Purpose: Accurate reproduction of the anatomic relationship is important in the treatment of shoulder arthroplasty.
In this study, we evaluated the relationship between the neck shaft angle and various geometric measurement values in the glenohumeral joint
Methods: Radiographs of 475 shoulders without osseous lesions were reviewed. There were 275 males and 200 females, and the mean age was 49.7 years old. The diagnoses were impingement syndrome in 245 patients, rotator cuff tear in 140, glenohumeral instability in 68 and frozen shoulder in 22. Nine parameters were measured on true anteroposterior radiographs.
Results: There were significant differences in all parameters between the males and the females (P<0.01). There was no correlation between any parameters and diagnosis. The lateral glenohu meral offset, parameter of the lever arm of the deltoid and supraspinatus muscles, correlated with the radius of the curvature of the humeral head and the head diameter. The neck shaft angle did not correlate with the offset values. However, considering the individuals, there was a significant correlation observed with the neck shaft angle.
Discussion and Conclusion: The radius of the curvature of the humeral head, the head diameter and the neck shaft angle were correlated with the length of the lever arm in the abductor muscles. Therefore, adequate attention should be paid to them.

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[Purpose] The pathogenesis of calcifying tendinitis has still not been cleared. The purpose of this study is to clarify the molecular biological regulation of calcification or resorption in calcifying tendinitis.
[Material and Methods] The tendinous tissues containing calcium were obtained at surgery from five patients with calcifying tendinitis, to whom conservative therapy was not effective. Macrophages were identified with TRAP staining, and by the synthesis of cathepsin K using the in situ hybridization method. The expression of mRNAs of BMP-2 and osteopontin were studied to evaluate the calcification.
[Results] The fibroblastic lining cells expressing mRNAs of BMP-2 and osteopontin existed around the calcifying area. Multi-nucleus giant cells with the TRAP positive staining had expressions of the mRNAs of cathepsin K and osteopontin.
[Conclusion] We hypothesized the molecular pathomechanism of calcifying tendinitis as follows. Osteopontin will work for the formative regulation of calcification and the adhesion of the osteoclastic cells to the calcified deposit.

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[Purpose] To reveal the early process of recovery at the bone-tendon interface, especially to demonstrate the process of collagen fiber's anchoring to the bone, light microscopic (LM) and scanning electron microscopic (SEM) observations were conducted using a cuff repair model.
[Materials and methods] Twelve beagle dogs were used in the present study. Under general anest hesia, the infraspinatus tendon was sharply released from the greater tuberosity of the humerus. The released infraspinatus tendon was then inserted into the cancellous bed, which was prepared in the greater tuberosity, and repaired. At postoperative weeks2,4, and 6, some animals were killed, and their specimens were harvested. Each specimen was separated into two pieces to show the tendon-bone interface. One piece was prepared for LM observations and the other was prepared for SEM observat ions. The LM specimen was stained with hematoxylin and eosin, and Safranin-O. The SEM specimen was observed after conductive staining.
[Results] At 2 weeks, the tendon, scar tissue, woven bone and lamellar bone were present at the insertion site. Pioneer collagen fibers of the scar anchored to the woven bone. At 4 weeks, these fibers increased and showed parallel arrangement with each other. The woven bone layer became thicker. At 6 weeks, the anchoring bundles were fully developed and distributed densely over the interface. The woven bone layer was identifiable as a distinct interface between soft tissue and hard tissue. Throughout all the periods, nothing was stained at the interface between the tendon and bone by Saf ranin-O.
[Conclusion] The collagen fibril bundles anchored to the woven bone at postoperative 2 weeks and developed over time. The presence and role of a woven bone formation are important during the early recovery of tendon-bone interface before the fibrocartilage-mediated insertion is completed.

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[Purpose] To assess the mechanical properties of repaired infraspinatus tendons after immediate and delayed repairs.
[Materials and methods] Sixteen shoulders were harvested from 8 beagle dogs, and were divided into two repair groups. Immediate repair (group I)(n=8): the insertion of infraspinatus tendon was detached from the greater tuberosity and then sutured to the bone trough with 4-strand sutures (2-0Ethibond). Delayed repair (group D)(n=8): the insertion of infraspinatus tendon was detached fro m the greater tuberosity and retracted proximally. Five weeks later, the shoulders were harvested and the tendons were repaired in the same way as for the immediate repair. The ultimate strength and stiffness of each tendon was measured with a force transducer, and the pattern of tendon disruption was also determined. The data were analyzed by Student's-t test and P <0.05 was regarded as statistically significant.
[Results] The average ultimate strength was 118.1±10.9 N in group I and 125.7±14.9 N in group D; with no significant difference between the two groups (p=0.261). The average stiffness was 1 ±2.56.13 1KN/m in group I and 13.59±2.43 KN/m in group D; again with no significant difference between the two groups (p=0.644). In both groups, the suture loops in the tendon moved distally during traction and then the sutures ruptured. Histological examination of the delayed repair specimens demonstrated that the tendon ends were covered with disorganized fibrous tissues and that immature fibroblasts had infiltrated among the tendon fibers.
[Conclusions] This experimental study investigated the mechanical properties of repaired infraspinatus tendons. There was no difference in the initial mechanical properties between the immediate and delayed repair tendons after surgery.

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[Purpose] The purpose of this study was to clarify the mechanism of tear of the rotator cuff, by studying the distribution of pathological lesions in the torn tendons, utilizing histochemical and morphometric analysis.
[Materials and methods] Fifty stumps of the torn rotator cuff tendons were obtained from 50 shoulders during surgery. Forty were men and 10 women. The average age was 59.1 years. The duration of symptoms was 8.7 months. The stumps of the cuff tendons were cut into 5 strips along the tendon fiber direction. All specimens were fixed in formalin/methanol, dehydrated, embedded in paraffin and sectioned at 3 μ m. These sections were stained with H&E, Masson trichrome, and Alcian blue. Microscopic image analysis was performed to evaluate the orientation of the collagen fibers and degenerative area in the torn tendons.
[Results] Histopathological examination revealed characteristic degenerative changes such as,1) thinning and disorientation of collagen fibers,2) myxoid degeneration,3) hyaline degeneration,4)chondroid metaplasia,5) calcification,6) vascular proliferation and 7) fatty infiltration. Fiber thinning and myxoid degeneration were found in all cases. Chondroid metaplasia and calcification were found in the patients with a longer history of the symptoms. These changes except vascular proliferation were demonstrated to be more pronounced in the deep layer than in the superficial layer of the tendon. Moreover, the fiber orientation in the tendon was less oriented in the deep layer in all 5 portions of the cuff tendons.
[Conclusion] Since the cuff tears examined in this study were seemed to occur through pre-existing degenerative lesions in the deep layer of the tendon, cuff tear may have a strong association with the intrinsic mechanism.

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Patients with rotator interval (RI) tears of the old age often have contract, e dw hilseh outhlodseer s of the young occasionally complain of apprehensive or unstable feelings of the affected shoulders.
The present study was undertaken to elucidate the morphological changes of torn RI o f patients 30years- old or more, and compare them with those of the younger generation which was previously published.
The diagnosis of RI tears were made by physical examination (tenderness at the RI ), arthrographically (irregularity of the RI contours) and arthroscopically (redness and proliferation of the synovium of the RI ). Patients with other abnormalities including partial cuff tears or superior labral injuries were excluded from this study. All the patients recovered from their shoulder pain showing a 90 points or more of the JSS shoulder score after removal and reconstruction of the RI capsules.
En bloc specimens from torn RI, were taken from 5 patients aged between 34 and 50 years old,, ccuut t horizontally showing both the synovium and capsules, embedded in paraffin and examined microscopically.
Fibrin deposits on the synovial surfaces and well developed small vessels in the synovial layers, which were similar findings to those of the young generation, were found in all of the specimens. Fibrosis of the capsular tissues with a regular arrangement of the fibers were evident in the specimens of patients 30- years- old or more, though edematous changes and random arrangement of the fibers were obvious in the younger generation.
These findings suggested a potential further stiffness of the RI capsules inducing subsequent shoulder contractures in older patients.

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[Introduction] Intrinsic degeneration of the supraspinatus tendon usually starts from the atricular side at the fibrocartilaginous insertion. To clarify the role of the biomechanical stress in the pathogenesis of the degeneration, we attempted to develop a 2-D finite element model of the supraspinatus tendon with its fibrocartilaginous insertion.
[Materials and methods] A histologic section of the normal rabbit shoulder was prepared. The shoulder was harvested and fixed at neutral position with 4% paraformaldehyde. Cutting was performed parallel to the direction of the supraspinatus tendon fibers. Sections were stained and photographed thereafter. Then, the outline of the specimen was traced and plotted on the computer. Commercial softwase, Mentat and Marc, was used to develop and to analyze the finite element model. A triangular mesh was created in the model and the material properties were determined based on histology. A tensile force was applied to the proximal end of the tendon and the analysis was performed.
[Results] The highest Von Mises stress was found at the articular surface of the supraspinatus tendon insertion, where degeneration was usually seen. Shear stress also concentrated at the same site. On the other hand, stress concentration was not seen in the bursal side of the tendon.
[Discussion and conclusion] The finite element model of the supraspinatus tendon was reported previously based on MR images by Luo et al. Unfotunately, however, their model did not include the fibrocartilage at the insertion. Since degeneration takes place at this site, the presence of fibrocartilage should be taken into consideration. In this study, we established our model with a fibrocartilaginous insertion based on histology. In our results, the highest stress was seen at the articular surface of the fibrocartilaginous insertion. We think our finite element model seems to recreate what is happening clinically.

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[Purpose]Satisfactory results were obtained by arthroscopic surgery in case of chronic calcific tendinitis of the rotator cuff, which had failed to respond to conservative treatment.
[Materials and methods] Seven patients underwent arthroscopic surgery for chronic calcific tendinitis of the shoulder which had failed to respond to conservative treatment such as non-steroidal analgesics and steroid injections. One patient was male and six were female. Their ages ranged between 46 and 56 with an average of 51. Six patients underwent surgery on the right shoulder andone on the left.. Duration of disorder ranged from one to eighteen years with an average of 4.9 years. A threedimensional computerized tomography was done on all patients in order to localize the calcium deposits in the cuff. The preoperative JOA scores of the seven patients was between 59 and 80, with an average of 67.2.
[Surgery] Following arthroscopic subacrominal decompression(ASD), calcium deposits were removed through a small incision made on the cuff. ASD was not performed on one patient and the incision on the cuff was not closed in two patients. Intraoperative X-rays were required to identify the calcium deposits in two patients. The range of motion exercises were started after three weeks of immobilization when the incision of the cuff had closed.
[Results] Calcium deposits were in the bursa of one patient and within the tendon of six patients. The JOA score of six patients were higher than 90 points in six to twenty-nine months following surgery with an average of fifteen months.
[Conclusion] 1. Arthroscopic surgery was performed on seven patients with chronic caltific tendinitis of the shoulder which conservative treatment condition had failed.2. Six patients were in satisfactory over six month period following surgery.3. A three-dimensional computerized tomography was beneficial to identify the location of the calcium deposits during arthroscopic surgery.4. The incision in the cuff should be closed.

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[Objective] Rotator cuff tears were examined by pre- and post operative MRIs was investigated.
[Materials and methods] Twenty shoulders of 20 patients with a rotator cuff tear who underwent surgery were examined. Ten patients had a clear case of trauma (trauma group) and 10 patients did not have trauma (non-trauma group). Patients with a preoperative contracture were excluded. The age, duration between onset and surgery, size of the rotator cuff tear, arthroscopic findings, and MRI findings (degeneration of supraspinatus and infraspinatus muscles, edema of the glenohumeral joint)were compared among these patients. Furthermore, the relationship between the MRI findings three and 12 months after surgery and the JOA scores were investigated.
[Results] On preoperative MRIs, degeneraticns (appearance of the linear band in the supraspinatus and infraspinatus muscles) were significantly increased as the size of the cuff tear increased. In the trauma group, degeneration was significantly increased as the duration between onset and surgery was prolonged. Similarly, in the non-trauma group, edema became more frequent as the duration between onset and surgery was prolonged. On postoperative MRIs, although the analyzed difference was not significant, the JOA scores tended to be decreased in patients with a degeneration and edema.
[Conclusion] In the trauma group, degeneration of supraspinatus and infraspinatus muscles on MRI was related to the duration between onset and surgery, and had not improved 12 months after surgery.

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We examined the intensity of the supraspinatus muscles of patients with a rotator cuff tear in Magnetic Resonance Imaging (MRI) findings.
One hundred and nice shoulders in patients with a rotator cuff tear were preoperatively scanned by MRIs. Using MRIs, the linear bands of the supraspinatus muscle were classified into three grades. We examined the age, period from onset, ratio of the rotator cuff and the patch graft method, and the JOA score in all three grades.
There were 46 shoulders in grade 1 (G-1),28 shoulders in grade 2 (G-2) and 35 shoulders in grade 3 (G-3). The mean ages of the patients in the three grades were 53.4 years-old,56.7 years-old and 61.3years-old respectively. The age of the G-3 was significantly higher than the other grades. The period from onset of the G-3 was shorter than the other grades, but there was no statistic significance. The ratios of massive tears were 2.2%,27.0% and 46.2% respectively. Reruptures were observed only in grade 3 and there were none in G-2 and G-3. The patch graft method was performed on one shoulder in G-2 and three shoulders in G-3. The average JOA scores were 89.3 in G-1,88.4 in G-2 and 86.9 in G-3. The JOA score of the G-3 was significantly lower than the other grades.
The results of the present study suggest that high intensity on MRI i s associated with poor clinical results in operative treatment. Some authors report that these finding of MRI demonstrate a fatty degeneration of the muscle. So we should select the best operation and carefully rehabilitate patients with a high intensity of the supraspinatus muscle belly on MRI.

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[Purpose]The coracohumeral(CH)ligament is deeply related to the restriction of lateral rotation of the shoulder joint. The present report concerns our experience in evaluation of the CH ligament by 3D MRI in relation to the restriction of a lateral rotation.
[Materials and methods]The study covered 43 shoulders of 43 patients who had disorders in the shoulder since 1999, and underwent 3D MRI examination. Of these subjects, llshoulders of llpatients were examined twice, when the symptom was distinct and at a stage of remission. As controls,9shoulders of 8 healthy persons were observed. The MRI equipment used was Model SIGNA HORIZON LX 1. OT of GE Yokokawa Medical, and images were constructed on the basis of 3D GRASS images (TR 32, TE 15) derived from 100 consecutive slices of 1mm thickness. The correlation of the angle of lateral rotation as measured at the time of MRI examination with the thickness, length and signal intensity of CH ligament determined on MRI image was checked.
[Results]The mean values of lateral rotational angle, and thickness of CH ligament were 71.1°and 3.1mm, respectively, in the normal group(N), while those in the symptomatic group(S)were 35.6°and 5.2mm. A significant correlation was recognized between the lateral rotation angle and the thickness of the CH ligament. No significant correlation was seen between the lateral rotation angle, signal intensity and ligament length. in group S2 where the MRI examination was carried out twice, at the symptomatic phase and at the remission phase, the lateral rotation angle increased and the thickness of the CH ligament reduced significantly in the remission phase in comparison to those in the symptomatic phase.
[Conclusion]The more the lateral rotation was restricted, the greater the thickness of the CH ligament was. This study indicates that the movable range of the shoulder joint can be estimated on the basis of image diagnosis.

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An isolated tear of the subscapularis tendon is rare and its patholgy is controversial. The aim of this paper is to clarify the pathology and surgical treatment of an isolated tear of the subscapularis tendon. Six patients with a tear of the subscapularis tendon were treated surgically and 5 were followed-up. Their physical, rediological, ultrasonographical, MRIs and arthrographical findings were studied. Their shoulders were evaluated by the Japanese Shoulder Association (JOA score) scoring system. The follow-up period was 44 months on average.
The six patients were males with an average age of 55.5 years. Each patient had an episode of trauma. The dominant shoulder was involved in 3 patients. Four patients complainted of anterior shoulder pain. Tenderness of the lesser tuberosity, a painful arc and Yergason's test was positive in 4 patients. Weakness of abduction were demonstrated in 5 patients and weakness of external rotation was in 1patient.3 patients underwent the Lift off test and 1 patient was positive.
Ultrasonography and MRI demonstrated the tear portion as an irregularity, a defect and a thinning. Arthrography often demonstrated a penetration of the contrast medium to the subacromial bursa and a pooling of the contrast medium in the anterior portion of the joint on the scapula Y view.
The JOA scores were 68.2 points at pre-operation and 92.4 points at follow-up.
Trauma seems to be an important factor of the cause of an isolated tear of the subscapularis tendon and concomitant injury of the long head of the biceps contributes to its pathology. A modified McLaughlin procedure with a repair of the bicipital mechanism is important.

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[Purpose]Regarding patients who underwent surgical treatment for calcifying tendinitis, the calcifying site, range of motion, and indications were examined.
[Subjects] Of 550 patients who were diagnosed as calcifying tendonitis of the shoulder,32 shoulders in 30 patients(male; 12 shoulders, female; 20 shoulders)who underwent surgical treatment due to heavy resistance to conservative treatment were selected as subjects. Their age ranged from 32 to 71years (mean,51.1 years).
[Methods]Subjects were divided into 3 groups according to the affected period: acute group(AG)composed of patients less than 1 month after onset, chronic group (CG), composed of patients more than 1 month after onset, and subacute group (SG) composed of patients who had aggravated symptoms after the chronic course. As with the range of motion, the preoperative external rotation,, aabbdduucc- tion, and flexion were evaluated. Based on the intraoperative findings, the calcifying site was classified into the subacromial bursa type (SAB type), the intratendinous type (IT type), and the transitional type (IT-SAB type). The indication for and timing of surgery were examined by comparison of these groups.
[Results]The mean affected period was: AG,11.8 days; SG,2.2 years; and CG,1.7 years. The sex was: AG,8 shoulders were female; SG,5 shoulders were male and 5 shoulders female; and CG,7shoulders were male and 7 shoulders female. Regarding the mean range of motion, every group had its limitations. In particular, The AG had the most limited range of motion with 45 degrees of external rotation,67.5 degrees of abduction and 95.0 degrees of flexion. As with the calcifying site: the AG, SAB and IT-SAB types in 3 shoulders and the IT type in 5 shoulders; the SG, SAB and IT-SAB types in 3shoulders and the IT type in 7 shoulders; and the CG, SAB and IT-SAB types in 2 shoulders and the IT type in 12 shoulders.
[Discussion]Though the patients of the acute group had a mean affected period as short as 11.8days, their symptoms did not disappear by intensive conservative treatment. Such patients should be surgically treated as soon as possible. The patients of the subacute group had recurrence of severe pain after a long affected period of 2.2 years on average. Thus, care should be taken for such patients even if no pain has developed for a while. The patients of the chronic group have a possibility of symptoms to be aggravated during the course, thus they also need careful observation. The patients in both groups, as in the acute group, should be surgically treated at an earlier stage, if they can resist conservative treatment.

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[Purpose]In shoulders with a rotator cuff tear, some have suggested that the long head of the biceps tendon (LHB) becomes an active depressor of the humeral head, while others maintain that it is a major source of shoulder pain. The former recommend preservation of the biceps tendon and the latter recommend a tenodesis or tenotomy procedure. The purpose of this study was to clarify the histological characteristics of the LHB in patients with complete cuff tears.
[Materials and methods]LHB tenodesis operations were performed in five patients who had complete cuff tears with a damaged LHB tendon. The intraarticular part of the tendons were dissected and analyzed. The patient ages ranged from 55 to 70, with a mean of 60.2 years. Physical examinations revealed both cuff tear signs and symptoms indicating an LHB injury. Specimens were fixed in 10%formalin, embedded in paraffin, stained with H-E and Azan, and then observed with a microscope.
[Results]All of the LHB tendons showed dense connective tissue with some degenerative changes, which included failure of the collagen bundle, hyalinization, and myxoid changes. All the tendons showed a foci of proliferated capillaries, which traveled between the degenerated collagen fibers, and the granulation tissues.
[Discussion]Our results demonstrated that degenerative changes in the LHB tendons with a cuff tear were more severe than those due only to aging. As a result, we recommend biceps tenodesis rather than preservation in patients with complete cuff tears.

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[Purpose]To evalutate the glenohumeral joint abnormalities concomitant to partial rotator cuff tears (PRCT)compared with complete rotator cuff tears(CRCT)
[Materials and methods]257 shoulders that had undergone a rotator cuff repair were investigated.66shoulders had PRCT and 191 had CRCT. All of thcm had undcrgonc an arthroscopic cxamination bcforc thcir rotator cuff rcpair. The average age of the PRCT patients, was 56 years (range,23-84)and they consisted of 40 men and 16 women. The average age of the CRCT patients was 60 years (r ange,25-84) and they consisted of 130 men and 61 women.
[Results]In the shoulders with PRCT, synovitis with a villous formation was found in 31 shoulders (47%), the SLAP lesion type II III IV was found in six cases(11%), a partial tear of the long head of biceps was in three cases(4.5%), an osteoarthritic change with a chondral defect was in one case (1.5%). In the shoulders with CRCT, synovitis with a villous formation was found in 130 shoulders (68%), a SLAP lesion type II III IV was found in five cases(2.5%), a partial tear of the long head of the biceps tendon was in 27 cases (14%), complete tears of the long head of biceps tendon were in 12 cases (6.3%), and an osteoarthritic change with a chondral defect was in six cases (3.1%). Comparing the two groups, the shoulders with PRCT had a more superior labral injury than those with CRCT, but synovitis and tears of the long head of the biceps tendon were more prominant in shoulders with CRCT.
[Conclusion]Because there were differences between the glenohumeral joint abnormalities concomitant to PRCT and CRCT, pathogenesis of PRCT and CRCT can vary.

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[Purpose]The purpose of this study was to evaluate the activity of shoulder muscles in various shoulder positions in the external rotational motion.
[Materials and methods]We examined the non-dominant side of shoulders of 8 adult males who did not have any shoulder disorder. We pasted surface electrodes for 7 outer muscles and stuck needle electrodes into 3 inner muscles of each subject. Each person performed isometric external rotation motion in various loads (0,3,9,15Nm) in 6 positions (60° internal rotation, neutral,30° external rotation with arm at side, and neutral,45° external rotation,90° external rotation with arm at 90° abduction position) with a Cybex-NORM770. We obtained electromyograms of each muscle. An electromyogram signal during a maximum manual muscle strength test (MMT) was selected as the normalizing value (100%) for each subject.
Each activity (%MMT) was atatistically compared, using Scheffe's test. The statistical significance was set at 0.01.
[Results and conclusion]During isometric external rotation motion, in internal rotation or arm at side position, the activities of the muscles were low and the activities of the inner muscles were higher than those of the outer muscles, so these positions might be appropriate for rotator cuff exercises in the early phase of rehabilitation. While, in the 90° external rotation with arm at 90° abduction positi on, which is similar to the cocking phase of throwing, the activities of all the muscles including the outer muscles were very high. So we must be careful when we do shoulder exercise in such like position not to overload the shoulder muscles.

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[Purpose]To evaluate the role of external rotator muscles on the centralization of the humeral head relative to the glenoid during arm elevation in the normal shoulder.
[Materials and methods] Seven male volunteers without any history of shoulder disease were examined. The maximum external rotation torque was measured manually with a dynamometer (Microfet 2) in the lateral decubitus position. Glenohumeral radiographs in the anteroposterior view were taken at 0°,45°,90° and 135° of abduction in the scapular plane before and after external rotation exercise. With a dumbbell approximately 5% of the body weight, external rotation exercise was undertaken until a 30% reduction in the external rotation torque as compared to the initial maximum torque was achieved. The change in the humeral head translation (the distance between the center of the humeral head and the bisector of the glenoid surface) was measured with an NIH image before and after external rotation exercises.
[Results]For all subjects, before fatigue, the position of the humeral head was below the center of the glenoid at 0° of abduction (0.3±0.5 mm). The humeral head migrated superiorly at 90° and 135°of elevation (p =0.0022) as compared to 0°. After fatigue, the humeral head, with the arm at 0° of abduction, migrated more inferiorly (0.9±0.3 mm, p=0.0234). However, at 45_ of abduction, the humeral head migrated 1.3±0.5 mm superiorly (p=0.17). The distance of the superior migration during the initial abduction (from 0 to 45° ) before fatigue was 0.2±0.6 mm, which significantly increased to 1.3±0.5 mm (p=0.0085) after muscle fatigue.
[Conclusion]Fatigue of the external rotator muscles causes significant superior translation of the humeral head during the early phase of abduction in normal shoulders.

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Abstract
To determine the most effective exercise for the supraspinatus, we measured T2 relaxation time (T2)for the rotator cuff and deltoid before and after three type of exercise ("empty can", "full can", "horizontal abduction in the prone position" ) on MRI. Six males performed three sets of each exercise with a weight of 20 repetitive maximum. Subjects were imaged before and immediately after the exercise. T2 for rotator cuff and deltoid on sagittal MR images were calculated using the software routines on the MRI system. An increase in T2 for the supraspinatus after the empty can and full can exercises (10.5±2.0,10.5±2.0 respectively) was significantly higher than that after the horizontal abduction (.63±1.3). There was no significant difference in the value for the supraspinatus between the empty can and full can exercises. This study has demonstrated that the horizontal abduction exercise is less effective for strengthening the supraspinatus than the empty can and full can exercises. We found no significant differences in loading of the supraspinatus between the empty can and full can exercises. Therefore, the full can exercise should be used for rehabilitation, because it involves less risk of pain provocation due to subacromial impingement.

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[Purpose]We studied the radiological changes of the acromial spur and glenohumeral joint because the degenerative changes of the shoulder were not fully understood. Materials and methods: We examined 88 patients 162 shoulders (42 male and 46 female). Their ages ranged from 15 to 87 years old (mean: 55.6 years old). Anteroposterior, axial and 30-degree caudal tilt shoulder radiographs were performed. Rheumatoid arthritis, cuff tear arthropathy and fractures were excluded. We divided the glenohumeral osteoarthritis (OA) in early, advanced and end stages, and classified the acromial spur to type I (sharp end) and type II (dull end).
[Results]There were 19 cases (23 shoulders) in type I of the acromial spur,47 cases (74 shoulders)in type II,39 normal cases (65 shoulders). The mean age of type I was larger than those of type II and the normal. The rates of the same type in bilateral shoulders were 26.7% in type I,65.9% in type II and 74.3% in the normal. Two shoulders (I1 II1) were in the advanced stage of OA and 9 shoulders (I2, II3, normal 4) were in the early stage.
[Conclusion]60% of the shoulder patients had acromial spurs. The mean age of type I was larger than those of type II and the normal. The occurrence rate of type I was larger than that of glenohumeral osteoarthritis.

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[Purpose]The purpose of this report is to evaluate the patterns of degenerative change in the general joints in chronic massive rotator cuff tears (C MT) and osteoarthritis (OA) of the shoulder.
[Materials and methods]The CMT, OA, chondrocalcinosis (CC) and generalized OA (GOA) are defined as follows: the CMT is characterized by the narrowing acromio-humeral interval (AHI) (AHI<5mm). The OA is characterized by osteophyte, sclersis, irregularity and narrowing in the glenohumeral joint (AHI ≥5mm). The CC is characterized by the calcific deposite in the meniscus of the knee. The GOA is characterized by the osteoarthritis in the multiple joints including both the upper extremities and the lower extremities.
[Results]The CMT group was composed of 54 cases 77 shoulders (both side 23 cases, right side 25cases, left side 6 cases).21 cases were male and 33 cases were female. Their average age was 78.8. The OA group was composed of 18 cases 28 shoulders (both side 10 cases, right side 3 cases, left side 5 cases).2 cases were male and 16 cases. female. Their average age was 81.6. In the CMT group,21cases were associated with CC,16 cases with GOA and 14 cases with OA of only the upper extremiti es. In the OA group,6 cases were associated with CC,7 cases with GOT and only one case with OA of only the upper extremities.
[Conclusion]It possible that CTM is caused by both degenerative change of the rotator cuff and overuse of the upper extremities, on the other hand, OA is a constitutional disease.

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[Purpose]The purpose of this study is to investigate the factors which influence the range of motion of the shoulder after prosthetic arthroplasty in patients with rheumatoid arthropathy and osteoarthrit is.
[Material and methods]We reviewed 22 shoulders (RA-13, OA-9). Their average age 62 years old. Six shoulders had received humeral head replacement, the other sixteen shoulders had total shoulder arth roplasty. We divided the cases into two groups. Groupl (13 shoulders) were cases unable to elevate their arm more than 120 degrees. Group2 (9 Shoulders) were cases able to elevate their arm more than 120 degrees postoperatively.
The factors we investigated were sex, age, pathology, surgical procedure, the position of the center of the prosthesis and muscle strength of the elevation, and external and internal rotation.
[Results]The significant factors were the pathology and muscle strength. Although 67% cases of Group2 were in the OA, only 23% of the cases in group2 were in the RA. The averaged muscle strength of Group2 was significantly greater than that of Groupl.
[Conclusion]The impartant factors which influenced the postoperative elevation anger of the affected shoulder was the muscle strength around the shoulder.

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Septic arthritis of the shoulder of eight adult patients that we treated were reviewed. The patients'ages were between 32 and 83 years old, and the follow-up period ranged from four months to three years and six months (mean: one year and four months). The infectious organisms isolated were staphylococcus aureus in five, and haemophilus influenzae in one. A delay of treatment influenced the method of treatment. Eight adult patients who received treatment within one week following the onset of septic arthritis of the shoulder were treated and reviewed. The patients' ages were between 32 and 83years old, and the follow-up period ranged from four months to three years and six months (mean: one year and four months). The infectious organisms isolated were the disease, septic arthritis of the shoulder, which was cured by drainage in combination with an intraveneous administration of antibiotics. In those patients whose treatment was delayed more than two weeks following the onset, more invasive treatment such as arthroscopy or an open synovectomy was required. Though arthritis caused by staphylococcus aureus showed a slightly poorer outcome, the type of causative organisms did not influence the term of improvement of the inflammatory reaction. It was thought that the administration of ineffective antibiotics delayed the improvement of the inflammatory reaction.

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[Objective] Pain after shoulder surgery is so severe that postoperative rehabilitation is prolonged. The purpose of this study was to determine the clinical usefulness of the oral administration of loxoprofen sodium and clonidine hydrochloride in postoperative patients with subacromial impingement.
[Patients and methods]Twenty-four patients with subacromial impingement syndrome (Grades I to III) who underwent open surgery were selected at random to take loxoprofen sodium with (Group CH; 11cases) or without (Group no-CH; 13cases) clonidine hydrochloride. For seven days, patients in group CH took l tablet of loxoprofen sodium and 5μg/kg of clonidine hydrochloride 30 minutes before rehabilitation. They exercised with a physical therapist the pendulum, in passive elevation and external rotation. The postoperative visual analog scale (VAS) and passive ranges of motion (ROM) in elevation and external rotation were evaluated. Each parameter was statistically analyzed by MANOVA (p<0.05).
[Results] Passive ranges of Non-CH and CH groups improved similarly, but Group CH patients showed more satisfaction than Group no-CH patients. The postoperative VAS in Group CH was lower than that in Group no-CH up to the 5th postoperative day. Seven days after surgery, all of the patients in both groups obtained approximately 135 degrees in passive elevation and 40 degrees in passive external rotation. Clonidine hydrochloride sedated patients mentally, and may have minimized musculotendinous stiffness. Thus, medication of the LS and CH had analgesic effects at an early stage after shoulder surgery.
[Conclusion] Oral administration of loxoprofen sodium and clonidine hydrochloride accelerated rehabilitation in patients with subacromial impingement syndrome postoperatively.

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[Purpose] To analyze the clinical diagnosis of a rotator cuff tear.
Materials and method: The clinical findings of 1,926 patients over 40 years old with shoulder problems were analyzed to study the clinical diagnosis of the rotator cuff tear. Patients have been examined by the authors for 16 years since 1984. Patients consisted of 451 rotator cuff tears,1159 bursitis,147calcific tendinitis,56 impingement syndromes,25 paralytic shoulders,22 degenerative arthritis of the acromioclavicular joint,21 degenerative arthritis of the glenohumeral joint and 45 other disorders. The patients with a rotator cuff tear were separated from patients with other disorders. Then the clinical findings of sensitivity, + predictive value and accuracy were analyzed.
[Results] Sensitivity orders were; 76.8% for the impingement sign,71.6% for night pain,66.5% for crepitus,54.3% for a painful arc sign,50.1% for a history of trauma,49.6% for atrophy of the infraspinatus muscle,45.2% for weakness of the abductor muscle and 40% for the effusion sign. +Predictable value orders were; 86.5% for the effusion sign, +predictable value orders were; 86.5%for the effusion sign,84.0% for below 6mm AHI,62.5% for crepitus,57.4% for a history of trauma,49.6% for atrophy of the infrasupinatus muscle,41.8% for the drop arm sign,40.9% for tenderness of the greater tuberosity,40.5% for the painful arc sign. Specificity orders were: 99.2% for below 6mm AHI,98% for the effusion sign,93% for the drop arm sign,87.8% for a history of trauma,87.5% for crepitus,86.4% for the weakness of the external rotator muscle,85.4% for a decrease of tolerance,84.7% for atrophy of the infraspinatus,79.6% for tenderness of the qreater tuberosity, and 75.6% for the painful arc sign. Accuracy orders were: 84.5% for the effusion sign,82.8% for crepitus,79.6% for a history of trauma,79.3% for below 6mm AHI,76.45 for atrophy of the infraspinatus,75% for a drop arm sign,72.2% for a decrease of tolerance,71.9% for tenderness of the qreater tuberosity,71.8% for weakness of the external rotator muscle.
[Conclusian]Reliable factors in clinical diagnosis of a rotator cuff tear are effusion sign, below 6mm AHI, crepitus, a history of trauma, atrophy of the infraspinatus muscle, and the drop arm sign.

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[Purpose]The purpose of this investigation was to evaluate the clinical results of open repair of rotator cuff tears at 6 months after surgery. The preoperative and intraoperative factors were assessed for their potential impact on the results.
[Materials and Methods]Three hundred and twenty-seven cuff tears (305 patients) were treated surgically. The study group included 196 men (213 shoulders) and 109 women (114 shoulders) whose mean age at surgery was 55 (ranging,20-77) years old. Based on the intraoperative assessment of the tear size, the tears were classified into five as follows'. Group I: macroscopic partial-thickness tears. Group S: full-thickness tears of which defects were less than 1 cm. Group M: the defects were 1 to 3 cm. Group L: the defects were greater than 3 cm without difficulty in tendon mobilization. Group G: the defects were greater than 3 cm with difficulty in tendon mobilization. Statistical analyses were performed using Schaffer's F test and the postoperative JOA score of each group. The Mann-Whitney test was used to compare the patients with preoperative contracture with those without a preoperative contracture. The patients were analyzed for statistically significant Spearman correlations between the postoperative JOA score and the following variables: duration of symptom and the preoperative JOA score of pain.
[Results]There were statistically significant correlations between Groups G-I, G-S, G-M and G-L. Patients with a preoperative contracture tended to have lower postoperative JOA scores than those without one. There were statistically significant negative correlations between the post scores and the duration of the symptom and the prescore of pain.
[Conclusions]The postoperative JOA scores correlated closely with not only the cuff tear size, but also with cuff mobility. Patients with a preoperative contracture tended to have worse results. The longer the duration of the symptom and the higher JOA scores of pain suggested the likelihood that there would have lower postoperative JOA scores.

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[Purpose]The present study was undertaken to elucidate the pathological conditions of both the capsule and subacromial bursa of contracted shoulders associated with rotator cuff tears.
[Materials and methods]Twenty-six shoulders of 26 patients,22 males and 4 females, aged from 37to 75 years old (mean 57) received brisement procedures prior to cuff surgeries. There were 8 large,12 small and 6 partial thickness tears. Arthroscopic observation was done to find out the site of the capsular injury after the brisement procedures. Macroscopic observation of torn cuffs and the adhesion of the bursa were also performed.
[Results]Arthroscopic findings after brisement procedures revealed redness, proliferations, and bleeding of the synovium in the glenohumeral joint. There were two types of capsular injuries. TypeA: tear of the axillar region(17 shoulders), Type B: tear of the axillar and rotator interval regions(9 shoulders). The number of cases of (Type A: Type B) was (7: 1) with large tears, (6: 6) with small tears and (4: 2) with partial thickness tears. If cuff tears included the rupture of the anterior band of the supraspinatus tendon, the number of (Type A: Type B) was (12: 3), while it was (1: 4) without a rupture of the band. Although there were adhesions between the bursa and cuff in 85% shoulders, no disruptions were found in the subacromial bursae.
[Conclusion]The main cause of a shoulder contracture assosiated with rotator cuff tears was located at the axillar and rotator interval capsules and was influenced by the size of the location and cuff tears.

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[Purpose]The purpose of this study was to clarify the advantages of two surgical procedures for massive, irreparable tears of the rotator cuff. Materials and methods: We evaluated 34 shoulders of 32patients who were surgically treated for irreparable rotator cuff tears. Between 1991 and 1993 we performed latissimus dorsi transfer (LD). After 1994 we used a teflon felt patch procedure (TP) for rotator cuff reconstruction. The LD group consisted of 14 shoulders of 12 patients, and their average age at surgery was 64.1 years old (48 - 82 years old), and their mean follow-up was 43.7 months (24 - 78months). The TP group consisted of 20 shoulders of 20 patients, whose average age at surgery was 65.5years old (48 - 73 years old), and their mean follow-up was 32.6 months (24 - 60 months). The functional outcome was assessed with the JOA shoulder score and strength component of the UCLA shoulder score, and contrasted between the two groups pre- and postoperatively.
[Results]The average total JOA score increased from 60.6 to 80.3 (p<0.001) in the LD group and from 58.9 to 82.1 (p0.0001) in the TP group. Each component of the scores in both groups also improved significantly. The average age at surgery, preoperative total and each component of the JOA score and strength component of the UCLA shoulder score, the postoperative total, function and ROM scores showed no significant difference between the two groups. But the average postoperative pain score was significantly higher in the TP group (p<0.05), and the average postoperative strength score was higher in the LD group (p<0.05).
[Discussion and conclusion]Latissimus dorsi transfer is a major procedure, but favorable in terms of the postoperative strength. So it is speculated that a transferred muscle is actively contracting. We recommend a latissimus dorsi transfer for active patients and the use of a teflon felt prosthesis for the old, inactive patients.

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Thirty two patients with massive rotator cuff tears were treated by three different procedures, eighteen cases by the McLaughlin's procedure, seven cases by the Dacron patch procedure and seven cases by the Debeyre's procedure. There were twenty-three males and nine females with an average age of sixty four years old.
The authors evaluated and compared the post-operative results of the three procedures according to the shoulder evaluation sheet of the Japanese Orthopaedic Association (JOA score). The average JOA score of the McLaughlin's procedure group was 91.8±6.9 points, the group repaired with the Dacron patch had 84.1±7.8 points, and the Debeyre's procedure group had 85.4±13.1 points.
The clinical symptoms of the group treated by the McLaughlin's procedure tended to improve during one year after surgery. On the other hand, the group treated with the patch needed more than one year for the improvement of the clinical symptoms and the osteoarthrosis of the shoulder joint had advanced on the radiological examination during the follow-up periods.

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[Purpose]The purpose of this study was to evaluate the post operative isotonic strength of the shoulder after a patch method, grafted with Fascia late (FL) and Marlex mesh (MM).
[Materials and methods]Nine shoulders in 9 patients, on which we performed the patch method for rotator cuff massive tears, underwent isotonic shoulder strength assessment, at 6 months,1 year, and an average 3.4 years after surgery. The FL was used in four shoulders in 4 patients (2 males and 2 females)with an average 63.3 years old. The MM was used in five shoulders in 5 patients (5 males) with an average 58.8 years old. The isotonic strength was recorded, using a Dynatrac Dynomometer, in f lexion, abduction, and external rotation.
[Results]At 6 months after surgery, the isotonic strength of the FL was 31% in flexion,37% in ab duction,73% in external rotation, of the uninvolved shoulder, and the isotonic strength of the MM was 20%,23% and 49%. The isotonic strength at 6 months after surgery was low, and especially that of the MM in flexion and abduction was lower than that of the FL. (P<0.05) At 1 year, the strength of the FL was 35%,38%, and 87%.
The strength of the MM were 46%,44% and 81%. There was no significant difference in the isotonic strength of the FL between 6 months and 1 year. However the isotonic strength of the MM in flexion and abduction at 1 year were statistically higher than at 6 months. (P<0.05) At 3.4 years, the isotonic strength of the FL were 48%,58%,69% and the strength of the MM were 33%,35% and 76%. There was no significant difference in the isotonic strength between at 1 year and 3.4 years.
[Conclusion]The isotonic muscle strength of the MM at 6 months after the patch method was lower than that of the FL. The strength of the MM in flexion and abduction at 1 year was statistically higher than at 6 months. There was no significant difference in isotonic strength of the FL and the MM between at 1 year and 3.4 years after surgery.

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We evaluated the clinical results of a fascial patch procedure for massive rotator cuff tears. Eight shoulders of eight male patients with massive rotator cuff tears, which had been operated on by a fascial patch procedure, were available for this study. There were four right and four left shoulders. The mean age of the patients was 60 years old (range,56 to 72 years old). We repaired massive tears of the rotator cuff with autologous fascia lata grafts, which were folded in two, in conjunction with an anterior acromioplasty. The shoulder was immobilized with an abduction brace for five weeks postoperatively. The clinical results were evaluated using the JOA score.
The postoperative mean JOA score was 91 points (range,74 to 9 8). The score of the patient, whose supraspinatus muscle had had poor mobility intraoperatively, was lower. All the patients returned to their previous occupations. The satisfaction of the patients had a relatively high rate, although the clinical results of a fascial patch procedure for massive rotator cuff tears were inferior to those of a primary repair.

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[Objective]We encountered three patients who had sustained sport injuries with characteristic findings of a partial tear of the tendon of the LHB.
[Subjects]The subjects ranged in age from 24 to 40 years. The tendon tear had occurred in the right hand. Two of the patients had sustained contusions on the anterior aspect of their right shoulders during judo and the third during rugby. Although they experienced pain on horizontal abduction and external rotation, they were, however, able to continue playing their respective sports.
[Results]Tenderness was noted extending from the bicipital groove(BG) to the lesser tubercle(LT) in all the patients. Only one patient complained of concavity and tenderness in the supraspinatus muscle which limited the range of motion of the joint. In this patient, pain occurred on the anterior surface of the shoulder during Yergason's test. In two of the patients, the tendon of the LHB within the BG appeared thin and its inferior part appeared thick on arthrography. MRIs revealed retention of the synovial fluid within the joint in all cases; however, it was difficult to confirm any tendon injury of the LHB. The diagnosis of a partial tear of the tendon of the LHB was confirmed by arthroscopy. Fusion of the tendon of the LHB to the BG was performed.
[Conclusion]When a tendon rupture occurs secondary to traumatic injuries in the absence of degeneration, the patients experience pain during exercise. Since diagnostic imaging methods fail to reveal a partial tear of the tendon of the LHB, arthroscopy is necessary for a definitive diagnosis for a partial tear of the tendon of the LHB.

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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 Bankart lesion(BL). Sixteen shoulders of 16patients (age range 18-49 years old, mean age 33.7 years old) with traumatic anterior dislocation were examined. T2*-weighted images with 3D-FT gradient echo sequences (TR = 100, TE = 15, flip angle =15°,2mm continuous slices) were obtained in both the ABER method and the usual transverse and oblique images using a superconducting MR imager (1.5 tesla). MR findings of the anterior labrum included high signal intensity, unclear appearance, dislocation, disappearance, and fracture or bone defect of the anterior glenoid rim were regarded as BL. On MR images, regarding the anterior edge of the glenoid rim as a linear line, the anterior labrum was evaluated in the range from one-sixth to fivesixths of all slices with a glenoid cavity.
While arthroscopically, the anterior labrum was evaluated in the range from 1 to 5 o'clock. The range of anterior labrum of MR findings corresponding to arthroscopic findings was presented with a percentage. The significant difference between the ABER method and the usual transverse and oblique images was regarded as more than 10%. In the ABER method was more useful in evaluating the BL and normal labrum, eight shoulders ( 50% ). Two shoulders ( 12.5% ) with usual transvers and oblique images were more useful. The others ( 6 shoulders: 37.5% ) were almost equivalent. MR imaging with the ABER method was more useful for evaluating the range of BL.

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[Purpose] Characteristic features, such as a deficiency of the posterior margin of the glenoid and the hypoplasia of the acromion in the loose shoulder are reported here. We presented at the 21st JSA meeting the correlation between hypoplasia of the acromion and loose shoulder using X-ray findings. This time they were evaluated using three dimensional MRI.
[Materials]The materials consisted of 30 loose shoulders (group LS) and 50 normal shoulders (group N).
[Methods] 3D-MRI (Siemens) images were extracted in the supine position. The images were put into a three dimensional analysing software (3D Virtuoso UA3OA). It was possible to detect the point or the plane voluntarily. The following measurements were evaluated; 1) the anterior transverse diameter of the acromion 2) the distance(Rr) between the acromial angle and the medial angle of the acromion 3) the angle(R) with the most lateral edge of the acromion and the acromial angle and the point on the scapular spine
[Results]There were significant differences between group LS and group N in the anterior transverse diameters, the Rr distances and the R angles.
[Conclusions]Hypoplasia of the acromion could be found in loose shoulders, especially the bony structure from the acromial angle to the distal part is undeveloped and the acromial angle tends to be round.

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[Purpose] The purpose of this study was to present the results of the conservative treatment for atraumatic shoulder instability.
[Materials and methods] Between 1981 and 1999,35 patients,56 shoulders were treated conservatively. They included 41 loose shoulders ( group L),7 voluntary dislocations ( group V),8 habitual dislocations ( group H), and 4 shoulders were combined groups V and H. The mean age at first visit was 21.4 (8 47) years old, the duration of follow-up was 12.2 (2 - 18) years. The situation of the symptoms, MMT, ROM, pain, restriction of ADL and sports activities were researched by medical examinations and questionnaires, and evaluated according to the JOA score.
[Results] The chief complaints were sensation of incongruity of the shoulder and motion pain. Complaints caused by an unknown situation were in 77% of the cases. The duration until the first visit was over 1 year in 77% of the cases. Restrictions of ROM were observed in 8% (flexion),13% (external rotation),22% (internal rotaiion) of the cases.49% of the cases had some restriction of ADL, and 59% of cases had restricted or given up sports. Their self evaluations were 49% (no change),34%(improved),14% (healed) and 3% (worse).
[Discussion] It is difficult to decide on an operative indication of atraumatic shoulder instabilities because of their complicated conditions. We usually selected a conservative treatment that included guidance of ADL or sports activities. It is, important to explain to patients their condition in detail, so many cases will be satisfied.

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[Patients and methods] The pressure between the humeral head and the subscapular tendon was determined in two groups. In the first group(16 shoulders), it was measured during Boytchev procedure before and after transposition of the conjoined tendon and in the second group(15 shoulders), it was done one year after surgery. There was no recurrence in the second group. A micro-tip catheter transducer was inserted between the humeral head and the subscapular tendon. Pressure was measured at two positions: 0,15,30,45,60 degrees of external rotation of arm at side and 0,30,60,90 degrees of external rotation at 90 degrees abducted position.
[Results] In the first group, the pressures after the conjoined tendon transfer were statistically higher than those before the tendon transfer in each degree of two positions. In external rotation of the arm at side, the average pressure before the transfer are from 17±10 to 161±158mmHg and the average pressure after the transfer are from 62±36 to 580±300mmHg, respectively. In external rotation at 90 degrees abduction, the average pressure before the transfer are from 19±10 to 210±137mmHg and the average pressure after the transfer are from 106±47 to 1095±51OmmHg, respectively. The second group revealed the same levels of pressure as the first group after the tendon transfer (not statistically significant)in external rotation of the arm at side and in external rotation at 90 degrees abduction.
[Conclusion] 1) Boytchev procedure increases the pressure between the humeral head and the subscapular tendon.2) This increased pressure was kept one year after surgery.3) The stabilizing mechanism of this procedure seemed to be this increasing pressure.

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[Purpose]An arthroscopic Bankart repair for anterior shoulder instability had a relatively high rate of recurrence but the limitations of external rotation were small comapared to an open Bankart repa ir. We performed transglenoid multiple suture (Caspari) technique reinforced with subscapularis to get better stability. However, the limitation of external rotation remained in the internal rotation arm fixation position. So, we changed the arm position to neutral rotation position with arm at the side. The purpose of this study was to evaluate the effects of the neutral rotation position with arm at the side.
[Materials and Methods] We retrospectively studied 31 patients after reinforced Caspari procedure more than one year postoperatively. The average age at the operation was 24 years old. ROM exercises were started after 3 weeks immobilization.17 shoulders were fixed in the internal rotation position with arm at the side, and 14 shoulders were in the neutral position.
[Results] As to the postoperative external rotation, affected/unaffected side ratio (%) at 3 months postoperatively,48±24% in the internal group (IR),66±20% in the neutral group (NR) (Mann-Whitney U, P<0.05). At 6 months,64±23% in the (IR),84±23% in the ( NR), at 12 months 78±21% in the (IR),86±9 % in the (NR) (N. S).2 patients in the IR Group complained of pain 12 months after the operation, but in the NR group, patients did not complain of pain.
[Conclusion] In the immobilization at neutral rotation position after a reinforced Caspair procedure, patients got a larger external rotation angle, ant complainer less of pain in the earlier period. How ever, over a long period, we could not obtain a significant difference between internal and neutral ro ttation.

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The recovering process of the operated shoulder function was observed in 21 shoulders of 21 patients who underwent surgery for a recurrent anterior dislocation or subluxation of the shoulder. Putti-Platt procedure was carried out in the affected shoulder and none of the 21 patients demonstrated a recurrence of the shoulder dislocation or subluxation after surgery. The muscle powers were measured at 6months, and one year postoperatively using a torque machine (BIODEX) after confirming the patients at level 5 in the manual muscle testing without having any apprehension of a dislocation. The power was measured on the affected and unaffected shoulders in both of the directions of flexion/extension, and external rotation/internal rotation at 90 degrees abduction at 2 speeds of 60 degrees/second and 180 degrees/second. The measured values were compared between the affected and unaffected shoulders for statistically significant differences. The cross-sectional area of the subscapularis muscle was measured on MRI transverse images and the values obtained preoperatively,6 months postoperatively, and one year postoperatively were compared to each other.
The peak torque/body weight (%) 6 months postoperatively was significantly smaller in the affected shoulder than that in the unaffected shoulder when the patient actively internally rotated his shoulder at 90 degrees abduction at a speed of 60 degrees/second (p<0.0l). But the power appeared to recover one year postoperatively since there was no significant difference one year after the operation. No significant differences were detected among the cross-sectional area of the subscapularis muscle before the operation,6 months postoperatively, and one year postoperatively. Postoperative assessment of the muscular power by a torque machine (BIODEX) appears to be more sensitive a method than the measurement of the cross-sectional muscle area on MRI in observing the postoperative recovering process of the shoulder function in the patients with a dislocation or subluxation.

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[Purpose]To clarify the trait of anterior capsular mechanism (ACM) of the shoulder with evaluations of the morphological relevances between the glenohumeral ligaments and the subscapularis.
[Materials and methods]Thirty-five shoulders underwent arthroscopic surgery with normal ACM (32males,3 females, average age 23 years old). We evaluated with an arthroscopy, the type of MGHL (type 1: band like, type 2: sling like, type 3: membrane or non), the origin of the AIGHL and the existance of an inferior foramen. To evaluate the form of the subscapularis, we established the ratio (S- value) between the length from the anterior point of the glenoid surface to a contact point of the subscapularis and the diameter of the glenoid surface with MR arthrography. We compared the S-value with types of MGHL, the origin of AIGHL, the existance of an inferior foramen statistically.
[Results]There were statistical significances between type 1 and type 2 (p<0.01), type 1 and type 3(p=0.01) on MGHL, between 2 o'clock and below 3 o'clock (p<0.01) on the AIGHL.
[Conclusion]When there was a band like MGHL and a wide AIGHL, the subscapularis attached on the scapula close to the glenoid surface.

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[Purpose]A glenoid rim fracture of the scapula is a relatively uncommon injury. The treatment and operative indication of which remain unclear. We have treated operatively 5 patients with a glenoid fracture of the scapula. The purpose of this study is to evaluate the results of the surgical treatment for these patients.
[Materials and methods]There were 5 Patients,4 males and 1 female. Their ages ranged from 24 to 88 years old (average: 46years old). The causes of 4 cases were traffic accidents, and 1 case fell.. All the cases had an anterior dislocation of the shoulder. According to Ideberg's classification system,4 cases were type I and 1 case was type II. The bone fragments were assessed by a computed tomography. The operative technique is reducing bone fragments anatomically, repairing the avulsed lubnum and transfering the coracoid process to the antero-inferior glenoid edge. Post-operatively, Desault's immobilization was performed for 3 weeks and then rehabilitation was started.
[Results]The duration of follow-up ranged 3 to 19 months(average: 7 months). In all the cases, the anterior apprehension test was negative and a recurrent dislocation did not occur during the follow-up period.4 patients achieved normal function and 1 patient had minimal limitation of shoulder function.
[Conclusion]Five cases with a fresh glenoid rim fracture of the scapula with an anterior dislocation of the shoulder were treated operatively. The results were almost satisfactory. Open reduction and internal fixation should be applicated for glenoid rim fractures of the scapula with an anterior dislocation of the shoulder.

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[Purpose]We treated 5 patients who had axillary nerve paralysis by nerve graft and present the results here.
[Materials and methods]Five patients who had axillary nerve paralysis underwent surgery from 1993to 1997. All the patients were men, and their mean age was 24.4 years old. The cause of axillary nerve paralysis was a motorcycle accident in 3 patients, a traffic accident in 1 and an industrial accident in 1. The associated injuries were brachial plexus paralysis, multiple-rib fracture, hemato-pneumothorax, clavicle fracture, etc.. The mean period from injury to operation was 8.4 weeks. We performed a neurolysis of the brachial plexus. Subsequently, we freshened both ends of the ruptured axillary nerve and performed a cable graft with the sural nerve between the defect. The mean length of the grafted nerve was 5.3 cm and the number of grafted nerves was 3 for 4 patients and 2 for 1 patient. We evaluated the recovery of the paralysis with the British Medical Research Council (BMRC) score and investigated the ROM of the shoulder joint. The mean follow-up period was 52.8 months.
[Results]All the patients obtained the outcome of S4 (complete recovery of the sensory) and M5(complete recovery of the motor) on the BMRC score. The ROM of the shoulder joint was 94.2 % for flexion and abduction,93.0 % for extension,100.0 % for adduction,97.6 % for external rotation, and 96.2 % for internal rotation.
[Conclusion]We treated axillary nerve paralysis by nerve graft and obtained a satisfactory outcome.

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The purpose of this study is to investigate the anatomical variations of the coracoid process in Japanese people using CT scan.
[Materials and methods]102 shoulders in 71 cases were examined with a CT scan.46 men and 25women were included. The diagnosis of these cases were a rotator cuff tear in 40 shoulders and others in 62 shoulders. (1)the coracoglenoid angle (CGA), (2)the coracoid overlap (CO) and (3)the coracohumeral distance (CHD) were measured from CT images using an Advantage Windows Version3.1.
[Results] The CGA averaged 147.0°, the CO averaged 11.2mm and the CHD in patients with a rotator cuff tear averaged 8.8mm and the CHD in patients without rotator cuff tear was 10.7mm. No significant difference was observed between the right and left shoulders. In the CHD, there was a significant narrowing in the group with a rotator cuff tear compared to the group without a rotator cuff tear.
[Discussion]Although the morphological variation of the coracoid process was found in each case, a variation between the right and left shoulder was not observed. Comparing CHDs between right and left shoulders is useful to diagnose a subcoracoid impingement,

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[Purpose]It is very important to evaluate the exact function and the role of the scapula in solving shoulder problems. The purpose of this study was to analyze the scapular abduction motion in patients with a painful throwing shoulder.
[Materials and Methods]Painful throwing shoulders and the non-throwing shoulders with a positive painful arc sign were studied. Each group had 10 cases. The cases that had a preoperative limited motion or inferior laxity of the joint were excluded. Ten shoulders of healthy dominant side controls were also studied. Scapular plane dynamic radiographs were taken at a sitting position. Patients raised the arms from 0 to maximum degrees actively in thirty-degree intervals. The scapular abduction angle (ABD), scapulo-thoracic angle (STA), and gleno-humeral angle (GHA) were measured and analyzed. The scapular abduction ratio (SAR=STA/ABD) was calculated and compared the throwing shoulders and the non-throwing shoulders, throwing shoulders and the healthy control, the non-throwing shoulders and the healthy control. The Mann-Whitney U-test for unimpaired groups was used for statistical analysis, and the P value of < 0.05 was considered significant.
[Results and Conclusion]The increase of the scapular abduction ratios from 30 degrees to 60 degrees and from 60 degrees to 90 degrees were significantly small in the painful throwing shoulder group compared with non-throwing shoulders (P=0.028,0.037) and with the healthy control (P=0.041,0.049). It suggests that some cases with painful throwing shoulder may have a scapular dyskinesis.
[Significance]Scapular plane dynamic radiographs can be one of the screening examination tools that can analyze a scapular abduction motion.

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The purpose of this study is to investigate the relationship between isometrical muscle strength of a shoulder abduction and grip strength.
The materials were 363 persons who were older than 65 years old and had no shoulder disorders. There were 157 males and 206 females with an average age of 73 years old. Muscle strength of shoulder abduction was measured by using a MicroFET, grip strength was done by using a digital dynamometer. The correlation between the muscle strength of the shoulder abduction and grip strength was analysed.
In the right arm of males, for example, the muscle strength of shoulder abduction and grip strength were, respectively,86.0N and 31.7kg in persons aged from 65 to 69 years old,75.4N and 29.1kg from 70to 74 years old,70.9N and 28.5kg from 75 to 79 years old, and 65.1N and 21.9kg over 80 years old. A significant correlation between the muscle strength of a shoulder abduction and grip strength was noted (p<0.0001). The correlation coefficients were 0.421 in the right arm and 0.513 in the left arm in m ales. They were, respectively,0.513 and 0.536 in females.
A significant correlation between muscle strength of a shoulder abduction and grip strength was noted. However, the correlation coefficients were not so high.

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[Purpose]To clarify the specific arthroscopic finding for diagnosis of symptomatic Bennett's ossification in patients with throwing shoulder.
[Materials and methods]Twenty-three baseball players with Bennett's ossification who underwent arthroscopic examination were studied retrospectively. While 13 of them were symptomatic,10asymptomatic patients were studied as the control.
[Results]Ossifications were detected by probing in 12 symptomatic shoulders and 3 asymptomatic shoulders. Fibrosis of the postero-inferior gleno-humeral ligament was seen in 6 symptomatic shoulders and 2 asymptomatic shoulders. The frequency of the fraying of the postero-inferior labrum was similar in both groups, but detachment of the postero-inferior labrum was more frequently seen in the asymptomatic group. As for other labral injuries, rotator cuff tear, greater tuberosity notching, and subacromial bursitis, there were no significant differences detected.
[Conclusions]As no specific arthroscopic findings were detected in patients with symptomatic Bennett's ossification, careful pre-operative diagnosis should be done.

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