It is well known that an external rotation at 90 degree abduction(ER90) increases while an internal rotation at 90 degree abduction(1R90) decreases on the throwing arm in mature baseball players. This alteration of the shoulder should be adaptation to throwing action. It is unknown whether this is caused by the soft tissue or a bony adaptation. To determine the cause of this alteration, we examined the correlation between the range of motion and the humeral retroversion in baseball players. Preparticipation examinations of the shoulder were performed in forty-eight collegiate baseball players during spring training. There were 11 pitchers and 37position players with an average age of 19.6 and an average playing year of 10.6. Measurements of the range of motion, laxity and retroversion of humeral head were performed. The retroversion of the humeral head were measured with the player supine on a table, the angle between the long axis of the forearm and a line perpendicular to the table while the bicipital groove faced up using ultrasonography. The dominant shoulder showed 15.7° higher ER90and 22° lower IR90 compared with the nondominant side. The total arc(ER90+IR90) decreased in the dominant arm. The dominant arms showed 10° less retroversion, which meant a shift of rotation towards external rotation. Ultrasonography is a reliable method to measure the retroversion of the humeral head. There was a significant difference in the range of motion and the retroversion of the humeral head between the dominant and nondominant sides. However there was no correlation between range of motion and humeral retroversion in both dominant and nondominant sides. This might indicate that soft tissue adaptation was more significant than bone adaptation. Recognition of these changes will aid in the prevention of throwing injuries.

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[Purpose] The purpose of this paper is to report on the short term results of arthroscopic surgery for a type 2 SLAP lesion in baseball players and the operative technique using an anchor system.
[Materials and Methods] Seven shoulders underwent arthroscopic surgery form 1996. There were six pitchers and one infielder. The average age at the operation was 19.1 years (range: 16-26). All the patients complained of severe shoulder pain during pitching. Six shoulders had pain on anterior apprehension test and 5 of these 6 shoulders had more pain with forearm pronation. Compression rotation tests were positive in 5 shoulders. All the shoulders had superior labral detachment on MR arthrography. Arthroscopic evaluation revealed a type 2 SLAP lesion in all the shoulders. Arthroscopic procedures were performed including a labral debridement in 3, a labal stapling in 1 and a labral suture in 3 shoulders. A Mini-revo screw anchor and nonabsorbable suture materials were used (Snyder's procedure)for the labral suture. The average follow-up period was 15 months (range,10-24 months).
[Results] Six patients were able to return to their previous level with no pain. One pati ent who had had a labral debridement returned but had slight pain and weakness when throwing. The average duration between the operation and the return was 9.1 months (6-12 months). Six months postoperatively MR arthrographies were performed on 3 shoulders using a Mini-revo screw or staple. No superior labral detachments were recognized.
[Conclusion] We recommend the labral repair using a suture anchor system because this method can reconstruct the anatomical attachment of the superior labrum and biceps tendon.

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[Purpose] We have been performing repair for the rotator interval (RI) lesion since 1970. The purpose of this study is to evaluate the results of RI repair for atthetes.
[Material and Methods] 152 shoulders of 147 patients underwent RI repair from 1973 to 1996. They consisted of 112 males and 35 females. Their age ranged from 14 to 47 years old (mean 21.5 years old)at time of surgery. The body spica cast was applied in the Zero position for about 2 weeks postoperatively. Intensive exercises were started after removal of the cast. Their sports activities after surgery were assessed and the factors influencing the results were evaluated.
[Results] 145 athletes were able to return to their original sports but 21 of them had some difficulties because of pain or muscle weakness.7 patients could not participate in any sports. They included cases of loose shoulder, reinjuries and athletes who complained of pain due to overuse.
[Conclusion] 95% of them could return to their original sports activity. The prin cipal factor influencing the surgical outcome was the degree of preoperative shoulder instability.

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[Purpose] We examined the glenoid version in order to study the relationships between it and the age, the sex and the stage of the glenohumeral osteoarthritis. [Materials and Methods] Seventy-eight patients 134 shoulders were examined using the plain axial roentgenograms of their shoulders. There were 40 men 38 women,67 right and 67 left shoulders. Their age ranged from 16 to 88 years (mean: 48.3 years). Acute trauma, rheumatoid arthritis and cuff tear arthropathy were excluded in these cases. Anteversion was expressed+and retroversion-. Statistical significance was determined using the unpaired t-test and Spearman's rank correlation, and the difference was considered to be significant if p value was less than 0.05.
[Results] The glenoid version was -6.6° for men and -4.3° for women. The retroversion of the group who were older than 60 years was larger than others. These were significant differences in this study, but further investigation is needed in order to clarify them. There was no relationship between the glenoid version and the stage of the glenohumeral osteoarthritis in this study.
[Conclusion] The glenoid retroversion in the early stage of glenohumeral osteoarthritis was not larger than that of a normal shoulder. An increase of the glenoid retroversion might not occur in the early stage of glenohumeral osteoarthritis.

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[ Purpose ] The purpose of this study was to compare the time threshold with the detection of passive motion(TTDPM) among any angle speeds in normal shoulders.
[Materials and Methods]The shoulers of nine healthy subjects(mean age: 22±3)were tested. The subjects were positioned supine, in 90 degrees shoulder abduction and 90 degrees external shoulder rotation.
The forearm was placed in a Cybex 6000 lever arm with foam elastic rubber rapped around the fore arm. The lever arm was moved at the three angle speeds( 5,20,100degrees/sec) passively. The subjects were asked to rotate their shoulders internally once movement was sensed. EMG surface electrodes were placed over the pectoralis major. The latency between the onset of the lever arm movement and EMG signal(TTDPM) were determined.
[ Results ] When the lever arm moved at 5,20, and 100 degrees/sec, the mean values of latency were 129±22,124±36,117±34msec respectively. It was nodifference between the three angle speeds, and no difference between the dominant and nondominant sides.
[ Conclusion ] These results indicated that kinesthsia depended on the duration of stimulation, and that we could detect abnormalitis when comparing side to side differences of TTDPM.

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[Purpose]We attempted to investigate the characteristics of the concentric and eccentric contraction of the internal and external rotators of the shoulder joint after modified Bristow and Bankart procedure.
[Materials and Methods]The sublects were 17 cases(14 males and 3 females)with a mean age of 23.6years (range from 15 to 30 years). Using a BIODEX dynamometer, the strength of the rotator muscles of the shoulder was measured at concentric contraction (CC) and eccentric contraction (EC). Angle velocity was set at 60 and 120 deg. /sec. in CC and 20 and 60 deg. /sec. in EC.
[Results]The muscle strength of the intemal rotators during CC and EC gradually increased after surgery. But there was no statically significant difference in the peak torque between preoperaion and 6 months after surgery. The peak torque of the external rotators during CC at 6 months after surgery was smaller than that of preoperation. However external rotators strength at 1 year after surgery was statically higher than preoperative strength. The peak torque of the external rotators during EC gradually increased after surgery, but there was no statistically significant difference between preoperation and 6months after surgery. E/C (eccentric torque/concentric torque) ratio at 60 deg. /sec. velocity gradually decreased in the internal rotators, but gradually increased in the external rotators.
[Conclusion]The muscle strength of the internal and external rotators recovered at 1 year after surgery.

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We compared the rotator cuff tear size determined from surgical findings with that measured by MRI. Differences arising from the imaging method used were also examined.
The subjects were 13 patients(14 shoulders)with a complete rotator cuff tear who underwent MRI before surgery. Six of the patients were men and 7 were women. Eleven tears involved the right shoulder and three involved the left shoulder. The meanage of the patients was 64.8°8.62(SD)years, with a range of 52-78 years. The distance between the high-signal regions was measured in the oblique coronal and oblique sagittal planes of T2^* -weighted image of gradient echo technique and T2^*-weighted images of fast spin echo technique(fast T2- weighted image)were compared with the pre-debridement tear dimensions measured during surgery. The usefulness of T2^* -weighted and fast T2-weighted images was also examined by comparing the two methods to determine which gave a measurement to closest to the operative value.
Using oblique coronal images, the correlation coefficient was 0.934 between T2^* -weighted images and operative findings, and was 0.934 between fast T2^* -weighted images and operative findings. The correlation coefficients were also high using oblique sagittal plane images(0.850 and o.946 respectively). The mean difference between the operative findings and the values measured with MRI was 4.1°3.6mm for T2^*-weighted images and -1.0°3.8mmforfastT2-weighted images obtained in the oblique coronal plane. The mean differences obtained using oblique sagittal images were 5.9°7.6mm and-1.6°5.8mm, respectively. There was a significant difference between the results for oblique coronal and oblique sagittal images shown by the t-test.
Our findings indicate that MRI is useful for estimating the size of rotator cuff tears. Measurements obtained from fast T2^*-weighted images more closely matched the operative findings than measurements obtained from T2^*-weighted images.

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[Purpose]The purpose of this study is to determine the diagnostic performance of MR arthrography and MR bursography in evaluating an incomplete rotator cuff tear.
[Materials and Methods]Twenty shoulders in 19 cases of surgically proved incomplete rotator cuff tears (8 articular side,9 bursal side,3 intratendinous alone ) were studied retrospectively. Fourteen patients were men and 5 patients were women. Their age range was 29-80 years (average age,42.5 years).
Six of the 8 shoulders with an articular side tear and 6 of the 9 shoulders with a bursal sid e tear were accompanied by intratendinous tears. After a 10m1 injection of diluted Gd-DPTA into the articular capsule or subacromial bursa, Ti weighted (SE) MR images were obtained on the 1.5T MR system. The injection site was determined by the tear site expected by the arthrogram previously performed. An incomplete tear was diagnosed using MR arthrograms and MR bursograms whenever a sharply delineated region in the cuff revealed an increased signal intensity without encompassing the whole thickness of the cuff substance.
[Results]MR arthrography and MR bursography reveale dadequate diagnosis in 8 pf the 8 (100%)articular side tears, in 5 of the 9 (55.5%) bursal side tears and in 1 of the 3 (33.3%) intratendinous tears. Combined intratendinous tears were identified in 6 of the 6(100%) articular side tears, and in 3of the 6 (50%) bursal side tears. In all of the 4 cases which had failed to interpret bursal side tears, Gd-DPTA had not been injected into the subacromial bursa accurately.
[Conclusion]Our preliminary results show that MR arthrography is a reliable method for demonstrating articular side tears and the intratendinous tears accompanied by them. MR bursography is not helpful because it is difficult to inject Gd-DPTA accurately into the subacromial bursa.

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The advantage of repairing a ruptured rotator cuff tendon to the original insertion is that it provides an ideal site of ideal site of tendon attachment for the rotator cuff to stabilize the humeral head effectively. This canine histologic study disclosed the healing process at the bone-tendon interface of a repaired rotator cuff tendon attached to the surface of the calcified fibrocartilage. The left infraspinatus tendons of six mongrel dogs were transected and repaired. Specimens were harvested at 3,6,12, and 16 postop erative weeks. Histologic specimens were treated with H&E stain and were viewed with polarized light. In the 3rd postoperative week, the fibrous did not attach to the surface of the calcified fibrocartilage. In the 6th postoperative week, the connection was still sparse. In the 12th postoperative week, collagen fibers in the interface attached to the surface of the calcified fibrocartilage without penetration. In the 16th postoperative week, collagen fibers had attached securely to the surface of the calcified fibrocartilage. The results of this study demonstrated healing of a tendon re-attached to a calcified fibrocartilage surface, indicating that collagen fibers do not seen to connect securely until the 16th postoperative week.

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The purpose of this study was to clarify the isokinetic strength of the shoulder abduction and external rotation in tears of the isolated supraspinatus tendon.
Isolated tears of the supraspinatus tendon were present in 7(area<4cm² on MRI),7 shoulders(7 patients)without a history of shoulder pain on the contralateral side were enrolled in this study. Their mean age was sixty-five years (50 to 78). We measured the isokinetic strength of abduction and external rotation of both shoulders using a Cybex 6000 isokinetic dynamometer (Cybex, Division of Lumex, New York). The strength of abduction was measured with the patients seated on a chair. The test was carried out between 0° and 110° of abduction at angular velocities of 60 °/s and 180° /s. The strength of external rotation was tested with the subject standing with the elbow flexed to 90° and carried out between 45° of internal rotation and 45° of external rotation. To relieve pain we then injected 5ml of 1% carbocaine into the glenohumeral joint.
The peak torque which were the highest torque value seen from all repetitions were measured and expressed percentages of those of the contralateral side. The abduction strength of the isolated supraspinatus tears as percentages of those of the contrateral side was 67.0±9.2% at 60°/sand70.1±8.3% at 1800/s. The external rotation strength of the isolated supraspinatus tears as percentages of those of the contralateral side was 67.0±23.8% at 60°/s and 71.9±24.4% at180°/s.
The decreases in isokinetic strength in abduction and external rotation of the isolated supraspinatus tendon rupture was about 30% of the contralateral side.

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The post-operative isokinetic strength of the shoulder and arthrogram were evaluated in eighteen patients who had a repair of a full thickness cuff tear. Arthrography was performed in all patients at six months after operation and the isokinetic strength was evaluated at one year after operation using Myolet (Kawasaki Heavy Industry, Ltd.) The post-operative arthrograms revealed that the only four shoulders (22%) were intact. Other than that, five (28%) shoulders had either intratendinous leakage of the contrast medium or a pinhole tear, and nine shoulders (50%) had obvious leakage of the contrast medium into the subacromial bursa namely a residual defect. The mean peak torque was 97%/89%,102%/89% of the uninvolved shoulder in adduction/abduction at 60°/sec and 120°/sec respectively, and 87%/91% in internal/external rotation at 60°/sec. Recovery of strength correlated primarily with the size of the tear and not with the watertightness of the repaired cuff.
Postoperative muscle strength of the shoulder is one of the most i mportant factors for good clinical results of a rotator cuff repair. This study, however, did not show a significant relation between the status of a repaired rotator cuff and the strength of the shoulder suggesting that a watertight repair of the rotator cuff tear may not be necessary for the recovery of isokinetic strength of the shoulder.

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[Purpose]To evalutate the incidence of glenohumeral joint abnormalities concominant to rotator cuff tears.
[Materials and Methods]305 patients who underwent an arthroscopic examination of glenohumeral joint and a rotator cuff repair were studied. The average age of the patients was 58.8years and they consisted of 213 men and 92 women. The rotator cuff tears included 239 complete tears and 66 incomplete tears. The diagnosis of the joints was determined by an arthroscopy.
[Results]Synovitis with a villous formations at the superior capsule were found in 152 cases(50%), at the rotator interval in 177(58%)and at the axillary pouch in 19(6.2%). Type 1 SLAP lesions were found in 52 cases(17%), type II in 14(4.6%), type III in one(0.3%)and type IV in 2(0.7%). Bankart lesions were in cases(1%). Partial tears of the long head of biceps tendon were in 34cases(11%), com-Plete tears in 15(4.9%)and dislocation of the tendon in 2(0.7%). Osteoarthrotic change of the glenoid were in 18 cases(5.9%), of the humeral head in 29(9.5%)and free bodies in 3(1%).
A Total of 239 cases(78%)out of 305 had glenohemeral joint abnormalities and 72 cases(24%)needed arthroscopic treatments or a change of post operative rahabilitation.
[Conclusion]Glenohumeral joint abnormalities concominant to rotator cuff tears can sometimes be overlooked because they are masked by the pathology from a rotator cuff tear. Using an arthroscopy as a rotator cuff repair has the advantages of both an examination and treatment of the glenohumeral joint.

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Many arthroscopists recognize the importance of diagnostic and operative arthroscopy for the treatment of associated pathology before rotator cuff repair. We use arthroscopy even during open and mini-open procedure to secure sutures and repair. The purpose of this study is to report the utility of arthroscopy in open/mini-open rotator cuff repair as well as its short-term postoperative outcome.
Twenty-one shoulders in 19 patients underwent open/mini-open rotator cuff repair through the use of arthroscopy. Average age at time of surgery was 52.2 years and average postoperative follow-up was 12.3 months. All patients were seated in the beach-chair position under general anesthesia. Diagnostic arthroscopy and bursoscopy were performed for the purpose of evaluating rotator cuff tear (RCT) configuration and tendon tissue quality. After treatment for associated pathology, open cuff repair was performed in cases of poor tendon tissue quality/mobility and large complete RCT. In other cases, arthroscopic subacromial decompression and mini-open repair were performed. Arthroscope was used to secure sutures and repair from inside the joint during open/mini-open procedure.
Six out of 21 were incomplete and 15 were complete RCT. Nine shoulders, including 8 large complete tear, underwent open cuff repair, while 12 underwent mini-open repair. Associated pathology were as follows: anterior labral lesion in10 cases; SLAP lesion in 7(type I: 4, type II: 3); partial subscapularis tendon tear in 6; and synovitis in all cases. Postoperative/preoperative JOA score was 94.5/69.6 (pain: 26.9/10.3, function: 19.4/15.6, and ROM: 27.6/23.7). In conclusion, arthroscopy with patients in the beach-chair position is useful and helpful for open and mini-open rotator cuff surgery.

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We evaluated the usefulness and limitation of oblique coronal MR imaging for the prediction of the size of a rotator cuff tear.
39 patients (39 shou l ders,24 men) with complete rotator cuff tear (involving supraspinatus tendon)were examined. Their mean age was 59 (41-75) years old. The sizes of tears were confirmed at surgery (31 cases of tendon advancement and 8 cases of muscle advancement). T2-weighted images with 5mm oblique coronal sections and 1mm intersection gap were used for MR evaluation. The length of the high signal area on the tear (length on MRI) was compared to the length of the tendon retraction (retraction), and the number of slices showing complete tears (number of slices) was compared to the widths of the tear (width).
In the cases with tendon advancement surgery, the mean length on MRI was 15 (5-30) mm and mean number of slices 2.7 (1-5). The mean retraction was 19 (5-40) mm and the mean width 18 (3-35) mm on surgery. Retraction was correlated to the length on MRI (ρ=0.773: p<0.0001) and width to the number of slices (ρ=0.770: p<0.0001) (Spearmans correlation). In the cases with muscle advancement ment surgery, the supraspinatus tendon was fully involved and retracted over 40mm. The mean length on MRI was 30 (18-40) mm and the number of slices was more than 4 (mean 4.8). There were two cases on which muscle advancement was necessary in spite of the lengths of 20mm or shorter on MRI. Thickened bursae and/or scars may have pretended to be a rotator cuff on the image. In conclusion, oblique coronal MRI is useful for the prediction of the size of rotator cuff tear. But the sizes tend to be interpreted smaller than they are actually, particularly in large tear.

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[Purpose] The purpose of this study is to evaluate the results of the operative treatment for rotator cuff tears using the analysis of the correlation between the size of the tear and pain before and after surgery.
[Materials and Methods] We examined two hundred shoulders with rotator cuff tears after surgery. The subjects consisted of 127 males and 73 females aged aged from 20 to 77 years (average age: 53.7±8.8SD years). Based on the intra-operativeassement of the tear size, the tears were classified as follows.
Group I: macroscopic incomplete rotator cuff tears, which included either partial-thickness tears or arthrographic complete tears. Group S: full-thickness tears of which the defects were less then 1 cm. Group M: the defects were 1 to 3 cm. Group L: the defects were greater than 3 cm with retention of tendon mobility. Group G: the defects were greater than 3 cm with loss of tendon mobility. We evaluated pain according to the shoulder evaluation sheet of the Japanese Orthopaedic Association (JOA)score pre-and post-operatively.
[Results] Ther e were statistically significant differences between Group I and Group M before surgery (p<0.05), Group I and Groups S, M, and L after surgery (3 months: p<0.0005,6 months: p<0.01,12months: p<0.05). Furthermore, we found statistical correlations between the pre-operative J OA pain scores and the post-operative ones.
[Conclusion] Patients with intraoperative incomplete tears were likely to have more pain before and after surgery than the other groups. Patients with severe pre-operative pain often had residual pain. It is very important to reduce pre-operative pain and muscle spasms for the success of operative treatment.

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The purpose of this study is to elucidate the causes of the cases which underwent re-operation, due to persistent pain and dysfunction after rotator cuff repairs. Since 1970,1037 shoulders with rotator cuff tears have been repaired in Nobuhara Hospital, of which 7 shoulders (males 7, femalel, mean age 60.1yrs. ) were used in this study. The following items such as occupation, the side, elapsed time before surgery were discussed. Surgical findings (the form of the rotator cuff, the condition of the long head of the biceps, and the surgical method), were examined and analized comprehensively. All of the subjects were engaged in hard work labor. There were 3 right sides and 4 left. All the dominant arms were on the right. There were 4 complete tears, of which there was only massive tear, and 3 incomplete tears (concealed). The long head of biceps was invisible in 2 and there was a partial tear in 1. Mc Laughlin's procedure was abopted to complete the tear and only suturing on the superficial layer was carried out to concealed tear, without seeing the condition of the inside of the joint. In general, complete tears are considered to be more often re-operated on. However, our data reveals that even in a concealed tear, it is necessary to anchor the tendon end to the humeral head, after incising and observing the existence of a retracted deep layer's tear, which develops again in a rotator cuff tear. Also, a tear of the long head of the biceps was related to re-operated cases.

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[Purpose] We investigated changes in the supraspinatus muscle with a rotator cuff tear by dissecting the shoulders in cadavers.
[Materials and Methods] We dissected the 76 shoulders in 38 cadavers to study changes of the supraspinatus muscle with cuff tear and advancing in age. We made the transverse section of the supraspinatus muscle and stained by van Gieson method. Then we analyzed changes of the supraspinayus muscle belly with cuff tear and by age, measuring the short and long diameter of a slice of the muscle belly and the area of tendon fiber.
[Results] In the group with normal cuff, there was a negative correlation between aging and the short diameter of the slice of the supraspinatus muscle but no significant correlation between aging and the long diameter of the slice. In the group with a cuff tear, not only the short diameter but also the long diameter of the slice of the supraspinatus muscle decreased with increase in the length of cuff defect. The area of tendon in the slice was increased with the length of cuff defect.
[Conclusions] We concluded that measuring the long diameter of the slice of the supraspinatus muscle was more efficient than measuring the short diameter to evaluate the suprapinatus muscle atrophy with a rotator cuff tear.

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[Purpose] Magnetic Resonance Imaging (MRI) has become widely used for the diagnosis of a rotator cuff tear of the shoulder. The preoperative MRI findings of the rotator cuff tear and intraoperative findings were examined.
[Materials and methods] The subjects were 42 patients with a rotator cuff tear of the shoulder aged 42-81 years (mean,62.3 years). The apparatus used was an MRT-200FX,1.5 Tesla (Toshiba).
[Results] In five of the eighteen patients with the massive and global rotator cuff tear showing clearly high signal intensity on the supraspinatus muscle belly in the T1-and T2-weighted images compared to the trapezius muscle belly, pulling by McLaughlin procedure could not be performed during surgery. The persistent tear of the rotator cuff causes fibrosis and fatty degeneration in the supraspinatus muscle with myostatic contracture, resulting in a high signal intensity on MRI.
[Discussion] MRI of a rotator cuff tear of the shoulder can be used fo r not only the identification of the rupture site and area, but the determination of operative methods by examination of changes in the signal intensity of the supraspinatus muscle belly.

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[Purpose] Recently, great progress has been made toward the improvement of the diagnosis for a partial tear of the rotator cuff (R. C. ). However, in spite of these fine preoperative evaluations, it has been very difficult to identify the location of a partial tear of the R. C. during surgery. The purpose of this study was to investigate the degree of relaxation of a R. C. With a partial tear and was to identify the location of the tear intraoperatively.
[Materials and Methods] 15 shoulders of 12 males and 3 females were diagnosed with partial R. C. tears by arthrogram and intraoperative findings. Their mean age was 59 years old (range 32 to 80 yrs. ). All the cases had an incomplete rupture in the tendon of the supraspinatus,14 cases showed an articular side tear and 1 case showed a bursal side tear. The traction test of the R. C. was done in the following manner: A load of 20 N was applied to the three parts of the R. C.2cm proximally from the facet in the direction of each tendon through the suture traction. The displacement of the suture point was measured.
[Results] The partial ruptured tendon had a 9.4mm length displacement by the load. Against these results, the intact tendon indicated a 4.7mm length displacement in the anterior cuff and 4.9mm length displacement in the posterior cuff.
[Discussion] In a partial tear of the R. C. the tendon was seen to be relaxed even if the tendon appeared to have continuity. This means a partial tear of the R. C. would be similar to a full thickness tear of the R. C. in terms of shoulder function. Consequently, the intraoperative traction test of the tendon is a useful method for the diagnosis and a functional evaluation for a partial tear of the R. C..

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[Purpose]To evaluate the efficacy of fascial patch procedure with latissimus dorsi transfer (patch procedure with a LD transfer) for massive rotator cuff tears, we examined the patients after this operation.
[Materials and Methods] From 1995 to 1997,13 shoulders in 13 patients were operated with this procedure. The average age at the operation was 59 (52 to 67)years old. The patients consisted of 10 males and 3 females. The right shoulders were affected in 8 cases, and the left in 5 cases. A fascial patch procedure was according to Tabata's reports, and a latissimus dorsi transfer according to Gerber's were added. The range of active elevation and external rotation and the muscle strength of abduction (ABD)by MMT were measured. The clinical results were evaluated with the JOA score.
[Results]The average active elevation before an operation was 95 °, and it increased significantly by 37 °after the operation. The average muscle strength of ABD was 2.9 before the operation and it became 4.0 after. The preoperative mean JOA score was 63.1 points, and the postoperative one was 82.8points. In 6 cases, the JOA scores were more than 90 points. The results of patients whose deltoids were atrophic before operation were poor.
[Conclusion] We thought that a patch procedure with a LD transfer was worthwhile for massive rotator

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[Purpose] We have treating patients with full-thickness rotator cuff tears by arthroscopic debridement. We report here the results of our investigation with regard to the prognosis of these patients.
[Indication and technique of arthroscopic debridement] Our indications were: 1)When massive rotator cuff tear was present.2)When pain was the chief complaint.3)When a block test resulted in an analgesic effect and the patients wished that state be continued.4)The patient showed low life activity(over 65years of age). Arthoscopic debridement consisted of trimming of the cuff stump which causes imping ement, bursectomy and synovectomy which may cause pain and rest and at night.
[Material] Twenty-two cases(24 shoulders)with full-thickness rotator cuff tears who underwent arthroscpic debridement were enrolled in this study. The mean at operation was 69.1 years. The mean follow-up period was 72.7 months.
[Results] There were no patients whose JOA score showed lower values after the procedure. Rather, an average increase of 19.9 points with regard to the JOA score was observed in our patients.
[Conclusion] We conclude arthroscopic debridement is an effective therapeutic for the treatment of senile patients with full-thickness rotator cuff tears.

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[Purpose] We operated on 3-part proximal humeral fractures on patients age over 70 years. This is a report of the result of the surgery.
[Patients and methods] Patients were 6 cases (7 shoulders) who could be follwedup for 1 year after operation. They were 2 males (2 shoulders) and 4 females (5 shoulders). Fractures were classified by Neer's classification.2 shoulders were 3-part fractures and 5 shoulders were 3-part fractures with a dislpcation. Open reduction and internal fixation with prosthesis (O group) consisted of 2 patients (2shoulders,1 shoulder with a dislocation). They were all males. Prosthetic aryhroplasty (P group)consisted of 4 patients (5 Shoulders,4 shoulder with a dislocation). They were all females. We used 1 Neer's prosthesis and 4 P. S. S. prosthesis. We evaluated their results by range of motion and the J. O. A. score. We also researched the waiting period till operation and any other fractures caused by osteoporosis.
[Results] The average waiting peiod was 15 days (from 11 days to 22 days),3cases were 2 weeks before and 4 cases were 2 week 2 weeks after.
All the Females had old compression fractures in their spines. Two females had femoral neck frac tures. The J. O. A. mean score results were: total score 73.8,2 weeks before group 74.9 and 2 weeks after group total score 72.9.
[Conclusion] We used prosthetic arthroplasty for patients whose bones presented severe osteoprosis. Open reduction and internal fixation with prosthesis was performed on patients whose humeral head tubecular pattern was clealy visible. For older patients, it is important that the post operative shoulder present no pain and is able to support the body.

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[Purpose] We have performed surgical treatment for the proximal end of humeral fractures in severe joint displacement and instability. In this report, we aim to study about the factors of poor prognosis of these fractures from the surgical results at our hospitals.
[Subjects] During the past 10 years, surgical treatment was performed on 13 cases with a fracture in the proximal end of the humerus: 6 men and 7 women.9 cases had a fracture in the left arm, and the other 3 cases had a fracture in the right arm. Their age ranged from 15 to 82 years (average: 55.9years), and the duration of postoperative follow-up ranged from 8 months to 4 years and 10 months (average: 2 years ). According to Neer's classification system,6 cases were type III,3 cases were 3part in type IV,1 case was 4-part in type IV, and 2 cases were 4-part in type IV.
[Results] Surgical osteosynthesis was performed on 9 cases, and endoprosthesis was performed on 4cases. The postoperative results were assessed by the JOA score. The JOA score of the 13 cases ranged from 69 to 98 points (average: 83.1 points), and a factor that reduced the JOA score the most was the range of motion, followed by pain.
[Discussion] In particular, the range of motion was limited and pain was confirmed in cases with a fracture of type IV or VI in which the greater tubercle displacement persisted and rotator cuff function was reduced. These findings suggest that the prevention of elevated greater tubercle and the reconstruction or maintenance of rotator cuff function are important in surgically repairing fractures in the proximal end of the humerus.

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(Purpose) We have performed open reduction and internal fixation by intramedullary pin and wire on 25 cases of fractures of the proximal humerus. The purpose of this study is to introduce our method and to evaluated the postoperative results.
(Materials and Methods) They consisted of 5 males and 20 females whose average age was 69.0 years. According to Neer's classification,24 cases were 3-part fracture and one case was 4-part fracture. The original methods (19 cases); humeral head and shaft were fixed by two Rush pins intramedullary through the rotator cuff. The rotator cuff and humeral shaft were fixed by a wire extramedullary. Modified method (6 cases); interlocking nail and wire were used in 3 cases, and two Ender pins and wire were used in 3 cases.
(Results) All fractures healed without postoperative displacement within 2 months. The average JOA score was 87.4 points and good results were obtained. In 8 cases, the Rush pin was removed because a subacromial impingement occured. The interlocking nail and Ender pin were not removed because they were inserted fully into the humeral head to avoid a subacromial impingement.
(Conclusion) The intramedullary pin can stabilize the humeral head and shaft longitudinally. Compressive force at the fracture site can be obtained by the wire. The greater tuberosity or lesser tuberosity can be firmly fixed to the humeral head by the wire. In addition, the wire can prevent the rotation of the humeral head and shaft. Our method is useful for unstable fractures of the proximal humerus. The modified method is more useful than the original method as it avoids a subacromial impingement.

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We investigated the clinical results of surgical treatment for 3- and 4-part fractures of the proximal humerus.
We studied 35 patients who underwent surgery for 3- and 4-part fractures of the proximal humerus between 1980 and 1997. They consisted of 16 males and 19 females aged from 20 to 84 years (mean 65 ). The fracture type was a 3-part fracture in 21 patients and a 4-part fracture in 14. Osteosynthesis was performed in 18 cases of 3-part fractures, and prosthetic arthroplasty in 17 cases,3 cases of 3-part fracture-dislocation and 14 cases of 4-part fracture and fracture-dislocation. The follow-up period ranged from 12 to 197 months (mean 83). We investigated the postoperative JOA score, range of motion of the shoulder joint and roentgenographic findings.
All the patients who underwent osteosynthesis obtained a bony union and exhibited no osteonecrosis of the humeral head.
The postoperative mean JOA score was 91 points in osteosynthesis and 78 points in prosthetic arthroplasty.
The patients who underwent prosthetic arthroplasty noted many problems in activities of daily living, but little shoulder pain.
The patients who underwent osteosynthesis showed 125 degrees(mean) in shoulder elevation and those who received prosthetic arthroplasy revealed 91 degrees(mean). The patients with osteosynthesis demonstrated 52 degrees (mean) in shoulder external rotation and those with prosthetic arthroplasy had 26degrees (mean) postoperatively.
Improved surgical procedures must be developed for osteosynthesis, because some patients exhibited comminution even in cases of 3 part fractures and fracture dislocation. The surgical technique and the design of the humeral endo-prosthesis must be modified to improve the postoperative results in patients with prosthetic arthroplasty.

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[Purpose] The purpose of this is to evaluate the results of hemiarthroplasty for displaced proximal humeral fiacture. [Materials and Methods] The patients were 3 males and 7 females, with their ages ranging from 54to 82, (average of 68.7 years). The follow-up period ranged from 1 year to 8 years and 1 month (average 4 years 3 months). Seven patients had an acute 4-part fracture, two had an acute 3-part fractu re, and one had a chronic 3-part fracture-dislocation with RSD. All the cases were treated using a Neer II prosthesis.
The operative results were assessed with the Japanese Orthopaedic Association (JOA) score.
[Results] The average of postoperative JOA score was 72.6, range a from 46 to 92. The average active motions were forward elevation,92.2: external rotation,7: and internal rotation, L5. Relief of pain was predictable with an average of 23 points. But one patient with RSD had severe pain and limited range of motion. Three patients with a limited range of motion had difficulty in reattaching the greater and lesser tuberosities anatomically.
[Conclusion] Anatomical reattachment of the greater and lesser tuberosity and early operation after injury (within 2 weeks) are important to gain satisfactory results.

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[Purpose] The labrum is important structure for shoulder stability. The torn labrum is often seen after a dislocation of the shoulder (Bankart lesion). This study was undertaken to elucidate the characteristic histological changes of the torn labrum.
[Materials and Methods] 22 biopsy spcimens of the labra were taken from 4-5 o'clock of the glenoid (in cases of the right shoulder) from 22 shoulders during a modified Bristow's procedure, Microscopic investigations were done regarding the changes of the collagenous structure, presence of the fatty degeneration and enchondral ossification. The distribution of the blood vessels and inflammatory cell proliferation were also investigated. Findings of each item were classified from grade I to III.
[Results] There were no necrotic changes within the substance of the torn labra. The regularly arranged collagen fibers (grade I) were seen in 13 cases, while their pattern was random (grade II, III) in 9 cases. Eighteen cases had a mild fatty degeneration (grade I). Enchondral ossification was seen in only one case. The vessels were relatively sparse: there were 4 cases with grade I,11 cases with grade II and 7 cases with grade III.
[Conclusion] The characteristic histological changes of the torn labrum in a recurrent dislocation of the shoulder was the random arrangement of the collagen fibers. There were no necrotic changes in the substance. The blood supply was maintained. These results confirm that the torn labrum has a potential of healing if the ligament-labrum complex is strained properly by a reconstruction procedure.

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It is difficult to reduce a chronic unreduced dislocation of the shoulder when long time has passed since the dislocation. We have treated operatively five patients with a chronic dislocation shoulder. The purpose of this study is to evaluate the results of surgical treatment for these patients.
The five patients were followed up for 6 months to 12 years. There were 2 males and 3 females. Their ages ranged from 30 to 70 years (average 53 years). The duration of the dislocation was between 6 weeks and 56 weeks (average 19 weeks). All the patients had anterior dislocation of the shoulder with a bony defect of the anterior part of the glenoid. Glenoplasty with a bone graft was attempted in 4 c ases, and total shoulder arthroplasty (TSA) in one case. We evaluated the postoperative results according to the shoulder evaluation of the Japanese Orthopaedic Association (JOA score).
The patient with TSA was infected postoperatively, so the prosthesis was removed. His preoperative JOA score was 32 points and his postoperative score was 48 points. The postoperative JOA score of the other patients were75,59,89,97 points respectively.
The patients with glenoplasty had good results except in one case. However, even these patients whose assessments based on the ROM or JOA score did not demonstrate good results had improved their ADLs.

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Purpose: The superior and middle facets of the greater tuberosity are the useful landmarks to identify the location of rotator cuff tears, but it is difficult to obtain the reproducible images of the facets in oblique sagittal plane. The purpose of this study was to determine the most favorable conditions for the identification of the superior and middle facets on MRI.
Materials and Methods: Five cadaver shoulders were enrolled in this study. Fast SE T2 weighted images in sagittal oblique plane were obtained using a 0.5-T imager (Toshiba FLEXART). On the axial plane, the base line was drawn from the center of the humeral head to the base of the bicipital groove. Three sagittal oblique planes were obtained at the angles of 40 degrees,50 degrees,60 degrees from the base line. The length of the superior and middle facets of the greater tuberosity on MRI were measured, and compared with the lengths of each facet on cadaver shoulders.
Results: The length of the superior facet of the greater tuberosity on MRI at the angles of 40 degrees,50 degrees,60 degrees from the base line were 12.8 ± 1.1 mm,14.1± 1.8 mm,13.9 ± 1.7 mm (avg ± SD), respectively. On the other hand, those of the middle facet were 21.6 ± 1.6 mm,18.2 ± 2.2 mm,6.1 ± 2.1 mm, respectively. The length of the superior and middle facets on cadaver shoulders were 12.4 ± 0.7 mm,1.5 ±0.9 mm, respectively.
Conclusion: Identification of the superior and middle facets should be assessed with MR images located by the humerus, especially with the angle of 40 degrees from the base line. by Minagawa Hiroshi, Itoi Eiji, Shimizu Togo, Nishi Tomio

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Our objective was to elucidate the effective factors for atrophic changes of a torn supraspinatus muscle quantatively.
Patients and Methods. We analyzed the data of 100 patients with shoulder pain and examined their MRIs due to shoulder pain; the clinical features and the measured data from the MRI; the severity of the cuff tear, the area of the supraspinatus muscle sectioned oblique sagittally at the articular edge of the glenoid (S). To revise the physique differences, the maximum transverse diameter of the humeral head (D) was also measured. The severity of the cuff tears were divided into 6 grades; no tear (grade 0), partial thickness tear (grade 1), small tear (grade 2), medium tear (grade 3), large tear (grade 4), massive tear (grade 5). A stepwise regression analysis was used for the detection of the effective factors.
Results.1) 67 cases had no-cuff tear and 33 cases had a cuff tear.2) In the no-cuff tear group, the sectioned area of the supraspinatus muscle (S) simply correlated with the maximum transverse diameter of the humeral head (D) no relation with sex or the side, hence the S/D was used as the revised marker of the sectioned area of the supraspinatus muscle. The stepwise regression analysis resulted in S/D=550.9-2.5x(age) in the no-cuff tear group (P<0.01).3) In the cuff tear group, stepwise regression analysis resulted in S/D=705.0-53.3x(cuff tear grade)-4.5x(age) (P<0.01).
Conclusion. Deterioration of the rotator cuff tear may be a more of a causative factor for atrophic changes of the supraspinatus muscle than aging.

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Postoperative imagings have the following problems: 1)partial volume averaging of subacromial sp ace.2)Difficult visualization of repaired cuffs especially in the early postoperative period. Therefore, we developed a new system named Traction MRI to produce a clear visualization of the tendons.
Primarily repaired rotator cuffs of 113 patients (115 shoulders), aged from 20 to 77 (mean 55) were evaluated from 3 to 12 months after surgery. Preoperative tears were 93 complete (58 small and 35large) and 22 incomplete tears (13 bursal side,5 intratendinous,4 articular side). The operative methods adopted were 96 tendon to bone,10 tendon to tendon and 9 tendon to bone plus fascial patch pro cedures.
MRI was performed with a 1.5T Signa unit. A Traction MRI device made of vinyl chloride was attached to the table and 3 kg weight was applied to each upper extremity and maintained during exa minations.
All 115 repaired tendons were observed with a Traction MRI. High signal intensity was seen in tendons in 42% of the shoulders at 3 months, and this rate decreased to 25% at 6 months and 20% at 12months. Low signals were seen in only 38% at 3 months, and increased to 47% at 6 months and 60%at 12 mouths. In the bursa, high signals were seen in 61% at 3 months, and this rate decreased to 46%at 6 months and 41% at 12 months. In the shoulder joint, high signals were seen in 60% at 3 month s, which went down to 41% at 6 months and 33% at 12 months.
Comparing the postoperative signal intensity and the JOA shoulder score, when the high signal was present, the score tended to be lower than the average. However, there was no statistical difference among the three groups.
When we view the consecutive imagings of the repaired cuffs, high signals were observed in 42% at 3 months.65% of these cases still had high signals at 12 months, while 23% returned to the low sig nals. Out of the 20% cases with intermediate signals at 3 months,86% returned to the low signals after 12 months. All the cases with low signals at 3 months, kept the low intensity throughout the postoperative course. These findings suggest that retearing of tendons occurs in the early stage (within 3months) after surgery.

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The diagnosis and treatment of shoulder problems depends upon the knowledge of anatomy. The purpose of the present study was to determine the prevalence and variation of the glenohumeral ligament complex (GHLC) in a series of specimens from cadavera.
Twenty-two cadavera were dissected and 44 shoulders were examined. The age of the subjects at the time of death was 70.7 (range 44 to 88) years. There were 9 female cadavera and 13 male. The prevalence of SGHL, MGHL and IGHL was investigated. The width of the SGHL at the attachments to the glenoid labrum were measured. The shapes of the attachments of the MGHL to the glenoid were rec orded. The location of the attachments of the anterior band of the IGHL were recorded. GHLC was assigned to one of six anatomical categories described by De Palma et al.
SGHL, MGHL, and IGHL were present in 86.4%,56.8% and 79.5% respectively. The mean width of the SGHL at the attachment of the glenoid was 5.9mm.44% of the MGHL attached to the SGHL.62.8%of the IGHL anterior band attached to the glenoid labrum at 3 o'clock (right shoulder). GHLC were categorized as follows: Type 1 (28.1%), Type 2 ( 3.1%), Type 3 (21.9%), Type 4 (43.8%), Type 5(0 %), Type 6 (3.1%). Variations of MGHL were noted in this study.

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[Purpose] Experimental study has been performed on the repair process of the rotator cuff tear using rabbits or dogs. However, the degeneration of rotator cuff was not concerned in these studies. In this study, it was attempted to make a degenerative tendon using patella tendon of the rat.
[Subjects and Methods] Female Wistar rats (12 weeks after birth) were used. Lateral half of the patella tendon was detached from the tibia. The detached tendon was turned up subcutaneously in right leg (subcutaneous group), and was turned down into the patello-femoral joint in left leg (intra-joint group). At 1,2 and 3 weeks after operation, the patella tendons (N= 4; 1 week, N= 3; 2 weeks, N= 5; 3 weeks) were removed and examined histologically. Numbers of tenocyte was measured by histologic findings and the density of tenocyte was obtained.
[Results] In intra-joint group, wavy appearance disappeared and the collagen fibers were longitudinal splitting at 3 weeks after operation: But, neither hyaline degeneration nor hyperplasia of intima were observed in any tendon. Density of tenocyte in intra-joint group was significantly lower that those in subcutanecus group at 3 weeks after operation.
[Discussion] It is speculated that the degeneration of the patella tendon was caused by insufficiency of blood flow due to detachment and mechanical stress between patella and femur. In This study, all tendons were able to be degenerated in a short period, and this model seems to be useful for experimental study of the rotator cuff tear.

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The purpose of this study is to evaluate the effects of extracorporeal shockwaves on chronic calcific tendinitis of the shoulder. We studied 4 patients with chronic calcific tendinitis of the shoulder. Extracorporeal shock wave therapy was applied using Dornier Epos (Dornier Company, Germany). The JOA score, the VAS score (resting pain, night pain and tenderness) and plain radiographs before and after the shock wave treatments were studied in 4 shoulders.
The average JOA score was 55.5 points (range,37-70 points) just before the start of the shock wave application. At the end of this study and over-three months after the shock wave application, it was 75.5 points (range,57-98 points). The VAS scores were decreased in all 4 patients after the shock wave application. The areas of calcification were reduced in 3 out of 4 shoulders. We concluded that extracorporeal shock wave therapy was useful for chronic calcific tendinitis of the shoulder.

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[Purpose] We wish to report traumatic dislocation of the tendon of the long head of the biceps(LHB)with a characteristic lesion.
[Patients] Case 1: A 43-year-old female was injured by a direct blow on her shoulder while skiing. She was diagnosed as a dislocation of the LHB by arthroscopy. Case 2: A 32-year-old male was injured by a direct blow on his shoulder during a football match. He was diagnosed as a dislocation of LHB by the arthrography, CT arthrogram and MR arthrogram.
[Results] In the operations, the LHB was incompletely dislocated from the bicipital groove (BG) in case-1 and dislocated in the tendon of the subscapularis muscle in case-2, injuries of the glenohumeral ligaments and the transverse humeral ligaments were seen. At the diagnostic arthroscopy and the operations, the cartilage-like tissue was peeled off the superior edge of the BG and the LHB lay between this tissue and the floor of the groove.
[Conclusion] We consider that an avulsion of the cartilage-like tissue from the floor of the groove is a characteristic sign of a traumatic dislocation of the tendon of the long head of the biceps.

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This is to evaluate the clinical results of conservative treatment for complete dislocations of the acromioclavicular joint.
Twenty-seven patients with acromioclavicular dislocation (21 patients with type III and 6, with type V of Rockwood's classification) were followed up for 46 months, on average. The mean age at the time of injury was 39 years (17 to 64 years). Clinical and roentgenological evaluations were done according to the JOA scores.
The average JOA score was 79 points in patients with type III and 69 points, in those with type V. This difference between the two types resulted from pain in daily activities. There were no differences in JOA score between the injury of the dominant and non-dominant side. But 2 patients with type III, one a baseball play and the other a badminton player at university, could not return to their pre-injury activity levels, due to the injury being on the dominant side.
In the type III of acromiclavicular. dislocation, conservative treatment may be indicated, except in patients such as a university athlete with an injury on his dominant side. The results of conservative treatment were not satisfactory in a typeV injury.

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Fourteen patients with rheumatoid shoulder underwent prosthetic arthroplasties over the last seven years. The results of prosthetic arthroplasties in 12 patients on whon a follow-up study could be made more than one year after surgery were evaluated by the J. O. A. score.
These patients consisted of 4 males and 8 females and the age at the time of operation ranged from 46 to 72 years. The follow-up period after the operation ranged from one year to 6 years and 4 months. A single modular total shoulder arthroplasty system (Biomodular Total Shoulder System, Biomet, Warsaw, Ind. ) was used in each case. All polyethylene glenoid components were implanted with cement. In 7 Shoulders, humeral stems were inserted by the press-fit technique. At follow-up period each patient was evaluated according to the J. O. A. score. The rotator cuff tear was torn in 6 patients. The results were excellent in one case, good in 4 cases, fair in 5 cases and 2 patients had poor result. A remarkable relief of pain was observed in most of the patients. Range of motion improved 50° in forward elevation. In the analysis, functional results of the prosthetic arthroplasty depend on the status of deltoid muscle rather than that of rotator cuff (p<O.05).
A modular total shoulder system provides better adjustment to the soft-tissue tension on the shoulder joint and better results than non-modular shoulder arthroplasty.

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[Purpose] To clarify the diagnostic value of load and shift test (LST) for the assessment of glenohemeral joint laxity compared with examination under anesthesia (EUA).
[Material and Method] We retrospectively reviewed the healthy-side shoulders of 100 patients (65males,35 females) who underwent surgical treatment of their opposite side. Their mean age was 27.5years. We examined the anterior and posterior laxity at 30° and 90° of abduction, and inferior laxity in neutral rotation with the arm at the side. The anterior or posterior laxity was graded into three degrees (-, +, + +), and the inferior laxity was graded into two degrees (sulcus sign -, +). We detrmined the joint laxity positive when the laxity was graded + or + +. We calculated the sensitivity, the specificity and the accuracy of the LST based on the results of the EUA. In addition, when a joint laxity existed at the anterior and posterior transelation on LST, we assessed the discrimination of the grade of the laxity on LST based on the results of the EUA.
[Results]Sensitivity, specificity and accuracy of LST were as follows: inferior; 50.0%,96.0%,98.0%, anterior at 30°of abduction; 45.0%,96.3%,86.0%, anterior at 90°of abduction; 54.2%,100%,78.0%, posterior at 30°of abduction; 36.4%,92.9%,68.0%, posterior at 90°of abduction; 56.0%,88.9%,71.0%, respectively. The discrimination of the grade of laxity: anterior at 30°of abduction; 100%, anterior at 90°of abduction; 84.6%, posterior at 30° of abduction; 87.5%, posterior at 90°of abduction; 77.4%.
[Conclusion]LST was not sensitive but a specific examination compaired with EUA fbr shoulder joint laxity. Moreover, LST was excellent for the discriminating the gradeof the laxity.

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Late degenerative glenohumeral arthrosis following recurrent anterior shoulder dislocation (RASD)is evaluated by radiographic evidence of the degenerative changes. However, the time of the appearances of these changes and the variables that correlated with the appearances are unclear. We attempted to determine the prevalence of preoperative evidence of these changes and to identify variables that correlated with the radiographic evidence.
Preoperative 238 patients (246 shoulders) of RASD were reviewed. The average age of the patients was 23.8 years at preoperative evaluation and 19.0 years at the time of the initial dislocation. The radiographs(anteroposterior, axillary lateral and 45°cephalocaudal view)showed a marginal osteophyte on the anteroinferior portion of the humeral head in 26 (10.6%) shoulders. The other degenerative changes were not detected by the radiography. Bilateral CT-pneumoarthrograms showed that those osteophytes existed in 78 (31.7%) shoulders, including 26 cases detected in radiographs, and mainly enlarged inferiorly from anteroinferior margin of the humeral head. The osteophyte was not existed in the contralateral nondislocated shoulders. The age at preoperative evaluation, the age at initial dislocation, the interval from the initial dislocation until the preoperative evaluation, the unmber of dislocations and subluxations including dead arm syndrome, those average numbers per year, the range and the limitation of external rotation, and the degrees of general joint laxity were compared between 78 shoulders with the osteophyte and 168 shoulders without the osteophyte. Statistical analysis of the date using Mann-Whitney's U test revealed that the number of subluxations and its average number per year were significantly(p<O.05)1arger in the shoulders with the osteophyte. There were no statistical difference among the other variables. The Osteophyte on the anteroinferior portion of the humeral head were clearly detected by CT -pneumoarthrography. The degenerative change already existed in the early period of RASD with no operation. The existence was correlated with the number and the frequency of subluxations.

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The purpose of this study is to investigate the natural course of recurrent anterior dislocation of the shoulder without an operative treatment.
The materials for this study were 145 patients with recurrent anterior dislocation of the shoulder who were once reduced a dislocation of the shoulder at our hospital. Questionnaires about the history of an operation, the history of the dislocations, an apprehension of dislocation, sports activities, and other items were sent to them by mail. The answerers without an operative treatment were divided into three groups. Group A (active) consisted of the patients with redislocation for 2 years before the time of this study. Group C (cured) consisted of the patients without redislocation and an apprehension of dislocation and subluxation over 5 years. Group Q (quiescent) consisted of the rest.
Eighty-one patients answered the questionnaires, including 60 patients without an operative treatment. There were 42 males and 18 females. The age at the time of the initial dislocation averaged 21.6years (10 to 59). The time of dislocation averaged 4.9 times (2 to 15). There were 21 patients in group A,7 in group C and 32 in group Q. We could detect significant factors relevant to the natural healing. The factors were a low frequency of dislocations for a year, a high age at the time of follow-up and a long period between the time of an initial dislocation and the time of follow-up.
Seven (12%) of 60 patients who had recurrent anterior dislocation of the shoulder and no operative treatment had no redislocation and an apprehension of dislocation and subluxation over 5 years.

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[Purpose]The purpose of this study was to clarify the difference of the pathological findings of recurrent subluxation and dislocation of shoulders treated with the modified Bristow' s procedure in the past 10 years.
[Materials and Methods]Patients with a history of self reduction only were selected for the subluxation group. Patients with the history of passive reduction only were selected for the dislocation group. The subluxation group (group S) was made up of 24 patients (23 men,1 woman). Their average age was 21.3 years ( ranged from 14 to 33). The dislocation group (group D) was made up of 20 patients (14 men,6 women). Their average age was 25.2 years (ranged from 15 to 63). The average follow-up period was 3 years and 10 months in group S, and 4 years and 5 months in group D. Evaluations were based upon clinical findings, radiological findings. Each case with an operative procedure was scored according to the shoulder scoring system of the Japanese Orthopaedic Association.
[Results]The uncountable dislocations had been occured in 62.5% of patients of group S and, in 30%of patients of group D. The incidence of positive in the apprehension test was 74% in group S and 50%in group D. Seventy percent of group S and 30% of group D showed a sulcus sign. Bankart lesion was observed in 69% of group S and 90% of group D. Hill-Sachs lesion was positive in 88% of group S and 75% of group D. The total scores were 95.2 in group S and 96.1 in group D.
[Conclusion]The uncountable dislocations had been occured significantly higher in group S than in group D. Group S seems to be classified the group with the tendency to have capsular laxity such as the sulcus sign. The operative results were satisfying in both groups. According to these results, group S and D may be able to managed in one concept of anterior instability.

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Modified Boytchev procedure was perfomed on 149 traumatic unstable Shoulders, and this procedure combined with a glenoid bone graft was perfomed on 12 shoulders that had over 20% of glenoid bone defect compared to the contralateral side, it was combined with a capsular shift in 17 shoulders that had an inferior laxity of Endo type II and III. The age ranged from 13 to 50 years (ave 23.7). The follow up period was 2 to 11 years (ave4). The balance between an insertion point to the conjoined tendon of the musculo-cutaneous nerve and the length of the tunnel under the subscapular tendon was measured in 62 Shoulders. The link between the occurrence rate of musculo-cutaneous nerve palsy and its insertion points were studied.
The redislocation rate was 8.1% before changing the operative indication, and was 3.1% after it. Only one subluxation occurred after the capsular shift, but there was no recurrence after a glenoid bone graft. Twenty-three of the patients who underwent a modified Boytchev procedure, and 31% of the patients with a combined operation complained of slight pain during sports activity or heavy work. Ninety-six patients who wanted to play sports could do their original sport activity. Musuculocutaneous palsy occurred in 10% of the patients, but almost all the palsy recovered within 3 months. The length from the top of the coracoid process to the insertion of the musculo-cutaneous nerve should be 1.5cm longer than the tunnel of the subscapular tendon.

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[Purpose]To investigate whether STATAK is useful in Bankart repair&modified Bristow procedure (: B&B).
[Materials and Methods]Forty patients with recurrent anterior dislocation with severe bone defects of the anterinferior glenoid border underwent surgery by B&B with STATAK (group S). The 43 patients who underwent surgery with a conventional bone tunnel suture were the control group (group B). We investigated the clinical results by using the Rowe's scoring system and operation time of both groups and the failure of STATAK insertion.
[Results]The average of Rowe's score was 92.8 in group S, and 92.5 in group B, and there was no significant difference in either group. The average of operation time including arthroscopic examination was shorter by about five minutes in group S than in group B. The failure ratio of STATAK insertion was 6.3% of all 128 anchors. The modes of failure were four anchor pullouts, one anchor cut out, and three suture cutouts.
[Discussion]Under accurate management a STATAK insertion will be useful in B&B for recurrent anterior dislocation of the glenohumeral joint with severe bone defect of the anteroinferior glenoid bo rder.

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[Purpose]Since April 1996, we have performed the reattachment of the detached capsulo-labrum complex using an anchor suture device. We wish to report an our procedure for recurrent anterior dislocation/subluxation and the short term clinical results.
[Materials and Methods]59 cases were evaluated. They were followed-up at least nine months after surgery. The subjects consisted of 42 males, and 17 females,34 dominant sides, and an age range from 16 to 60 with an average of 26.1. In our procedure we divided the subscapular muscle in its fiber, incised the capsule at the level of the glenoid edge, and three anchors were inserted at the glenoid edge, and sutured incised capsulo-labrum complex with the anchored threads. The day after surgery, active rotation exercise was started in the sling. The average follow-up period was 1.4 year.
[Results]5 cases were re-dislocated with a major trauma. According to the recovery to their sports activity,13 cases out of 16 cases fully returned to their recreational levels.5 out of 29 high leveled athletes retired.4 cases did not return to their sports activities. The remaining 20 cases returned to their sports activities. The average range of external rotation was 57.8 degrees.
[Conclusion]Our surgical procedure resulted in excellent recovery to their activities but was less effective in the limitation of R. O. M..

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[Purpose]Caspari's transglenoid multiple suture technique is an arthroscopic Bankart repair with sufficient capsular shift, but recurrence is high for the patients with a defective middle/inferior glenohumeral ligament structures. We tried the Caspari technique using the subscapularis muscle to increase the buttress effect of the anterior capsular mechanism.
[Material and Methods]We retrospectively studied 26 patients with recurrent anterior dislocation of the shoulder. The average age at operation was 24 years. The average postoperative follow-up period was 26 months. In addition to the conventional Caspari technique, we abraded medially to the base of the anterior glenoid neck and placed nonabsorbable sutures into the superior portion of subscapularis tendon. In the arthroscopic finding, anterior inferior glenohumeral ligament was poor quality in 17shoulders, thin or narrow and thin/narrow in 15. Defect of the glenoid was in 11, and a bony Bankart lesion was in 9. Middle glenohumeral ligament was cord-like or membranous in 13, and the inferior foramen in 19.
[Results]No recurrence was observed postoperatively. According to Rowe's scale, the clinical outcome was excellent in 18 patients, good in 8. The average limitation of external rotation was 13.6 degrees with the arm at the side and 4.3 degrees with the arm in 90 degrees of abduction.
[Conclusion]Caspari technique using the subscapularis muscle was useful for those patients who could not be expected to achieve the anterior buttress effect by a conventional arthroscopic Bankart procedure.

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The purpose of this study was to know the time-course from primary shoulder dislocation to recurrence in young rugby players. We sent questionnaire about shoulder dislocation to all highschool/college rugby teams in the Kyushu area (No. of players; 5476). Based on the answers from the players who had undergone shoulder dislocations, we divided them into two groups; Group I: immobilization for 0-3 weeks at the time of initial dislocation(n=61), and Group II: immobilization for 4-7weeks (n=18). We compared the time-course from primary dislocation to recurrence between the two groups using the Kaplan-Meier method. The age of primary dislocation was between 14 and 23 years old ( ave.; 16.7 ). The probability of recurrence was 78%,44%, and 70% after one year; 85%,69%, and 81% after two years in Groups I, II, and the whole groups respectively. The average period from restart of rugby to recrurrence was 9.8,30.6, and 19.7 months in Groups I, II, and the whole groups respectively. The symptom-free period could be elongated if immobilization was done for 4 weeks or more in comparison with cases immobilized for 3 weeks or less (p<0.05). However, the high recurrence ratio showed limitations of immobilization therapy for primary shoulder dislocations of rugby players.

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Purpose: As one of the anterior stabilizing mechanisms of the shoulder, the importance of thesubscapularis has been an object of attention in several literatures. The purpose of this study was toclarify the manner of the subscapularis extension in recurrent anterior dislocation of the shoulder.
Materials and Methods: Both shoulders of 44 patients with a recurrent anterior dislocation underwentMR arthrography after an intraarticular injection of 20 ml of Gd-DTPA solution (diluted 1:400). Tlweightedimages were obtained using SE sequences. The average age was 26.6 years. To evaluate theform of the subscapularis extension, we established three parameters in transverse and oblique sagittalplanes: M value: the ratio between the length from the anterior labrum to a contact point of the musclebelly on the anterior aspect of the scapula and the diameter of the glenoid articular surface, A value:the ratio between the length from the anterior labrum to the subscapularis tendon and the diameter ofthe glenoid, and S value: the angle determined by intersection of a line drawn from the center to the 0 o'clock position of the glenoid and a second line drawn from the clossing point of the outline of theglenoid and a horizontal line passing the superior border of the subscapularis tendon to the center ofthe glenoid. These values were compared between the involved sides and the healthy sides using t-tests.
Results: The averages of each value were higher in the involved sides. There were statisticaly significant differences in each value(M:p=0.007, A: p=0.001, S:p<0.001).
Conclusion: The subscapularis extension had tendencies of separating from the scapular neck, shiftinganterior, and displacing downward in recurrent anterior dislocation of the shoulder.

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The purpose of this study was to evaluate anterior translation of the glenohumeral joint (GHJ) for patients with traumatic anterior instability of the shoulder by examination under anesthesia. We retrospectively studied the bilateral shoulders of 170 patients, who were diagnosed and operated on as unilateral traumatic anterior instability of the GHJ. Before each operation, we graded the amount of anterior translation of the humeral head relative to the center of the glenoid fossa at 90 degrees of abduction and neutral rotation under general anesthesia, utilizing a modified 5-step grading method reported by Hawkins et al. Intraarticular lesions were classified into 5 types: labral detachment type, labral defect type, small bony fragment type, big bony fragment type, and bony defect type. The grades of the anterior translation in each type were statistically compared, using a Mann-Whitney U test. The statistical significance was set at 0.05. The anterior translation of the involved GHJ for a small bony fragment type was significantly smaller than those for other types. The anterior translation of the uninvolved GHJ for a small bony fragment type was significantly smaller than those for the labral detachment type and the big bony fragment type. The anterior translations of the involved GHJ significantly increased more than the uninvolved GHJ in all types.

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