The outcome of surgical treatment of acromioclavicular joint dislocation (Tossy type III) is generally satisfactory, but not in patients aged 40 years or more. Twenty-five patients aged 40 years or more (18 men and 7 women), who underwent the modified Cadenat procedure for acromioclavicular joint dislocation (Tossy type III), were followed-up from 10 to 65 months after surgery. The therapeutic results were almost satisfactory, with the rating being “excellent” in 21, “good” in 3 and “fair” in 1.There was no limitation to range of motion 3 or 4 months after surgery. Postoperative residual subluxation occurred in 5 patients, but OA changes occurred in only 3 patients. Findings obtained during surgery included a marked thickening of the synovial membrane in 11 of the 25 patients, a partial thickness cuff tear in 1, and a full thickness cuff tear in 4. The results of surgery may be poor in patients aged 40 years or more because of complications such as thickening of the synovial membrane and a cuff tear. Therefore, the modified Cadenat procedure is recommended for these patients.
The purpose of this study was to review the results of surgical treatment with modified Cadenat procedure for a grade III dislocation of acromioclavicular (AC) joint. Materials and Metho ds. The study sample was 63 patients (54 males and 9 females) who underwent surgical treatment, their average age at surgery was 35.1 years, ranging from 16 to 56. The duration from injury to operation was from 3 to 186 days, average 29.1 day and that of follow-up was from 6 to 88 months, average 26.9 months. The evaluation consisted of 1) the clinical score described by Kawabe and factors related to them (age at operation, the duration from injury to operation, time of the removal of the K-wire, re-dislocation, reontgenographical classification of the AC joint, calcification of the coracoclavicular (CC) ligament, bone changes of the AC joint).2) Correlation between the severity of the displaced clavicle and reontgenographical abnormality. Re-dislocation was defined if the distance between the lower margin of the acromion and that of the distal end of the clavicle was 6mm or more.
We wish to report on 14 cases of post-traumatic osteolysis of the distal clavicle. Materials and methods: From 1982 to 1998,14 patients (average age: 33.1 years,13 men and 1woman) with osteolysis of the distal clavicle were treated.9 cases were concerned with acute injury to the A-C Joint and 5 cases were associated with repeated minor trauma. Results: The last roentgenograms were classified in 2 cupping ty pes,4 tapering types and 8 complete types by Takahei's grading system. The outcomes using Cahill's grading system were not concerned with the style of osteolysis and were worse for those cases that had suffered through a repeated minor trauma. The findings of discs of the A-C joint on MRI were divided into three types. Normal types tend to show good results but degenerative or disappeared types did badly.2 specimens of cupping type showed many osteocrust cells and ostelytic lesions on the border of the A-C joint. Conclusion: This study suggested that post-traumatic osteolysis of the distal clavicle was related to some change of the A-C joint.
Treatment of a fractured proximal humerus in the elderly often encounter difficulties, including nonunion, bone absorption and severe osteoporosis. The treatment of such a case with severe osteoporosis has been challenged. Such a fragile humerus shaft can not be fixed firmly with a plate and nails. We wish to report on a new method of core fixation for such cases of nonunion of the proximal humerus, using a fibula graft as the intramedullary rod. Four women (ave.66 years old) were operated on with the core fixation method. The mean period from initial fracture to operation was 145 days. All were diagnosed as a neck fracture of the humerus and treated conservatively. A fibula graft was inserted intramedullary into the humeral shaft and head as a core (core fixation). First, the supplemental fixation between the graft and the humeral head was provided by a No.20 stainless steel wire. Next, a hook plate and nails were penetrated toward the core. Thereby, a firm fixation was obtained between the shaft and the head in nonunion cases. The average postoperative JOA score was 80.0 points. ROMs of those shoulders were excellent or good in 4 months after operation in all cases. Bone union was completed and there were no residual complaints in any of the cases. A core fixation was useful as a preferred method in the nonunion of proximal humeral fractures with severe osteoporosis in the elderly.
The treatment of chronic anterior dislocation of the shoulder is a difficult problem in shoulder surgery. The purpose of this study is to investigate the clinical results of open reduction in patients with chronic anterior dislocation of the shoulder. Materials & methods Eight shoulders of 8 patients were included in this study. The average age at the time of surgery was 67.5 (range: 53 to 79) years old. The period from trauma to surgery ranged from 2 weeks to 20 mo nths. Axillay nerve palsy was found in 2 shoulders, Bankart's lesion in 5, rotator cuff tear in 4, and fracture of the greater tubercle in 3. All cases but one had received open reduction without a temporary fixation of the shoulder joint. A rotator cuff tear, a Bankart's lesion and a fracture were also repair ed. A case which did not have open reduction of the shoulder received arthrodesis of the shoulder joint due to having complete axillary nerve palsy. Postoperative results were evaluated by the shoulder score of the Japanese Shoulder Assciation (JOA score). Follow-up periods ranged from 14 to 42 (average: 28.4) months.
Three dimensional MR images of the zero position were analyzed in order to investigate various patterns of normal and abnormal positions which might be closely related to clinical symptoms. Fortythree shoulders were included in this study. They consisted of 33 normal shoulders and 10 loose shou lders. The average age was 23.4 years old (rangel4-42) in normal shoulders and 19.4 years old (range 15-25) in loose shoulders. By using open MRI sistem (SIEMENSO.2T) and computer software (3DVIR TUOSO), three dimensional images at the zero position were built and their positions at the humeral axis on the glenoid were measured. It was revealed that the center of the normal humeral head was fixed on the glenoid in the axial plane, whereas there were various positions of the humeral center in the coronal plane. In loose shoulders however the humeral head slipped posteriorly in the axial plane with its axis tilted posteriorly. An open MRI system enabled us to understand the shoulder motion from a functional point of view and distinguish an abnormal one from a normal.
The repair process of an injured rotator cuff is still unknown with the details and the role of the subacromial bursa (SAB) including the synovium in the repair process has not yet been elucidated. The purpose of this study is to examine not only the self-healing capacity of the rotator cuff but also the effect of the synovium of SAB on the healing process using the organ culture system. Comparatively uninjured portions of the rotator cuff and of synovium of SAB were excised from 14shoulders undergoing surgery. They were dissected into 7×7mm segments and a cylindrical hole 3 mm in diameter was prepared in the central area. They were classified into the following 3 groups: group F with only cylindrical hole, group R with the cylindrical hole filled with rotator cuff tissue, and group S with the cylindrical hole filled with synovium. After the organ cultures for 1,2 and 4 week, the specimens were investigated using H-E staining and immunostaining with antibodies against C-terminal of procollagen 1. In group F using an H-E stain, a new migration and formation of collagen fibers were slightly observed around the hole, but no definite trend could be observed. In also group R, collagen fibers around the hole showed similar findings, but some cases showing positive findings in PCI stain were scattered around the hole. In group S at week 2 and 4, due to new cell migration and collagen fiber formation, incorporation of the rotator cuff and synovium could be observed. In group S using the PCI stain, there was a more remarkable staining in the fibrous tissue around the hole and in cells of the adjacent synovium tissue were observed more than in group R. These findings suggested that the human rotator cuff possesses a self-healing capacity and that the synovium plays an important role in the healing process of the rotator cuff.
Post-traumatic osteolysis of the distal clavicle has been regarded as a rarity, however it occurs more often than generally recognized. This disease has been reported in literature for over 50 years, however, its etiology remains unclear. This report concerns two patients with post-traumatic osteolysis of the distal clavicle and discusses the pathogenesis. Case reports Case1 A 22-year-old student injured his right shoulder during snowboarding. Radiographs two months after injury showed osteolysis of the distel clavicle. Angiography showed hypervascularity of the distal clavicle. Case2 A 35-year-old man injured his right shoulder in a motor vehicle accident. Radiographs three months after injury showed osteolysis of the distal clavicle. Surgical excisions of the distal clavicle were performed due to persistent pain. These sections revealed loss of articular cartilage of the distal clavicle, many inflammation cells in the bone marrow of the acromion and the clavicle, overgrowth of the synovium in the acromio-clavicular joint and granulation tissue with a vascular proliferation and multinuclear giant cells covered the distal clavicle. Discussion Both cases had no evident fracture or dislocation of the distal clavicle, however, minor recess of the articular surface of the distal clavicle. It may show a minor fracture of the distal clavicle. Histologic examination displayed regions of hypervascular connective tissue and invasive synovial destruction of the bone. We suggest the possibility that the post-traumatic osteolysis of the distal clavicle arose from osteochondral fracture and synovial invasion.
The purpose of this study was to investigate the utility of MR imaging of shoulders in abduction and external rotation positions (ABER method) for evaluating the anterior inferior glenohumeral ligament (AIGHL). Nineteen shoulders (8 with traumatic anterior instability; 3 throwing shoulders; 8 normal contralateral shoulders) were examined by 3D-FT gradient echo sequences (TR = 100, TE = 15, flip angle = 15, thickness = 2mm) using a superconducting MR imager (1.5T, Shimadzu Corporation). The subjects' mean age was 24.2 years (range 16-44 years). Axial scapular images were taken in ABER position (with hand on back of head in 135° abduction) and compared to usual hand-down plain images or hand-down MR arthrograms (15ml of 0.5% lidocaine). MR arthrography was performed on the injured side only. In 9 of the 11 injured shoulders, the ABER images were equivalent to the hand-down plain images or hand-down MR arthrograms, in terms of detecting Bankart lesions and anterior capsular low signal band. In 7 of the 11 injured shoulders, the ABER images showed an anterior capsule low signal band continuity, with a similar continuity observed in MR arthrograms as well. The ABER images of every normal shoulder also showed a low signal band continuity. We have previously reported that shoulders with traumatic anterior instability showed low signal band continuity in MR arthrography have a wide and thick AIGHL, as demonstrated by arthroscopy, and represent good indication for an arthroscopic Bankart repair. These findings suggest the potential of MR imaging with the ABER method for AIGHL evaluation, even without an MR arthrography.
There are a few reports about the natural history of positional posterior instability of the shoulder. The purpose of this study is to investigate the clinical cutcomes of treated positional posterior instability of the shoulder non-operatively by questionnaire. From 1983 to 1996,9 patients who were diagnosed with positional posterior instability of the shoulder were evaluated by questionnaire. Diagnosis of the positional posterior instability of the shoulder was evaluated by the method described by Rockwood. There were 3 females and 6 males. The averaged age was 21.2 years old ranging from 14 to 31 years old. Sulcus sign is positive in 3 cases, and in 2 of them anterior and posterior drawer test is positive. All cases were given physical therapy including rotator cuff exercise. Shoulder instability, pain and restriction of daily and sports activities were investigated. The average follow-up period was 79 months ranging from 59 to 104 months. In 3 cases, shoulder instability improved after 1.1 years from the first visit to our hospital and had disappeared after 4.2 years. They continued physical therapy averaged 26.6 months, while 6 cases whose symptoms was not improved continued it averaged 9.5 months. Shoulder instability did not improve in 3 cases who had shoulder joint laxity evaluated by sulcus sign, anterior and posterior drawer test. Restriction of daily activities remained in 4 cases. Restriction of sports activities continued in 2 cases. On the basis of these outcomes, patients who had positional posterior instability of the shoulder were treated with physical therapy, such as rotator cuff exercise for 1 year before surgical treatment.
Although magnetic resonance imaging (MRI) is known to be useful for diagnosis of a rotator cuff tear, a system to obtain best images is still controversial. The purpose of this study is to determine the diagnostic performance of MRI including Gd-enhanced MRI in evaluation of a rotator cuff tear. Materials and methods: The subjects were 41 shoulders (40 patients) with a rotator cuff tear that had had an MRI performed on before surgery,37 cases were complete tears and 4 cases incomplete. MRI's performed on oblique coronal plane and oblique sagittal plane of T1 and T2 weighted images in all cases. After an intravenous injection of Gd-DTPA,14 shoulders (10 complete tears,4 incomplete tears)underwent MRIs on the oblique coronal plane of T1 weighted images. Results and discussion. In 37cases with a complete tear confirmed by surgery, thirty-four were diagnosed as complete tears and the remaining 2 cases diagnosed as incomplete preoperatively. In 4 cases with an incomplete tear, two were diagnosed as complete tears and two diagnosed as incomplete. On Gd-enhanced images in 10cases with a complete tear, the stump was clearly enhanced in three, but not so clearly in six. Only the bursal side was enhanced in the remaining one. In 4 cases with incomplete tears, one with an articular side tear was not enhanced but three with a bursal side tears were clearly enhanced. Conclusion Although Gd-enhanced MRI for the diagnosis of rotator cuff tear was not clearly defined in this study, this technique might be, at least, useful for bursal side partial-thickness tear.
CT osteoabsorptiometry is a method of predicting the long-standing stress distribution over individual joints by measuring the pattern of subchondral bone density. The purpose of this study is to predict the subacromial stress distribution in normal and rotator cuff tear shoulders using this method. CT image data of 9 shoulders with rotator cuff tears and 5 normal shoulders were prepared for this study. CT values of the undersurface of the acromion were measured on coronal view. For analysis, mapping data depicted by a gray scale were created from the CT values at each coordinate point. The distribution patterns were classified into 3 types according to the location of the high density area: Anterolateral type, anterior type, posterior type. In the cuff tear group,5 shoulders were classified in anterolateral type, and 4 in anterior type. In the control group,1 shoulder in antero-lateral type, and 4 in posterior type. The quantitative analysis was based on the ratio of the high bone density area of the undersurface of the acromion. The ratio of the high density area was significantly high at the anterolateral zone in the cuff tear group. In conclusion, the distribution of the high bone density at the antero-lateral part of the acromion was considered to reflect the long-standing stress by subacromial impingement in patients with rotator cuff tears. The difference of stress distribution types in cuff tear group was considered to suggest that the stress distribution area varied in each case.
The purpose of this study is to elucidate a rotator cuff injury concealing itself in an acromioclavicular separation (A-C Separation). The materials were ten cases of A-C separation which had overlooked rotator cuff injuries. The ratio of male and female was 9 to 1, with an average of 38.7years. All the cases had been diagnosed as A-C separation and treated at other hospitals. They were evaluated with the following items, such as onset of trauma, the degree of A-C separation, the initial treatment, the elapsed time before surgery, their chief complaints, their treatments, and their prognosis. There were 7 cases which had fallen down,2 cases with a traction force to the upper extremities, and 1 case due to a bruise. Three cases involved serious conditions, such as unconciousness in 2 and a lung injury in 1. The others were a dislocation of the elbow in 1, ulnar nerve palsy in 1, and, a bruise of the shoulder in 1.2 were classified into Type 1,2 in Type 2, and 6 in Type 3. Seven cases were treated conservatively and 3 cases operatively. The elapsed time brfore surgery was 9.9 months on average. The chief complaints were mainly motion pain and dysfunction of the shoulder. Five cases had repaired torn rotator cuffs, with resection of the clavicular end in 3, reduction of the scapular spine in 1, and a re-operation on A-C separation in 1. The other 5 cases had their damaged rotator intervals, repaired with resection of the clavicular end in 2, reduction of the acromion and the coracoid process in 1, and a re-operation on A-C separation in 1. Satisfactory results were achieved in 9, however, dysfunction and motion are still complained about in 1 case. Two cases were law. We considered an A-C separation is easy to diagnose by clinical signs and roentgenograms. Orthopaedic surgeons, however, have to pay attention to the existence of a hidden rotator cuff injury, when a violent force affects the acromioclavicular joint.
The repair of massive rotator cuff tears is difficult and is associated with a higher incidence of failure. Several techniques have been described to aid in mobilization and reconstruction of the tendon defects. Magnetic resonance imaging (MRI) was used for the evaluation of a postoperative rotator cuff.
We used to graft tensor fascia lata for massive rotator cuff tears. But restoration of external rotation strength was not so good. Then from 1996 we have performed an infraspinatus tendon repair in addition to a patch graft. We report on its operative technique and the results. Ten shoulders of 10 patients were evaluated. The average age was 59.1 years old. The average followup period was 23 months. All shoulders had atrophy of the infraspinatus. In MRI T2 weighted axial images high intensity of the infraspinatus was found in all the shoulders. The opearative technique: in the lateral decubitus position, a saber cut incision was made. The deltoid was detached from the acromion. The avulsion of the the infraspinatus tendon insertion was often recognized and this tendon tear site was covered by a membranous tissue. This membranous tissue was cut off and the infraspinatus tendon is exposed and repaired to a bone trough. Supraspinatus tendon defect was closed with a fascia lata patch graft. Postoperative program: In the first 2 weeks the shoulder was immobilized with a sling and swathe. Passive elevation exercises were started at 2 weeks and active elevation exercises were begun at 4 weeks. A patch graft rupture occurred in 2 patients. These 2 patients had a patch graft again and a latissimus dorsi transfer. The preoperative average JOA score was 58 points and the postoperative one was 82points. There were 4 patients with excellent results,3 with good results,1 with a fair result and 2 with poor results. The strength of external rotation was improved in 8 shoulders. In 6 months postoperative MRI T2 weighted axial image low intensity of the infraspinatus was found in 7 shoulders. We recommend an infraspinatus tendon repair to restore the external rotation strength for massive rotator cuff tears.
We evaluated the findings of MR imaging (MRI) of professional baseball players with omalgia. MR images of 30 shoulders of 30 professional baseball players with omalgin were taken. Right shoulders were 26, left shoulders were 4. There were 17 pitchers,1 catcher and 12 fielders. The average age was 24.5 years (range,18-32). We examined their high signal intensities of the supraspinatus (oblique coronal view) and their cystic changes in the greater tuberosity (obilique coronal view and axial view).We also statistically examined the relations between their changes and their positions. High signal intensities of the supraspinatus were found in 13 shoulders (deep surface: 8, intratendinous: 2, superficial surface: 3). Cystic changes in the greater tuberosity were found in 15 shoulders (poster ior: 13, middle: 2). Statistically there was no relation between their positions, high signal intensities of the supraspinatus and their cystic changes in the greater tuberosity. High signal intensities of the supraspinatus on the deep surface and cystic changes in the posterior greater tuberosity were characteristic in the professional baseball players.
A rotator interval lesion is caused by the excessive tension between rotator cuff tendons in a throwing motion. The tension of the sutures used to repair the rotator intervals was intraoperatively measured while the upper arms were moved. The pathomechanism was studied from the results and analysis of a throwing motion. Subjests and methods: The tension of the sutures was measured in five patients with rotator interval lesion. A digital force gauge DPX-T (IMADA co. ) was used for the measurement.. A 1-0 monofilament nylon suture was connected to the device and the tension was measured. The change of the tension was measured and recorded while performing a throwing-like motion. The motion analyser (Peak co. ) and two analog videos were used for the motion analysis of six professional pitchers in Osaka. The angle and velocity were calculated by manual tracking of the frames (60 frames/sec). Results: The rotational center of the trunk was the shoulder of a nonthrowing side. The arm was abducted and remained in this position during the arm cocking, acceleration, and deceleration phases. The major feature of the throwing motion was the quick and wide internal and external rotation of the arm. The tension of the sutures increased from an internal rotated position to a external rotated pos ition. We suggest that the rotator interval lesion was accelerated by arm cocking motion.
The effect of the throwing form correction for a baseball shoulder was evaluated. Materials and methods: Forty-five baseball pitchers with throwing pain in their shoulders were examined. All were males aged 10 to 31 years (mean 17.4), with a duration of shoulder pain on throwing of 32 months in average (range 2 weeks to 11 years). The throwing motions were recorded by a digital video camera and were evaluated as to whether there were any problems in the throwing form. The throwing form was corrected and grade of pain relief and return to pitching was inquired into. Results: Forty-two of the 45 cases (93%) had one or more problems in their throwing form. Problems in the throwing arm in 35 cases (83%), in the trunk or lower extremities motion in 32 cases (76%) and in the opposite arm in 23 cases (55%) were observed. Remarkable or moderate pain relief in 28 cases (67%) and complete return to pitching in 21 cases (50%) were gained by throwing form correction. The outcomes were better in the younger cases and the cases with the shorter periods form the onset of the pain. Conclusion: The throwing form correction was effective for baseball shoulder, especially for the younger cases.
We studied the MRI findings of a frozen shoulder in three different phases. Forty-one frozen shoulders were available for this study. The mean age of the patients was 58 years (range,43 to 77 years). The mean range of elevation of the shoulders was 118 degrees (range,80 to 140 degrees). There were 10 shoulders in the acute phase (less than 2 months),16 in the subacute plase (2 to 3 months),15 in the chronic phase (4 to 12 months). Oblique coronal, oblique sagittal, and axial sequences were made with the fast spin-echo technique using a 0.5-tesla MR Vectra unit. On T2-weighted images, high signal intensities (HIS) in the glenohumeral joint (GHJ), the subacromial bursa (SAB) and the bicipital groove (BG) were analyzed, and then the contraction of the axillary pouch was evaluated. HIS at the GHJ was moderate in 40%, slight in 20% and none in 40% of the shoulders in the acute phase; in 0%, in 63% and in 37%, respectively, in the subacute phase; and in 7%, in 40% and in 53%, respectively, in the chronic phase. HIS at the SAB was moderate in 0%, slight in 30% and none in 70% of the shoulders in the acute phase; in 0%, in 25% and in 75%, respectively, in the subacute phase; and in 0%, in 27% and in 73%, respectively, in the chronic phase. HIS at the BG was moderate in 30%, slight in 60% and none in 10% of the shoulders in the acute phase; in 25%, in 19% and in 56%, respectively, in the subacute phase; and in 13%, in 40% and in 47%, respectively, in the chronic phase. Contraction of the axillary pouch was observed in 20% of the shoulders in the acute phase,69%in the subacute phase, and 73% in the chronic phase. In conclusion, there were increased amounts of fluid at the GHJ and BG in the acu, t eb upt haosnely a small amount at the SAB. Shoulder stiffness may be caused by contraction of the GHJ capsule which develops as the intraarticular synovitis resolves.
We examined the relationship between effusion of MRI findings and the clinical symptoms. Materials and methods: We examined MRI findings in patients with periarthritis scapulohumeralis. We excluded cuff tears, calcified tendinitis, instability of the shoulder fractures and impingement syndrome in young patients. The subjects comprised 75 cases 77 shoulders (45 men and 30 women), with an average age of 58.3 years (range 40-78). Scanning was performed on a Gyroscan T5- II 0.5-T (Philips). T1-weighted and T2-Weighted sequences in the coronal oblique plane, T2-weighted sequences in the coronal sagittal plane and horizontal plane were taken. Results: Degeneration of the rotator cuff was observed in 34 shoulders. Joint effusion was observed in 68.8% of glenohumeral joints, and 23.4% of subacromial bursa.69.4% had effusion in the sheath of the long head of the biceps long tendon. We studied the relationship between the MRI findings and the clinical symptoms. Conclusion: Glenohumeral joint effusion was observed in 68.8%. This suggested that there was arthritis in cases of periarthritis scapulohumeralis. We could not find a clear relationship between the effusion the clinical symptoms.
We performed medical checks of baseball injuries of the shoulder joint on junior and senior high school students in Kochi prefecture during 1997 and 1998. Materials and methods: 116 junior high school baseball players and 76 high school players were investigated by means of a questionnaire and physical examination in 1997.105 junior and 95 high school baseball players were in 1998. Results: The positive findings (tenderness and limited R. O. M of the shoulder joint) were revealed in 34.5% of the junior high school baseball players and 35.5% of the high school baseball players in 1997.30.4% of the junior and 24.2% of the high school baseball players in 1998. Almost 30% of the junior and high school baseball players showed a painful condition and overused states of their shoulder joint. Discussion: Our results suggest that an early search for shoulder injuries in young baseball players is useful for treating throwing injuries of the shoulder joint.
To detect changes in the shoulder after throwing with Dynamic MRI. Subjects and methods; We studied 10 shoulder joints of 10 baseball players aged 20 to 22 who belonged to a university baseball club using a 0.3-tesla MR unit before and after throwing. Each player threw a baseball 200 times as hard as he could. Following a first, Gd-DTPA was adminstered intravenously. Gradient echo images were then obtained every 30 seconds, for a total period of 11 minutes. The signal intensity changes for the first 11 minutes were used to calculate the coefficient of enhancement(CE) in regions of interest which were the humeral head, the acromion, the deltoid, the trapezius, the subscapularis, the supraspinatus, the infraspinatus and the teres minor. Results and discussion. CE after throwing increased in the deltoid, the trapezius, the supraspinatus, the infraspinatus and the teres minor. In cases with joint laxity, CE in the infraspinatus, the teres minor were especially increased. These changes were caused by repetitive throwing. Our findings show that it is possible to objectively evaluate the stress on the shoulder joint caused by throwing using MR imaging.
The purpose of this study was to evaluate the postoperative findings of an arthroscopic Bankart repair reinforced with the subscapularis tendon (the reinforced Caspari technique) using an MR arthrography (MRA). Materials and methods: Seventy-two patients (73 shoulders) who had undergone a reinforced Caspari technique were evaluated using a MRA. MRAs were performed before and 6 months after surgery. The mean-age at surgery was 27 years (14-62 years), and the mean-postoperative follow-up period was 18months (6-42 months). We compared the postoperative MRA findings with the preoperative one. Results: All cases (100%) showed good healing of the Bankart lesion. Twenty-six cases (35%) showed a smooth transition between the labrum and the glenoid, while the others showed a protrusion. Fourteen cases (19%) that had a large bony defect of the glenoid fossa had soft tissue-like mass at the defect postoperatively. In 43 cases (58%), the subscapularis muscle showed a good contact with the entire area of the glenoid neck; 27 cases (38%) showed the contact with the glenoid neck through soft tissue-like mass, and three cases ( 4 %) showed no contact. Atrophic change of the subscapularis muscle belly was not noted postoperatively in any of the cases. Conclusion: MRA showed good healing of a Bankart lesion and good contact of the subscapularis muscle to the neck of the scapula after a reinforced Caspari technique.
To clarify the clinical efficacy of a Bankart & modified Bristow procedure for a recurrent anterior dislocation of the shoulder. Materials and methods: 120 shoulders with recurrent anterior dislocation who had recieved a Bankart & modified Bristow procedure were investigated. They were able to be observed for more than two years postoperatively. There were 94 men and 26 women, and the mean age at operation was 25 years (range,14-69). The mean follow up period was 41 months (range,24-75). The operation was done according to a Bankart's procedure augmented by a coracoid transfer (modified Bristow technique). Postoperative immobilization was maintained in a Velpeau position for 3 weeks, after that, ROM excercises were started. Normal daily activity was allowed after 2 months. A return to athletic activity was allowed at 3 months, and to contact sports at 6 months. We evaluated the clinical results by the Rowe scoring system, the return to sports activity, satisfaction with the operations, and the complications. Results: According to the Rowe scoring system, the clinical results were graded as excellent for 76%, good for 13%, fair for 11%, and poor for 0%, with an average score of 90 points. There was no redislocation postoperatively, but subluxation was seen in 2 cases(1.6%). The average loss of range of motion compared with the opposite side was 13° for external rotation.93% of the athletes could return to their previous sports and 53% could return to their preinjury levels. The complication seen in this series consisted of only one screw breakage. No one had osteoarthritic change of the glenohumeral joints. Discussion: With our method, repair of the main lesion of the IGHL complex and a buttress effect by the conjoined tendon in abduction seemed to secure a strong stability. This procedure can achieve a good clinical outcome for high level athletes with recurrent anterior dislocation of the shoulder.
It is generally recognized that postoperative recurrence rate of arthroscopic stabilization for traumatic anterior shoulder instability is higher than that of the open procedure and the appropriate patient spectrum is limited. We perform arthroscopic stabilization using the anchor suture technique to a wider spectrum of patients by applying rotator interval(RI) reinforcement and anterior portal closure seeking excellent postoperative outcome. In this series,27 shoulders including poor ligament-labrum tissue quality as well as bony Bankart lesions and contact/collision athletes underwent arthroscopic procedure. Exclusive criteria are large bony defect at the glenoid surface greater than 25% and humeral avulsion of the glenohumeral ligement(HAGL lesion). Average age at time of surgery was 26.9 years and average postoperative follow-up 6.5 months. All patients were seated in the beach-chair position under general anesthesia. Anchor suture technique using FAStakTM and PanalokTM anchors with #2 permanent braded suture was performed after preoperative manual evaluation and arthroscopic inspection. In cases of poor ligamentlabrum complex and wider RI, we performed arthroscopic RI reinforcement and portal closure besides ordinary Bankart repair and capsular shift. Fourteen shoulders required only Bankart repair and capsular shift while other 13 required RI reinforcement and anterior portal closure as well. Currently, no recurrence is observed and no patient complains of apprehension. Seventeen patients observed for more than 4 months postoperatively returned to their former recreational level sports. It is possible that application of RI reinforcement and portal closure as well as capsular shift enables better postoperative outcome of arthroscopic stabilization even to the patients who has not been considered to be good candidates for arthroscopic treatme nt.
We analyzed the clinical results of a modified Bristow procedure and the changes of arthroscopic findings before and after surgery to confirm the relative advantages and the disadvantages of this procedure. Thirty-two patients (25 men,7 women) who underwent modified Bristow procedures was evaluated. The average age was 26.5 years. The average follow-up period was 47.6 months. Arthroscopy was performed on 16 shoulders preoperatively and on 5 shoulders postoperatively. Postoperative arthroscopy was performed at the time of the removal of the screw. The surgical results were evaluated according to JOA shoulder instability score. The changes of arthroscopic findigs, ligament, labrum injury and bone and cartilage defects were investigated. After a Bristow procedure, JOA score averaged 89.5 points (before surgery: 52.4 points). Two patients had a non-union of the transferred coracoid. One of these two had a recurrent dislocation. Only one of the nine athletes whose dominant side was affected in an over head throwing sport returned to it. In preoparative arthroscopies, we noted that the severity of the labrum injury and bone defects of the humeral head had increased according to the number of dislocations. In postoparative arthroscopies, congested membrane covered the articular side of the transferred coracoid. Bone defects and labrum injuries did not change, and cartilaginous defects of the glenoid which had not been seen before surgery were seen in two cases. Modified Bristow procedure is one of the good operations which prevent redislocation. But from the arthrocopic findings showing an anterior instability indicated that this procedure cannot maintain the centripetal position and this may lead to an osteoarthritic change in the future.
To evaluate the effects of corticosteroid on tendon insertion sites, we used corticoteroids-administrated rabbits and evaluated biomechanical and biochemical characteristics of the insertion of the infraspinatus tendon. Twenty-one abult New Zealand White Rabbits were divided into two groups: 9rabbits were with Prednisone 0.150mg/kg subcutaneously daily for 14 weeks; 12 for untreated controls. All of them were sacrifficed at 14 weeks. The bone mineral density (BMD) was measured by DEXA. The specimens were tested for failure load, failure mode, and stiffness of the tendon-bone construct. The BMD was significantly lower in the steroid-administrated group (p<0.001). Two failure modes occurred-failure at the insertion/due to a fracture. There was no significant correlation between BMD and failure load or stiffness. Although not statistically significant, the average BMD tended to be lower in those that failed as fracture and the steroid-administrated specimens tended to fail by fracture with elevated of the tendon-bone construct. There was no significant difference in either stable or reducible collagen cross-link content between the two groups, although there was a tendency for maturation of cross-links in the steroid treated group. After 14 weeks of the abministration, corticosteroids affected bony density and strength, which is more obvious than the effect on the tendon and its insertion.
The purpose of this study was to evaluate the activity of the shoulder muscles with various loads in the external rotational motion of the shoulder and to find the load in which only the inner muscles work mainly and the outer muscles don't work.
Two lesions in the proximal humeri which seemed to be benign enchondromas on images were curetted widely and packed with bone cement and beta tricalcium phosphate respectively. Both lesions were diagnosed as low rade chondrosarcoma histologically. The differential diagnosis between enchondroma and low-grade chondrosarcoma is very difficult to make. The standard treatment for a malignant bone tumor is a curative with a wide resection, and the impairment after a wide resection is very difficult to mend, especially in the shoulder. So the overdiagnosis should be admonished. Recenly, we reported on the low risk of a recurrence of low-grade chondrosarcoma was reported. Curettage with adjuvant therapy is recommended for these lesions.
The aim of this paper is to discuss the method of treatment for septic sternoclavicular (SG)arthritis, based on combined MR findings retrospectively. [Case 1] A 40-year-old female complained of pain in her right SC joint. The X-rays were normal. The T1-weighted images showed low signal in the right clavicle and SC joint. Short-tau inversion-recovery (STIR) showed high signal in the right clavicle and SC joint. Operative findings revealed lytic change of the cortical bone, and showed abnormal granulation in the bone marrow and surrounding SC joint. She underwent a curettage and continuous irrigation. [Case 2] A 50-year-old female on hemodyalysis complained of pain over her left SC joint. X-rays showed a lytic change in the clavicle. T1- weighted images and STIR showed the same signals as in case 1. Operative findings revealed osteomyelitis and arthritis of the SC joint. A curettage and continuous irrigation were performed. [Case 3] A 21-year-old female with systemic lupus erythematosus complained of pain in the right clavicle. The X-ray, T1-weighted and STIR images were normal. Gd-DTPA enhanced MR images (Gd) showed an enhanced area in the SC joint. The operative findings showed a proliferation of synovial tissue. She underwent debridement and continuous irrigation. [Case 4] A 54-year-old male with liver cirrhosis complained of pain in the left clavicle. Gd images revealed an enhancement of the abscess wall in the surrounding SC joint. The Operative finding showed an abscess forming in the surrounding SC joint. We treated him with a debridement. Discussion: Early and aggressive surgical therapy is important, especially in the immunocompromised host because arthritis can cause mediastinitis and sepsis. We evaluated the treatment, based on our operative findings and combined MR images. If the MR images showed osteomyelitis, we recommended a debridement and continued local drainage. If MR images revealed normal appearance of the clavicle, we treated them conservatively. If the Gd images showed an enhancement of the abscess wall in the surrounding SC joint without osteomyelitis. Our strategy should be analyzed more because our study included only 4 patients, but our combined MR images were helpful in diagnosis and choosing the treatment.
Functional reconstruction by multiple muscle transfer achieves less shoulder joint stability than arthrodesis, but a far greater ROM can be obtained by functional reconstruction. We performed multiple muscle transfers for upper brachial plexus paralysis with sufficient donor muscle strength (5for trapezius,4 or more for the sternal head of pectoralis major, and 4 or more for any of latissimus dorsi, teres major, or serratus anterior) and in the absence of shoulder joint contracture. We wish to present our method and results here. Subjects and methods: Five patients were operated on at our department from 1993 to 1996. All the patients were men, and their mean age was 21.8 years. The cause of upper brachial plexus paralysis was a motorcycle accident in all cases. We moved the sternal head of the pectoralis major to the distal clavicle for flexion reconstruction, attached the trapezius to the lateral aspect of the proximal humerus for abduction reconstruction, and attached one or more of the latissimus dorsi, the teres major, or the serratus anterior to the infraspinatus for reconstruction of external rotation. Range of motion (ROM) and muscle strength were measured before and after surgery while standing and while lying on a bed. The mean period from injury to operation was 24.2 months. The mean follow-up period was 51.6 months. Results: The ROM for flexion, abduction, and external and internal rotation had improved significantly after surgery. The muscle strength for flexion, abduction, and external rotation was also significantly improved from 0 or 1 before surgery to 2 after surgery. Conclusions: Functional reconstuction of the shoulder by multiple muscle transfers was performed for upper brachial plexus paralysis and a good outcome was obtained.
To clarify the pathology of a rotator cuff tear accompanied by contracture, we compared the arthroscopic, pathologic and clinical findings between a group with rotator cuff tear accompanied by a contracture and a group with rotator cuff tear not accompanied by a contracture. Matereials and methods: 19 patients with a rotator cuff tear which were treated by surgery were examined. The contracture group included 9 patients and the non-contracture group 10 patients. Arthroscopy and pathological examinations were performed. The contracture groups were subdivided into two groups; Group A showed a synovial congestion and proliferation in both the GHJ and Group B showed these findings only in the GHJ. The non-contracture was divided as Group C. These 3 groups were compared by age, the period between onset and surgery, history of trauma, the shape and size of the te ar, arthroscopic finding, and acromiohumeral interval (AHI) on X-ray films. Results: HE staining of the synovial specimens revealed interstitial edema, capillary hyperplasia and congestion in both the SAB and the GHJ. Inflammatory cell infiltration was sligh but tended to be more frequently observed in the GHJ than in the SAB. Significant differences were observed in age, period between onset and surgery and AHI between Group A and B. Concerning the morphology of the cuff tear, the bursar surface was mainly injured in Group A, and the articular surface was in Groups B and C. Conclusion: The contracture group could be divided into two groups. Group A was characterized by aged patients and a tear mainly involving the bursar surface, while Group B was by young patients and a tear mainly involving the articular surface.
The tension of a repaired rotator cuff was evaluated in nineteen patients who had a repair of a full thickness rotator cuff tear. The tension of the repaired cuff was measured at the operation using a simple spring scale. The tension was evaluated regarding the size of the tear, the duration of the symptom, the presence of trauma, and the post operative results using a JOA score. The average of the tension at the arm in 0,30, and 60 degress elevations were 39.2±18.4N,23.5±17.2N, and 14.2±13.4N respectively. The average tension of the patient who suffered from a trauma was 20.3±15.8N, whereas the one in the patients who had no history of trauma was 35.0±18.0N. The slight positive relation, not statistically significant, was found between the tension and the size of the tear. We could not find a significant relation between the tension and the range of motion or the muscle power in this study. The JOA score was significantly higher in those patients who had less tension of a repaired rotator cuff. We have to be careful not to put too much tension on the rotator cuff when we repair it. Too much tension might damage the muscles and musclotendious units of the rotator cuff or fail to unite the cuff to the bone, resulting in dysfunction of the rotator cuff postoperatively. Then, how much is “too much”? Only a few papers have described the details of the tension of a repaired cuff. Our results show that the lower the JOA score in patients with a higher tension of the repaired cuff. These results suggest that the tension of the repaired cuff, indeed, changes the results of a rotator cuff repair. We need fur ther study to determine the threshold of the tension of a rotator cuff at repair to achieve better results.
We developed a low invasive method (L method), which is an intermediate procedure between the usual open method (O method) and an arthroscopic cuff repair to minimize surgical intervention and thus to enable an earlier earlier return to ADL or sports activities. Materials and methods: We applied L method to all rotator cuff tears except a massive tear. After identifying the location and size of the tear arthroscopically, a skin incision 3cm long was made from the center of the acromion toward axilla. The acromiplasty was carried out under direct vision, and cuff repair was performed using McLaughlin's procedure. When the rotator cuff was found difficult to be treated by the L method, it could be changed to the O method by extending the skin incision and detaching the deltoid muscle.30patients (20 men and 10 women) have been treated by the L method to date and their results were compared to 45 patients (25 men and 20 women) treated by the O method in terms of the JOA score and the ROM with a minimum follow-up of 6 months. Results and conclusion: The patients scored well in both groups and there was no statistically significant difference between the two groups regarding pain and function. However, patients in the L method group demonstrated a significantly better ROM at 3 and 6 months postoperatively. Thus the L method appears to enable an earlier return to ADL or sports activities than the O method.
The purpose of this study was to evaluate the clinical results of reconstruction with PTFE felt augmentation for irreparable massive rotator cuff tears. Materials and methods: Thirty patients,24 men and 6 women, with irreparable massive rotator cuff tears who had undergone rotator cuff reconstruction with a PTFE felt augmentation more than 24months previously were investigated. The average age at the time of surgery was 64 years (range: 4476) and the mean follow-up period was 38 months (range.: 25-60). Clinical results were evaluated the JOA system of pain, function, motion, and total evaluation. Plain X-ray photographs were used to investigate whether bony changes existed. Results: Using the J. O. A system, the total score improved from an average of 57 points preoperatively to an average score of 82 points postoperatively. In particular, the average pain score improved significantly from 9.5 to 23.2 points. The plain X-ray photographs revealed OA change in only one case, which had been present preoperatively. Enlargement of the bone gutter of the greater tuberosity were seen in nine cases(30%)after 12 months postoperatively. After 6 months postoperatively, a subacromial busal infection in 1 patient which subsided after drainage and treatment with antibiotics. Discussion: Reconstructio n of rotator cuff with a PTFE felt augmentation ofters the following advantages. It can substitute for the defects in a rotator cuff which may lead to the upward migration of the humeral head and aquire the subacromial space, but it might also induce the connective tissue to from among the PTFE fibers around the defect. On the other hand, PTFE felt is a foreign substance and its introduction into a living body presents the problem of any biological reaction. The enlargement of the bone gutter may be due to a biological reaction against the PTFE felt, so follow-up over a longer period is necessary.
The surgical results of the rotator cuff tear were studied in relation to age and size of the tear. Materials and Methods: One hundred shoulders of 98 patients with a cuff tear had performed a bone-tendon suture. The mean age was 57 years, ranging from 28-81 years of age. The average followed up period was 34 months. These patients were divided to 4 groups according to their ages: group A (>70 yrs), group B (60-69 yrs), group C (50-59 yrs), group D (<49 yrs). The ranges of motion of the shoulders and the JOA score were studied according to these groups and the tear size. Results: Width and length were 3.5 and 3.1 cm in group A,3.2 and 3 cm in group B,2.7 and 2.5 cm in group C,2.4 and 2.2 cm in group D. The pre- and post-operative elevation angles were 113.6° and 130° in group A,106.3° and 152.4° in group B,127.7° and 148.5° in group C,131° and 152.5° in gro up D. The pre- and post-operative external rotations were 53.8° and 40° in group A,40.4° and 50.2° in group B,54.8° and 57.7° in group C,62.6° and 53.4° in group D. The pre- and post-operative JOA scores were 56.8 and 82 in group A,61.5 and 93.6 in group B,70.7 and 91.3 in group C,66.5 and 90.1 in group D. In our study about tear sizes, the larger width showed a restricted range of motion and a lower JOA score. Conclusions: Older patients had a larger tear size. The larger width of the tear size revealed a lower range of motion and a lower JOA score at pre- and post-operative states.
We compared the post-debridement size of rotator cuff tears determined from surgical findings with those measured by MRI. The subjects were 20 patients (21 shoulders) with a complete rotator cuff tear who underwent MRI before surgery. Seven of the patients were men and 13 were women. Sixteen tears involved the right shoulder and five involved the left one. The mean age of the patients was 65.1±8.1(SD) years, with a range of 52-78 years. MRI was performed with a superconducting Shimadzu 1.0-T Magnex 100 HP. The distance between the high-signal regions was measured in the oblique coronal and the oblique sagittal planes of T2-weighted image of fast spin echo technique (fast T2-weighted image)and T2*-weighted image of gradient echo technique was compared with the post-debridement tear dimensions measured during surgery. The mean difference between the operative findings and the values measured with MRI was 10.1±9.2mm for fast T2-weighted images and 4.6±9.1mm for T2-weighted images obtained in the oblique coronal plane. The mean differences obtained using oblique sagittal images were 9.1±5.7mm and 2.7±7.0mm, respectively. Our findings indicate that T2*-weighted image is useful for estimating the post-debridement size of rotator cuff tears.
The Recurrent posterior subluxation of the shoulder caused by a trauma is rare. We report the case of a sumo wrestler who had surgical treatment. Case report: A nineteen-year-old-sumo wrestler, whose favorite trick was to push. Present history: In March 1998 his right shoulder was injured in extension and internal rotation while practicing sumo. He came to our hospital and complained of pain and fear of using his shoulder. A thin bone fragment from the posterior glenoid rim was seen in an x-ray axillar view. The MR arthrogram showed a posterior labrum detachment. The feeling of subluxation gradually became worse. In Octorber 1998 he came to our hospital again. Physical finding: He had a remarkable feeling of subluxation and pain with the Jerk test. When he moved his shoulder from flexion and internal rotation to abduction and external rotation, he had no snapping. Posterior subluxation of the humeral head was seen in the x-ray axillar view. There was a big spur-like a Bennett lesion. An operation was performed in December 1998. The posterior spur was removed. Tri-cortical bone was taken from the iliac crest (length 20 mm, height 15 mm). A bone graft was placed into the glenoid neck at the level of the particular surface, and secured by two small compression screws. The grafted bone united with the glenoid neck 4 months postoperatively. He returned to sumo wrestling 6 months after the operation. Remaining Issues: The stress on the posterior capsule by the pushing sumo trick caused on increase of bone fragment and a spur- like Bennett lesion.
To report three cases of recurrent anterior dislocation of the shoulder joints treated operatively. Cases Case1: An 82-year-old female had dislocated her shoulder from a fall. Three years later, she dislocated her shoulder again, and it then became highly unstable. Intraoperatively, it was confirmed that the supraspinatus and subscapularis tendons were ruptured, the joint capsule was highly stretched, and the joint labrum had vanished. We performed an inferior capsular shift and the Bristow procedure. Eleven months later, the patient had no complaints of pain, ROM restriction or dislocation. Case2: A 72-year-old-male's shoulder had become highly unstable in spite of a three-week-immobiliza tion. Arthro CT revealed a bony Bankart lesion. Intraoperatively bony fragments found adhering to the soft tissue at the anteroinferior glenoid were excised. We reattached the capsule and performed an inferior capsular shift. Eight months later, the patient had no complaints of pain, ROM restriction or dislocation. Case3: A 74-year-old-male experienced several subluxations after his first dislocation. Twelve years 1ater, he dislocated his shoulder while exerting only a slight force and it then became highly unstable. His rotator cuff was not patently ruptured, but intraoperatively it was found that the labrum had become mostly detached from the glenoid rim. We reattached the capsule and performed an inferior capsular shift. Three years later, the patient had no complaints of pain, ROM restriction of dislocation. Discussion: Generally, dislocation in the elderly will often result in a rotator cuff rupture that could be the primary lesion of a recurrence, while a Bankart lesion is rare. However, in some cases, the primary lesion is an anteroinferior labrum lesion and we believe that the possibility of an anteroinferior Bankart lesion in the elderly should not be overlooked and anterior stabilization should be more effective than repair of frayed rotator cuff.
We wish to report on a case of MRSA infection after an open Bankart & Bristow procedure. A 19year-old-man had recurrent anterior dislocation in his left glenohumeral joint. An open Bankart & Bristow procedure was performed. Postoperatively 4 g Cefazolin sodium per day was injected intravenously for 4 days. On the second postoperative day, his temperature rose to 39° C and he had a sore throat and nausea. On and after the fourth postoperative day, he had symptoms including abdominal pain, watery diarrhea and a dittuse erythrodermatous rasn au over nis may. Laboratory examinations showed CRP of 17.7 mg/dL and liver dysfunction. But no focal sign of a wound infection was found. On the twelfth postoperative day, the wound had a swelling and discharged DUS. A wound debridement was performed, the screw and suture threads were not removed. Microorganism cultured was methicillin-resistant Staphylococcus aureus (MRSA). Following Arubekacin sulfate, Minocycline was administered. In the fourth postoperative week, the focal sign of a wound infection had disappeared and the CRP decreased to 0.2 g/dL. There were no symptoms for a year. But a focal sign of infection in his shoulder was found again, a fistula had formed after that. Fistelectomy and resection of an absess were performed. Thick suture threads were the cause of the fistula and abscess. Fortunately septic arthritis did not arise, his shoulder function was preserved. He had no pain and no instability at the time of a follow-up. The JOA score was 94 points. The causes of MRSA infection were unclear. Early diagnosis of this case was difficult, because there was initially no focal sign of a wound infection. Early systemic symptoms seemed to be toxic shock syndrome. We did not imagine that prolonged infection was due to suture threads.
The purpose of this report was to evaluate the limb salvage operations following a scapulohumeral resection with a deltoid resection for “clinically malignant tumors” of the proximal humerus. Case I. The radiogran of a 39-year-old-woman showed destruction of the proximal humerus. A histological diagnosis was a grade I chondrosarcoma. The proximal half of the humerus, the lateral one third of the scapula and the deltoid muscle with the surrounding muscles were resected. Arthroplasty without a glenoid component was performed. Case II. The invasion of a tumor into the glenohumeral joint and the deltoid muscle were found in CTs and MRIs of a 54-old-man. The histological diagnosis was a giant cell tumor. The proximal half of the humerus, the scapular bone from the grenoid to the scapular neck, and the deltoid muscle with the surrounding muscles were resected.An arthrodesis was performed by using a free fibula graft with the iliac bone. The skin defect was closed by a muscloctaneous graft. Two ways of reconstruction usually exist. One is an arthroplasty, and the other is an arthrodesis. An arthrodesis is preferable without an abductor mechanism. An arthroplasty without a glenoid component was performed in case I under the circumstances without an abductor mechanism, because the scapular neck which is important to fix a fibula graft was resected. An arthrodesis was chosen in Case II by using a free fibula graft. The bone union was delayed. This could be the result of a soft tissue absence to contribute to the local blood supply. The two salvaged limbs were functionally limited. However, we assure these procedures, which are a curative wide margin resection, prevent humeral bone tumor from recurrence and protect the function of the elbow and fingers.