The purpose of this study was to determine the strain on the superior labrum, both anterior and posterior with the arm in simulated positions of the pitching motion. Ten fresh frozen cadaveric shoulders were used. After removal of the superficial soft tissues, the anterior and posterior cuff muscles were elevated from the scapula and loads applied to stabilize the humeral head. The supraspinatus muscle was elevated from its humeral insertion to visualize the biceps-labral complex. Using linear transducers, the strain in the anterior and posterior superior labrum was measured with the arm in various planes and rotations simulating the pitching motion: early cocking, late cocking, acceleration, deceleration and follow-through. Predetermined loads according to % maximum voluntary contraction (%MVC) of the biceps muscle during each phase of pitching were calculated and applied to the long head of the biceps tendon using a spring device. The increase in the strain was statistically significant for the anterior and posterior portions of the labrum during the late cocking phase than with all the other phases. The increased strain in the posterior portion of the superior labrum may be due to the anatomical orientation of the long head of the biceps at the superior labrum.

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[Purpose] Post-operative MR images sometimes reveal a retear after a rotator cuff repair. On the hypothesis that the shape of the suturing of the cuff stump may influence a retear, we evaluated the signal changes of the cuff stump on MR images after a rotator cuff repair.
[Materials and methods]Forty-three shoulders had taken MR images at 1 year after the cuff repair. The patients were thirty-three males and ten females with an average age of fifty-five years (twentyeight to seventy-three). We classified the bony trough according to its shape into two types: Rectangular (R) type and Smooth (S) type. The R type has an angle between the edge of the humeral head and the bony trough. The S type does not have this angle and the line between the edge of the humeral head and the bony trough is smooth. The signal intensity of the cuff stump was classified into three groups: high intensity (H) group, intermediate (I) group and low intensity (L) group.
[Results]Thirty cases were S type. In the S type, twenty-three of the cases, the patients were in the L group or I group, and in five cases were in the H group. Two cases were retears. The JOA score was 93 points. Fourteen cases were R type. In the R type, six cases of repaired rotator cuff were recognized a high intensity, and four of the cases were retears. The JOA score was 87 points.
[Conclusion]There was less of an impingement between cuff sutures when we used a smooth bony. So we believe operators had better make a smooth bony trough.

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[Purpose] The purpose of this study is to confirm the pathogenesis and treatment of small and incomplete rotator cuff tears by evaluating the clinical and operative findings.
[Material and methods] Fifteen patients (9 small,6 incomplete,12 men,3 women) who underwent surgical treatment were evaluated in clinical findings (painful arc sign, impingement sign, MMT, JOA score etc. ), operative findings and compared the size tears (10 medium,12 large,10 massive). The average age of these patients was 50.5 years. They were followed-up for 12 to 36 months (average 18months) after surgery. Arthroscopy was performed in all cases preoperatively and repaired by the Mc Laughlin method. The surgical results were evaluated according to the JOA score.
Result: In the clinical findings, there were no obvious differences excluding the MMT and contracture. In the arthroscopies, we could not evaluate the condition of the tears more precisely than in direct observation. Intra-tendinous tears were seen in 10 cases and joint side tears were seen in all cases. In almost all of the cases, joint side stump had retracted severely. After open surgery, the JOA score averaged 93.6 points (before surgery: 51.7 points).
[Consideration] In this study cuff tears seemed to occur from articular side. In the clinical findings there were no obvious differences between the small and incomplete tears and other size tears. In the surgical treament the cuff repair is most important, so open surgery using Mc Laughlin method should be selected.
[Conclusion]Care must be taken about advanced intra-tendinous and joint side tears in its treatment. The disorder of a rotator cuff occurs even in small and incomplete tears.

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[Purpose]We have performed the McLaughlin procedure for rotator cuff tears, and the Debeyre procedure if suturing by the McLaughlin method was impossible. The present study was conducted to evaluate various factors that may influence the postoperative course of rotator cuff tears.
[Subjects and methods]The subjects were 37 surgically treated patients with rotator cuff tears(22males and 15 females) whose postoperative courses were followed for more than 1 year. The patients age ranged between 35 and 80 years(mean age: 61 years). Based on the size of the tears, shoulder were classified into the following 3 groups: Group I (shoulders with incomplete tears or tears measuring less than 1 cm in width); Group II (shoulders with a single rotator cuff tears measuring 1 to 3 cm in width); and Group III( shoulders with more than two rotator cuff tears measuring more than 3 cm in width). Rotator cuff tears in 4 shoulders were surgically treated by end-to-end and side -to-side sutures or by an arthroscopic debridement. The McLaughlin procedure was used to treat rotator cuff tears in 29 shoulders, while the Debeyre procedure was used in 4 shoulders. Shoulder joint functions were evaluated before and after surgery using the JOA scores.
[Results]The postoperative JOA scores were signifcantly higher than those before surgery in all groups. Moreover, shoulder joint functions improved more in Group I than in Groups II and III postoperatively. However, there were no significant differences in other factors that might have influenc ed the postoperative course of rotator cuff tears.
[Conclusion]The postoperative course of rotator cuff tears correlated with the size of the tears. However, other factors did not influence the postoperative course of rotator cuff tears.

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A full-thickness rotator cuff tear is uncommon in3decades of life. The purpose of this study is to investigate the clinical results of surgical treatment of rotator cuff tears in patients younger than age 40.
We performed a retrospective analysis of the case of 8 consecutive patients under the age of 40 treated surgically. The mean age of the patients was 31.0 years, there were 5 males and 3 females. Afullthickness tear was found in 5 and a partial-thickness tear in 3. The average follow-upwas 19.9months. They were evaluated according to the JOA shoulder scores.
The JOA shoulder score had improved from 70.1 points to 93.0 points postoperatively. Seven of the 8patients showed satisfactory pain relief. All the cases were able to function with their arms above shoulder level with minimal or no compromise. Six of the 7 patients have returned to their preinjury performances.
The surgical results of rotator cuff tears in patients younger than 40 years of age, a good outcome was obtained. Especially in activity of daily living and sports activities.

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The purpose of this study is to investigate the pathogenesis and treatment of shoulder pain in hemiplegia.60 shoulders in 60 patients were available and separated into three types on the bases of pain (no or slight, mild, severe). The duration of the hemiplegia, tenderness points, range of motion, manual muscle testing, sensory deficit, edema and the X-ray findings were statistically analyzed. The subacromial bursae of 31 shoulders in 60 patients were injected (A group: 9 shoulders, xylocaine and dexamethazone / B group: 22 shoulders, sodium hyaluronate). Then 4 shoulders were operated on using the one portal arthroscopy. The tenderness points of the C-A arch and around the C-A arch increased with the pain. The improvement rates of pain were 61.7% in A group and 59.1% in B group. A decrease in pain was noted in all of the patients who had been operated on with the one portal arthroscopy. Pain of the shoulder in hemiplegia may be attributable to the C-A arch. Attention to the C-A arch may be of importance.

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[Purpose] We evaluated the grafted patches and clarified the clinical results of postoperative massive rotator cuff tears. The risk factors of the disappearance of the grafted patches were also determined.
[Materials and methods] Fifteen shoulders had fascia lata patch graft for massive rotator cuff tears. We retrospectively investigated the JOA scores, ROM (flexion, abduction and external rotation) and muscle strength. MRI was done to evaluate the condition of the grafted patches. The risk factors were investigated preoperatively as well as AHI (acromiohumeral index), width of the supraspinatus muscle belly and also the size of the defects.
[Results] The group where the patch remained (group R) consisted of 10 shoulders, while the group where it had disappeared (group D) consisted of 5 shoulders. There were no significant differences in age and postoperative terms. The JOA scores, ROM and muscle strength at 90& abduction improved significantly only in group R (P<0.05).
[Conclusion] We considered that this method for a massive rotator cuff tear is effective to reconstruct the shoulder function, while the grafted patch remains.

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[Purpose]A pure vertical tear or the longitudinal rents of a rotator cuff have a tear not in the tendon but in the rotator interval. These special types of tear were evaluated on surgical results, operative findings and clinical features.
[Materials and methods]Between 1970 and 1999, fifteen hundred and twenty three shoulders with a rotator cuff tear were operated on in our hospital. Of these,110 shoulders in 109 patients were diagnosed as a pure vertical tear or the longitudinal rents of the rotator cuff by our intraoperative findings. There were 80 men and 29 women, and their mean age was 51.5 years old (range,14 to 80).
[Results]The causes of injury were a fall (39%), lifting (9%), a bruise (7%), overuse (14%) and unknown (16%). The injuries were located in the rotator interval (30%), in the RI and the subscapularis tendon (51%), in the RI, subscapularis tendon and supraspinatus tendon (12%). A rupture of the LHB was observed in 7% of all cases. On surgical procedures, side to side suturing was done in 70% of the cases, the McLaughlin method in 10% and a combination of the side to side suturing and the McLaughlin method in 10%. The postoperative muscle strength was evaluated as a normal 85% and as a slightly weak 15%.83% of the patients had no pain and 16% of the patients had a mild pain because of overuse.89% of the patients could live without any shoulder problem and 11% of the patients had some disability in the ADL.
[Conclusion]The intraoperative findings showed an extention from the rotator interval to the supraspinatous or the subscapularis. Therefore, the longitudinal rents seem to be an important cause of a various type of tear in the rotator cuff.

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We present a case of recurrent anterior shoulder dislocation which requiring reconstruction of the ruptured, retracted capsule.
A 23-year-old man had injured his right shoulder at 13 years of age while playing volleyball, resulting in the shoulder being abducted and externally rotated. Dislocation occurred 10 times after the first dislocation, eventually even during sleep.
Muscle atrophy was not apparent. The apprehension sign was positive both anteriorly and posteriorly. Range of motion was slightly restricted in elevation. Plain radiograms showed Hill-Sachs lesion, but no apparent bony Bankart lesion. Pneumo-arthro CT revealed extraarticular anteromedial bulging of the capsule below lesser tuberosity. On exploration, we found that the subscapularis muscle had been replaced by fibrous membrane that covered the humeral head directly. The MGHL was intact. The anterior capsule was torn obliquely, and the course of the tear, starting from 3 o'clock along with the IGHL, reached the anatomical neck. The ruptured capsule was displaced toward the scapular neck and retracted. To add to the Bankart repair, we reconstructed the ruptured thin capsule with Teflon felt and the Latarjet method.
Conclusion
Many cases of recurrent shoulder dislocation owing to capsule rupture have been reported. Most are successfully repaired by primary suturing. Due to capsule retraction in our case, the capsule required supplementation. We consider such remarkable capsule retraction to have resulted from the absence of traction force concomitant with joint motion from the attached subscapularis muscle. Pneumoarthro CT was useful in preoperatively diagnosing irreparable capsule rupture.

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(Case 1) A 29-year-oldfemale complained of right shoulder pain and a decrease of the range of motion (ROM) of her right shoulder in September 1996. She was diagnosed as adhesive capsulitis and treated conservatively by a local doctor, but her shoulder pain was increased. She visited our clinic in June 1997. CTs and MRIs showed a soft tissue tumor in the subscaplaris. According to the microscopic finding, the tumor was diagnosed as an extra-abdominal desmoid.
(Case 2) A 47-year-old-female complained of right shoulder pain and a limit of the ROM of her shoulder in March 1992. Although she was treated conservatively by a local doctor as adhesive capsulitis, the symptom was not resolved. She visited our clinic on May 1997. CTs and MRIs depicted a soft tissue tumor in the deltoid and teres minor. The pathological specimen indicated that her diagnosis was desmoid.
(Case 3) A 57-year-old-female complained of right shoulder pain and limit of the ROM of her shoulder in March 1996. She was diagnosed as adhesive capsulitis and treated conservatively by physical therapy at a local doctor, but her symptoms did not improve. So, she visited our clinic on February 2000. CTs and MRIs showed soft tissue tumor surrounded by the subscaplaris, teres minor, pectoralis major, lst-2nd rib and brachial plexus. Histopathological diagnosis was a desmoid.
(Conclusion) An extra-abdominal desmoid around the shoulder joint often creates shoulder pain and a decrease of the ROM of the shoulder. The symptom is similar to that of adhesive capsulitis. We must remember that desmoid tumor is one of differential diagnoses of adhesive capsulitis.

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[Purpose] The purpose of this study is to clarify the problems of the open Bankart procedure using a suture anchor with MR arthrography (MRA) and arthroscopy.
[Subjects and methods] We studied 18 cases (16 male cases and 2 female cases) after surgery with a recurrent anterior dislocation or subluxation. The patients ranged in age from 17 to 58 years old (average,27.8 years old). MRA was performed after the operation at an average 12.9 months and arthroscopy was performed at an average 13.2 months. In the MRA with the oblique axial image in abduction and external rotation (ABER) position, we evaluated the loosening and the reattached position of the anterior inferior glenohumeral ligament (AIGHL). In the arthroscopy,1) the deviation of the anchor,2) the loosening of the suture,3) the existense of a limited contact of the capsule to the glenoid edge,4) the condition of AIGHL, were observed and evaluated.
[Results]The MRA (ABER position) demonstrated normal AIGH-labral ligamentous attachments in 15 cases(83%). Loosening of AIGHL was recognized in 4 cases (22%) in MRA. In the arthroscopy, there was no deviation of the anchor and limited contact of the capsule to the glenoid edge. A loosening of the suture was recognized in 5% of the sutured division. Normal tension of AIGHL were seen in 16 cases (89%) but the space in anterior recess existed in 2 cases (11%).
[Conclusion] The results of the open Bankart procedure with suture anchor were satisfactory in MRA and arthroscopy. The reattachment of AIGHL-labral complex was satisfactory and there was no case of a limited contact of the capsule to the glenoid edge.

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[Purpose] We investigated the utility of MR imaging of the shoulders in abduction and external rotation position (ABER method) for evaluating the anterior inferior glenohumeral ligament (AIGHL).
[Materials and methods] Nineteen shoulders of 19 patients (age ranged from 17 to 49 years old, average 28 years old) with traumatic anterior glenohumeral instability were examined. Seven shoulders were first dislocations and 12 shoulders were recurrent anterior dislocations. T2*-weighted images with 3D-FT technique (2mm continuous slices) were obtained in the ABER position with superconducting MR imager (1.5 tesla). According to the MR images obtained in the ABER position, the shoulders were classified into two groups: Group A with a well delineated anterior capsule, and Group B without one. Arthroscopically, the shoulders with a thick and wide AIGHL were regarded as AIGHL(+)and those with a thin or no AIGHL as AIGHL(-). We compared the classification on the MR images with arthroscopic conditions of the AIGHL.
[Results] Eight out of 9 Group A shoulders were AIGHL(+), and nine out of 10 shoulders of Group B were AIGHL(-). The sensitivity and specificity of MRI evaluation were 89% (eight of nine shoulders)and 90% (nine of 10 shoulders) for prediction of the AIGHL condition. There were significant differences between Groups A and B.
[Conclusion] MR imaging with the ABER method was useful for evaluating the condition of the AIGHL.

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[Purpose] The purpose of this study was to evaluate the arthroscopic thermal capsular shrinkage for habitual posterior instability of the shoulder.
[Materials and methods] 4 patients (4 shoulders) were treated with arthroscopic thermal capsular shrinkage and reviewed. There were 3 males and 1 female. The mean age at operation was 22.8 years old ( 15-32 ), the mean follow-up period was 13.3 months (2-20). We evaluated the post operative results according to the JSS Shoulder Instability Score and Bigliani's rating system.
[Results] There were no recurrences in any of the cases. The average scores were 52 preoperatively and 97 postoperatively in the JSS Shoulder In. st3a bcialisteys wSerceore excellent and 1 case was good in Bigliani's rating system.
[Conclusion] Thermal capsular shrinkage is useful for habitual posterior instability of the shoulder in the short term results. The causes of habitual posterior instability are 1) a non-traumatic capsular redundancy and 2) a traumatic soft tissue lesion and 3) a rare case of osseous abnormality.

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The treatment of posterior shoulder instability remains a clinical problem because it is uncommon and its criteria is not clear. In this paper, we reported the results of a posterior glenoid osteotomy (Scott) for posterior instability of the shoulder. From 1978 to 1997, we operated on 17 patients with posterior shoulder instability in our hospital. There were 11 males and 6 females with a mean age of 16.7years old (range; 10 to 29 years old). The average follow-up period was 7 years 5 months (range; 10months to 18 years 8 months).
A posterior subluxation of the shoulder could be felt when an examiner pushed humeral head posteriorly in all the patients. The posterior subluxations were demonstrated in axillary stress roentgenograms. Seven cases showed a habitual subluxation and three cases could subluxate their shoulder at will. Six cases could demonstrate habitual and voluntary subluxation.
In the first 4 cases, we performed Scott's original method and tightening of the posterior capsule. The remaining 13 patients were operated on by a modified Scott's procedure ( a skin incision was changed and a bone graft was harvested from the iliac bone) and tightening of posterior capsule. All the patients were evaluated by the shoulder evaluation score of the Japanese Orthopaedic Association.
The pre-operative average point of the JOA score was 74.7 points, which improved to 95.3 points at the final follow-up. Recurrence was observed in 3 cases, which had voluntary posterior subluxation and inferior instability. All these patients were female. One of them also had a general joint laxity. All except these three patients showed no difficulties in ADL and sports activities. From this study it can be suggested that satisfactory results can be obtained in the patients with posterior shoulder instability by posterior glenoid osteotomy.

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The purpose of this study is to introduce a simple method of evaluating the shape and quantity of osseous defect of the glenoid rim using three-dimensional computed tomography (3DCT). Glenoid morphology of 84 consecutive shoulders in traumatic anterior glenohumeral instability, including 6 acute glenoid rim fractures, was evaluated through the use of 3DCT, comparing with 13 normal shoulders. Humeral head was deleted during the process of creating reconstructed 3D images. A ratio of osseous defect (fragment) against the outer fitting circle of the lower part of the glenoid contour (from 3o'clock to 9 o'clock) was obtained by images viewed from the perpendicular direction to the glenoid surface.
Forty-one out of 78 chronic cases (52.6%) had an osseous defect. Average ratio of the osseous defect was 7.9 (range,1.3-26.9) % in chronic cases and 24.3 (range,11.5-34.5) % in acute cases. Morphologic abnormality was seen even in 30 out of 37 no defect glenoids(38.5%). The unique imaging technique of this study enables precise morphologic and quantitative evaluation of glenoid and would be a great asset in the preoperative decision making of the surgeons.

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[Purpose] We report the results of the release operation for internal rotation contracture of the shoulder in obstetric birth palsy in children.
[Surgical procedure]Under general anesthesia, an anterior approach to the shoulder was used. The elongated coracoid process was resected and the contractured subscapularis muscle was elongated with a Z-plasty technique. The shoulder was immobilized for 6 weeks with the arm in full external rotation. This method was applied in two cases.
Case 1: A 3-year-old boy. The left upper type. The boy could hardly flex his fingers, wrist, or elbow. The ROMs of the shoulder were 90in flexion and in abduction. However, internal rotation contracture was present and passive external rotation was -30°. X-rays revealed that the glenoid cavity was shallow, the humeral head was deformed and the coracoid process was slightly elongated downward.
Case 2: A 10-year-old girl. The left upper type. Her hand and wrist were quite normal, but extension of her elbow was restricted to -20. The ROMs of the shoulder were 130in flexion and 140in aduction, however, there was a internal rotation contracture present and passive external rotation was -5°. X -ray revealed that the glenoid cavity was shallow, the humeral head was deformed and the coracoid process was extremely elongated- downward.
[Result]In Case 1,1 year post-operatively, active external rotation of the shoulder is possible to 15° and passive external rotation is possible to 45°. Hand function itself has improved to some extent. In case 2,6 months post-operatively, active external rotation of the shoulder is possible to 15° and passive external rotation is possible to 30°.
[Conclusion]The ROMs of the shoulder, hand reach and hand function have improved and eventually the ADL improved in both cases.

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[Purpose]The aim of this study is to report on the morphologic change of the upper limb by measuring the length of the humerus, forearm and between the proximal end of the humerus and the deltoid tuberosity.
[Materials and methods]Bilateral anteroposterior radiograph of the humerus, radius and ulna were performed on 80 upper limbs of forty baseball players, with an average age of 23.3 years old. The radiographic examination was performed with the elbow in extension and the forearm in supination. In each radioglaph, we measured the longest length of the humerus, radius and the distance between the proximal end of the humerus and the top of the deltoid tuberosity.
[Results]The average length of the humerus was 33.52cm on the throwing side and 33.57cm on the non-throwing side. The average length of the forearm was 26.88cm on the throwing side and 26.78cm on the non-throwing side. There was no statistically significant difference between the throwing and nonthrowing side. The ratio between the proximal end of humerus and the deltoid tuberosity to the length of the humerus was 45.59% on the throwing side and 46.27% on the non-throwing side. There was a statistically significant difference between the throwing and non-throwing sides.
[Conclusion]These results suggested the morphologic change of the humerus resulted from excessive stress to the attachment of the muscle tendon.

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[Purpose]Ultrasonographic evaluation has been popular recently. But the Power Doppler technique is not so common in the orthopaedic field. We assessed the value of the Power Doppler in the evaluation of the rotator cuff.
[Materials and methods]108 shoulders of 54 patients were investigated with an Aloka SSD5000 and Toshiba Powervision 6000 which had the function of a Power Doppler. We checked the location of the small vessels around the rotator cuff.62 shoulders were normal. Rotator cuff tears were detected in 13shoulders.6 shoulders were postoperative shoulders of a rotator cuff tear. In addition, we investigated the small vessels of 6 shoulder joints in 3 cadavers macroscopicaly.
[Results]In the normal cases, small vessels were detected at the bicipital groove (102/108 joints), the greater tuberosity (68/108 joints) and the anterior edge of the acromion (85/108 joints). There was no vessel in the rotator cuff. In the postoperative cases, there were a lot of vessels around rotator cuff and in itself. We could detect more vessels in the patients who complained of pain at night. In the cadaver study, we found the small vessels at those 3 parts of the shoulder joint macroscopicaly.
[Conclusion]The Power Doppler is a reliable and useful technique to evaluate the vasculality of the rotator cuff.

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This study examines the glenoid cavity using three-dimensional MRI. Forty volunteers were enrolled in the study. Three-dimensional scapular images were reconstructed using an open MRI and computer software. The tilting angles of the glenoid bone were measured in five consecutive axial planes perpendicular to the glenoidal long axis. Cross sections were divided into three types (concave, flat, and convex)according to the shape on each plane.
The average tilting angles for the five planes from the bottom to the top were 3.3±4.1,1.4±3.8, -0.6±1.9, -1.4±3.3, -6.2±3.3 degrees anteriorly, indicating that the three-dimensional bony structure of the glenoid was twisted anteriorly to posteriorly. Images on the bottom plane consisted of 82.5% concave type,15% flat type, and 2.5% convex type, while only 3 cases (7.5%) showed a concave shape in the top plane. The shape of the glenoid cavity is thought to be conducive for glenohumeral motion and stability.

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[Purpose]The purpose of this study is to investigate the effect changes of the breast's position in the function of the shoulder complex.
[Materials and methods]Twenty-six healthy women were examined in this study. The age of subjects ranged from 22∼64 years old. We compared the naked breast with which underwear was worn on the breast and the function of the shoulder complex. (1)The difference of the breast's position. (2)The changes of the muscle hardness of the upper fiber of the M. trapezius using a muscle meter. (3)The changes of tilting angles of the scapula in the horizontal plane using the slant rules. (4)The difference of the angle in horizontal abduction of the shoulder joint.
[Results](1)The naked breast's position were lower than the ideal position. (2)There was a significant change. The hardness of the M. trapezius was lower with underwear compared to nakedness. (3)The tilting angles of the scapula decreased under the condition depending on which underwear was worn. (4)The angle in horizontal abduction of the shoulder joint extended to take the underwear.
[Conclusion]The function of the shoulder complex was influenced by the position of the breast.

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The purpose of this study is to elucidate the prognosis of untreated humeral neck fractures. Subjects were 12 patients (4 men and 8 women) of the humeral neck fracture, and their mean age was 83.7years old. None of them had been treated appropriately due to various reasons. Seven patients were missed the humeral neck fracture, and 5 patients rejected the recommended therapy. Mean period after injury was 27 months.
They were evaluated with following items; radiographic findings (at right after injury and 6 months after injury), range of motion of the shoulder and subjective satisfactions (mealing, dressing, and excretion)at final examination.
Radiographic findings were evaluated by Neer's classification; 2 part fracture (6 patients),3 part fracture (2 patients),4 part fracture (4 patients). Bone union were observed in 10 out of 12 patients at 6 month after injury. Mean range of flexion was 50 degrees, mean range of abduction was 30 degrees, and mean range of external rotation was 10 degrees.2 patients were subjectively unsatisfactory. A Strict treatment including reduction, fixation, and surgical treatment was not necessary for all senile patients, who were in poor risk.

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[Purpose] Fractures of the proximal humerus in Neer group III (two part) are commonly treated well by the conservative treatments. However, in some cases of severe displacement of these fractures, we have performed the surgical treatment. This study is a review of evaluating the therapeutic results of the anatomical plate fixation for the fractures.
[Materials and methods]We treated nine patients (five males and four females) with a mean age of forty-four (twenty-two to sixty-seven). One of them was a nonunion case. None of the case could be reduced and maintained stabilized fractures by closed reduction as the initial treatment. Our surgical procedure was performed by using an anatomical plate on these patients. Surgical treatment was done eight to 240 days after the injury. We evaluated the results by the Japan Orthopaedic Association (JOA)score.
[Results] Bone union was accomplished at a mean time of 19.4 weeks (thirteen to twenty-five weeks)in all cases without a nonunion, a necrosis of the humeral head or infection. The range of motion of the affected side was a mean degree of 164° (105 to 180°) in flexion and 158°(ninety-five to 180°) in abduction. The JOA score was a mean of 90.5 points (seventy-nine to ninety-six points). There was only one complication that one of the patients had a new fracture of the humeral shaft at the distal side of the anatomical plate one month after operation.
[Conclusion] We recommended to perform the surgical treatment using an anatomical plate on the patients with fractures of the proximal humerus, whose fracture were classified as two part fracture using the Neer's criteria.

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[Purpose] Open reduction for proximal humeral comminuted fractures and fracture dislocations are often difficult to perform. We have been performing cementless artificial humeral head replacements in such cases, and wish to report our investigations, including the literature studies.
[Patients] From 1993 to 2000, cementless artificial humeral head replacement on 11 patients were performed. The patients ranged in age from 58 to 80 years old with an average age of 76. The patients were l male and 10 females. In 3 cases, the artificial joints used were short stem type and in 8 cases, they were medium stem type, both types using alumina-ceramics head Physio-shoulder system by Kyocera, Japan.
[Results] Active exercises were started average 4days after the operation when pain at rest was relieved. External rotation was permitted in the 3rd week. Fase washing and shampooing were possible in all cases, and pain in the shoulder joint was almost unnoticeable.
[Conclusion]As Neer reported, the artificial humeral head replacement for the shoulder joint has been practised in Japan. In total 11 cases were treated. Although the number is small, we consider that when an elderly patient expects early functional recovery, dislocation fracture and comminuted proximal humeral fracture of 3 parts or more should be treated with an artificial humeral head replacement, in order to improve ADL as soon as possible.

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: Purpose:: The purpose of this study is to evaluate the factors of poor results.: Materials:: We performed prosthetic arthroplasty in 25 cases from 1982.20 cases were humeral head fractures,3 rheumatoid arthritis,1 osteoarthritis, and1 osteonecrosis. They almost all had good results. But three cases had poor results. Their mean was under 70 points of the JOA score and they were dissatisfied aftersurgery. [Case1] 4-part fracture; an 83-year-old man fell down in a hole. He hada prosthetic arthroplasty a week later.5 days later, passive exercise was started, and active exercises ware 2 weeks later. Eight months later his shoulder hadsubluxated upward with pain. [Case2] Osteoarthritis; a 66-year-old woman hadhad a cuff repairment at a previous hospital. She had a reccurent dislocationof the shoulder. She had a prosthetic arthroplasty. A Bristow procedure was addedfor the anterior instability.20months later the head of the prosthesis was in subluxation with a glenoid migration. The prosthesis was pulled out because of the severe pain. [Case3] Rheumatoid arthritis; a 67-year-old woman had a prosthetic arthroplasty with the cuff repairment. There was no pain relief after thesurgery. The shoulder was subluxated when she elevated her arm. We can touch the head at the subdermal layer.: Conclusion:: The most important factor for poor results was a disfunction of the cuff.

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[Propose] We studied the problems of fixation of fractures of the distal ends of the clavicles by using the "Wolter clavicular plate" and "Best acromioclavicular plate".
[Meterials] Fifteen fractures of Neer type 2 distal clavicle fractures were treated by plates. Ten patients were treated by "Wolter clavicular plate" and 5 patients were treated by "Best acromioclavicular plate".
[Results]The active elevation in the affected shoulder joint acquired over 100° after removal of the plate. All the patients had neither pain nor muscle contracture after removing the plate. A good union was obtained in all of the cases, but a wire had to be used to fix the plate instead of a screw because the Wolter clavicular plate did not fit the clavicle of one patient. The hook holes of both plates expanded in patients when they raised their upper arms over 135°. Those patients who used a "Wolter clavicular plate" had superior scores to those who used a "Best acromioclavicular plate" on the JOA score.
[Conclusions] The Wolter clavicular plate and the Best acromioclavicular plate could maintain the anatomical repositioning of an unstable distal clavicle fracture and the former was superior to the latter on the JOA score after removing the plates. But the affected shoulder joint could not be elavated more than 90° before removal of the plate. The plate should be removed as soon as the union is completed.

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The purpose of this study is to report the results of surgical treatment for a fractured coracoid process in acromio-claviclar joint separation. We experienced 8 shoulders with a fractured coracoid process in A-C joint separation. They all consisted of men. Their ages ranged from 11 to 45 years old. The affected sides were 5 right shoulders and 3 left. According to Ogawa's classification, coracoid fractures were type III in 5 shoulders and type IV in 3. According to Tossy's classification, A-C joint injuries were grade I in 1 shoulders and grade II in 1 and grade III in 6. There were 7 fresh injuries and a old one. In the fresh cases, the coracoid process was fixed by a screw after the A-C joint had been repositioned by a k-wire. The old case was treated by Dewar's method. The ORIF of the coracoid process was not perfect in some cases, but a union was achieved in all cases. There were 2 subluxations of the A-C joint. The ROM had improved and painless during ADL. To treat a fractured coracoid process on A-C joints separration, good results were obtained using a fixation of the coracoid fragments after a temporaty fixation of the A-C joints. If a fractured coracoid process is suspected in a AC separation, cephalic tilt view should be taken.

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[Purpose] A floating shoulder is an unstable fracture involving the scapular neck and ipsilateral midclavicular fractures. It is almost necessary to treat this fracture surgically. In this study, we report the clinical outcome in cases with a floating shoulder which were treated surgically for a clavicular fracture alone.
[Materials and methods] From 1994 to 1999, we observed five male cases with a floating shoulder, whose average age was 38.6 years old (range,22 to 54 years old). Four patients had their right sides affected; four of the injuries had been caused by traffic accidents, and one by falling. The average duration from injury to surgery was 10days(range,3 to 20 days). Fixation of the clavicular fracture was achieved with a bone plate in one case and with Kirschner wires in four cases. Postoperatively, after three weeks immobilization by Desault's bandage, physical therapy was started. The average follow-up period was 43 months (range,8 to 66 months).
[Results]All the cases obtained union of the both fractures, The average time for both fracturehealing was 17 weeks (10 to 24 weeks), as assessed by the disappearance of the fracture lines on the radiographs. According to the JOA scoring system, the average score was 98 points (95 to 100 points).
[Conclusion] Herscovici et al reported that in floating shoulder, muscle forces and the weight of the arm pull the fracture fragment, and that internal fixation of the clavicular fracture was recommended to prevent late deformity. In our cases, we obtained excellent outcomes by fixing the clavicular fracture alone. The severity of the displacement of scapular neck fracture and the presence or absence of a coracoclavicular ligament rupture should be evaluated before the operation.

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[Purpose] Over a period of 8 years, acromioclavicular(A-C)-hook plate was used in 8 patients of A-C dislocations (or distal clavicle fractures) which had accompanying scapular fractures. We have evaluated of functional outcome of their shoulders.
[Material and methods] Six male and 2 female with a mean age of 42.1 years old (range,11-61 years old). Six had acromioclavicular dislocations and 2 cases had distal clavicle fractures. Five had associated coracoid process fractures,2 cases; acromion fractures,1 case; scapular neck fracture,1 case; intraarticular glenoid fossa fracture, and 1 case; a scapular body fracture. There were two very rare cases, which combined injury of acromion fracture with coracoid process fracture and A-C dislocation. Their were followed up after surgery an average of 7.7 months. They were evaluated according to the JOA shoulder score and Kawabe's A-C joint score.
[Results] The mean JOA score was 97.6 points (range,95-100 points) and their mean Kawabe's A-C joint score was 95.6 points (range,90-100 points). The reduction of A-C joint were anatomical or excessive in all the patients.
[Conclusion]A number of reports have shown the significant benefits of surgical treatment for the AC dislocation associated with the fracture of the coracoid process. In the cases of unstable coracoid process fracture, both the A-C dislocation and the coracoid process fracture should be stabilized surgically. We conclude that the utilization of A-C hook plate is a preferred method for the management of A-C dislocations associated with scapular fracture.

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We performed a comparative study on shoulder injuries between snowboards and skis.
1665 patients injured by snowboarding or skiing visited our hospital from 1997 to 1999 (males: 1173, females: 492, averagc age: 25.3). There were 883 patients injured by snowboarding (males: 667, females: 216, average age: 23.6) and 782 patients injured by skiing (males: 506, females: 276, average age: 27.3).
There were 523 patients (59.2%) with upper extremity injuries caused by snowboarding. Among them there were 191 patients (21.6%) with shoulder injuries. There were 62 fractures (clavicle: 40, proximal end of the humerus: 22),78 dislocations (acromioclavicular joint: 32, shoulder joint: 46) and 1 dislocation fracture (shoulder joint). There were 235 patients (30.1%) with upper extremities injured by skiing. Among them there were 133 patients (17.0%) with shoulder injuries. There were 53 fractures (clavicle: 36, proximal end of the humerus: 14, scapula: 3),41 dislocations (acromioclavicular joint: 10, shoulder joint: 31) and 6 dislocation fractures (shoulder joints).
Snowboarders fall on their hands frequently. Therefore upper extremity injuries and shoulder injuries caused by snowboarding are considered to be more than by skiing.

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[Purpose] The purpose of this paper is to report on the clinical findings and natural course of spontaneous sternoclavicular joint subluxation. All the patients had a positional anterior subluxation with elevation or horizontal extension and reduction with a descent or horizontal flexion.
[Materials and methods] Eight patients ( 9 joints) were studied. There were 6 males and 2 females,5 right,2 left and 1 bilateral joints. The average age was 19.6 years old (14-44 ). In one patient the reconstruction surgery using a plantaris tendon was performed. Seven patients were treated nonoperatively. Four patients (5 shoulders) with non-operative treatment were followed by telephone calls. The average follow-up period was 8.6 years ( 2 - 19 years ).
[Results] The average age of the onset was 18.4 years old ( 13-44 ). The spontaneous subluxations were caused by minor trauma in 4 joints and by overuse in 3 joints. Another 2 joints had no causes. The chief complaints were snapping with subluxation or reduction in all of the patients. Four patients had dullness or mild pain. General joint laxity was evaluated by Carter's 5 signs in 6 patients. Three patients had one or two signs and another three patients had no signs. In x-rays there were no bone or joint deformities. The operative case had recurrence of subluxation and snapping three months after the operation, and the results were poor. On the other hand, in 3 patients ( 3 joints ) with non-operative treatment the subluxation and snapping diminished over several years. In one patient ( 1 joint ), snapping persisted but the amount of discomfort decreased over time.
[Conclusion] A spontaneous sternoclavicular joint dislocation is apt to occur in teenagers. Minor trauma and overuse induce this disorder. Some patients had dullness or mild pain with snapping. Few patients had an operative indication. We recommend conservative treatment for a spontaneous sternoclavicular joint dislocation

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[Purpose] The purpose of this study was to clarify the stabilizing effect of Caspari's technique for anterior shoulder instability with MDI.
[Materials and methods] We retrospectively studied 18 patients (7 males and 11 females) with anterior shoulder instability with inferior and multidirectional laxity who underwent a Caspari technique. The mean age was 23 years old, and the mean follow-up period was 3 years and 8 months. There were three additional procedures; an inferior capsular shift (method-C), reinforced with a subscapularis tendon (method-S), and rotator interval closure (method-R).
[Results] In the Rowe scoring system, there were 17 excellent and good for and one poor. Both inferior and posterior laxity had improved in all the cases. Anterior laxity had improved in 14 (78%) at abduction 30°,17 (94%) at abduction 90°. There was a residual anterior laxity in the method-C group at low abduction, while in the method-S group, laxity had improved in all directions.
[Conclusion] Caspari's technique was effective for stabilization for anterior
shoulder instability with MDI. Caspari's technique reinforced with a subscapularis was thought to be reliable.

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[Purpose] Since 1997, we have performed Caspari's procedure for traumatic anterior shoulder instability. The purpose of this study is to evaluate the short term results.
[Materials and methods] Twenty shoulders of 20 patients (16 males and 4 females) with traumatic anterior shoulder instability were treated with Caspari's procedure.
The average age at operation was 28 years old (range 14-65 years old), and the mean postoperative follow-up period was 10 months (6-20 months). Our indications for the arthroscopic Bankart's repair were as follows; instability caused by trauma and there was no multidirectional instability.
[Results] According to Rowe's evaluation score,14 shoulders were excellent,5 good and 1 poor. The mean limitation of the range of motion was 9.7 degrees in external rotation at the side, and 4.7 degrees in external rotation at 90 degrees abduction.
Caspari's procedure using non-absorbable sutures achieved excellent stability, but there was a limitation of external rotation.

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[Purpose]The purpose of this study was to evaluate the arthroscopic findings and postoperative results between the staple capsulorraphy and the suture anchor procedure for an anterior instability of the shoulder.
[Materials and methods]Fifty five shoulders of 55 patients,41 males and 14 females, were examined. The age at operation ranged from 13 to 33, average 24.5 years old. Bankart's lesion was classified into 4 types using Kurokawa's arthroscopic classifications.35 cases (type1=15, type2n=15, type2a=3, type3n=1 and type3a=1) were treated by staple capsulorraphy and 20 cases (type1=15, type2n=2, type2a=2, type3n=1) were treated by suture anchor procedure.
[Results]After the staple capsulorraphy, the apprehension sign remained in 9 cases (typte1=3, type2n=4, type2a=1 and type3a=1) and subluxation recurred in 5 cases(typte1=1, type2n=3 and type3a=1). On the other hand, after suture anchor procedures, the apprehension sign was remained in only 2 cases (typte1=2) and a subluxation did not occur in any case.
[Conclusion]Arthroscopic Bankart's repair using a suture anchor resulted in better recovery than that of the staple capsulorraphy in patients with anterior instability of the shoulder.

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[Purpose] We performed arthroscopic suture anchor repair of Bankart lesion for traumatic anterior instability of the shoulder. Although we had chosen the Caspari technique, one of the transglenoid suture techniques since November 1992, we have performed suture anchor repair since November 1998. The purpose of this study is to evaluate the short-term clinical results of arthroscopic suture anchor repair of Bankart lesion
[Materials and Methods] We retrospectively studied 15 patients (15 shoulders) who had received arthroscopic suture anchor repair and were followed up more than 1 year. Patients were 12 males and 3 females. Seven patients had initial traumatic dislocation, and 8 had recurrent anterior subluxation or dislocation. The average age at operation was 20 years (range,13-28). The average postoperative follow-up period was 16 months (range,12-24).
[Results] There was no re-dislocation or re-subluxation postoperatively. In the Rowe scoring system,11 shoulders were exellent,4 good. The average Rowe's score was 94 points (80-100). There was no complication. The average limitation of external rotation was 4° at 90° abduction but it was not inconvenient for them. Average strength of external rotation was higher than who received Caspari technique.
[Discussion] There is a risk of suprascapular nerve injury in the transglenoid suture technique. In the suture anchor technique it is said that there is a problem of anchor stability in some cases, but this procedure achieved good clinical results in short-term follow-up.

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IDE Junji, MAEDA Satoshi, YAMAGA Makio and TAKAGI Katsumasa, Department of Orthopaedic Surgery, Kumamoto University School of Medicime The purpose of this study was to evaluate the results of arthroscopic Bankart repair using suture anchors on our selected patients.17 patients (F/M=2/15Cmean age=20) with unidirectional traumatic anterior-inferior instability and an isolated anterior detachment of the glenohumeral ligament complex were repaired arthroscopically. They did not a have large anterior glenoid defect or Hill-Sacks lesion.15 patients were graded excellent,2 good by Rowe's grading system after 30 (12-40) months follow-u p. The recurrence rate was 0%. The mean loss of ER was 9°(arm at side),4°(90° abduction). This operation for selected patients restored the stability of the shoulder and led to the same favorable outcome as open surgery.

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[purpose] We evaluated the findings of MR arthrography (MRA) of professional baseball players.
[Materials and methods] The MRAs of 29 shoulders in 29 professional baseball players were taken, excluding dislocation, subluxation and painful Bennett lesion. The average age was 24.9 years old (range: 18 31). There were 25 pitchers and 4 fielders.22 right and 6 left shoulders. The MRA findings of BLC were classified as follows: linear appearance: typeI, cleft appearance: typeII, intra-superior labrum linear appearance: typeIII, These lesions were observed in 1 or 2 slices: type A, and in more than 3 slices: type B. Furthemore we evaluated their high signal intensities of the supraspinatus tendon and cystic changes in the posterior greater tuberosity. We also statistically examined.
[Results] BLleCs ions were found in 17 shoulders. (TypeI A: 5, I B: 1, II A: 1, II B: 9: III B: 1). High signal intensities in the articular side of the supraspinatus tendon were recognized in 13 shoulde rs, and cystic changes were found in 16 shoulders. There was no correnlation among the MRA findings, and between throwing pain and the MRA findings.
[Conclusion] There were many BLC lesions in professional base ballplayers, but no correlation with throwing pain. It is necessary to evaluate throwing shoulders totally.

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[Purpose]The purpose of this study is to evaluate the effects of arthroscopic surgery in throwing athletes with a second look at arthroscdpy.
[Materials and methods]Twenty-eight shouldars which had been operated on from 1993 to 2000 were evaluated. Their average age at the operation was 23 (15-33) years old. There were 25 male and 3 female. The average period from the arthroscopic surgery to second look arthroscopy was 3.9 (3-7)months. There were 25 labral tears which involved 20 type II SLAP lesions. Their additional lesions were 7 articular-sidep artial rotator cuff tears (APRCT),12 inflammatory subacromial bursa (SAB)within 4 subacromial impingement and one bursal-side partial rotator cuff tear (BPRCT). There were 2 Bennett's lesions. One of which was accompanied by APRCT and an inflammatory SAB. There was one APRCT with stretched anterio-inferior glenohumeral ligament (AIGHL). The operative methods were as follows. The labral tear was sutured. The loose middle glenohumeral ligament (MGHL)and/or AIGHL were tensioned with labral repair in 15 cases. APRCT was treated with debridement, and BPRCT underwent arthroscopic repair. Inflammed SAB was treated with bursectomy. Subacromial impingement was treated with arthroscopic subacromial decompression. The stretched AIGHL was shrunken. Then second look labral findings were classified in four grades, complete healing, incomplete healing with granulation, incomplete healing without granulation, and no healing.
[Results]Type II SLAP lesions had complete healing in five cases, incomplete with granulation in six, incomplete without granulation in five and no healing in four. Twelve of fifteen cases of which loose MGHL and/or AIGHL had been tensioned had kept the tension. The previous irregular parts of APRCT were covered with white and smooth membrane in five cases. All of the twelve bursectomy cases had smooth synovial membrane in SAB. All of the four subacromial impingement cases had kept subacrornial space. The cuff was continuing into the greater tuberosity in BPRCT case. Two posterior labral tears in Bennett's lesion were completely healed. The shrunken AIGHL had kept good tension.
[Discussion] 80% of superior labral tears were stabilized repaired with arthroscopic surgery in throwing athletes.100% of SAB lesions had excellent result.

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39 patients with a clavicular nonunion had conservative treatment before surgery was indicated. There were 23 nonunions in the middle third,14 in the distal third, and 2 in the proximal third.21 patients became less symptomatic and did not necessarily require surgery. The reminders, which were 14 in the middle third,4 in the distal third, did not satisfy their condition and underwent an operation. Possible factors, which finally need surgery, were analyzed. Nonunions with surgery were relatively young and had a short period between trauma and start of the conservative treatment. In the middle third, a male athlete needed surgery, and in the distal third, a non-operative case at the time of trauma or atrophic nonunion needed surgery.

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[Purpose]The outcome of three common procedures for unstable fracture of the distal clavicle was compared in this study.
[Materials and methods] Pins and wires (Zm), Wolter's clavicular plate (Wm) or Recohook plate fixation (Rm) was performed in 41 shoulders out of 65 unstable distal clavicle fractures ( Craig's classification type II A: 15, II B: 9, V: 17). There were 34 males and 7 females, aged between 18 and 86. These 41 shoulders were followed-up until the removal of implants. Their fixation period, bone union, residual deformity and breakage or loosening of materials were evaluated. The statistical differences among the three procedures were examined by X2 test(p<0.05).
[Results] The fixation period of Rm was statistically shorter than the others. A non-union was seen in 4 shoulders, including 3 of type V, but there was no statistical difference in the union rate among the procedures. Rm showed the best results with regard to residual deformity unless type V fracture occupied 50% in this procedure group. Material breakages were seen in 5 of the Zm and 2 of the Wm.
[Conclusion] Rm was superior to Zm or Wm in the fixation period of residual deformity and material problems.

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[Purpose] We used hook plates for the surgical treatment of distal clavicular fractures and acromioclavicular joint dislocation. We wish to report the postoperative results.
[Patients and methods] Since 1994 to 1999,16 patients with distal clavicular fractures and 17 patients with acromioclavicular joint dislocation have been treated with a hook plate. Wolter's clavicular plate was used in 29 patients and Reco hook plate was used in 4 patients. Mail patients were 26 and femail patients were 7.
They ranged in age from 16 to 80, with an average age of 44.4. The causes of injurie were traffic accidents in 17 cases, sports injuries in 10 cases, industrial accident in 3 cases and simple falls in 3 cases. The mean follow-up period was 7.7 months. The results were assessed using the Japan Orthopaedic Association's shoulder scores and Kawabe's scores.
[Results] The average JOA score was 94.8 points(52-100). The average Kawabe's score was 92.4points (excellent; 24. good; 4. fair; 4. poor; 1).
[Conclusion] The hook plate fixed the acromioclavicular joint firmly. Therefore, Range of motion exercise could be started soon after the surgery. But some patients complained motion pain of the sholder joint due to stimulation of the hook part.

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[Purpose] Many surgical options have been reported for acromioclavicular dislocation. We have performed a modified Neviaser's procedure for grade III acromioclavicular dislocation using Wolter's clavicular plate. The purpose of this study is to evaluate the clinical outcomes of the cases performed since 1995.
[Materials and Methods] In this study,30 cases (24 males and 6 females) which were diagnosed as grade III acromioclavicular dislocation according to Tossy's classification were evaluated. The mean age of the cases was 41.7 years old ranging from 19 to 75 years old and their mean follow-up period was 15 months (8-28 months). The cases were treated by a modified Neviaser's procedure using Wolter's clavicular plate as a temporary fixater of the acromioclavicular joint. The clinical results were evaluated by Kawabe's scoring system and the JOA shoulder rating system.
[Results] According to Kawabe's scoring,21 cases were excellent,4 cases were good,2 cases were fair and 3 cases were poor. The mean value of the JOA score was 93.0 points. Osteoarthritic change of the acromioclavicular joint had progressed in one case and fracture of the acromion occurred in two cases which were considered poor results.
[Conclusion] The use of Wolter's clavicular plate enables secure reduction and rigid fixation of the acromioclavicular joint for a modified Neviaser's procedure. In the present study, satisfactory clinical results were obtained. However, the appropriate position of the hook on the acromion is essential to prevent complications of this procedure.

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[Purpose]Arthroscopic acromioplasty (AA) has become a common procedure for the treatment of chronic impingement syndrome. AA allows earlier rehabilitation than open surgery because a complete detachment of the deltoid is not performed, yet AA is technically more demanding and has a long learning curve. Especially, measurers areas where a bone is removed is difficult. We developed a shaver guide which make an acromioplasty without the arthroscope easy.
[Method] 50 shoulders of 50 patients were exarnined by X-ray with an average age of 63 years (ran ge,41-77). The radiographs consisted of the supraspinatus outlet view and AP view. The width and thickness of the anterior acromion were measured.
[Results] The average width was 26.2mm and the thickness was 8.6mm of the anterior acromion. A shaver guide was made based on these data. The shaver guide has a hook and shaver sleeve which is like a drill guide for the ACL. The interval between the shaver sleeve and the hook can be changed. In order to make an AA and measure the thickness of the acromion, the hook of the shaver guide is placed on the top of the acromion through the skin and the shaver is inserted toward the shaver sleeve and the depth gauge. The operator does not need to hold the shaver guide because of the sleeve guide has a locking system which maintains the interval. The hook is placed and moves the skin of the ac romion, and an acromioplasty can be done without using an arthroscope.
[Conclusion] We can easily make an acromiopiasty and measure the thickness of the acromion easily with a shaver guide.

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