrated a small bony fragment inferior to the joint space in 1 shoulder and a slight irregularity at the inferior of the grenoid in 2 shoulders. The isokinetic muscle strength of the shoulders were evaluated by CYVEX showing no significant differences between the pre-op. and the follow-up. The questionnaires revealed that none of the patients had any limitations in ADL. Twenty six patients (84%) returned to their previous sports activities. Among 19 patients whose diminant shoulders were involved,5 patients had no limitations in throwing. [Conclusion] A modified inferior capsular shift for RSSL and RSD seems most valid.
[Purpose] We have performed a Caspari procedure or an open Bankart procedure with approach similar to reinforced capsular cruciate repair (a modified Bankart procedure) for traumatic anterior instability of the shoulder. The purpose of this study was to compare the short-term results of both procedures. [Materials and methods] The Caspari group consisted of 21 shoulders in 19 patients (14 males and 5females). The modified Bankart group consisted of 21 shoulders of 21 patients (16 males and 5 f emals ). The mean age at operation was 26.4 years (range 16-57 years) in the Caspari group and 21.3 years (range 15-37 years) in the modified Bankart group. When there was a bone defect of the glenoid rim, a modified Bankart procedure was performed. Patients with an intact bony glenoid had a chance to choose the method, a modified Bankart procedure or a Caspari procedure. The Caspari procedure was performed according to the original method except that we used nylon. A modified Bankart procedure was performed to suture the capsule side by side, not to implicate the capsule. The postoperative period of sling and swathe was 2-4 weeks in the Caspari group and 4 days in the modified Bankart group. The mean follow-up period was 17 months (6-32 months) in the Caspari group and 13 months (6-30 months)in the modified Bankart group. [Results] According to Rowe's scoring system, there were 9 excellent,5 good,1 fair and 6 poor results in the Caspari group, and 15 excellent,5 good and 1 poor result in the modified Bankart group. Instabilities recurred in 6 (29%) shoulders in the Caspari group and in 1 (5%) shoulder in the modified Bankart group. After 8 weeks postoperatively, the range of shoulder flexion and external rotation at the side was greater in the modified Bankart group than in the Caspari group. These became the same at 1 year and 1.5 years, respectively. The modified Bankart group obtained a final range of flexion at 5months postoperatively, whereas the Caspari group needed a further 7 months to reach maximum flexion. After 5 months postoperatively, the range of external rotation in abduction is greater in the modified Bankart group than in the Caspari group. The Caspari group was superior only in internal rotation postoperatively. [Conclu sion] The higher recurrence rate and the delayed recovery of range-of-motion isn the Caspari group indicate that, for the time being, the modified Bankart procedure with approach similar to reinforced capsular cruciate repair is the treatment of choice for a traumatic anterior instability of the shoulder.
[Purpose] We have obtained excellent clinical results with Boytchev's procedure for a r ecurrent dislocation of the shoulder. Few patients who had a preoperative inferior laxity complained of apprehension after this surgery. We operated on these patients with Boytchev's procedure and an anterior capsular shift without detachment of the subscapular tendon. [Patients and Methods] This procedure was perform ed on 9 shoulders of 9 patients which had type II inferior laxity of Endo's classification. Their average age was 27.3 years old, and average follow-up period was 37 months. Four patients had general joint laxity of Carter's index 3/5 and all the patients except for one had inferior laxity in the contralateral side. The subscapularis was divided horizontally along the direction of its fiber at the lower one-third level and was never detached from the lessor tuberosity. Anterior capsular shift was performed through the divided interval of the subscapularis. After that, Boytchev's procedure was performed. [Results ] Nothing of redislocation occurred, excep t for one subluxation. One shoulder revealed a positive anterior apprehension test. The average inferior laxity of the humeral head was 66 % preope ratively, and 33% postoperatively. The average restricted range of motion was 9 degrees in elevation,22 degrees in external rotation,19 degrees in horizontal external rotation,15 degrees in horizontal internal rotation. The average JOA score was 66 point preoperatively, and 88 points postoperatively. [Conclusion] We can increase the tension of the subscapularis without d etachment of this tendon from the lesser tuberosity, and can perform an anterior capsular shift of the shoulder.
We investigated whether a modified Bristow procedure, as an extracapsular restraint mechanism, was effective for traumatic anterior shoulder instability combined with inferior laxity as well as for a non lax unidirectional anterior instability by evaluating the clinical results of the procedure. A patient who had more than a grade 1 inferior shift according to Endo's classifi cation was defined as having an inferior laxity. The clinical results were evaluated with the recurrence rate of anterior instability, the residual rate of anterior apprehension sign and the JOA score, and compared with those of the same procedures which were performed during the same period on patients without an inferior laxity. There were 16 shoulders with an inferior laxity and 23 shoulders without inferior laxity. The average age of both groups at the operation was 24 years and all were followed-up for more than one year postoperatively. Nine ty-four percent of the non affected contralateral shoulders in the laxity group also showed a typel inferior laxity. This indicates that these inferior laxities may based on a congenital joint laxity. There were two subluxations (13%) in the laxity group and one (4%) in the non-laxity group postoperatively. The mean JOA scores were 90 points and 96 points, respectively. Ten (63%) residual anterior apprehension signs were recognized in the laxity group and 4 (17%) in the non-laxity group, which was statistically significant. We co ncluded that the extracapsular procedure alone was not sufficient to improve the anterior instability completely for traumatic anterior shoulder instability combined with capsular laxity. So some additional procedure should be considerd for those cases to obtain better results.
Preoperative arthroscopic findings in cases treated according to the modified Boytchev procedure for recurrent dislocation and subluxation of the shoulders were examined to clarify the factorsof a recurrence.
In this study, we investigated the indication for and effectiveness of a capsulorabral reconstruction for a recurrent anterior dislocation of the shoulder after a Boytchev procedure. Three cases (3men) were re-operated on with capsulolabral r econstruction using suture anchors. Their age at surgery ranged from 17 to 27 years (average,21). All the patients were diagnosed as traumatic anterior dislocation during sports activity. The period from the initial dislocation to the first operation (Boytchev procedure) ranged from 1 to 2 years. The interval from the first operation to the reoperation (modified anterior capsulolabral reconstruction using suture anchors) ranged 2 to 9 (average 5.3) years. The follow-up period ranged from 3y4m to 3y9m. The results were assessed using Rowe's scoring system (1987). Rowe's scores were 97 (excellent),97 (excellent) and 78 (good) at the final examination. Neither anterior nor inferior instabilities were observed in case 1, but psychological anxiety made him abandon playing sports. In case 2 which was categorized as excellent at the final examination, an inferior instability was noted, but he showed no disability. He returned to sports on a recreational level. Subluxation was encountered once in case 3. Anterior and inferior instabilities were noted. General joint laxity was revealed (3/5; thumb, elbow and knee) in this case. A capsulolabral reconstruction was indicated for in cases with Bankart lesion, even if they had previously been operated on with a muscle transfer procedure (such as Boytchev procedure). But, when the capsulorraphy is done, it is important that the inferior capsule should be elevated sufficiently in cases with inferior instability and general joint laxity.
Our method improved the Putti-Platt procedure (P-P procedure) by cutting the subscapular tendon and joint capsule together with the non-detached coracoid process. The purpose of this study was to investigate the long term results (more then ten years) of this modified P-P procedure. 124 recurrent dislocations except habitual, voluntary, paralytic and non- traumatic dislocations or subluxations of the shoulder with more then ten years since surgery. Of them,52 shoulders were exmined. The average follow-up period was 15.6 years. Redislocation of the shoulder could be observed in only one patient, and she had no further recurrence.8 cases take care of their redislocations,2 shoulders had anterior instabilities.The improvement of the external rotational angle was 52.4% in the 1st. plane and 65.8% in the 2nd. plane. The percentages of return to sports was 100% in judo and 50% in baseball. On MRI, the subscapular tendon looked thick and fibrosis of the tendon could be seen in some cases. Although, there were no osteoarthritis changes in the X-rays,28% of the cases had a focal osteoarthritis change at the anterior humeral head in the MRIs. The percentage of a dislocation was very low. Not only our surgical procedure, but also the appropriate indications for surgery could make the results excellent. The diminution of elasticity in the subscapular tendon after surgery might cause the focal OA change at the humeral head.
The purpose of this study was to compare the limitations between the external rotation (ER) of athletes in overhand sports players (OS) and judo players (JP) with traumatic anterior shoulder instability after a modified inferior capsular shift (MICS)procedure. Thiryt-two shoulders of OS and 38 shoulders of JP were operated on using MICS and were observed for more than 12 months postoperatively. Twenty-six dominant and 6 nondominant shoulders were examined directly. There were 21 “tsurite” (lapel grip) and 17 “hikite” (sleeve grip) shoulders in JP. The average ages at surgery of OS and JP were 22.9 and 21.5 years old, respectively. All the patients had had an episoders of sports injury. There were no recurrences in OS, but 3 (8%)in JP. In OS,12% of the dominant shoulders and 67% of the no ndominant sides after MICS could perform better their sports activities than preoperatively. The ratios of JP which showed a better performance were 15% of operated “tsurite” and 52% of the operated “hikite” sides. The average decrease of ER motion in dominant shoulders of OS was 18.8°in the hanging position and 14.5°in 90°of abduction. In JP, “tsurite” sides had 3.3°and 4.8°of limitation on 0°and 90°of abduction, respectively. There was on other limitation of ROM in either OS or JP, postoperatively. Based on comparisons of ER motion between OS and JP showing better sport activity, ER at 90°abduction should be 80°for the dominant side of OS and 85°for the “tsurite” side of JP in order to get a better performance, postoperatively. Thus, the “tsurite” side in JP should be treated in the same manner as that of the dominant side of OS.
A modified Bristow's procedure is good for stability, but sometimes patients complain of loss of external rotation. The purpose of this study was to investigate the preoperative factors affecting loss of external rotation. We performed this operation on 27 shoulders of 27 patients. There were 18 men and 9 women, with a mean age of 24.7years. We measured the external rotation angle with shoulder abduction at 0°The mean loss of external rotation (ER) was 15.1 degress, compared with the unoperated on side. Patients were divided into two groups by the loss of ER: Group A with less loss of ER than the average. Group B with more loss of ER than the average. We statistically evaluated their sex, past trauma history (fall down or not), times of dislocation, age at first injury, age at operation, term from first injury to operation, term from last injury to operation, the Carter sign, the sulcus sign, anterior instability, posterior instability and the preoperative loss of external rotation. There was a significant correlation between restriction regarding age at operation and preoperative loss of external rotation. We should consider shortening the postoperative length of an outer-fixation more as well as preoperative rehabilitation in cases with more loss of ER before an operation.
The results of arthroscopic Bankart suture repair were demonstrated in this report. Forty-three patients with recurrent anterior shoulder instability underwent an arthroscopic Bankart suture repair: 30patients were males and 13 patients were femals. The average age at operation was 28.2 years (range 15-44years). The postoperative follow-up averaged 38.5 months (range 6-75 months). We performed the Craig Morgan technique transglenoid absorbable suturing technique from 1990 to 1996 and the Suture anchor technique with FASTak since 1996. At arthroscopy, all 43 patients were found to have Bankart lesions. All had had an anterior apprehension sign preoperatively. The preoperative JOA score was 75.2points and improved by 17.0 points to 92.2 points, postoperatively. The apprehension sign disappeared postoperatively in 37/42 cases. Two patients had a recurrent dislocation postoperatively, and another three had recurrent subluxations. No complications (infections or neurologic injuries) occurred in this series. Arthroscopic Bankart suture technique appeared to be useful for a recurrent anterior shoulder instability.
The purpose of this study was to evaluate the results of Caspari's procedure for recurrent anterior dislocation of the shoulder. Forty-six recurrent anterior dislocations of the shoulder were investigated. The mean age at surgery was 22.7 years. The operative indications were a band of AIGHL, no bony Bankart, no joint laxity, no contact sports and understanding of the postoperative therapy. The operation was followed by Caspari's procedure. We recently added the PLLA button and the anterior anchor (FASTak) to this procedure. According to Rowe's criteria, the clinical results were graded excellent in 34 shoulders, good in 5, fair in 5 and poor in 2. There were redislocations in two cases, positive apprehension signs in 8 and 3.2 degrees loss of external rotation. Complications of this procedure were breakage of the drill bit in one case and temporary palsy of the suprascapular nerve in two cases. Caspari's procedure gave good results to these patients who selected it.
A follow-up study was attempted to elucidate a correlation between the intraarticular parthology of the anterior supporting structures and clinical results of an arthroscopic Bankart repair for recurrent anterior dislocation or subluxation of the shoulder. Patients with 45 dislocations and 31 subluxations were treated by a transglenoid suture technique using a grasping stitcher system, and were followed up for more than one year after their operations. There were 50 males (51 shoulders) and 25 females (25shoulders), aged from 13 to 50 years (mean 23). Arthroscopic Bankart repairs were applied in 65% of the total patients with these ailments in our institutes under strict criteria of the patients' profiles and intraarticular pathology: ligament-labrum(L-L) complex detachment type and small bony fragment type. Re-dislocation occurred in 8 of the total 76 shoulders (10.5%). The recurrence rate was 4.4% (2/45)in patients with a preoperative diagnosis of recurrent dislocations, while it raised up to 19.4% (6/31)in those with subluxations. It was higher in those with a pathlogy of a small bony fragment type (13.8%=5/21) than in the L-L complex detachment type (5.5%=3/55). These data clearly showed the close relation between the intraarticular pathology and the clinical outcome of the arthroscopic Bankart repair for a recurrent anterior dislocation or subluxation of the shoulder. The re-dislocation rate was considered to reflect on the preoperative morphological and biomechanical conditions of the L-L complex of the injured shoulder.
The coraco-humeral (CH) ligament and its surrounding tissues have recently been considered to be related with the pathology of the shoulder pain and restriction of motion. The purpose of this study is to evaluate the effectiveness of a local injection into a CH ligament for a frozen shoulder. Twenty patients with frozen shoulder aged from 43 to 70, six males and fourteen females were treated by a local injection of 2ml lidocaine and a liquid steroid into the CH ligament under ultrasonographic guidance bimonthly. After the injection, pain relief, improvement of the motion based on the Japanese Orthopaedic Association's scoring system (JOA score) and changes of ultrasonographic findings were investigated. We did a statistical analysis to establish a correlation between a patient's factors and the clinical outcomes. Remarkable pain relief and motional gain were found in 10 cases. There were 10 cases which had not indicated sufficient clinical impairments. The failed cases consisted mostly of those who had been suffering for more than 6 months or showed severe joint contracture. An ultrasonography of the CH ligament in these cases showed no remarkable changes in width or echogenesity after the teatment. A local injection into the CH ligament seems to be effective for the early phase of a frozen shoulder with severe pain which is mainly caused by a disorder of the CH ligament and its surrounding tissues.