The purpose of this study was to refer to the clinical characteristics and etiology of the cystic changes in the humeral head in patients with a rotator cuff tear. One hundred four patients who underwent surgery for the rotator cuff tear were divided into two groups depending on whether they had a cyst in the humeral head or not. Twenty-three patients had cysts in the humeral head (the cyst group) and eighty-one did not (the non-cyst group). Preoperative radiographs, JOA scores, and clinical findings as well as the size of the tear were compared between the two groups to reveal the clinical characteristics and factors, which might relate to cyst formation. There was no significant difference between the cyst and non-cyst group in age of the patients at surgery, gender, affected side, causative mechanism (traumatic or degenerative) of the cuff tear, and duration of symptoms prior to surgery. No significant differences were seen in the incidence of arthritic changes on radiographs between the two groups. The pain score in the preoperative JOA scores was significantly higher in the cyst group than that in the non-cyst group (p<0.05), although there was no significant difference between the two groups in the function, active forward flexion, muscle strength and total score of the preoperative JOA scores. There was no significant difference in the positive rate in Neer or Hawkins's impingement test or that in the full or empty can test between the two groups. The size of the rotator cuff tear was significantly smaller in the cyst group than that in the non-cyst group (p<0.05). Trauma, impingement, and arthritic changes did not appeared to relate to the cystic change in the humeral head in patients with a rotator cuff tear.

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[Purpose] The purpose of this study was to evaluate the effects of a modified Bristow procedure in the apprehension test position with open MRI.
[Materials and methods] A 31-year-old man had undergone a modified Bristow procedure for recurrent anterior dislocation of the shoulder 6 years ago. MRI was performed with an open MRI (Signa Ovation, GE, U.S.A.) in the apprehension test position with the shoulder in 90° of abduction and 60° of external rotation. Then stable shoulders in eight patients and five shoulders in five patients were scanned too. Then the stability of the shoulder was evaluated in the transverse image.
[Results] The transported coracoid process and conjoined tendon were scanned clearly in the axial and coronal images. The humeral head pressed upon the conjoined tendon and the course of the conjoined tendon was an antero-inferior arc curve. The conjoined tendon prevented the humeral head from anterior dislocation. The gleno-humeral joint was stable.
[Conclusion] This study suggests that the conjoined tendon plays an important role in preventing anterior dislocation of the shoulder.

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We wish to present a rare case of painful throwing shoulder accompanied by a glenoid osteocndral injury. A 31-year-old male complained of left shoulder pain when throwing. He had participated on a non-professional baseball team as a pitcher. His dominant shoulder was the left one. He had complained of pain during the cocking-up phase when he was a 20-year-old. He had no symptoms in daily life, so he felt pain. He visited our hospital when he was a 31-year-old, as he began to feel pain in daily life after throwing through a whole game. Although ROM limitations were not detected, posterior shoulder pain occurred at abduction. Crank test was positive. MRI study showed a SLAP lesion type II, cartilage injury of the humeral head like PLN, internal impingement at the ABER position and a slit-shaped contrast medium invasion into the glenoid fossa at the 10 o'clock level. Conservative treatment was not effective. An arthroscopic surgery was carried out. The arthroscopic findings were similar to MRA study. The labrum was repaired and thermal shrinkage of the anterior capsule and debridement of the SSP were carried out. There were some reports concerning the glenoid osteochondral damage. However, a report concerning a non-traumatic groove-shaped cartilage damage is quite rare. We think that this injury is connected to the shearing force to the fossa and anterior instability of the shoulder. We would like to examine the cause of the defect in future.

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The purpose of this study was to analyze the factors of a poor outcome after shoulder surgery. Eleven patients (15 shoulders) were evaluated, who got a poor outcome after shoulder surgery. The cases included 1 male and 10 female. The mean age to get shoulder discomfort was 18.1 (ranged, 10-32) years old. The shoulders included 11 loose shoulders, 2 rotator interval lesions, 1 recurrent dislocation of the shoulder and 1 acromioclavicular dislocation. They all had shoulder instabilities. The causes of shoulder discomfort were unknown in 8 shoulders and injuries in 7 shoulders. Eleven glenoid osteotomies, seven N-H method (modified Putti-Platt procedure), four rotator interval repairs, and 1 Dewar method were performed. In 10 shoulders after surgery the scapulo-humeral rhythm was bad, in 9 severe pain continued, in 8 instability remained, and in 8 the range of motion of the shoulders was bad. All the patients had psychiatric problems. In our study the factors of a poor outcome after shoulder surgery was shoulder instability, which was based on psychoneurosis.

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The purpose of this study was to clarify the clinical results of coracoacromial ligament (CAL) preserving anterior acromioplasty for rotator cuff tear. Thirty-two patients (thirty-three shoulders) underwent a rotator cuff repair between April 1997 and March 1999. CAL preserving anterior acromioplasty was performed on twenty-five shoulders (18 males and 6 females), with a mean age of 60.4 years old. They were followed for an average of 32 months postoperatively. All the patients completed a short form-36 (SF-36) health status questionnaire and Hospital for Special Surgery (HSS) scoring system questionnaire pre- and postoperatively. The average preoperative HSS score was 26 points. Postoperatively, the HSS scores improved significantly to an average of 86 points. The postoperative clinical evaluations of these patients were ; 13 excellent, 10 good, and 2 poor. The average preoperative physical component summary score of the SF-36 was 29.5 and the mean mental component score was 40. The average postoperative physical and mental component scores increased significantly to 72.2 and 78.3 points. The Hawkins sign was positive in two patients postoperatively. Patients with rotator cuff tears have been treated with traditional anterior acromioplasty. Recently biomechanical studies have indicated that the CAL contributes to glenohumeral stability. This study indicates that the retained CAL after beveling of the inferior acromion does not always jeopardize the shoulder joint.

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We studied the effect of the critical path introduced into repair of a rotator cuff tear. The subjects comprised of 17 cases using the critical path excluding massive tears and 9 cases before introduction of the critical path. In setting the outcome (criteria for discharge, number of days in hospital) removal of the abduction brace and daily activities such as taking a meal and washing face were used as the criteria for discharge. The clinical outcome, number of days in hospital, the patient's satisfaction, staff member, satisfaction and the financial outcome before and after introduction of the critical path were studied in these cases. As a result, the number of days in hospital shortened. No difference in the chinical outcome was found despite the shortening of the duration in hospital. The path for patients resulted in improvement of informed consent, a decrease in work due to unified instruction and an increase in satisfaction of staff members owing to the team treatment (bringing professional skill of different job categories into full play). At present in Japan, a shift from the process-piling type medicare to the outcome management is being called for. The critical path is said to be one of the most effective tools for the outcome management. It is considered effective for rotator cuff tears as well.

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The purpose of this study was to evaluate the surgical results of rotator cuff tears which received brisement procedures for preoperative shoulder contractures. Twenty-six shoulders of 26 patients who received brisement procedures prior to cuff surgeries were followed-up over one and a half years. There were 22 males and 4 females, aged from 37 to 75 years old (mean 57 years old). There were 4 massive, 4 large, 12 small and 6 partial thickness tears.
Operations were performed at 6 months on average (1-11 months) after the onset of the symptoms. They were followed-up for 29 months on average (18-45 months) after surgery. According to the arthroscopic findings, there were two types of capsular injuries by brisement procedures. Type A : tear of the axillar region, Type B : tear of both the axillar and rotator interval regions. The outcome was assessed with the JOA score and the transition of ranges of motion. The factors that influence the degree of preoperative contractures were also analyzed. Each parameter was statistically analyzed by SPSS (p<0.05). Postoperative shoulder functions improved significantly in both types. The average total JOA score increased from 62.1 to 89.6 (p<0.001) in type A and from 57.8 to 89.2 (p<0.001) in type B. The range of passive flexion changed from 99° to 167° in type A, while it moved from 96° to 166° in type B. The range of passive abduction changed from 93° to 166° in type A, while it moved from 89° to 169° in type B. The most significant difference between type A and type B was found in the range of external rotation, which moved from 44° to 44° in type A, and 29° to 45° in type B. Flexion and abduction improved by the brisement procedures and were maintained. But, the range of external rotation which had been increased by brisement procedures could not be kept in the post-operative course. The results were not affected by age, tear types, nor follow-up period. The range of motion before surgery was influenced by the patient's age and duration of symptoms. Rotator cuff tears which received brisement procedures for pre-operative shoulder contractures had good surgical results. The improvement of range of motion in external rotation gained more in those shoulders which had had disrupted capsules at both the axillar and rotator interval regions.

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Diagnosis of an isolated rupture of the sabscapularis tendon is difficult because it is rare. The purpose of this study was to suppose the pathogensis and to clarify the clinical features of this injurt.
This subject consisted of 16 cases confirmed by surgery. We divided these cases into two groups. One is the complete tear of the subscapularis tendon fromthe lesser tuberosity (n=11) and the otheris partial tear near the bicipital groove (n=5). We investigated the causes of this injury, the tenderness points, the usefulness of the Lift off test, the period to the operation, the clinical results and the conditions of the bicipital long tendon (LHB). In addition, we compared the two groups and investigated the tendency.
All of the patients had a definite history of trauma to an affected shoulder, but there is no tendercy about the causes of this injury. Majority had tenderness on the lesser tuberosity and the bicipital groove. The Lift off test was positive in all cases of the complete tear group, while in two cases (40%) of the partial tear group. There were some remarkable changes on the LHB in 14 cases (87%), 12cases of which were dislocation or subluxation from the bicipital groove, 2cases of which were inframmatory change. These disturbed LHB distuebed LHB were treated by only reduction in 5 cases, tenodesis to the intertubercular groove in 3 cases, transfer to the conjoined tendon in 4 cases. The average JOA score at follow up was 92 (78∼100).
[Conclusion] An isolated sabscapularis tendon rupture often involved the failure of LHB gliding mechanism. This injury shouid be treated operativery, because it was difficult to be treated conservatively.

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The purpose of this study was to investigate the clinical outcomes of the mini-open subacromial decompression surgery for subacromial impingement syndrome cases. Seven shoulders in six patients (all male cases who underwent mini-open subacromial decompression were studied. The average age of these patients was 61.1 years old (range, 46 to 66), and the average post operative follow-up period was 4.6 months (range, 3 to 7). Five shoulders in four patients had partial rotator cuff tears detected by magnetic resonance imaging, In this study, the performed mini-open subacromial decompression surgery consisted of bursectomy of the subacromial bursa, resection of the coraco-acromial ligament and anterior acromioplasty with minimal skin incision and splitting between anterior and middle part without resection of origin of the deltoid muscle. The range of motion including flexion, abduction, and external rotation and the shoulder function score proposed by the Japan Orthopaedic Association (JOA score) were evaluated. The average of JOA score before surgery was 56.6 points which improved to 80.9 points at the follow-up period. The range of motion also improved in all cases, however, the improvement of pain score in five shoulders which had partial rotator cuff tears was lesser than the other two shoulders. The open subacromial decompression surgery was considerd to be a suitable surgical method for subacromial impingement syndrome. Whether repairment to partial rotator cuff tear is necessary or not remains controversial.

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[Purpose] The purpose of this study was to investigate the factors in preoperative radiographs and MRI which would influence the results of surgery for the massive rotator cuff tear.
[Materials and methods] Radiographic and MRI studies were performed in 33 shoulders of 31 patients who underwent surgery for a massive rotator cuff tear using McLaughlin's procedure modified by Nobuhara. This procedure is indicated for massive rotator cuff tears which cannot be repaired using the conventional McLaughlin's procedure. The age of the patients ranged from 44 to 78 (average 66.9) years. They were divided into four groups according to Gerber's classification and into three groups according to Thomazeau's classification. The JOA score of the patients was also evaluated at the final follow-up and the relationship between the final JOA score and severity of arthritis and that between the score and the supraspinatus atrophy was assessed.
[Results] The average JOA score was 92.6 points at the final follow-up in the 33 shoulders. There was no significant difference in the final JOA score between the patients with mild arthritis and those with moderate arthritis. However, the patients with a thicker supraspinatus muscle demonstrated significantly higher JOA scores than those with a thinner muscle (p<0.01). The clinical results of the Nobuhara's procedure for the massive rotator cuff tear was good or excellent in almost all the patients except for several patients with insufficient recovery of muscle power.
[Conclusion] The low postoperative JOA score was related with preoperative supraspinatus muscle atrophy but not with preoperative osteoarthritis of the shoulder.

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The purpose of this study is to make the results of trapezius transfer and Patte's procedure for massive rotator cuff tears clear. Eleven cases of trapezius transfer and eight cases of Patte's procedure were observed more than one year after the surgery. In cases of trapezius transfer, the mean age was 59 years old, and the mean size of the tear was 16.2cm2. In cases of Patte's procedure, the mean age was 62 years old, and the mean size of the tear was 17.3cm2. The mean JOA total score in cases of trapezius transfer was 62.4 before surgery and 79.5 after surgery. The mean scores of each item were as follows : pain : 12.7→24.5, function : 12.4→14.3, range of motion : 20.1→22.5, X-ray : 3.5→3.2. The mean acromiohumeral interval was 6mm before surgery and 4.6mm after it. The mean angle of active elevation was 109.5° before surgery and 121.4° after it. There was no significant difference between before and after surgery in every item except the JOA total score and pain. Rupture of the transferred trapezius was recognized in 2 cases. The mean JOA total score in cases of Patte's procedure was 61.9 before surgery and 85.3 after it. The mean scores of each item were as follows : pain : 13.1→26.9, function : 11.6→17.1, range of motion : 18.9→22.3, X-ray : 4→4.8. The mean acromio-humeral interval was 6.7mm before surgery and 8.5mm after it. The mean angle of active elevation was 101.9° before surgery and 138.1° after it. There were significant differences between the before and after surgery in any item. In cases of trapezius transfer, only pain improved after the surgery. In cases of Patte's procedure, all of the pain, function, muscle power, and acromio-humeral interval improved significantly after the surgery.

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We performed a reconstruction of massive rotator cuff tears using McLaughlin's procedure, but in difficult cases using this procedure, We needed a tensor fascia lata grafting. The purpose of this study was to evaluate the results of the surgical treatment for patients with massive rotator cuff tears. 19 shoulders of 19 patients were evaluated. There were 13 males and 6 females with an average age of 60.8 years old.
The average follow-up period was 17.2 months. McLaughlin's procedure was performed on 6 patients, and patch graft procedure was done on 13 patients. We evaluated the post-operative results of those patients according to the shoulder evaluation sheet of the Japanease Orthopaedic Association (JOA), and the strength of external rotation was evaluated using Cybcx.., Thc prc-operative avcrage. JOA score was 58.8 points and the post-operative one was 83.3 points totally. The post-operative JOA score with McLaughlin's procedure was 93.9 points and the one with a patch procedure was 78.5 points. The strength of external rotation increased post-operatively. The results of patients with a patch proctedure were not so good, because patch graft ruptures occurred in 3 patients post-operatively. We achieved a good result of surgical treatment for patients with massive rotator cuff tears totally. Should patch graft ruptures decreased, we thought the results of patch procedure would have improved. Recently, we used an anchor suture in addition to the previous suture.

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We performed McLaughlin's procedure and the patch method as operative treatment for massive rotator cuff tears. The purpose of this study was to clarify the advantage of these two procedures. Fifteen shoulders (12 men and 3 women) of fourteen patients with massive rotator cuff tears were examined. The average age at surgery was 60.1 years old. The average follow-up period was 40.7 months. The McLaughlin procedure was performed on 5 shoulders and the patch method was performed on 10 shoulders. Tensor fascia lata was used in 5 shoulders and Marlex mesh was used in 5 shoulders. The functional outcome was assessed with the JOA score and muscle strength was measured. The average JOA score improved from 51.6 points to 88.6 points in the McLaughlin group, and 50.3 points to 87.0 points in the patch group. The muscle strength of the McLaughlin group was higher than that of the patch group. The clinical results of the patch method for massive rotator cuff tears were satisfactory as good as McLaughlin procedure.

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We wished to clarify the clinical efficacy of a modified Bankart and Bristow procedure for a recurrent anterior dislocation of the shoulder. 43 shoulders with recurrent anterior dislocation of the shoulder who had received a modified Bankart and Bristow procedure at our universities or related hospital and were able to be observed for more than five years postoperatively were investigated. There were 35 men and 8 women, and the mean age at operation was 22.1 years old (17-46). The mean follow-up period was 71.3 months (60-88). The operation was done according to Bankart procedure augmented by a coracoid transfer (modified Bristow technique). According to the Rowe scoring system, the clinical results were graded as excellent for 91%, good for 2%, fair for 7%, poor for 0%, with an average score of 94.3 points. There were no redislocations or subluxations post-operatively. The average loss of range of motion compared with the opposite side was 12° for external rotation. 57% of the athletes could return to their preinjury levels. With our method, repairing of the main lesion of the IGHL complex and a buttress effect by the conjoined tendon in abduction seemed to result in a strong stability. This procedure can achieve a good clinical outcome for contact athletes and cases with bony defects of the glenoid or damage to the glenohumeral ligament-labrum complex.

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We investigated the validity of the implantation of the humeral component of the Aequalis shoulder system. Eight patients (9 shoulders) were treated with the Aequalis shoulder system (humeral head replacement with cement). The mean age at the surgery was 52 years old, and the mean follow-up period was 5 months. Patients with rheumatoid arthritis were found in 6 shoulders, osteoarthrosis in 1, and osteonecrosis in 2. The JOA shoulder score was used for the short-term clinical outcome. The radiographic evaluation was considered pre and post-operatively about as follows : alignment of the stem post-operatively (varus/valgus tilt), inclination angle of the proximal humerus, retrotorsion of the humeral head, and posterior offset of the outer head. The mean JOA shoulder score was improved (especially in the pain score). There was no case of varus position of the stem. The difference of the mean inclination angle between pre and postoperation was 5 degrees. The difference of the mean retrotorsion angle between pre and postoperation was 4 degrees. There was no but one case with a protruded outerhead from the osteotomied surface of the humeral neck. The clinical outcome of the humeral head replacement with Aequalis shoulder system resulted in good during a short period. The alignment of the prosthesis was acquired almost precisely.

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[Purpose] We performed a biomechanical comparison of the pullout strength of a suture anchor that we have been using for arthroscopic rotator cuff repair with a transosseous suture.
[Materials and methods] Four pairs of fresh-frozen cadaveric human shoulders were used. The average age was 75.8 years old. Each had an intact rotator cuff. The proximal part of the humerus was harvested and a bone trough was created on the greater tuberosity. Each one was tested three times using three sites of the trough. A screw anchor (Fastin RC, Mitek) with two No. 2 braided sutures was inserted at an angle of 45 degrees to the humeral axis. The humerus was fixed and sutures were distracted in direction of the humeral axis until an anchor pullout or suture breakage occurred (anchor group, n=12). Then, a bone tunnel was created through the greater tuberosity and doubled No.2 braided sutures were placed, and tested in a similar way (suture group, n=12).
[Results] The modes of failure were anchor pullout in ten and suture breakage in two of the anchor group, bone cutout in eight and suture breakage in four of the suture group. The average failure load of the anchor group was 211.3 N (SD=65.2) and that of the suture group was 208.7 N (SD=68.6). The average stiffness of anchor group was 48.33 KN/m (SD=15.97) and that of suture group was 28.78 KN/m (SD=16.47). There was no significant difference in the average failure load, but the average stiffness was significantly higher in the anchor group (p<0.01, unpaired t-test).
[Conclusions] Since the average stiffness was significantly higher in anchor group, the size of the gap at the tendon repair site during ROM exercises after suture anchor repair may be smaller than that after a transosseous suture repair. These findings are the background in the clinical use of the suture anchor for a rotator cuff repair.

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The purpose of this study was to analyze the kinematics of the glenohumeral joint of normal volunteers, patients with cuff tear and traumatic anterior instability during active abduction using open MRI. Ten normal volunteers (23∼39 years old), 9 patients with cuff tear (54∼70 years old), and 6 patients with anterior instability (17∼30 years old) were examined with an open MR system (0.2T Magnetom Open, Siemens). There was 1 incomplete tear, 1 small tear, 3 middle tear, and 4 massive (supraspinatus and infraspinatus) tear. The scans were done at five different active abduction positions (30°, 60°, 90°, 120°, 150°). The translation of the center of the humeral head relative to the center of the glenoid was measured for both the coronal plane and the axial plane in each case. In the normal shoulders, the translation was within 1mm from the center of the glenoid in the coronal plane, and within 2mm anterior from the center of the glenoid in the axial plane. The massive cuff tear shoulders showed superior and posterior translations, while no remarkable translation was observed in supraspinatus tear shoulders. In anterior instability shoulders, inferior translation was observed at 150° abduction, and anterior (n=4) or posterior (n=2) translation was observed in the axial plane. Normal shoulders showed ball-and-socket kinematics. From the results of the analysis of cuff tear shoulders, the anterior and posterior cuff tendons were considered to play an important role in stabilizing the humeral head toward the glenoid. In anterior instability shoulders, translation of the humeral head in the axial plane was observed even during scapular abduction. This analyzing method is useful to evaluate the three-dimensional kinematics of the glenohumeral joint.

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This study was aimed to clarify the pathogenesis of the calcification in a rotator cuff tear (CR) and a calcifying tendinitis (CT). Eighty stumps of torn rotator cuff tendons were obtained from 80 shoulders during surgery. The stumps of the cuff tendons were cut into 5 strips along the tendon fiber direction. All specimens were sectioned at a 3 μm and stained histochemically and immunohistochemically. The CR cases were divided into two groups as follows : A- 15 cases with calcium deposits in torn tendons ; B- 65 cases without any calcium deposits. The clinico-pathological features were investigated and compared between the two groups. Eight cases of calcifying tendinitis (group C) were examined by the similar methods. Calcified deposits in the CR were microscopically observed as free and scattered micro-calculi among the fibroblasts and collagen fibers particularly at the torn ends of a cuff, accompanied by other degenerative changes. Histologically, remarkable thinning and disorientation of collagen fibers, and intense myxoid degeneration in the tendons were found in group A. CR was found in the cases with a longer duration of symptoms and frequently found in the cases with a massive tear. In CT, calcification appeared in the aggregated globular pattern and was always found with the degenerative collagen fibers. There were some histiocytes and vascular proliferations as reparative reaction, and no evidence of inflammation around the calcified areas. In conclusion, calcification in CR was considered to be dystrophic and may be one of the chronic pathological changes correlated with the long duration of the degenerative processes or aging. CT seemed to be characterized by direct calcium deposits between or on the degenerated collagen fibers without any inflammatory change or enchondral calcification. CT may occur in association with a trigger of micro-trauma probably due to genetic factor or joint laxity.

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In this study, we analyzed the clinical outcome and radiological evaluation in cases with proximal humeral fracture or fracture-dislocation of the shoulder treated by hemiarthroplasty. Eighteen cases with an acute displaced proximal humeral fracture and five cases with an acute fracture-dislocation were the subjects of this study. There were twenty-two women and one man whose mean age was 75.4 years old (64 to 92 years old). Global shoulder hemiarthroplasty was applied in 14 cases, the Biomodular-type in 7 cases and the Neer-type in 2 cases. The average follow-up period was 5.8 years (1.2 to 14 years). The postoperative results were evaluated according to the Japanese Orthopaedic Association shoulder score (JOA score). Parameters for radiological evaluation were values of AHI, humeral offset, medial and lateral projections, and the existence of a spur beneath the acromion, a radiolucent zone of the humeral shaft and an osteolytic change of the greater tuberosity. The average postoperative JOA score was 83.7 points (64 to 97 points). The mean values of AHI and humeral offset were 9.0mm and 28.4mm, respectively. A spur beneath the acromion was observed in five cases, and a radiolucent zone at the humeral shaft in three cases. There was a significant correlation between the postoperative JOA score and values of AHI or humeral offset. The average JOA score in the cases with a spur beneath the acromion or a radiolucent zone of the humeral shaft was markedly lower than that in cases without them. This study suggests that results of hemiarthroplasty be influenced by factors reflecting functions and conditions of the rotator cuff. We conclude that anatomical reconstruction of the greater tuberosity and the rotator cuff is important to obtain satisfactory results in hemiarthroplasty.

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The shoulder functions after arthroplasties in rheumatoid arthritis (RA) were evaluated.
32 shoulders of 24 RA patients (23 females, one male) were evaluated. The mean age at operation was 49.1 y.o., the mean period of morbidity was 14.7 years and the mean follow-up period was 5.5 years. These shoulders had 15 total shoulder arthroplasties, 8 monopolar hemiarthroplasties and 9 bipolar hemiarthroplasties performed on them. The pain was reduced in all cases. There were no significant differences of the range of active flexion in the sitting position among three types of arthroplasties. There were also no significant differences of the range of active flexion between 27 shoulders of the Larsen's grade IV and 5 shoulders of grade V. The ability of active flexion after the operation was affected only by the ability before the operation. There were no significant differences of the range of active external rotation in the first position among three types of arthroplasties and between the Larsen's grade IV and grade V. The shoulder function before an operation in RA shoulders will be one of the most important factors of the operative success.

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[Purpose]] We examined student sumo wrestlers in order to study the relationship between their sports performance and the muscle strength around their shoulders.
[Materials and Methods] Twenty-three wrestlers were examined in 2000. Twelve were collegiate and eleven were high school wrestlers. The isokinetic strength of their internal (IR) and external (ER) rotators and flexor (FX) and extensor (EX) were measured using a Cybex. We also divided them into two groups : strong group and weak group. Strong group has higher sports performance than weak group in sumo wrestling.
[Results] Their mean height was 177.6cm, weight 108.6kg, body mass index 34.3kg/m². Their IR, ER, EX and FX of strong group was significantly larger than one of weak group, but the ratio of strength to their weight, the ratio of ER to IR and the ratio of FX to EX between strong group and weak group had no significant difference.
[Conclusion] In order to improve their sports performance of student sumo wrestlers, it was significant to increase their IR, ER, FX and EX, especially.

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The purpose of this study was to determine the availability of a local anesthetic test for throwing athletes with posterior shoulder pain. Forty-eight cases with posterior shoulder pain in throwing athletes were evaluated. Their mean age was 26.6 years old, and the mean period from onset to the test was 34.4 months. After 1 % lidocaine was injected into the posterior margin of the glenoid rim, each patient did some pitching. We observed the ball speed and questionned each patient about pain relief. In local anesthetic tests : 5 cases were ineffective (all cases ; Bennett lesion -, tenderness of the RI +, slipping +). 19 cases were effective (Bennett lesion -7 cases, tenderness of the RI + 12 cases, slipping + 4 cases, PL lesion of the humeral head + 9 cases). 24 cases were very effective (Bennett lesion -9 cases, tenderness of the RI + 11 cases, slipping + 1 cases, PL lesion of the humeral head + 0). We considered that the posterior margin of the glenoid rim must be taken into consideration as a symptomatic lesion of posterior shoulder pain during the throwing motion. A local anesthetic test into the posterior margin of the glenoid rim was available for throwing athletes with posterior shoulder pain.

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[Purpose] There are many reports about rotator cuff repairs but we could find only one report describing return to sporting activity for golfers. The purpose of this study is to investigate the sporting activity after rotator cuff repairs.
[Materials and methods] We retrospectively studied 19 patients after rotator cuff repairs. All the patients participated in recreational sporting activities before the operations. The average age at the operation was 53 years old.
Of the 19 shoulders, 16 shoulders could undergo a primary rotator cuff repair. In 3 shoulders that could not be repaired primarily, a Latissimus dorsi transfer was chosen in one shoulder, teflon felt patch procedures were in two shoulders. The sporting activities after the operations were classified using Yoneda's classificatiions of throwing shoulders.
[Results] Sixteen shoulders were classified as complete return (9 were golf, one of each of the following swimming, skiing, judo, kendo, badminton, indiaca and football). One shoulder (volleyball) had an incomplete return and two shoulders could not return to sporting activities. These two shoulders had teflon felt patch procedures.
[Conclusion] For patients who participate in recreational sporting activities, when rotator cuff tears can be repaired primarily, favorable outcomes can be expected.

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We performed arthroscopic subacromial decompression (ASD) for an irreparable massive rotator cuff tear to allow low-activity elderly patients to elevate their shoulders. The purpose of this study was to evaluate the clinical results of ASD for an irreparable massive rotator cuff tear. We retrospectively studied 10 patients (10 shoulders) who had received ASD for an irreparable massive rotator cuff tear and were followed-up for more than 2 years. The patients were 4 males and 6 females. Their mean age at operation was 73 years old (range, 62-82). The mean postoperative follow-up period was 37 months (range, 24-65). Our operative indications were 1) irreparable massive rotator cuff tear 2) sedentary and elderly people 3) that pain was the chief complaint 4) who could elevate their arm if their pain was relief. The clinical results were assessed using the JOA scores and radiographic findings. The mean total JOA score was 90.4 points postoperatively compared to 62.2 points respectively improved from 9.0 to 27.5 (p=0.0045), 13.3 to 17.7 (p=0.0049), 22.3 to 28.4 points (p=0.0112) postoperatively. The mean acromiohumeral interval (AHI) decreased from 6.4mm to 2.5mm postoperatively (p=0.0029). Radiographic findings showed the progression of osteoarthritis (OA) in 5 patients who were followed-up over 35 months (p=0.0016). We cannot expect the total recovery of power using ASD for an irreparable massive rotator cuff tear. However, this procedure provides pain relief through minimal surgical invasion, and we can promote early rehabilitation. The total JOA score was improved, but radiographic findings showed the progression of OA and decreases in AHI. This procedure achieved good clinical results with limited indications, but further long term follow-up is necessary.

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We have been treating patients with rotator cuff tears by arthroscopic debridement (AD). We investigated our clinical outcome of AD and the character of the patients who have had a repair of rotator cuff tear after AD (RRCT group). From 1995 to 2000, we retrospectively studied 34 patients (23 males and 11 females). Their mean age at AD was 63.5 years old, and the mean follow-up period was 18.8 months (range 6-36). The tear types were 26 complete tears and 8 incomplete tears. The RRCT group was 5 males and 2 females. The tear types and occupations were investigated for the RRCT group. The tear types of the RRCT group were 5 complete tears (1 small, 3 medium, 1 massive) and 2 incomplete tears. The occupations of the RRCT group were farmers, fishermen and manual laborers. Character of the RRCT group was complete tear (medium) and under 70 years old. AD is useful for reducing pain of rotator cuff tears, but a cuff repair should be considered for patients who had a complete tear (medium) and who are under 75 years old.

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We compared the preoperative clinical and MRI findings between incomplete joint side tears (Group A) and incomplete bursal side tears (Group B), and investigated the possibility of the preoperative diagnosis of the incomplete tear side. Ten shoulders of 10 patients who were diagnosed as having incomplete rotator cuff tear by arthroscopy and macroscopic observation were examined. Group A consisted of five shoulders, and Group B five shoulders. Occupation, age, duration of the disease, past history of injury, pain, click, and MRI findings were compared among 2 groups. Many had occupations that palced a burder on their shoulders in Group B. The age was significantly higher in Group A. There was no significant difference in the duration of the disease. Group A had two shoulders with a past history of injury and Group B had one. The night pain was milder in Group B than that in Group A. Motion pain was higher in Group B than that in Group A. On preoperative MRIs, although the subacromial bursal edema was detected in all patients in both groups, the continuity of the tendon was retained. However, bone cyst was observed near the tendon attachment site in four shoulders in Group A, while there was no bone cyst in Group B. Group A was characterized as following : 1. physical activity was relatively high, as in the young, 2. patients mainly had motion pain rather than night pain, 3. clear clicking was observed, and 4. subacromial bursal edema was odserved on preoperative MRIs. While, group B was characterized as following : 1. aged patients, 2. patients mainly had night pain rather than motion pain, and 3. bone cyst of the humeral head was observed on preoperative MRI.

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[Purpose] The purpose of this study was to investigate the instability of the shoulder in apprehension test position with open MRI.
[Materials and methods] Five patients with persistent anterior instability after recurrent shoulder dislocations were examined in this study. MRI scanning was performed with an open MRI system (Signa Ovation, GE, U.S.A.) in the apprehension test position with the shoulder in 90° of abduction and 60° of external rotation. The shoulder image in the apprehension test position was investigated and the instability was evaluated.
[Results] The Bankart lesion and Hill-Sachs lesion were imaged clearly in the same image. The subscapuralis muscle peeling off the scapula was scanned clearly too. The course of the subscapuralis muscle and conjoined tendon was an arc. The joint surface of the humeral head was only contacted in the antero-inferior area in the glenoid cavity.
[Conclusion] The important muscle role of the anterior safe guard in the shoulder joint may be not only the subscapuralis muscle, but also the conjoined tendon. The gleno-humeral joint was unstable in the apprehension test position.

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The purpose of this study was to evaluate the clinical usefulness of multidetector-row CT (MD-CT) arthrography for recurrent dislocation of the shoulder and rotator cuff tear. This study involved 11 patients (7 : recurrent dislocation of the shoulder and 4 : rotator cuff tear) who were diagnosed for their manifestations by arthroscopy and open surgery. There were 8 males and 3 females with a mean age of 42 years old (range ; 23 to 71 years old). In recurrent dislocation of the shoulder, all patients had a labral Bankart lesion of which two had a bony Bankart, and two patients had Type II SLAP lesion. Arthrography followed by MD-CT (SOMATOM Plus 4 Volume Zoom : derector-row : 4, collimation : 1 mm, and rotation speed : 0.5s/revolution) were performed, then reconstruction images were obtained. The findings of MD-CT arthrography were compared with those of the MRI according to the arthroscopic and surgical findings. In two patients with a bony Bankart's lesion, MD-CT arthrography could diagnose both although one could not be detected by MRI. One of the two Type II SLAP lesion were detected by MD-CT arthrography, which were not apparent on MRI. However, AIGHL was confirmed by MD-CT arthrography in only one patient who had Type II arthroscopic finding outlined by Yoneda. In all the patients with a rotator cuff tear, MD-CT arthrography showed a precise shape of the acromion. In three patients with a fullthickness tear, the location and the size of the tear was apparent on MD-CT arthrography. One joint side tear was clearly demonstrated on MD-CT arthrography although it was not diagnosed by MRI. MD-CT can easily display the optional section of a reconstructive image and 3D image by fast scanning (about 10 seconds). It was useful for diagnosing particularly the precise configuration of the acromion, bony Bankart's lesion, and joint side tears of the rotator cuff.

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CT osteoabsorptiometry is a method of predicting the long-standing stress distribution by measuring the pattern of subchondral bone density. The purpose of this study was to predict the stress distribution of the glenoid in a normal, rotator cuff tear, and traumatic anterior instability of the shoulder using this method. Sixteen shoulders with rotator cuff tear, 3 contralateral shoulders of which, 5 shoulders with traumatic anterior instability and 8 shoulders as control were prepared for this study. CT values of the glenoid were measured in each coordinate point and mapping data depicted by gray scale were created. The quantitative analysis was based on the ratio of the high bone density area for each zone (central, antero-superior, antero-inferior, postero-superior, postero-inferior) of the glenoid. The high bone density area was located in the antero-inferior and postero-superior zone in the control group. In the cuff tear group, it was located in antero-superior and postero-superior zone. In the anterior instability group, the high bone density area was located in the antero-superior and antero-inferior zone, however, not in the postero-inferior zone. There were different stress distribution patterns between the cuff tear, the anterior instability and the control group. The changes of kinematics of the gleno-humeral joint due to an abnormal condition were considered to be the cause of the difference.

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The purpose of this study was to measure the glenoid rim defect in recurrent dislocations of the shoulders using CT. We retrospectively studied 34 patients who underwent surgery with the Bankart method. A CT was done in all cases. 30 patients were male and 4 patients were female. Their mean age at surgery was 28.4 years old (range 18-72). We measured the distance between the anterior and posterior edge of the bony glenoid rim (D) in both the affected and normal side. CT scans were performed with 3 mm slices each. Then we added the D×3 (mm²) of each slice for the area of the bony glenoid joint surface. The we compared these areas of both sides and calculated the ratio of the defect area of the glenoid joint surface. The mean ratio of the defect we measured on CTs was 6.3% (-13.4∼30%). The mean ratio of the defect we measured during the operation was 14.9% (0∼40%). A significant correlation was recognized between the ratio of the defect we measured on CT and the ratio of the defect we measured during the operation. A significant correlation was recognized between the number of dislocations and the ratio of the defect we measured on CT. Our method using a CT was easy and practical to measure the glenoid defect.

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The purpose of this study was to analyse the throwing motion biomechanically. The throwing motions of forty pitchers were investigated by a 3D motion capture system using seven CCD cameras. Thirty-three reflected markers were applied to each joint and body landmark of a pitcher for taking the images. The angle, velocity and accelerated velocity of each joint were measured with these data. The reactant force was calculated by using a simulated model. The turning point of these planes was identified ”TOP’’ in this study and also the ”TOP’’ position showed the maximum rotated position of the trunk. The velosity of an elbow joint accelerated from the ”TOP’’ position to the MER. And decelarated from the MER to releasing a ball. The direction of a resultant force indicated the anterior of the shoulder joint during the phase between the ”TOP” and the MER, a glenoid between the MER and releasing a ball, and a posterior of the shoulder joint after the releasing a ball.

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[Purpose] We examined scapular motion in abduction in the patients with throwing pain and analyzed the relationship between the dysfunction of scapular motion and the clinical findings.
[Materials and methods] Twenty-six patients who have pain during throwing motion (22 male and 4 female, mean age ; 22 years old) were reviewed retrospectively. All patients underwent bilateral shoulder A-P X-rays at every 30 degree abducted position from 0 to 150 degree abduction. Scapulo-thoracic angle (STA) and abduction angle (ABD) were measured on the X-ray films, and scapular abduction ratio (ΔSAR=ΔSTA/ΔABD) was calculated. According to the result of ΔSAR, the patients classified into two groups, large ΔSAR group and small ΔSAR group, and the clinical findings related to small ΔSAR were analyzed.
[Results] The ΔSAR was smaller in the throwing side at 60-90 degree abduction (p=0.04). Eleven of 26 were classified into large ΔSAR, and 15 were classified into small ΔSAR. The clinical finding related to small ΔSAR was painful arc sign (p=0.03), and the other findings (sulcus sign, impingement sign, lateral scapular slide, scapular assistance test, scapular wing, relocation test, clunk test, fulcrum test, Bennett lesion) were not related statistically.
[Discussion and conclusion] The result that small ΔSAR in throwing side related to painful arc sign means a loss of scapular upward rotation could increase loads to cuff and deltoid muscle and induce pain in abduction and in throwing motion.

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The purpose of this study was to determine the utility of MR arthrography (MRA) in abduction and external rotation (ABER) position for a painful shoulder in overhead athletes. We studied 28 cases (26 male cases and 2 femal cases) ranging in age from 16 to 31 years old (average, 21.5 years old). Standard MRA (S-MRA) and ABER MRA with an oblique axial image were performed in all cases. In S-MRA with or without the ABER position, we evaluated the glenoid labral detachment, the articular-side partial rotator cuff tear, internal impingement. Arthroscopic correlation was obtained in all patients. Tears of the glenoid labrum were identified with a sensitivity of 96.3% with S-MRA, with a sensitivity of 66.7% with ABER MRA. In articular-side partial rotator cuff tear, S-MRA had a sensitivity of 58.8% and a specificity of 90.9%, ABER MRA had a sensitivity of 76.5% and a specificity of 90.9%. Using both the S-MRA and ABER MRA, the sensitivity was increased to 88.2% but the specificity was equal to the one alone. Internal impingement was identified with a sensitivity of 83.3% and a specificity of 100% with ABER MRA alone. The ABER MRA was useful in detection and characterization of articular-side partial rotator cuff tear and in diagnosis of internal impingement.

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The purpose of this study was to report our experience with an arthroscopic surgery in the treatment of a painful throwing shoulder. The study subjects consisted of patients with painful throwing shoulder and followed up for more than one year after surgery/ There were 12 males. The age of the patients at operation ranged from 18 to 35 (average 24.3). The follow-up period ranged from 12 months to 52 months (aveage 31 months). Arthroscopic evaluation consisted of examination of the glenohumeral joint and subacromial space. Treatment consisted of debridement and repair of the rotator cuff, labral tears and subacromial space. The results were evaluated by the JSS Shoulder Sports score system. JSS Shoulder Sports score improved from 48.8 points to 88.8 points. All patients revealed undersurface tearing of the rotator cuff. 7 patients had lesions of the subacromial space. 5 patients also had tearing of the posterior labrum. Anterior labrum fraying was noted in all patients. 10 of 12 (83%) throwers evaluated had returned to their preinjury level of throwing, but 2 throwers have changed their positions. Arthroscopic surgery of the rotator cuff, labral lesions, and subacromial lesions are reasonable options for baseball players with symptomatic stable shoulders who wish to return to sports.

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The purpose of this paper is to report on our clinical findings and operative results of SLAP lesion in throwing athletes. Eighteen throwing shoulders underwent arthroscopic superior labrum repair. Snyder's procedure was performed using Mini Revo anchors or a Revo anchor in all the patients. One anchor was used in 16 shoulders and two anchors were used in 2 shoulders. The average age at the operation was 24.7 years old (range : 16 - 51). There were 17 baseball players (11 pitchers and 6 fielders) and one badminton player. In all the shoulders superior labrum detachments were recognized on MR arthrography. Eleven patients complained of pain during the cocking phase and 6 patients complained of pain at ball release. Only one patient had pain with follow through. Crank test was positive in all 18 shoulders (100%). Seventeen of 18 patients had pain on anterior apprehension test (94%). Mimori test was positive in 14 of 18 shoulders (78%). O'Brien test was positive in 12 of 16 shoulders (75%). Arthroscopic evaluation revealed type 2 SLAP lesion in 17 shoulders and type 3 in one shoulder. Fourteen patients were followed up over 12 months after arthroscopic surgery. Twelve of these 14 patients were able to return to their previous levels. Complete return rate was 86%. The average duration between the operation and the return was 8.4 months (range : 6 - 11) in 7 pitchers and 6.8 months (range : 5 - 8) in 4 fielders. Crank test, anterior apprehension test, Mimori test and O'Brien test are beneficial to diagnose as SLAP lesion. The results of arthroscopic superior labrum repair for SLAP lesion in throwing athletes were good.

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All previous studies of baseball throwing motion have been limited to elite mature adult pitchers like professional and collegiate athletes. On the other hand, the throwing motion of children might be poorer than the adults.
Ten baseball athletes were analyzed by a 3D motion analysis system. These subjects were divided into two groups. One included athletes of fifteen years and under (IM), the other included athletes of twenty years and over (MA). Reflective markers were attached to 34 bony landmarks and the subject threw 10 fast balls. The reflections of these markers were tracked by seven CCD cameras at 500Hz. The subjects' 3 fastest balls that passed through the strike zone were analyzed by Motion Capture System (Qualysis, Inc.). The data of each group was averaged to compare the throwing biomechanics between the two groups.
Fleisig et al. suggested that throwing mechanics did not change significantly with developmental level. The shoulder abduction was lower in the IM group than the MA group. So children threw with positioning their elbows lower. They kept the centers of gravity lower and more backward. Also their trunks were less twisted.

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We reported that greater tuberosity notches seen in shoulders of baseball players frequently accompanied rotator cuff tears. The purpose of this study was to investigate whether greater tuberosity notches could be detected by preoperative imaging. We investigated 45 baseball players who were evaluated as to the presence and size of greater tuberosity notches on shoulder arthroscopy. The presence of greater tuberosity notches on preoperative imaging data using plain X-rays (45-degrees cranio-caudal view), CTs, and MRIs were investigated regarding the relationship with the size of the notches. Statistical significance was evaluated by Fisher's exact probability test and Mann-Whitney U analysis. The presence of notches on plain X-rays, CTs, and MRIs correlated with the presence and size of the notches on arthroscopy. Sensitivity, specificity, and accuracy of each imaging data was 82%, 68%, and 75% on plain X-rays, 80%, 83%, and 82% on CTs, 96%, 70%, and 82% on MRIs, respectively. It was possible to detect the presence of greater tuberosity notches on preoperative imaging. While MRI could detect them more easily, they could be detected even with a plain X-ray using 45-degrees cranio-caudal view. Preoperatively, we can expect the presence of rotator cuff tears by detecting the greater tuberosity notches on imaging data.

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This clinical study was aimed at investigating the utility of an arthroscopic Bankart's repair for a second anterior dislocation of the shoulder. The subjects consisted of patients with a second anterior dislocation of the shoulder joint with a history of a frank trauma and followed-up for more than one year after surgery. The second dislocation of the shoulder happened within 5 months from the initial dislocation. We perfomed Morgan's technique (3 cases), Harbermeyer's technique (2 cases) and the suture anchor technique (1 case). There were 5 males and one famale. The ages of the patients at operation ranged from 14 to 27 (average, 18.8). The follow-up period ranged from 12 months to 86 months (average 33 months). The results were evaluate by Rowe's scoring system. The average Rowe's score was 85.8 points (50-100). According to Rowe's criteria the clinical results were graded excellent in 4 cases, good in 1 case and poor in 1 case. There was subluxation in one case, the positive apprehension sign in one case and 10 degrees loss of external rotation in one case. The cases with a second antetior dislocation of the shoulder should be diagnosed by an arthroscopy and treated by arthroscopic Bankart's repair, especially when we consider their ages and activities for preventing the recurrence of a shoulder dislocation.

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We would like to clarify the diagnosis of a patient who suffered from shoulder deformity after a minor trauma. The patient was a 58-year-old woman who had a history of breast cancer. The operation was performed in 1990 and radiation was followed for 8 weeks. In 1999 slight pain of left shoulder appeared, when she picked up a 10 kg package in her left hand. After which she was massaged by a bone setter for 3 days and her shoulder pain increased. The X-ray findings on February 8 showed inferior subluxation of the shoulder. A closed reduction and external fixation were performed for 3 weeks. In November 1999, a radiation ulcer appeared in her left breast. A skin grafting was performed in our hospital in May 2000. She consulted our clinic complaining of shoulder pain. The X-ray showed there was glenohumeral osteoarthritis in her left shoulder. We operated on a total shoulder arthr oplasty and the results after surgery were good. We thought the cause of this case was glenohumeral ostearthritis by osteoradionecrosis.

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We wish to report on a case of massive rotator cuff tear treated by Patte's procedure using the posterior subdeltoid approach on elevation position for the sake of a less invasive transposition of the infraspinatus.
The patient was a 67-year-old man unable to elevate his right arm after work using a vibration tool. He could abduct his right arm 30 degrees best. Radiographs showed the shortening of the acromiohumeral interval (4mm). T2-weighted MRI showed a massive rotator cuff tear ; the end of the supraspinatus tendon shortened by 1cm medially from the glenoidal edge. The shoulder score was 68.5 points assessed by the Japanese Orthopedic Association. The operation was performed in the decubitus position. At first, we tried a conventional open cuff repair. Unfortunately, the cuff was too short to cover the humeral head ; therefore we shifted the infraspinatus using posterior subdeltoid approach on elevation position to avoid detaching the deltoid muscle. An abduction brace (70°) was used for 6 weeks. ROM exercises started passively after 4 weeks and actively after 8 weeks. At 6 months after the operation, his shoulder improved ; active elevation (150°), 92 points (JOA score). We experienced only one case, but Patte's procedure using a posterior subdeltoid approach on elevation position may be less invasive, less painful, and useful for severe cuff tear patients.

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We reported on a rare case of synovial osteochondromatosis (SOC) of the shoulder with a severe degenerative glenohumeral arthrosis. The patient was a 24-year-old female who complained of pain and a subluxaition feeling in her left shoulder. She had experienced difficulty in left shoulder elevation for about 10 years, however no abnormalities had been pointed out on X-ray. She visited our clinic after having had 5 subluxation feelings without any trauma over the last 4 years. The active range of motion was 80o-forward elevation, 15o-external rotation, and the internal rotation was at a level of Th10. TT The X-rays showed intraarticular spotty ossification and severe glenohumeral arthrosis. Arthrography showed multiple loose bodies in the capsule. At a time of 7-year-follow-up after an operation, the range of motion was slightly limited, but she had no pain in the shoulder. The irregularities of the subchondral bone of humerus had improved on X-rays. SOC with severe glenohumeral arthrosis is rarely reported. This case was not a primary, but a secondary SOC with some underlying disease considering the histological findings.

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We reported two cases of chronic subacromial bursitis not complicated by Rheumatoid arthritis (RA) or tuberculosis (Tb). (Case 1) A 59-years-old man was observed because of progressive pain and swelling in his right shoulder for one year. On examination swelling and fluctuation on the shoulder were remarkabl but we noted no redness and local warmth. T2-weighted MRI demonstrated multiple nodules with low intensity in effusion of the subacromial bursa (SAB). Laboratory tests showed an elevated Creactive protein, positive rheumatoid factor (RF) and a negative Tb culture of fluid in the SAB. We performed a subacromial bursalscopy and resection of the SAB on Aug 3, 2000. Intraoperetive findings showed SAB was occupied by fluid and more than 200 numbers of rice bodies. No bursitis recurred one year later. (Case 2) A 31-years-old woman presented herself with left shoulder swelling and pain which had begun one year before evaluation. On examination swelling and fluctuation on the shoulder were remarkable but no redness or local warmth were noted. MRI findings were the same as the previous case. C-reactive protein and RF were elevated, and the Tb culture of the bursal fluid were negative. Subacromial bursalscopy and resection of the SAB were performed on Feb 19, 2001. The intraoperative findings demonstrated that SAB were filled with fluid and 693 numbers of the bodies. Twenty-six cases of chronic subacromial bursitis with rice bodies have been reported, 21 which had RA, and 1 had Tb. We assumed that subacromial bursitis had developed before the onset of RA in these cases.

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It is extremely uncommon to fail to reduce an acute anterior dislocation of the shoulder by manipulation. This report was on such a rare case of irreducible acute anterior dislocation of the shoulder owing to an interposed fragment of the anterior glenoid rim. A 68-year-old woman dislocated her right shoulder when she fell over. The shoulder was manipulated under brachial block by using the Hippocratic technique. But it was unsuccessful. In the initial radiographs, there seemed to be a common anterior dislocation of the shoulder. After reducing it, the radiographs showed an interposed fragment of the anterior glenoid rim. The computed tomographs showed an ”L-shaped” defect of the anterior glenoid rim. Closed reduction was abandoned and an operation was performed. The fragment was inside out. The glenoid labrum was attached to it. Furthermore nearly 30% of the articular cartilage of the glenoid was attached to the fragment. It was assumed that a fracture of the anterior glenoid rim had occurred at the time of reduction. The fragment was easily reduced and fixed with absorbable screws. Eleven months after the surgery, the shoulder was stable with slight restriction of the range of motion. This could be one of the extremely rare cases of irreducible acute anterior dislocation of the shoulder.

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[Case 1] A 49-year-old man with long-term hemodialysis complained of left shoulder pain with fever. Intravenous drip infusion of antibiotics was begun because pus had been obtained by joint aspiration (St. aureus). Two weeks later, surgical treatment was planned because of insufficient improvement. However, as he vomitted blood caused by a duodenal ulcer on a pre-operative day, surgical treatment was cancelled. The next day, we performed joint puncture with an epidural needle under local anesthesia, washed inside the joint, and inserted the tube for epidural anesthesia. Then continuous intrajoint infusion of antibiotics with a portable disposable pump was begun. Clinical improvement was immediately obtained, the tube was removed 4 weeks later.
[Case 2] A 68-year-old man complained of right anterior chest and left shoulder joint pain with fever. He had undergone a sigmoidcolonectomy 4 months before, then experienced IVH from right subclavicular vein. No clinical improvement was obtained with intravenous drip infusion of antibiotics. Partial resection of right clavicle was performed under the diagnosis of osteomyelitis. Then capsulotomy and drainage for septic left shoulder joint with insertion of the epidural tube were done. After the continuous intrajoint infusion of antibiotics with a portable disposable pump was begun, clinical improvement was immediately obtained, the tube was removed 4 weeks later.
[Conclusion] Continuous intrajoint infusion of antibiotics with a portable disposable pump is convenient and effective treatment for septic arthritis of the shoulder joint.

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There are many difficult problems in the treatment of cuff-tear arthropathy. Recently, Worland et al. have reported on good functional results in the hemiarthroplasty using bipolar prosthesis. We reported on two cases of cuff-tear arthropathy treated with bipolar hemiarthroplasty. [Case 1] A 73-year-old male. Because of continuous shoulder pain and hydrarthrosis, bipolar hemiarthroplasty was performed on him. Post operatively, he was relieved of pain, but active range of motion had increased slightly. The JOA score had improved from 32 points to 56 points. [Case 2] A 79-year-old female. She also had bipolar hemiarthroplasty performed on. Post operatively, active range of motion had decreased from 70° to 25° in shoulder flexion. The JOA score had improved from 27 points to 36 points. There was little improvement compared with the pre-operative score.
Options for surgical treatment of cuff tear arthropathy include a total shoulder arthroplasty, hemiarthroplasty and arthrodesis. Although they are useful for pain relief, the functional outcome doesn't improve. Therefore a new operative technique and prosthesis are necessary for the treatment of cuff-tear arthropathy.

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We reported on a case of paralysis of the trapezius due to an accessory nerve injury, that had a successful result with Eden-Lange procedure.
[Case] A 21-year-old male felt pain in his right shoulder girdle after an excision of a right cervical soft tissue tumor in 1995. He visited our hospital on August 16, 2000. Physical examination revealed drooping of the right shoulder girdle, a scapular winging of the right shoulder, muscle atrophy of the right trapezius, an asymmetric scapulohumeral rhythm, and motor weakness of the upper and middle fiber of the right trapezius. We performed a modified Eden-Lange procedure on December 5, 2000. The levator scapulae was transferred to the scapular spine 5cm medial from the posterior tip of the acromion, the rhomboid minor and rhomboid major were transferred to the supraspinatus and infraspinatus fossa 5cm to 6cm lateral to the medial border of the scapula. An abduction brace was applied for six weeks. Three months after the surgery, his right shoulder girdle pain had disappeared. He can elevate his right arm fully without asymmetrical scapulohumeral rhythm.
[Discussion] In cases of paralysis of the trapezius after an accessory nerve injury, instability of the scapula leads to pain of the shoulder girdle and restriction of shoulder elevation. For chronic paralysis, functional reconstruction of the trapezius is recommended. Eden-Lange procedure is one of the useful procedures for a chronic accessory nerve injury.

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